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Parts of neuro assessment performed thruout hlth exam Nsg. Hx, gen. appearance Nurse assesses cranial nerve fxns:
CN II, III, IV, V, VI assessed w/ the eyes and vision CN VIII assessed w/ the ears and hearing
Dyana M. M. Saplan, RN, MAN
Language
Aphasia
any defects or loss of power to express oneself by speech, or writing, or signs to comprehend spoken or written language due to a disease or injury of the cerebral cortex Sensory or receptive aphasia loss of the ability to comprehend written or spoken words
Auditory (acoustic) aphasia loss of ability to comprehend symbolic content associated w/ sounds Visual aphasia loss of ability to understand printed or written figures
Language
Motor or expressive aphasia
involve loss of power to express oneself by writing, making signs, or speaking Clients may find that eventho they can recall words, they have lost the ability to combine speech sounds into words
Orientation
Determines clients ability to recognize other persons, awareness of when and where they presently are, and who they are Orientation to PERSON, TIME, PLACE, and SELF
Memory
Nurse assesses the clients:
Immediate recall information presented seconds previously, Recent memory events or information from earlier in the day or examination, Remote/Long-term memory knowledge recalled from months or years ago
Serial Threes
Dyana M. M. Saplan, RN, MAN
Level of Consciousness (LOC) Can lie anywhere along a continuum from a state of alertness to coma Apply the Glasgow Coma Scale (GCS/NVS): eye response, motor response, and verbal response
GCS score of 15 pts. = alert and completely oriented Score of 7 or less = comatose client
Dyana M. M. Saplan, RN, MAN
Score 4 3 2 1
Motor response
To verbal command Localizes pain Flexes and withdraws Flexes abnormally Extends abnormally No response
6 5 4 3 2 1
Score
5 4 3 2 1
TOTAL
Dyana M. M. Saplan, RN, MAN
15
Cranial Nerves Nurse needs to be aware of specific fxn and assessment methods for each cranial nerve to detect abnormalities Test each nerve not already evaluated in another component of the health assessment
12 cranial nerves
I Olfactory (smell) II Optic (vision) III Occulomotor (EOM) IV Trochlear (EOM) V Trigeminal (Sensation) VI Abducens (EOM) VII Facial (expression, taste) VIII Auditory (equilibrium, hearing)
IX - Glossopharyngeal (swallowing, taste) X Vagus (sensation of pharynx and larynx; swallowing; vocal chord movement) XI Accessory (head movement; shrugging of shoulders) XII Hypoglossal (protrusion of tongue; up/down, side - side movement)
Reflexes
Automatic response of the body to a stimulus Tested using percussion hammer Scale:
0 No reflex response +1 Minimal activity (hypoactive) +2 Normal response +3 More active than normal +4 Maximal activity (hyperactive)
Dyana M. M. Saplan, RN, MAN
Reflexes tested:
BICEPS REFLEX
tests the spinal cord level C-5 and C-6
TRICEPS REFLEX
tests the spinal cord level C-7 and C-8
Reflexes
BRACHIORADIAL IS REFLEX
tests the spinal cord level C-3 and C-4
PATELLAR
tests the spinal cord level L-2, L-3, L-4
Reflexes
ACHILLES REFLEX
tests the spinal cord level S-1, S-2
Motor function
Evaluates proprioception and cerebellar function Structures involved:
Proprioceptors Posterior columns of the spinal cord Cerebellum helps control posture; acts w/
cerebral cortex = smooth and coordinated body movements; controls skeletal muscles = equilibrium Vestibular apparatus (innervated by cranial nerve VIII) in the labyrinth of the inner ear
Dyana M. M. Saplan, RN, MAN
Proprioceptors
Sensory nerve terminals, occurring chiefly in the:
Muscles, Tendons, Joints, Internal ear
Motor function
Gross Motor and Balance Tests
Generally Romberg test and one other gross motor function and balance tests are used
Walking Gait
Ask client to walk across the room and back, assess clients gait N: Has upright posture and steady gait with opposing arm swing; walks unaided, maintaining balance D: poor posture and unsteady, irregular staggering gait with stance, bends legs only from hips, has rigid or no arm movements
Dyana M. M. Saplan, RN, MAN
Romberg Test
N: Negative Romberg may sway slightly but is able to maintain upright posture and foot stance D: Positive Romberg: cannot maintain foot stance; moves the feet apart to maintain stance
Cannot maintain balance w/ eyes shut = sensory ataxia (lack of coordination of the voluntary muscles) Balance cannot be maintained whether the eyes are open or shut = cerebellar ataxia
Dyana M. M. Saplan, RN, MAN
Heel-Toe Walking
N: Maintains heel-toe walking along a straight line D: assumes wider foot gait to stay upright
Finger-To-Nose Test
N: Repeatedly and rhythmically touches the nose D: misses the nose or slow response
Fine Motor Tests for Upper Ext. Finger to Nose and to the Nurses Finger Fingers to Fingers Fingers to Thumb (same hand)
Sensory Function
Touch Pain Temperature Position, and Tactile discrimination
Pain sensation
sharp, dull, dont know using broken tongue depressor
Tactile Discrimination
For all tests, clients eyes need to be closed
Stereognosis
Ability to recognize objects by touching them Client w/ motor impairment of the hand write a number or letter on clients palm, using blunt instrument, ask to identify = GRAPHESTHESIA
Dyana M. M. Saplan, RN, MAN
Extinction phenomenon
Simultaneously stimulate 2 symmetric areas of the body
Thighs, cheeks, arms, or hands
Lifespan Considerations
Infants
Reflexes commonly tested in newborns:
Rooting Sucking Tonic neck (fencers pose) Palmar grasp Stepping Moro
Infantile Reflexes
Infantile Reflexes
Children
Present procedures as games whenever possible (+) Babinski abnormal after child ambulates or @ age 2 Note the childs ability to understand and follow directions. Assess immediate recall or recent memory by using names of cartoon characters.
Normal recall in children is one less than age in years
Children
Should be able to walk backward by age 2 balance on one foot for 5 seconds by age 4 heel-toe walk by age 5, and heel-toe walk backward by age 6. Romberg Test is appropriate over age 3
Elders
A full neurologic assessment can be lengthy.
Conduct in several sessions if indicated and cease the tests if the client is noticeably fatigued.
Elders
Intelligence and learning ability are unaltered with age.
Many factors, however, inhibit learning (e.g., anxiety, illness, pain, cultural barrier)
Because old age is often associated with loss of support persons, depression is a common disorder
Mood changes, weight loss, anorexia, constipation and early morning awakening may manifest it
Dyana M. M. Saplan, RN, MAN
Elders
As a person ages, reflex responses may become less intense. Many elderly clients may have some impairment of hearing, vision, smell, temperature and pain sensation, memory and mental endurance. Coordination changes, including a reduced speed of fine finger movements. Standing balance remains intact, and Rombergs Test remains negative. Reflex responses may slightly increase or decrease. Many show loss of Achilles reflex, and the plantar reflex may be difficult to elicit.
Achilles reflexes
Elders
When testing sensory function, the nurse needs to give the older client time to respond.
Normally, older clients have unaltered perception of light touch and superficial pain, decreased perception of deep pain, and decreased perception of temperature stimuli. May also reveal a decrease or absence of position sense in the large toes
Dyana M. M. Saplan, RN, MAN
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