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Chapter 43

Chapter 43. Assessment of the Nervous System. Mrs. Marion Kreisel MSN, RN Nu230 Adult Health 2 Fall 2011. Anatomy and Physiology. Neurons: The basic unit of the NS, the neuron transmits impulses.

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Chapter 43

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  1. Chapter 43 Assessment of the Nervous System Mrs. Marion Kreisel MSN, RN Nu230 Adult Health 2 Fall 2011

  2. Anatomy and Physiology • Neurons: The basic unit of the NS, the neuron transmits impulses. • Mechanism for nerve impulse conduction: Motor neurons for movement and sensory neurons for sensation • Neuroglial cells: provide protection , structure & nutrion for the neurons • ANS, sympathetic and parasympathetic

  3. Anatomy and Physiology (Cont.)

  4. Assessment • Family history and genetic risk • Current health problems • Level of consciousness and orientation • Memory and attention • Language and higher levels of cognition

  5. Assessment (Cont’d) • Cranial nerves: KNOW CHART 43-4 on PAGE 935 • Sensory function • Motor function • Cerebellar function

  6. Assessment (Cont’d) • Reflex activity

  7. Glasgow Coma Scale A score of 15 is normal neurological functioning. A score of 7 represents a comatose state. The lower the score the lower the patients LOC Intubated patients and cannot talk get a “T” after the number. The highest they can score is an 11

  8. Posturing DECORTICATE DECEREBRATE

  9. Laboratory Tests • Blood cultures necessary • Skull and spine x-ray tests • Cerebral angiography • CT scan—possible use of contrast medium, assess for allergic response, fluids • MRI • Positron emission tomography • Single-photon emission CT • Magnetoencephalography (MEG)

  10. Electroencephalography (EEG) • Graphically records the electrical activity of the cerebral hemispheres • Sleep deprivation requirement • Anticonvulsants possibly withheld

  11. Evoked Potentials • Measure the electrical signals to the brain generated by hearing, touch, or sight • Auditory evoked potentials: assess high frequency hearing loss, damage to the acoustic nerve. Sound proof room, one ear at a time. • Visual evoked potentials: detect loss of vision from optic nerve damage particularly in MS. On eye at a time and focus on a shifting checker board pattern • Somatosensory evoked potentials: measure response from stimuli to the peripheral nerves. Detects nerve or spinal cord damage/degeneration esp. in MS. Tiny shocks to arm & leg

  12. Cerebral Blood Flow Evaluation • Particularly useful in evaluating cerebral vasospasms • Use radioactive substances measure the uptake of it in an area.

  13. Lumbar Puncture (Spinal Tap) • Insertion of spinal needle into the subarachnoid space (between the third and fourth lumbar vertebrae) • CSF pressure readings • Check for blockage by SC lesion • Inject contrast for test • Inject medications • Rarely used to reduce some ICP • Contraindicated in patients with increased intracranial pressure b/c sudden release of SF • Empty bladder • Position • Spinal headache possible from spinal tap

  14. Lumbar Puncture (Spinal Tap) continued • Normal Pressure <20 mm H20 • Normal Color: Clear • Normal Cells: 0-5 lymphocytes more than that means infection! • Normal Protein: 15-45 mg/dl. High means infection! • Normal Glucose: 50-75mg/dl • KNOW THIS SLIDE!

  15. Cerebrospinal Fluid

  16. Other Studies • Transcranial Doppler ultrasonography: Uses sound waves to measure blood flow through the arteries. • Muscle and nerve biopsy: used to DX neuromuscular disorders.

  17. NCLEX TIME

  18. Question 1 The nurse can best assess the patient’s cognition by: • Asking the patient about how he was transported to the clinic • Asking the patient about the meaning of various proverbs • Asking the patient to count backward from 100 by 7s • Writing down a simple command and giving it to the patient

  19. Question 2 The most common cause responsible for changes in an older patient’s mental state is: • Changes in extracellular electrolytes • Insufficient oxygen • Sedative agents • Changes in acetylcholine levels

  20. Question 3 Approximately how much cerebrospinal fluid (CSF) is produced daily by the choroid plexus? • <100 ml • 125 ml to 150 ml • 200 ml to 300 ml • 500 ml

  21. Question 4 The nurse provided colostomy care instruction to an older adult yesterday. Today, the nurse observes that the patient is not applying the colostomy collection device correctly. The nurse should: • Request the patient’s daughter learn how to care for the patient’s colostomy. • Re-instruct the patient on the care of the colostomy. • Offer to complete the colostomy care for the patient. • Ask the patient what he remembers about the colostomy care instruction he received the day prior.

  22. Question 5 Which assessment variable is the best indicator of a change in a patient’s neurologic status? • Alert and oriented to place, person, time • Alert but not oriented to place, person, or time • Lethargic but arousable • Deep stimulation needed to arouse patient

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