Ch 60
To evaluate a client's cerebellar function, a nurse should ask:
"Do you have any problems with balance?"
Motor ability Muscle Strength Balance & coordination
Examining the Motor System
Tests for tactile sensation Superficial pain Temperature Vibration Position sense (proprioception)
Examining the Sensory System
Displaying lack of muscle tone; limp, floppy
Flaccidity
Inability to tolerate light
Photophobia
Deep tendon Superficial Pathologic
Types of Reflexes
An illusion of movement, usually rotation
Vertigo
A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following?
"It can mean a traumatic puncture or a subarachnoid bleed."
Spasticity Rigidity Flaccidity
Abnormalities in muscle tone
Loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile
Agnosia
Inability to coordinate muscle movements, resulting in difficulty in walking, talking, and performing self-care activities
Ataxia
Which of the following terms refers to the inability to coordinate muscle movements, resulting difficulty walking?
Ataxia
Division of the nervous system that regulates the involuntary body functions
Autonomic nervous system
Portion of the neuron that conducts impulses away from the cell body
Axon
A reflex action of the toes, indicative of abnormalities in the motor control pathways leading from the cerebral cortex
Babinski reflex (sign)
5: indicates full power of contraction against gravity and resistance or normal muscle strength 4: indicates fair but not full strength against gravity and a moderate amount of resistance or slight weakness 3: indicates just sufficient strength to overcome the force of gravity or moderate weakness 2: Indicates the ability to move but not to overcome the force of gravity or severe weakness 1: indicates minimal contractile power 0: no movement
Clinicians use a 5-point scale to rate muscle strength
Abnormal movement marked by alternating contraction and relaxation of a muscle occurring in rapid succession
Clonus
Tested carefully using a clean wisp of cotton and lightly touching the outer corner of each eye on the sclera.
Corneal Reflex
Are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease.
Cranial Nerves
0 No response 1+ Diminished (hypoactive) 2+ Normal 3+ Increased (may be interpreted as normal) 4+ Hyperactive (hyperreflexia)
Deep Tendon Reflexes are graded on a scale of 0 to 4
Biceps reflex Triceps reflex Brachioradialis Reflex Patellar Reflex Achilles Reflex
Deep tendon reflexes
Transient loss of intellectual function, usually due to systemic problems
Delirium
Portion of the neuron that conducts impulses toward the cell body
Dendrite
Elicited by gently touching the back of the pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other.
Gag reflex
Evaluated by testing two-point discrimination. When the patient is touched by two objects simultaneously, are they perceived as two or as one? If touched simultaneously on opposite sides of the body, the patient should normally report being touched in two places. If only one is reported, the one not being recognized is said to demonstrate extinction.
Integration of sensation
Division of the autonomic nervous system active primarily during non stressful conditions, controlling mostly visceral functions
Parasympathetic nervous system
Are seen in the presence of neurologic disease; they often represent emergence of earlier reflexes that disappeared with maturity of the nervous system. Ex. Babinski reflex.
Pathologic Reflexes
Elicited by stroking the sole of the foot with a tongue blade or the handle of a reflex hammer. Stimulation normally causes toe flexion
Plantar Reflex
Awareness of position of parts of the body without looking at them; also referred to as propioception
Position (postural) sense
May be determined by asking the patient to close both eyes and indicate, as the great toe or index finger is alternatively moved up and down, in which direction movement has taken place.
Position sense or proprioception
An automatic response to stimuli
Reflex
Involuntary contractions of muscles or muscle groups in response to a stimulus.
Reflexes
Increase in muscle tone at rest characterized by increased resistance to passive stretch
Rigidity
Test for cerebellar dysfunction requiring the patient to stand with feet together, eyes closed and arms extended; inability to maintain the position, with either significant stagger or sway, is a positive test
Romberg Test
Sustained increase in tension of a muscle when it is passively lengthened or stretched
Spasticity
Corneal Palpebral Gag Upper/lower abdominal Cremasteric (men only) Plantar Perianal
Superficial Reflexes
Pain & temperature sensations are transmitted together in the lateral part of the spinal cord, so it is unnecessary to test for temp sense in most circumstances. Determining the patient's sensitivity to a sharp object
Superficial pain perception
Division of the autonomic nervous system with predominantly excitatory responses; the "fight-or-flight" system
Sympathetic Nervous System
A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?
Tactile agnosia
Assessed by lightly touching a cotton wisp or fingertip the corresponding areas on each side of the body. The sensitivity of proximal parts of the extremities is compared with that of distal parts, and the right and left sides are compared.
Tactile sensation
Vibration & proprioception are transmitted together in the posterior part of the cord. Vibration may be evaluated through the use of a low-frequency tuning fork. The handle of the vibrating fork is placed against a bony prominence, and the patient is asked if he or she feels a sensation and is instructed to signal the examiner when the sensation ceases.
Vibration