NEUROLOGICAL Study Guide NR 304 Sept Oct 2013 Key Vocabulary: Agnosia: loss of ability to recognize objects, persons, sounds, shapes,

or smells while the specific sense is not defective nor is there any significant memory loss.Agraphia: inability to write resulting from brain disease. Agraphia can exist on its own or combine with other issues.Aphasia: a disturbance of the comprehension and formulation of language caused by dysfunction in specific brain regions. Having difficulty remembering words to losing the ability to speak, read, or write.Apraxia: unable to perform tasks or movements when asked, even though: The request or command is understoodAtaxia: (Ataxic gait): Loss of voluntary coordination. Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements. It leads wide base, uneven steps, feet slapping, tendency to sway, and an unsteady gait (walking style). Clonus: Rhythmically alternating flexion and extension, confirms upper motor neuron disease.Dysphagia: Difficulty with swallowingFasciculation: small, spontaneous twitchesNystagmus: Constant involuntary movement of the eyeball.Tremors (involuntary and intention): Rhythmic or alternating involuntary movement from the contraction of opposing muscle groups. Vary in degree, seen with Parkinson’s, multiple sclerosis, and alcoholics.Tic: “habit” involuntary spasmodic movement of the muscle is seen in a muscle under voluntary control. Usually face, neck, shoulders. Increases during stress. Rigidity: aching muscles and muscle stiffness or weaknessFlaccidity:Paralysis: loss of muscle function for one or more musclesParaplegia: impairment in motor or sensory function of the lower extremities.Paresthesia: a sensation of tingling, tickling, prickling, pricking, or burning of a person's skin with no apparent long-term physical effect.Nuchal rigidity: Stiffness of the neckSpasticity: condition in which muscles are continuously tight or stiff.

Developmental Considerations

ElderlyList the expected changes in the neurological system as a result of aging: Reduced/slowing gait, diminished senses, reduced gag reflex. Memory is NOT a normal change.

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Cranial Nerves “oh, oh, oh to touch and feel very good vagina after humping” S= sensory M= motor

Cranial Nerve Nerve Type

How to assess: briefly Normal Finding Abnormal Finding/Cause

I OlfactorySensory

Have pt smell something common. Lemon, cinnamon

Correctly identifies scents in both nares.

Unilateral/ bilateral anosmia.(loss of smell)

II Optic- VisionS

Pt do the snellen chart 20/20 vision

III OculomotorM

Pupillary reflex & extrinsic eye movement.PERRLA

PERRLA Indirect and Direct, No eyelid drooping

IV TrochlearM

Eye muscle movement, Cover uncover test.

V Trigeminal S/M Sensory impulses “feeling”, Motor teeth clenching, movement of jaw.

Ability to chew, and feel sensations. Ability to feel sharp/dull sensation over forehead.

Loss of facial sensation, can’t chew, decrease in blinking.

VI Abducens S/M Extrinsic muscle movement of eye. Ex: * move penlight in a star formation.

Able to follow without any twitches

Diplopia: Dbl vision.Strabismus: cross eyed

VII Facial S/M

Taste, facial movements smiling, closing eyes, frowning, tears/ salvia.

Ability to do listed. Plus puff out cheeks, wrinkle forehead

Bell’s Palsy (stroke on 1 side of face), decreased ability to distinguish tastes.

VIII Vestibulocochlear S

Vestibular branch= sense of balance. Cochlear= sense of hearing.EX: Rombergs test : stand straight/arms at side (no sway)

Ears Deaf, vertigo (dizzy), tinnitus

IX Glossopharyngeal S/M Gag/swallowing reflex. Taste on posterior third of tongue.

Gags & swallows, uvula/ soft palate rises symmetrically

Loss of gag and taste, difficulty swallowing.

X VagusS/M

Muscles for throat and mouth for swallowing and talking. Responsible for pressoreceptors & chemoreceptor activity.

Talks & Swallows Loss of voice, impaired voice and difficulty swallowing.

XI Accessory M Movement of the trapezius and sternocleidomastoid muscles, some movement of larynx, pharynx, and soft plate.

Shrugs/ turns head L and R

Can’t shrug, or turn head to left and right.

XII Hypoglossal M

Movement of tongue to swallow, movement of food for chewing, and speech.

Tongues moves side to side and up and down against resistance.

Difficulty with speech, swallowing, inability to protrude tongue.

Which cranial Nerves can be assessed together? III, IV,VI (3,4,6) Oculomotor, Trochlear, Abducens. All test visual fields, PERRLA, Cover uncover test, six cardinal field of gaze (star test)

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PERRLA assesses which cranial nerve? III Oculomotor

Describe papilledema: swelling of the optic nerve as it enters the retina. Symptom: increase intracranial pressure.

- Significance? Can be indicative of brain tumors or intracranial hemorrhage.

Functions of brain by region:

Brainstem::

Alertness, Arousal, Breathing, Blood Pressure, Digestion, Heart Rate, Other Autonomic Functions

Relays Information Between the Peripheral Nerves and Spinal Cord to the Upper Parts of the Brain

Frontal lobe: Speech, Motor cortex Temporal: Smell, Hearing, Auditory association area Occipital: Visual association area Parietal: Somatosensory association area, speech, taste, reading

Explain the sensory and motor reflex arc? Autonomic reflex arc (affecting inner organs) and somatic reflex arc (affecting muscles). Example: Knee Reflex test (no thinking required)

Explain why an unconscious patient has normal reflex responses? Reflex has nothing to do with the brain; reflexes are mediated in spinal cord.

What is a Dermatome? An area of skin innervated by the cutaneous branch of one spinal nerve. (All spinal nerve except C1).

What type of viral infection reactivates itself in a nerve dermatome? Shingles (herpes zoster)

What does the following positive Review of System(symptoms) suggest:

o Syncope: Brief loss of consciousness, usually sudden.o Loss of balance /falling: + Rombergs Signo Diplopia: (double vision) + for muscle weakness within the eye lido Dysphasia: (trouble swallowing) Example: Diminished or absent gag reflexo Severe Morning Headache:

Abnormal speech patterns

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o Aphasia: Global, Expressive or Receptive (define each)o Word Salad: incoherent mixture of words, phrases, disconnected contento Echolalia: imitation, repeating others’ words

Components and order of neuro exam: 1- mental status/loc 2- cranial nerves 3- motor and cerebellum 4- sensory 5-reflexes.

Mental Status exam: o Appearanceo Behavior: Body language, affect, tremors, facial affect, etc…o Cognition: LOC, orientation, abstract reasoning, judgmento Thought Processeso MiniMental exam: cognitive assessmento Four unrelated words test for new memory

Grading of reflexes: o 0+ No Response

1+ Diminished2+ Normal3+ Brisk, Above Normal4+ Hyperactive,

What is normal? 2+ What is hyperreflexia? Defined as overactive or overresponsive reflexes.

Examples of this can include twitching or spastic tendencies, which are indicative of upper motor neuron disease When will you observe? Common cause spinal cord injury

What is the maneuver to distract client when trying to elicit reflexes? The

Jendrassik maneuver is a medical maneuver wherein the patient clenches the teeth, flexes both sets of fingers into a hook-like form and interlocks those sets of fingers together

+Babinski in adults: What does the finding indicate? Present in a child older than 2 years or in an adult, it is often a sign of a brain or nervous system disorder. Fanning of toes only normal in children.

What is the difference between the Planar reflex and the Babinski sign? Picture Above Assess Sensory Function

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o What is Anesthesia? Absence of sensation.o What is Parasthesia? A sensation of tingling, tickling, prickling, pricking, or burning of

a person's skin with no apparent long-term physical effect.o Sterognosis? the ability to perceive and recognize the form of an object using

cues from texture, size, spatial properties, and temperatureo Graphesthesia? Is the ability to recognize writing on the skin purely by the sensation

of touch.o What conditions have decreased or absent sensation?

Peripheral Neuropathy associated with DM2

Decerebrate: Posturing and extensor. Pt extends one or both arms, possibly legs. Indicates a brain stem lesion.

Decorticate: Posturing and flexor. Pt flexes one or both arms on the chest and may stiffly extend legs. Indicates a nonfunctioning cortex.

Major signs and symptoms Myasthenia Gravis: an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigue. Muscles that control eye and eyelid movement, facial expressions, chewing, talking, and swallowing are especially susceptible

Multiple Sclerosis: First attack typically 20 – 40 yrs old. Symptoms: unsteadiness, tingling, blurred vision, slurred speech, and difficulty urinating.

Bell’s palsy: form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve) causing an inability to control facial muscles on the affected side. Physical findings on exam

What is the difference between a Rest tremor and intention tremors? Intention tremors are common among individuals with multiple sclerosis. Intention tremor: Triggered by movement toward a target (for example, reaching for a glass). Resting tremor: Occurring mainly at rest

Assessing balance in elderly safely: Rhomberg: stand with arms together and feet together, pt closes eyes for 20 seconds. Should complete without swaying or falling or moving feet apart. heel to shin, alternating hand movements Normal versus abnormal

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Glascow coma scale:o What are the categories of assessment? Best eye opening, Best motor response,

Best verbal response.o What parameters require immediate referral? Scoring below an 8 indicates coma.

Seizures: general vs partial describe each?

Abnormal gait r/t neurological abnormality: describe each

o Parkinsons: Stooped posture walks with short shuffle, steps, pill rolling finger movements.

o Ataxic gait: wide base, uneven steps, feet slapping, and swaying. Seen in Multiple Sclerosis or drug/alcohol intoxication.

o Scissor gait: spastic lower limbs and movement in a stiff jerky manner. Knees come together crossing one in front of the other, short, progressive slow steps. Also seen with MS.

o Steppage gait: “foot drop” flexes and raises the knee. (pretending there is a step but really isn’t one) then flops foot to the ground. Seen with progressive muscular atrophy.

Definitions: obtunded: Decreased alertnessstuporous: Sleep like state but not unresponsive Comatose: No response to stimuli lethargic: Drowsy but arouses when stimulated (awake)Delirium: confusion often due to change in routine or environment

Problems: What are the key subjective and objective findings of the following conditions?

o Stoke (infarct versus hemorrhagic) Ischemic Stroke

In everyday life, blood clotting is beneficial. When you are bleeding from a wound, blood clots work to slow and eventually stop the bleeding. In the case of stroke, however, blood clots are dangerous because they can block arteries and cut off blood flow, a process called ischemia. An ischemic stroke can occur in two ways: embolic and thrombotic strokes.

Embolic StrokeIn an embolic stroke, a blood clot forms somewhere in the body (usually the heart) and travels through the bloodstream to your brain. Once in your brain, the clot eventually travels to a blood vessel small enough to block its passage. The clot lodges there, blocking the blood vessel and causing a stroke. The medical word for this type of blood clot is embolus.

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Thrombotic StrokeIn the second type of blood-clot stroke, blood flow is impaired because of a blockage to one or more of the arteries supplying blood to the brain. The process leading to this blockage is known as thrombosis. Strokes caused in this way are called thrombotic strokes. That's because the medical word for a clot that forms on a blood-vessel deposit is thrombus.

Blood-clot strokes can also happen as the result of unhealthy blood vessels clogged with a buildup of fatty deposits and cholesterol. Your body regards these buildups as multiple, tiny and repeated injuries to the blood vessel wall. So your body reacts to these injuries just as it would if you were bleeding from a wound; it responds by forming clots. Two types of thrombosis can cause stroke: large vessel thrombosis and small vessel disease (or lacunar infarction.)

Hemorrhagic StrokeStrokes caused by the breakage or "blowout" of a blood vessel in the brain are called hemorrhagic strokes. The medical word for this type of breakage is hemorrhage. Hemorrhages can be caused by a number of disorders which affect the blood vessels, including long-standing high blood pressure and cerebral aneurysms. An aneurysm is a weak or thin spot on a blood vessel wall. These weak spots are usually present at birth. Aneurysms develop over a number of years and usually don't cause detectable problems until they break. There are two types of hemorrhagic stroke: subarachnoid and intracerebral.

In an intracerebral hemorrhage, bleeding occurs from vessels within the brain itself. Hypertension (high blood pressure) is the primary cause of this type of hemorrhage.

In a subarachnoid hemorrhage, an aneurysm bursts in a large artery on or near the thin, delicate membrane surrounding the brain. Blood spills into the area around the brain, which is filled with a protective fluid, causing the brain to be surrounded by blood-contaminated fluid.

Meningitis: It's easy to mistake the early signs and symptoms of meningitis for the flu (influenza). Meningitis signs and symptoms may develop over several hours or over one or two days. The signs and symptoms that may occur in anyone older than age of 2 include:

Sudden high fever Severe headache that isn't easily confused with other types of headache Stiff neck Vomiting or nausea with headache Confusion or difficulty concentrating Seizures Sleepiness or difficulty waking up Sensitivity to light Lack of interest in drinking and eating Skin rash in some cases, such as in meningococcal meningitis

Signs in newbornsNewborns and infants may not have the classic signs and symptoms of headache and stiff neck. Instead, signs of meningitis in this age group may include:

High fever Constant crying Excessive sleepiness or irritability Inactivity or sluggishness Poor feeding A bulge in the soft spot on top of a baby's head (fontanel) Stiffness in a baby's body and neck

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Infants with meningitis may be difficult to comfort, and may even cry harder when picked up.

Brain tumor: New onset or change in pattern of headaches

Headaches that gradually become more frequent and more severe

Unexplained nausea or vomiting

Vision problems, such as blurred vision, double vision or loss of peripheral vision

Gradual loss of sensation or movement in an arm or a leg

Difficulty with balance

Speech difficulties

Confusion in everyday matters

Personality or behavior changes

Seizures, especially in someone who doesn't have a history of seizures

Hearing problems

o Parkinsons: Poor posture, trouble with walking, flat facial expression

o Multiple Sclerosis: ataxic gait, muscle weakness and balance disturbance

Describe Brudzinski Sign: flex the neck. Observe hips and knees for reaction. Normal = hips and knees will remain relaxed and motionless. Positive = pain and flexion at the hips is an abnormal exam.

Describe Kernig Sign: Flex knee and hip, straighten knee. No pain with normal exam. Positive is an increased resistance to knee extension and back pain.

Differentiate between TIA and CVA

While transient ischemic attack (TIA) is often labeled “mini-stroke,” it is more accurately characterized as a “warning

stroke,” a warning you should take very seriously.

TIA is caused by a clot; the only difference between a stroke and TIA is that with TIA the blockage is transient (temporary). TIA symptoms occur rapidly and last a relatively short time. Most TIAs last less than five minutes; the average is about a minute. Unlike a stroke, when a TIA is over, usually causes no permanent injury to the brain. View a detailed animation of TIA.

What assessment would the nurse expect to perform for a client with TIA and syncope? Glasgow scale. Tests the LOC of the pt on a continuum from alertness to coma and tests three body

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functions: verbal response, motor response, and eye response. A maximum total score of 15 indicates that the pt is alert, responsive, and oriented. A total score fo 3, the lowest possible score, indicates a nonresponsive comatose pt.

Describe the Romberg test and what it is used for? Used to test Cranial Nerve VIII (8). Pt stands straight legs together, hands at side, eyes closed. If they sway or need to spread feet it is a positive test.

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