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