Chap 25 Assessing Neurological System  Thoracic (T1-T12)

*T1 Hand
Neurological System *T2-T12 Intercostals (trunk)
- The nervous system is a highly complex series of *T7-L1 Abdominals
organs, tissues, and cells that regulate and *T11-L2 Ejaculation
integrate all body functions, mental abilities, and  Lumbar(L1-L5)
emotions. *L2 Hips
- It collects information from the internal and *L3 Quadriceps
external environment as sensory input, processes *L4-L5 Hamstrings-Knee
and interprets the input, and causes responses  Sacral (S1-S5)
that are manifested as motor or sensory output. *S2 Penile Erection
*S2-S3 Bowel and Bladder
Nervous System
 Coccygeal (spinal nerve)
Neural Pathways
 Ascending Neural Pathways
Central Nervous System Peripheral Nervous System - Spinothalamic Tract
(CNS) (PNS) - Posterior Column
 Descending Neural Pathways
- Corticospinal Tract
Brain Spinal Cord Autonomic Somatic - Extrapyramidal Tract
Nervous Nervous
System (ANS) System (SNS) Peripheral Nervous System
 Carries information to and from the CNS
The nerves are categorized as two types:
Sympathetic Parasympathetic  Somatic – voluntary skeletal muscles
division division  Visceral – involuntary smooth muscles
Cranial Nerves
 Evolves from the brain or brain stem and
Central Nervous System transmits motor or sensory impulses
Brain 1. Olfactory - smell
 Cerebrum 2. Optic – visual acuity and field
- Frontal 3. Occulomotor - EOM
- Parietal 4. Trochlear - EOM
- Occipital 5. Trigeminal – corneal reflex, facial
- Temporal sensation, & jaw movement
 Diencephalon 6. Abducens - EOM
- Thalamus 7. Facial – facial movement & taste
- Hypothalamus sensation
 Brain Stem 8. Vestibulocochlear /Acoustic –
- Midbrain hearing and balance
- Pons 9. Glosopharyngeal
- Medulla Oblongata 10. Vagus – gag reflex & phonation and
 Cerebellum voice- swallowing & rise of palate
- Left Hemisphere 11. Spinal Accessory – shoulder and
- Right Hemisphere neck movement
Spinal Cord 12. Hypoglossal – tongue symmetry
 Cervical (C1-C8) and position
*C1-C3 Neck Muscles  Vagus is the longest cranial nerve (from
*C4 Diaphragm brain to anus)
*C5 Deltoid (Shoulder)  Trigeminal is the largest nerve (has three
*C7 Triceps branches)
*C7-C8 Fingers  Close eyelids Cranial number 7 (Facial)
  Open the eyelids cranial number 3  Stimulation of glandular secretions
(occulomotor)  Decreased heart rate
Spinal Nerves  Vasoconstriction of coronary arteries
 Named after the vertebrae from where it  Constriction of bronchioles
originates from  Increased peristalsis and secretion of
Has two roots: gastrointestinal fluids
1. Sensory (Afferent) which exits at the dorsal
(posterior) root Neurologic Nursing Health Assessment
2. Motor (Efferent) that exits at the ventral Hallmark of Neurologic Assessment
(anterior) root of the spinal cord  Is the mental status intact?
 Are right sided and left sided examination
 If you got injured from a certain level of findings symmetric?
spinal nerve, the affected area will be from  If the findings are asymmetric or otherwise
that level downwards abnormal, does the lesion lie in the central
 If the injury is upwards it is called Epsilateral nervous system or peripheral nervous
 If the injury is downwards it is called system?
contralateral DSM
 Diagnostic and Statistical Manual of Mental
Disorders (DSM)
Autonomic Nervous System  Diagnostic and Statistical Manual of Mental
- Regulates the activities of internal organs Disorders, Fift Edition (DSM-5) is the
such as heart, lungs, blood vessels, digestive standard classification of mental disorders
organs, and glands. used by mental health professionals in
- Maintenance and restoration of internal United States.
homeostasis (Will be further discussed during Level III in
Has two Major Divisions: psychological nursing)
 Sympathetic Nervous System
 Parasympathetic Nervous System Nursing Health History
History of Present Health Concern
Sympathetic Nervous System  Numbness and tingling
- Prepares the body to handle situations that are  Seizure
perceived as harmful or stressful and to  Headaches
participate in strenuous activity, it causes the  Dizziness
following:  Senses
 Dilated Pupils  Difficulty Speaking
 Inhibited secretions  Difficulty Swallowing
 Increased rate and force of heartbeat  Muscle Control
 Vasodilation of the coronary arteries  Memory Loss
 Dilation of the bronchioles Patient Identifies for Mental Health Screening
 Decreased digestion  Medically unexplained physical symptom
 Increased release of glucose by the Liver  Multiple physical or somatic symptoms or
 Decreased urine output “high symptom count”
 Vasoconstriction of arteries to increase  High severity of the presenting somatic
blood pressure symptom
 Increased metabolic rate  Chronic pain
 Increased mental alertness  Symptom for more than 6 weeks
Parasympathetic Nervous System  Physician rating as “difficult encounter”
- Division of the ANS operates during non  Recent stress
stressful situations. It conserves the body’s  Low self rating of health
energy as it regulates digestion, elimination,  High use of health care services
and other activities.  Substance abuse
 Constriction of pupils Past Health History
  Hx of head injury with or without loss of - Size
consciousness - Tone
 Hx of meningitis, encephalitis, injury to - Strength
spinal cord, or stroke  Evaluate balance
 Associated physical or mental changes  Assess Coordination
 Treatment Must do’s
Family History  Assess for gross motor movements
 HPN  Assess for fine motor movements
 Stroke  Muscle size
 Alzheimer’s  Muscle tone
 Epilepsy  Muscle strength
 Brain Cancer Sensory System
 Hungtington’s chorea  Assess light touch, pain, and temperature
Lifestyle and Health Practices sensations
 Prescriptions or non-prescription meds  Test vibratory sensations
 Alcohol intake  Test sensitivity to position
 Recreational drugs  Assess tactile discrimination
 Smoking Must see’s…
 Protective practices  Pain and temperature
 Diet  Light touch
 Activity  Position and vibration
 Perceptions on present conditions  Discriminative sensation
Physical Examination REFLEX
 Mental Status  Deep Tendon Reflex
 Cranial Nerves - Biceps
 Motor System - Triceps
 Sensory System - Brachioradialis
 Reflex - Patellar
Mental Status Examination - Achilles
 Observe LOC (level of consciousness)  Superficial Reflex
 Observe posture and body movements - Abdominal reflex
 Observe dress, grooming, and Hygiene - Cremasteric reflex
 Observe facial expressions Grading for Reflex Responses
 Observe speech 0 – no response
 Observe mood, feeling, and expressions +1 Minimal activity (hypoactive)
 Observe though processes and perceptions +2 Normal response
 Observe cognitive abilities +3 More active than normal
- Concentration +4 Maximal activity (hyperactive)
- Remote and recent memory
- Abstract reasoning Red Flags…
- Judgement  Primitive Reflex
- Mathematical abilities - Babinski
Must do’s - Plantar
 Assess appearance and behaviour  Test for Meningeal Irritation
 Assess speech and language - Kernig’s
- Brudzinski’s
 Assess appropriateness of mood
 Assess thoughts and perceptions
Glasgow Coma Scale
 Assess cognition
Action Best Response Score
Eyes Open Spontaneous opening 4
Motor System To speech 3
 Assess condition and movement of muscles To pain 2
 None 1 If they can focus on you
Oriented 5 - Remote and recent memory
Confused 4 (Remote) things you have learned as a
Inappropriate words 3 child
Verbal (Recent) what is the current happening
Incomprehensible
2 - Memory to learn new things
sounds
None 1 - Abstract reasoning
Obeys commands 6 Ask them to Explain a motto
Localizes pain 5 - Judgement
Withraws from pain 4 Give them a scenario
Motor - Visual, perception and constructional
Abnromal flexion 3
ability
Abnromal extension 2
Flaccid 1
Cranial Nerve
TOTAL 15
 Test Olfactory
- Test sense of smell prepare two strong
odors for the patient to identify which is
Checklist!!!
which while the eyes are closed
 Introduce Self, Verify Client’s identity, and
 Test Optic
obtain health history
- For visual acuity use snellen chart then for
 Explain what you will do, why is it necessary,
visual field use the static wriggle finger test
and how he/she can cooperate and also assure
 Test Oculomotor
the confidentiality of the information that will
- Extra Occularmuscle Movement
be acquiring
 Test Trochlear
 Gather Equipments (be innovative) : Penlight,
- Extra occularmuscle movement
snellen chart, cotton tip applicators, sterile
 Test Trigeminal
cotton ball and paper clip, substance to smell or
- Cornea, cotton tip for reflex, stroke cheek
taste, tongue depressor, tuning fork, objects to
close eyes, clench jaw
feel, reflex hammer
 Test Abducens
 Wash hands ensure quiet and adequately
- Extraoccular muscle movement
lighted room
 Test Facial
 Provide client’s privacy then place the client in
- While the eyes are close put something in
sitting position
their mouth for them to identify what is the
taste of the food (taste sensation)
MENTAL STATUS
- Smile, frown, (facial movement)
 Observe LOC (Level of Consciousness)
 Test Acoustic
- Awake, coherent, sluggish
- Let the patient close their eyes then try to
 Observe posture and body movements
stand up they should be able to stand still
- Weakness on the other side
(Balance)
 Observe dress, grooming and hygiene
- Do the whisper test, stand 2 feet away from
- First to go if the person has mental
the patient then whisper 2 syllable words
disorders
and let them repeat it (hearing)
 Observe facial expressions
 Test Glossopharyngeal
 Observe speech - Let the patient swallow and say “a” while,
- Observe how they answer observe the rise of palate
- Receptive Aphesia (learn)
 Test Vagus
 Observe mood, feeling, and expressions - Say a e i o u, tongue depressor for gag reflex
 Observe thought processes and perceptions  Test Spinal Accessory
 Observe cognitive abilities (higher level - Let the patient look left and right, then
function of brain, ability to concentrate, if shrug.
they can focus on you)  Test Hypoglossal
- Orientation
- Concentration
 - Let the patient stick tongue out to check Reflexes
symmetry  Deep tendon reflexes
- Biceps
Motor System - Triceps
 Assess condition and movement of muscles - Brachioradialis
- Size and symmetry - Patellar
- Strength and tone - Achilles
- Note any unusual involuntary movement - Ankle clonus
*Let the patient straight out his hands forward then  Superficial reflex
check the size to see what’s bigger or smaller. Then - Plantar reflex
in assessing the tone, palpate the arms, should be - Abdominal reflex
firm then in assessing the strength, you will be - Cremasteric reflex
checking the resistance of the patient’s arms. While  Test for meningeal irritation/ inflammation
their arms are moved forward, let them push your  Test for Brudzinski’s sign
arms upward, downward then forward.  Test for Kernig’s sign
 Evaluate gait and balance
- Stand on one leg both each side Closing Phase
 Perform Romberg test
- Let the patient stand both eyes close they
should be able to stand in balance
 Assess coordination
- Alternating movement
 Assess rapid alternating movements
- Place one hand on top of another then
alternately remove and place

Sensory System
 Assess light touch, pain, and temperature
sensations
- Sharp, soft, hot or cold
 Test vibratory sensations
- Vibratory sensations eyes close
 Test sensitivity to position
- Let the patient close their eyes then hold
their hands and move from left or right and
let them distinguish which direction it was
 Assess tactile discrimination (fine touch)
- Let the patient close their eyes and give
them something to identify.
 Test point localization
- Try to prick some locations of the body and
let them identify which part of the body was
pricked
 Test graphesthesia
- Draw a number or letter on the hands of the
patient while their eyes are closed
 Test extinction
- Touch a certain part of the body of the
patient then remove it and let the patient
tell where the hand was placed