Week 11 Neuro-STUDENT
Week 11 Neuro-STUDENT
Week 11 Neuro-STUDENT
Objectives
e. Interpret common laboratory and diagnostic findings for the neurological system
of the adult
f. Based on national guidelines (Healthy People 2020, AHRQ Clinical Prevention
Guidelines, and other appropriate national standards), recommend the appropriate
health promotion and clinical prevention strategies for the adult
g. Assess self and patient scenarios utilizing the clinical reasoning model for the
neurological system of the adult
h. Demonstrate professionalism in the clinical simulation laboratory by: honoring
confidentiality of scenarios and other’s health histories; respecting other’s self-
determination and human dignity; and exhibiting integrity by abiding by
laboratory guidelines, equipment use, and dress code
i. Describe expected and unexpected findings in each body system to include ethnic,
cultural, and age variations
The Nervous System
Central Nervous System
Brain and spinal cord
Occipital
CEREBRUM
https://youtu.be/6fyiGUAg2GY (Stereognosis)
https://youtu.be/CEiVbK31wj0 (two point)
Spinal Cord
31 pairs of spinal nerves emerge from spinal cord
Cranial Nerves
Fight or Flight
Dominates during
calm, non-stressful
times
A & P Review- ANS
Sympathetic Parasympathetic
Sympathetic nervous system Parasympathetic nervous system
(SNS) arises from thoracolumbar (PNS) arises from craniosacral
segments of spinal cord and is segments of the spinal cord and
activated during stress (the “fight- controls vegetative functions
or-flight” response). (“breed and feed”).
SNS actions include:
PNS actions associated with
Increasing blood pressure and heart conserving energy such as:
rate
Decreasing heart rate and force of
Vasoconstricting peripheral blood myocardial contraction
vessels
Decreasing blood pressure and
respiration
Inhibiting gastrointestinal peristalsis Stimulating gastrointestinal peristalsis
Dilating bronchi
Neurotransmitters
Communicate messages from one neuron to another
or from a neuron to a specific target tissue
Excite or inhibit the target cell’s activity
Usually MULTIPLE neurotransmitters at
work in the neural synapse
Examples- dopamine, serotonin, GABA,
Epinephrine, and many others
Do you know how your brain
works?
https://youtu.be/_krtukeNB-w
Functional Organization of the Brain
Localization of
function
Can be assessed by
various techniques
(e.g., physiology,
imaging, neurological
exam,
neuropsychological
exam, post mortem)
Brain lateralization – the two halves of
the human brain are not exactly alike
Health History
Prenatal or birth events
Exposures (toxins, drugs)
Illnesses (Epstein-Barr, Bell’s Palsy, Rocky
Mountain Spotted Fever, Lyme disease,
encephalitis, etc.)
Injuries (concussion, closed head, etc.)
Health History – Focused Neuro
Health History
Clinical manifestations or symptoms
Abnormal sensation
Dizziness
Visual or sensory disturbances
Tremors or other motor tics
Pain
Weakness
Seizures
Health History – Focused Neuro
Family History
Diseases
Amyotrophic Lateral
Sclerosis Myasthenia Gravis
Parkinson’s Migraine
Multiple Sclerosis Neurofibromatosis
Seizure disorders Guillain-Barré
Tumors Syndrome
Alzheimer’s disease
Tourette syndrome
Muscular Dystrophy
American Academy of
Neurology
Mental Status
Level of alertness, appropriate responses
Orientation
Cranial Nerves
Motor System
Strength
Gait
Coordination
Sensory System
Light touch,
Pain/temperature
Proprioception
Reflexes
DTRs-biceps, patellar, Achilles
Plantar
Mental Status
Orientation
If orientation is a concern during history, determine if
oriented to time, place, person.
Date and time is first orientation to disappear.
Only a problem if remains disoriented after being reoriented
Place is second orientation to disappear.
Person is last orientation to disappear.
Orientations returns in opposite order in which is lost.
Appearance, general behavior, mood
Thought content, memory, recall
Intellectual/functional ability
Level of Consciousness (LOC)
Altered level of consciousness
Nurse can determine if client alert and oriented by way
questions are answered during interview.
Change in level of consciousness (LOC) is earliest and
most sensitive indicator of alterations in cerebral
function.
Awareness is higher level function controlled by reticular
activating system.
Wakefulness is controlled by brainstem.
When client’s awareness cannot be assessed because
unconscious, arousal is assessed.
LOC (Arousal)
Alertness
Lethargy
Obtunded
Stupor
Coma
LOC
Glasgow Coma Scale: assess LOC using 15-point
scale.
Assess for best response to eye opening, motor
response, and verbal response.
Determine stimulation/pain required to elicit response.
Only time acceptable to inflict pain on client
Glasgow Coma Scale
Glasgow Coma Scale
1 2 3 4 5 6
Opens
Opens eyes in Opens eyes in
Does not eyes
Eyes response to response to N/A N/A
open eyes spontaneo
painful stimuli voice
usly
Utters Oriented,
Makes no Incomprehensibl Confused,
Verbal inappropriate converses N/A
sounds e sounds disoriented
words normally
Abnormal
Extension to
flexion to Flexion /
painful stimuli ( Localizes
Makes no painful stimuli Withdrawa Obeys
Motor decerebrate painful
movements ( l to painful commands
response) stimuli
decorticate resp stimuli
onse
)
Abnormal Posturing
Cranial Nerves Group Activity
Cranial Nerves (12)
OnOld
Olympus’
Towering Tops,
A Fin And
German
Viewed Some
Hops
Abnormalities of Cranial Nerves
I- anosmia VII- asymmetrical facial
movements, loss of taste
II- defect in vision VIII- decrease or loss of
(central or peripheral) hearing
III, IV, VI- pupil IX & X- uvula deviates to
one side, no gag, hoarse or
abnormalities, EOM brassy voice, dysphagia
abnormalities XI- absent movement of
V- absent touch & pain, sternomastoid or trapezius
no blink, weakness of muscles
masseter or temporalis
XII- tongue deviates to one
side , slow rate of
muscles movement
Motor System
Motor System
Includes brain and spinal
cord motor pathways
Includes all major muscle
groups distal and
proximal
Muscle tone, strength,
symmetry
Unusual movements,
fasciculations, tics,
twitching
Gait and Posture
Gait
Walking or ambulating
requires coordination of
multiple voluntary and
involuntary functions
Strength, coordination,
symmetry, balance, stance,
speed, stride length, arm
movement, foot placement,
initiation & cessation
Coordination and
the Cerebellum
Cerebellum-
Cerebellum responsible for voluntary movement and motor
coordination
1+
2+
3+
4+
Meningeal Signs
Neck Mobility
Brudzinski’s Sign
Kernig’s Sign
Diagnostic Evaluation
CT Scan Cerebral Angiography
Myelography
Positron Emission
https://www.youtube.com/watch?v
Tomography =OZaoNof_CsY
Magnetic Resonance Noninvasive Carotid Flow
Imaging Studies
Transcranial Doppler
Lumbar Puncture
EEG
http://www.youtube.com/wa https://youtu.be/KXS268XsRic
tch?v=L9IvVRZdI9I
(1:22)
(3:51)
EMG
https://www.youtube.com/watch?v
=xdKwSymCpws
Nerve Conduction Studies
Sample documentation
Mental Status: alert, relaxed, and cooperative.
Thought processes coherent. Client oriented to
person, place, and time. Cranial Nerves: I-
deferred; CN II-XII- intact. Motor: Good muscle
bulk and tone. Strength 5/5 throughout. Cerebellar-
RAMs, F to N, H to S, intact. Gait steady with
normal base. Romberg- maintains balance with
eyes closed. No pronator drift. Sensory: light
touch, position, and vibration intact. Reflexes: 2+
and symmetric with plantar flexion of bilateral feet.
Pediatric Considerations
Factors to consider
General health and nutritional status
History of head injury, trauma, or neurological
disease
Smoking history
Substance use/abuse
Educational level
Social support
Geriatric Considerations
Decrease in taste & Loss of vibration
smell sense at the ankle
Decrease in muscle level
bulk Decrease position
Senile tremors sense
Dyskinesias DTRs less brisk
More deliberate
movements
Longer recall
Geriatric Considerations
Some decline in memory and
cognition is expected
Sensory processing may diminish
with aging
Rapid or dramatic declines, or
significant personality changes are
red flags
Tests for balance and gait are often
assessed for older adults to identify
those at risk for falls.
Health Promotion- CVA
Older adulthood; risk double each decade after 55
Male sex (slightly higher risk)
AA
HTN
Smoking
Chronic ETOH intake (>2 drinks/day)
Hx of CV disease
Sleep apnea
DM
Drug abuse
High estrogen levels
Overweight
Sedentary lifestyle
Family hx of CVA
Terminology
Clonus involuntary, rhythmic muscle contractions.
Agnosia Inability to recognize by sight (visual agnosia), touch (tactile agnosia), or hearing (auditory agnosia.)