Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Chapter 3: Cultural Competence: Cultural Care

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The Neurologic System

J Carley MSN, MA, RN, CNEFall, 2009

The Spinning Woman Illusion --Nobuyuki Kayahara

JARVIS , C. (2008) Physical Examination & Health AssessmentChapter 23

Unit Objectives

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•1. Describe the anatomic structures of the central nervous system and brain.•2. Identify the 12 cranial nerves and their function•3. Complete the Glasgow Coma scale, the Rancho Los Amigos scale, and the mini mental state exam as appropriate for case studies.4. Explain how to prepare the client for a neurological examination5. Discuss the appropriate equipment necessary for examining the neurological system.

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Peripheral nerves go from spinal cord

to arms, hands, legs, and feet

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Autonomic nerves go to the stomach, intestines, and other parts of the digestive system

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Cranial nerves go from brain to eyes, mouth, ears, and other parts of head (and others…e.g., Vagus)

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Central Nervous System (CNS)

Cerebral cortex- Frontal lobe- Parietal lobe- Occipital lobe- Wernicke’s area- Broca’s area

Basal ganglia Thalamus

Hypothalamus Cerebellum Brainstem

- Midbrain- Pons- Medulla

Spinal cord

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Cerebral CortexSlide

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CNS

[PRODUCTION NOTE: Please insert Figure 23-2 (from Jarvis Physical Examination and Health Assessment, 5e, ISBN: 978-1-4160-3243-4)]

© Pat Thomas, 2006.

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CranialNerves

I Olfactory

II Optic

III Oculomotor

IV Trochlear,

VI Abducens

V Trigeminal

VII Facial

VIII Acoustic (vestibulocochlear)

IX Glossopharyngeal

X Vagus

XI Spinal accessory

XII HypoglossalSlide

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  Olfactory I  Optic II  Oculomotor III  Trochlear IV  Trigeminal V  Abducens VI  Facial VII  Auditory (vestibulocochlear) VIII  Glossopharyngeal IX  Vagus X  Spinal Accessory XI  Hypoglossal XII

Cranial Nerves - IntroductionInteractive quiz to identify the cranial nerve function.

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CNS Pathways Sensory pathways

- Spinothalamic tract - Posterior (dorsal) column

Motor pathways - Corticospinal or pyramidal

tract - Extrapyramidal tracts - Cerebellar system

Upper motor neurons

Lower motor neuronsSlide

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Sensory Pathways © Pat Thomas, 2006. Slide 23-18

Motor Pathways

© Pat Thomas, 2006. Slide 23-19

Reflex Arc

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Subjective Data

Headache Head injury Dizziness or Vertigo Seizures Tremors Weakness

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Subjective Data

In-coordination / “uncoordinated” Numbness or tingling Difficulty swallowing Difficulty speaking (Dysphasia)

Environmental/occupational hazards

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Objective Data

Equipment needed - Penlight

- Tongue blade

- Toothpick

- Cotton swab / Cotton ball

- Tuning fork (128 or 256 Hz)

- Percussion hammer

- Familiar aromatic substance

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Motor System

Muscles - Size - Strength - Tone - Involuntary movements

Cerebellar function

- Balance tests - Coordination

- Skilled movements

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Romberg Test

Negative- ve

Normal

Positive+ ve

Abnormal Proprioceptive pathway Slide 23-25

Ambulation

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Describe…

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Abnormal Ambulation

Asymmetrical Spastic DiplegiaSlide

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Neuro Check (Crani Check)

Level Of Consciousness (LOC)PersonPlaceTime

Motor function Pupillary response Vital signs Glasgow Coma Scale (GCS)

Oriented x 3

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IntraCranial Pressure = ICP

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Pressure within the cranial cavity influenced by brain mass, the circulatory system, CSF dynamics, and skull rigidity

Increased ICP (IICP)

Critical event / Life threatening

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CT scan showing intracranial hemorrhage with cerebral edema, midline shift, and

increased intracranial pressure

Glasgow Coma Scale

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The GCS is the most widely used method of defining a patient's level of consciousness (LOC)

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Expanded Neuro

Assessment Tool

Mini-Mental Status ExamRancho Los Amigos Scale

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EARLY Signs of ↑ ICP

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1. LOC changes ******MOST IMPORTANT****

2. Pupils sluggish / Impaired eye movement

3. Limb strength changes

4. Headache

The most important neurologic “vital sign”!!!!!!!!!!!!!!!!!!!!!!!!!

LATE Signs of ICP

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1. Further decreased LOC

2. Cushing’s Triad

3. Abnormal respiration patterns

4. Pupils asymmetrical / Dilated

5. Projectile vomiting

6. Hemiplegia / decorticate or decerebrate posturing

anisicoria

“fixed & dilated

“Call the neurosurgeon”

“Call the chaplain.”

Pupils . .

Cushing’s “Triad”

Blood Pressure (Widening Pulse Pressure)

Temperature

Pulse

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Late Sign of IICP

Abnormal Postures

Flaccid quadriplegia Decorticate rigidity Decerebrate rigidity

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“Toward the Core”

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Dilated ? Consenusal ? Shape ?

Pupil Responses

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Rapidly Alternating Movement (RAM) Evaluation

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Finger to Nose Test

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Heel to Shin Coordination Test

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Test Deep Tendon ReflexesTechniqueGradingBabinski’s signBiceps reflexTriceps reflexBrachioradialis reflexQuadriceps reflexAchilles reflex (“ankle jerk”)Abdominal reflexes

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Reflexes

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Babinski Reflex

A normal response, B Babinski reflex

Positive+ ve

Abnormal

Negative- ve

Normal

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Testing the DTR’s provides data about the INTACTNESS of the REFLEX ARC at specific levels in the spinal cord.

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Abnormalities in Muscle Movement

Paralysis Fasciculations Flaccidity Ataxia

Rest tremor Intention

tremor Paresthesia Coma

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Sensory System

Spinothalamic tract - Pain - Temperature - Light touch

Posterior column tract - Vibration - Position (kinesthesia) - Tactile discrimination

(stereognosis, graphesthesia)

Alert, cooperative, and comfortable

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Aged – “Less” is Normal

- Walk slower- More careful walking- Decreased tactile sensation- Lose ability to feel vibration

at ankles- Decreased ability to smell

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Cultural Considerations “Epilepsy”

Uganda: contagious, untreatable

Greece: source of family shame

Mexican-American: evidence of physical imbalance

Hutterites: having endured a trial by God

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Narrative Charting

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Denies any of the following: frequent or severe headaches; history of head injury, dizziness, or vertigo. Denies weakness, numbness, or tingling; no difficulty swallowing or speaking. No past history of stroke, meningitis, spinal cord injury, or alcoholism.

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Narrative Charting

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Jarvis Page 679

Neuro Assessments

Neuro Assessment Practice:http://icarus.med.utoronto.ca/NeuroExam/

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Which area of the brain is most likely affected if the patient is having trouble with the finger-to-nose test?

A. CerebellumB. CerebrumC. HypothalmusD. Brain stem

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Vibratory sense is most frequently affected in cases of?

A. Heart diseaseB. Crohns’ diseaseC. Lung CancerD. Diabetes

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Brain Teasers

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http://brainconnection.positscience.com/teasers/

The Hermann Grid IllusionThis phenomena demonstrates a very important principle of perception: we don't always see what's really there. Our perceptions depend upon how our visual system responds to environmental stimuli and how our brain then interprets this information.1 Slide

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1 Bach, M. (n.d.). Grid illusions. http://www.michaelbach.de/ot/lum_herGrid/index.html

The Zollner IllusionThis illusion presents a series of oblique lines crossed with overlapping short lines. The oblique lines look as if they are crooked and will diverge. In reality, all of the oblique lines are parallel.This optical illusion demonstrates how the background of an image can distort the appearance of straight lines. Slide

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The End