ATI Chapter 31: Musculoskeletal and Neurosensory Systems

Biceps 3 facts: Expected Response:

- flex arm 45 degrees - place the thumb on the tendon in antecubital fossa - strike the thumb with a reflex hammer Expected Response for Biceps: flexion of elbow

Achilles: 1 fact Expected Response:

- flex the knee, dorsiflex the foot, and strike the tendon above the heel Expected Response for achilles: Plantar flexion of the foot

Brachioradialis 2 facts Expected Response:

- rest a forearm on the examiner's forearm with the wrist slightly pronated - strike the tendon 2.5 to 5 cm above the wrist Expected Response for brachioradialis: Pronation of the forearm and flexion of the elbow

Triceps 2 facts Expected Response:

- support the upper arm with the forearm hanging at a 90 degree angle -strike the tendon above the elbow Expected Response for triceps: Extension of the elbow

Patellar 2 facts Expected Response:

- with the upper leg supported and the lower leg dangling freely, strike the tendon below the knee Expected Response for patellar: Extension of the lower leg

Mini Mental Exam Assesses

**to assess cognitive status objectively. Orientation to time and place Attention and calculation of counting backward by sevens Registration and recalling of objects Language, including naming of objects, following of commands, and ability to write Reading

Standardized Screening Tools

*Mini Mental State Examination *Glasgow Coma Scale

heel-to-toe walk

-ask client to place heel of one foot in front of toes of the other foot as he walks in a straight line -expected finding: client is able to walk in a straight line without losing balance

Romberg Test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Health History: Review of Systems 5

1) Do you have any dizziness or HA? 2) Do you ever have seizures? If so, what triggers them? 3) Have you ever had a head injury ir any loss of consciousness? 4) have you noticed any change in your vision, speech, ability to think clearly, loss of memory, or change in memory or behavior?

Mental status 7 types

1) alert 2) lethargic 3) obtunded 4) stuporous 5) comatose 6) decorticate rigidity 7) decerebrate rigidity

Graded DTR responses

4+ very brisk with clonus 3+ more brisk than average 2+ expected 1+ diminished 0 no response

Judgement...

Ask the client about the solution to a specific dilemma. ("What would you do if you locked your keys in your car?")

Motor Function

Assess coordination by asking the client to extend his arms and rapidly touch his finger to his nose, alternating hands, and then doing it with his eyes closed. expected findings include smooth coordinated movements assess gait when client is unaware of the assessment. >> expected findings include gait is steady, smooth, or coordinated assess balance by using Romberg test and heal to toe walk muscle strength: assess the strength of muscle groups by asking the client to push or pull against resistance. >> expected findings: strength is equal or slightly stronger on the dominant side of the body

Use the Glasgow Coma Scale to obtain...

baseline assessment of the client's level of consciousness and for ongoing assessment. Looks at eye, verbal, and motor response, and assigns a number value based on the client's response. The highest value possible is 15, indicating full consciousness.

Sample documentation

Full ROM without pain in all joints and spine. No joint deformities, warmth, or swelling. Posture erect. Spin midline with expected cervical, thoracic, and lumbar curvatures. No scoliosis. Muscle strength equal and strong bilaterally.

Neurological examination includes 5

Mental status examination to test cerebral function Assessment of cranial nerves Motor function to test cerebellar function Sensory function Reflexes

CN III (Oculomotor), IV (trochlear), VI (abducens)

Motor -- PERRLA, six cardinal positions of gaze

CN XI (spinal accessory)

Motor -- turning head, shrugging shoulders

7) Comatose: Decerebrate rigidity

Neck and elbow extension, with the wrists and fingers flexed

Stereognosis

Place a familiar object (key, cotton ball) in the client's hand, and ask him to identify it.

Assess memory in two ways...

Recent - Ask the client to repeat a series of numbers or a list of objects. Remote - Ask the client to state his birth date or mother's maiden name (verifiable).

CN X (vagus)

Sensory -- gag reflex Motor -- swallowing, speech sounds

CN V (trigeminal)

Sensory -- light touch sensation to the face Motor -- jaw opening, clenching, chewing

CN I (olfactory)

Sensory -- smell

CN VII (facial)

Sensory -- taste (salt/sweet) Motor -- facial movements

CN IX (glossopharyngeal)

Sensory -- taste (sour/bitter) Motor -- swallowing, speech, sounds, gag reflex

CN II (optic)

Sensory -- visual acuity, visual fields

6) Comatose: Decorticate rigidity

flexion and internal rotation of upper extremity joints and legs

Neurosensory System

a neurological screening examination can evaluate the major indications of neurological funtion and assist with recognition of areas of dysfubction integrate the neurological system with other assessments

Abstract thinking...

ask the client the interpretation of a cliché such as, "A bird in the hand is worth two in the bush."

Level and fund of knowledge...

ask the client what he knows about his current hospitalization or illnes

Sensory Function (perform on all four extremities with clients closed eyes)

assess pain sensation by alternating sharp and dull objects on the skin and asking the client to report what he feels assess temperature by using 2 test tubes containing water (1 warm and 1 cold) and ask the client to identify which he feels assess light touch by asking the client to report when and where he feels a cotton ball touching his skin assess vibration by having the client report when and where he feels the handle of the vibrating tuning fork on his skin assess position by repositioning the client's appemndages and sking him to report whether each is positioned up or down assess discrimination by using one of the following: two point discrimination, stereogenosis, or graphesthesia

2) Lethargic

client is able to open his eyes and respond but is drowsy and falls asleep readily

1) Alertness

client is responsive and able to open his eyes and answer questions spontaneously and appropriately.

4) Stuporous

client requires painful stimuli (pinching a tendon or rubbing the sternum) to achieve a brief response. The client may not be able to respond verbally.

3) Obtunded

client responds to light shaking but may be confused and slow to respond

Ability for calculation...

count backwards from 100 in serials of 7

Assess mood by...

inspecting mannerisms and actions during interactions. Expected findings: client makes eye contact, and emotions correspond to the conversation and situation

Assess cognitive and intellectual process 8

memory level of knowledge ability for calculating abstract thinking insight judgement thought process thought content

CN XII (hypoglossal)

motor -- tongue movements

Thought process...

note processing differences, such as a rapid change of topic (flight of ideas) and use of nonsense words ("hipsnippity")

Thought content...

note the presence of delusions, hallucinations, and other ideas the client presents during the interview

Assess appearance by...

observing hygiene, grooming, and clothing choice. Expected findings: client is clean and dressed appropriately for the environment or situation.

Insight...

perform an objective assessment of the client's perception of illness

Expect speech and languge ...

rate and features (quality, quanitity, and volume, to be articulate and responses meaningful and appro

CN VIII (auditory)

sensory -- hearing and balance

5) Comatose

there is no response to repeated painful stimuli.

Graphesthesia

trace a number on the client's palm with the blunt end of a pencil and ask him to identify it.

Two point discrimination

use open paper clips to determine the smallest distance between the two points at which the client can still feel the two points on his skin and not just one. Compare bilaterally.

deep tendon reflexes (DTR) def. includes: 6

using a reflex hammer, assess DTRs bilaterally and compare results for symmetry biceps, brachioradialis, triceps, patellar, achilles, and grade DTR responses

Musculoskeletal changes with aging 8

›Reduced muscle mass ›Declines in speed, strength, resistance to fatigue, reaction time, coordination ›Osteoporosis (fragility of bones, loss of bone mass and height) ›Greater risk of fractures and vertebral compression ›Degenerative alterations in joints ›Limited range of motion ›Flexed elbows, hips, and knees ›Thinning intervertebral discs, kyphosis (with height loss), wider stance altering posture

Neurological changes with aging

›Some short-term memory decline ›Diminished/slowed reflex and motor responses, impulse transmission, and reaction times ›Altered vibration, position, hearing, vision, smell, and deep pain and temperature sensation ›Slower fine finger movement (no change in superficial pain and light touch sensation, standing balance) ›Decline in mental function probably related to less cognitive stimulation and solitude ›Fewer brain cells, smaller brain volume, deteriorating nerve cells, fewer neurotransmitters ›With infection, delirium more common than fever ›Greater risk of depression > impaired balance > decreased touch sensation