health assessment test#2 ch.23 neurologic system

syncope

Sudden loss of strength, temporary loss of consciousness, caused by lack of cerebral blood flow, low BP

gait test

(balance test) Observe as person walk 10 to 20 feet, turns, and returns to starting point. Normally person moves with sense of freedom. Should be smooth, rhythmic, and effortless

strabismus

(deviated gaze) or limited movement. Normal range of findings: check pupils for size, regularity, equality, direct, & consensual light reaction & accomodation

ptosis

(drooping) occurs with myasthenia gravis, dysfunction of cranial nerve III or Horner syndrome. Abnormal findings- cranial nerves III, IV, VI

screening neurologic examination

1. Mental Status (level of alertness, appropriateness of responses, orientation to date & place) 2. Cranial Nerves (II- visual acuity, pupillary light reflex; III, IV, VI- eye movements; VII- facial strength (smile, eye closure); VIII- hearing) 3. Motor Function: strength (shoulder abduction, elbow extension, wrist extension, finger abduction, hip flexion, knee flexion, ankle dorsiflexion); coordination (fine finger movements, fingers to nose); gait (casual, tandem) 4. Sensation (one modality at toes can be light touch, pain/temp or proprioception) 5. Reflexes: deep tendon reflexes (biceps, patellar, achilles)

grading of reflex response

4+ Very brisk, hyperactive with clonus, indicative of disease 3+ Brisker than average, may indicate disease, probably normal 2+ Average, normal 1+ Diminished, low normal, or occurs only with reinforcement 0 No response

positive romberg sign

A __ __ __ is the loss of balance that occurs when closing the eyes. The nurse asks the patient to stand up with the feet together and arms at the sides. Once in a stable position, the nurse instructs the patient to close the eyes and to hold the position and wait for about 20 seconds. Normally, a patient can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur

LOC

A change in the level of consciousness is the single most important factor. Earliest and most sensitive index of change in neuro status. A change in consciousness may be subtle. Note any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person

bell's palsy

A lower motor neuron lesion, asymmetric facial movements, and the inability to wrinkle the forehead indicate __ __ in a patient. A patient with __ __ may have paralysis of one half of the face. Cranial nerve VII, also known as the facial nerve, innervates the muscles of the face.

clonus

A set of rapid, rhythmic contractions of the same muscle. repeated reflex muscular movements

dysphasia

Difficulty with language comprehension or expression

PNS lesions

loss of movement and asymmetry of movement occur with this (e.g. bell palsy that affects the upper and lower face on one side)

cranial nerve VI

Abducens, motor, lateral movements of the eye. Can test by looking side to side

hyporeflexia

Absence of a reflex, is a lower motor neuron problem. It occurs with interruption of sensory afferents or destruction of motor efferents or destruction of motor efferents and anterior horn cells

cranial nerve VIII

Acoustic, sensory, hearing and equilibrium. Can test by hearing and whisper test

Paralysis Causes

Acute - trauma, spinal cord injury, stroke, poliomyelitis, polyneuritis, bell palsy Chronic - muscular dystrophy, diabetic neuropathy, MS Episodic - myasthenia gravis

reinforcement

Another technique to relax the muscles and enhance the response. Ask the person to perform isometric exercise in a muscle group somewhat away from the one being tested. Example - to test patellar reflex, ask person to lock fingers together and pull as hard as you can, then strike tendon for patellar reflex

Subjective Data - Headache

Any frequent or severe headaches, when did they start, how often do they occur, where in your head to you feel the headaches, are they associated with anything? A patient that says "This is the worst headache of my life", needs emergency referral to screen a possible stroke

rapid alternating movements (RAM)

Ask person to pat knees with both hands, lift up, turn hands over, and pat knees with the backs of the hands. Then ask person to do this faster. Normally done with equal turning and quick pace

romberg test

Ask person to stand up with feet together. Once in stable position,ask him or her to close eyes and to hold the position. Wait about 20 seconds. Normally a person can maintain posture and balance.

finger to nose test

Ask the person to close the eyes and stretch out the arms. Ask him or her to touch the tip of his or her nose with each index finger, alternating hands and increasing speed. Normally this is done with accurate and smooth movement

glasgow coma scale

Assess the functional state of the brain as a whole, not of any particular site in the brain. Also enhances interprofessional communication by providing a common language. Was developed as an accurate and reliable quantitative tool. A standardized objective assessment that defines the level of consciousness by giving it a numeric value. High numbers are good, low numbers are bad and can indicate a possible coma if number is 7 is lower A fully alert, normal person has a score of 15

plantar reflex

Babinski. With reflex hammer draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot like an upside down J. the normal response is plantar flexion of the toes and inversion and flexion of the forefoot.

reflex arc

Basic defense mechanisms of the nervous system. They are involuntary and permits a quick reaction to potentially painful or damaging situations. They also help the body maintain balance and appropriate muscle tone

the aging adult

Causes a general atrophy with a steady loss of neuron structure in the brain and spinal cord. This causes a decrease in weight and volume with thinning of cerebral cortex, reduced subcortical brain structures, and expansion of ventricles. decreased muscle strength, impaired fine coordination and agility, loss of vibratory sense at ankle, decreased or absent Achilles reflex, loss of position sense at the big toe, pupillary miosis, irregular pupil shape, and decreased pupillary reflexes. Velocity nerve conduction decreases making reaction time slower in some older people. As a result, touch & pain sensation, taste & smell may be diminished

motor function

Check voluntary movement of each extremity by giving person specific commands. Ask person to lift eyebrows, frown, bare teeth. Note symmetric facial movements. A weak grip occurs with upper and lower motor neuron disease and with local hand problems such as arthritis and carpal tunnel syndrome

Patterns of Paralysis

Hemiplegia - spastic or flaccid paralysis of one side of body and extremities Paraplegia - symmetric paralysis of both lower extremities Quadriplegia - paralysis of all four extremities Paresis - weakness of muscles rather than paralysis

concussion

Comes from a direct blow that causes the brain to shift rapidly back and forth inside the skull.

flaccidity

Decreased resistance, hypotonia occur with peripheral weakness

types of reflexes

Deep tendon reflexes (myotatic)(patellar) Superficial (corneal reflex, abdominal reflex) Visceral (pupillary response to light and accommodation) Pathologic (babinski reflex)

dysarthria

Difficulty forming words

subjective data - seizures

Ever had convulsions, when did they start, how often do they occur? When seizures start do you have warning sign. Where in the body do they begin, do they travel, on one side or both, does muscle tone tense or feel limp? Any color change? After seizure, are you told that you spend time sleeping or any confusion, do you have weakness, headache, or muscle aches? Does anything seem to bring on the seizures and does it affect your daily life?

hyperreflexia

Exaggerated reflex seen when the monosynaptic reflex arc is released from the usually inhibiting influence of higher cortical levels. This occurs with upper motor neuron lesions (stroke)

Three Parts of Glasgow Coma Scale

Eye-opening response, motor response, verbal response. Each area rated separately and a number is given for the person's best response.

face acronym

F - Face drooping A - Arm weakness S - Speech difficulty T - Time to call 911

cranial nerve VII

Facial, mixed, facial muscles, close eye, labial speech, close mouth, taste on anterior two thirds of tongue, saliva and tear secretion. Can test by smiling, puffing the cheeks, and lifting eyebrows

Cranial Nerve IX and X

Glossopharyngeal and Vagus Nerves. Depress tongue with tongue blade and note pharyngeal movement as the person says ahhh or yaws, the uvula and soft palate shuld rise in the midline and the tonsillar pillars should move medially. Touch posterior pharyngeal wall with tongue blade and note gag reflex. Absence or symmetry of soft palate movement or tonsillar pillar movement. Following a stroke, dysfunction in swallowing may increase risk for aspiration.

cranial nerve IX

Glossopharyngeal, mixed, phonation and swallowing in pharynx, taste on posterior one third of tongue, gag reflex, parotid gland, carotid reflex. Can test by gag reflex, saying ahhh while watching uvula and soft palate

cranial nerve XII

Hypoglossal, motor, movement of tongue. Move tongue side to side, up and down, ask to say light, tight, dynamite and see if it's distinct

asteriognosis

Inability to identify object correctly, occurs in sensory cortex lesions

positive romberg test

Loss of balance that occurs when closing the eyes. You eliminate the advantage of orientation with the eyes which had compensation for sensory loss. Occurs with cerebellar ataxia (MS, alcohol intoxiation), loss of proprioception, and loss of vestibular function

paralysis

Loss of motor function caused by a lesion in the neurologic or muscular system or loss of sensory innervation. Decreased or loss of motor power caused by problem with motor nerve or muscle fibers

warning signs of alzheimers disease

Memory loss, losing track, forgetting words, getting lost, poor judgment, abstract failing, losing things, mood swings, personality change, growing passive

cranial nerve II

Optic, sensory, vision. Can test by checking vision

pupillary response

Note size, shape, and symmetry of both pupils. Shine light into each pupil and note the direct and consensual light reflex. both pupils constrictly briskly. In a brain injured person a sudden unilateral dilated and nonreactive pupil is ominous

seizures

Occur with epilepsy, a paroxsymal disease characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances

rest tremor

Occurs when muscles are quiet and supported against gravity. Coarse and slow, partly or completely disappears with voluntary movement

cranial nerve III

Oculomotor, mixed, eye movements and pupil constriction. Can test by looking up, down, medial

cranial nerve I

Olfactory, sensory, smell. Can test by smelling and identifying items or occluding one nare at a time

paresis

Partial or incomplete paralysis

Parkinsonian

Posture is stooped, trunk is pitched forward, elbows, hips, and knees are flexed. Steps are short and shuffling. Hesitation to begin walking, and difficult to stop suddenly. The person holds the body as one fixed unit. Difficulty with any change in direction

aura

Subjective sensation that precedes a seizure. Could be auditory, visual, or motor

Fasciculation

Rapid, continuous twitching of resting muscle or part of muscle without movement of limb which can be seen by clinicians or felt by patients Fine - occurs with lower motor neuron disease, associated with atrophy and weakness Coarse - occurs with cold exposure or fatigue and is not significant

Intention Tremor

Rate varies, worse with voluntary movement as in reaching toward a visually guided target. Occurs with cerebellar disease and MS

deep tendon reflexes

Reflexes are gross motor skills. Reveals intactness of the reflex arc at specific spinal levels and the normal override on the reflex of the higher cortical levels. The limb should be relaxed, and the muscle partially stretched. Stimulate by directing a short snappy blow of the reflex hammer onto the insertion tendon of the muscle. Action takes place in your wrist, don't let hammer rest on tendon. Use just enough force to get a response, compare sides left and right

vertigo

Rotational spinning caused by nerurological disease in the vestibular apparatus in the ear or the vestibular nuclei in the brainstem

cranial nerve xi

Spinal Accessory Nerve, examine sternomastoid and trapezius muscles for equal size. Check equal strength by asking person to rotate the head forcibly against resistance applied to side of the chin

cranial nerve XI

Spinal accessory, motor, movement of trapezius and sternomastoid muscles (head and shoulder movement). Shoulder shrug, turn head to hand

Cerebellar Ataxia

Staggering, wide-based gait, difficulty with turns, uncoordinated movement with positive Romberg sign. Possible causes include alcohol or barbiturate effect on cerebellum, cerebellar tumor, MS

Chorea

Sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face. Occurs at irregular intervals, not rhythmic or repetitve, more convulsive than a tic. Some are spontaneous, and some are initiated, all are accentuated by voluntary acts. Disappears with sleep, common with Sydenham chorea and Huntington Disease

testing for clonus

Test for this particularly when the reflexes are hyperactive. Support lower leg in one hand, with other hand move the foot up and down a few times to relax the muscle. Then stretch muscle by briskly dorsiflexing the foot. With a normal response you feel no further movement.

heel to shin test

Test lower-extremity coordination by asking the person, who is in a supine position, to place the heel on the opposite knee and run it down the skin from the knee to the ankle. Normally person moves heel in a straight line down the shin

two point discrimination

Test person's ability to distinguish the separation of two simultaneous pin points on the skin. Apply the two points of an opened paper clip lightly to the skin in ever-closing distances. Note distance at which the person no longer perceives two separate points. The level of perception varies considerably with the region tested, it is most sensitive in the fingertips (2 to 8 mm) and least sensitive on the upper arms, thighs, and back.

stereognosis

Test person's ability to recognize objects by feeling their forms, sizes, and weights. With his or her eyes closed, place a familiar object in the person's hand and ask him or her to identify it. Normally a person will explore it with the fingers and correctly name it

spinothalamic tract - pain

Tested by person's ability to perceive a pinprick. Break tongue blade forming a sharp point, lightly apply the sharp point or the dull end to the person's body in a random, unpredictable order. Ask person to verbalize sharp or dull depending on sensation felt. Let at least 2 seconds between each stimulus to avoid summation

graphesthesia

The ability to read a number by having it traced on the skin. With the person's eyes closed use a blunt instrument to trace a single digit number or a letter on the palm. Ask the person to tell you what it is. A good measure of sensory loss if the person cannot make the hand movements needed for stereognosis as occurs in arthritis. If person can't do this, it occurs with lesions in the sensory cortex

peripheral neuropathy

Worse at the feet and gradually improves as you move up the leg, as opposed to a specific nerve lesion which has a clear zone of deficit for its dermatome

shrug shoulders

The nurse is assessing the integrity of the spinal accessory nerve (cranial nerve XI). What should the nurse ask the patient to do?

cranial nerve V

Trigeminal, muscles of mastication, sensation of face, scalp, cornea, mucous membranes of mouth and nose. Can test by touching forehead, cheeks, and clenching teeth

cranial nerve IV

Trochlear, motor, down and inward movement of eye

abnormal findings with vibration

Unable to feel vibration, loss of vibration sense occurs with peripheral neuropathy, often this is the first sensation lost.

posterior column tract - vibration

Use tuning fork over bony prominences, and use a low-pitched one because its vibration has a slower decay. Strike tuning fork on heel of hand and hold the base on a bony surface of the fingers and great toe. Ask person to indicate when the vibration starts and stops, compare left and right sides

cranial nerve X

Vagus, mixed, talking and swallowing, general sensation from carotid body, carotid sinus, pharynx, viscera, carotid reflex. Slows the HR and peristalsis. Can test this by checking hoarseness and gag reflex

finger to finger test

With the person's eye open, ask that he or she use the index finger to touch your finger and then his or her own nose. After a few times, move your fingers to a different spot. The person's movement should be smooth and accurate abnormal finding: lack of coordination

fully alert

a person is __ __ when his or her eyes open at your approach or spontaneously; when he or she is oriented to person, place, & time; & when he or she is able to follow verbal commands appropriately

paresthia

an abnormal sensation (e.g. burning, tingling)

stroke

an interruption of blood supply to the brain and is the fourth most common cause of death in the US

strokes

are the leading cause of long term disability and the 4th leading cause of death after heart disease & cancer. Nearly 75% of these occur in people over the age of 65. Another word for this is a CVA occurs when the blood flow is interrupted to a part of the brain, often referred as a brain attack

spastic hemiparesis

arm is immobile against the body, with flexion of the shoulder, elbow, wrist, & fingers and adduction of shoulder; does not swing freely. leg is stiff & extended and circumducts with each step

cranial nerve v - trigeminal nerve

assess the muscles of mastication by palpating the temporal and masseter muscles as the person clenches the teeth. muscles should feel equally strong on both sides. next try to separate the jaws by pushing down on the chin; normally you cannot

CNS lesions

loss of movement and asymmetry of movement occur with this (e.g. stroke that affects lower face on one side)

nystagmus

back and forth oscillation of the eyes. End point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs normally. Also occurs with disease of the vestibular system, cerebellum, or brainstem

senile tremors

benign tremors include an intention tremor of the hands, head nodding, and tongue protrusion go over p669

rigidity

constant state of resistance; resists passive movement in any direction; dystonia

ischemic stroke

occurs when a blood clot blocks a blood vessel in the brain

upper motor neuron

injury to corticospinal motor tract (paralysis with stroke develops spasticity days or weeks after incident) injury to extrapyramidal motor tracts

tone

is the normal degree of tension in voluntarily relaxed muscles. It shows as a mild resistance to passive stretch. To test this, move extremities through a passive ROM. Instruct person to completely relax. Move each extremity smoothly through a full ROM

hemorrhagic stroke

occurs when a blood vessel in the brain ruptures and causes bleeding

anosmia

decrease or loss of smell occurs bilaterally with tobacco smoking, allergic rhinitis & cocaine use. Abnormal finding when testing cranial nerve I - olfactory

paralysis

decresed or loss of motor power caused by problem with motor nerve or muscle fibers

cranial nerve xii

hypoglossal nerve inspect the tongue. no wasting or tremors should be present. note the forward thrust in the midline as the person protrudes the tongue. also ask the person to say "light, tight, dynamite" & note that lingual speech (sounds of letter l, t, d, n) is clear & distinct

spasticity

increased tone or hypertonia; increased resistance to passive lengthening; then may suddenly give way

lower motor neuron

injury anywhere from the anterior horn cell in the spinal cord to the peripheral nerve (peripheral neuritis, poliomyelitis, guillain barre syndrome) early stroke and spinal cord injury are flaccid at first

confrontation

test visual acuity & visual fields by __. Normal range of findings cranial never II - optic

deep tendon reflex

the __ __ __ has 5 components 1) an intact sensory nerve (afferent) 2) a functional synapse in the cord 3) an intact motor nerve fiber (efferent) 4) the neuromuscular junction 5) a competent muscle

US southeast region

there is a geographic disparity too; 8 states with high stroke mortality are concentrated in the __ __ __, called the stroke belt

abnormal involuntary movements

tic, tremor, fasciculation, myoclonus, chorea, and athetosis

cogwheel rigidity

type of rigidity in which the increased tone is released by degrees during passive range of motion; feels like a small knee jerk

ataxia

uncoordinated or unsteady gait

abnormal findings optic nerve

visual field loss papilledema w/increased intracranial pressure; optic atrophy

common symptoms of a stroke

weakness or numbness in the face, arms, or legs especially when it is on one side of the body confusion, trouble speaking or understanding changes in vision such as blurry vision or partial or complete loss of vision in one or both eyes trouble walking, dizziness, loss of balance, or coordination severe headache with no reason or explanation