Neuro objectives

 

1.      Identify the 12 cranial nerves, and their function.

 

EASY WAY TO REMEMBER THESE =

 oh,oh,oh, to touch, and feel very green vegetables, AH!

 

Nerves

   #

Nerves Name

Nerves            =  SENSORY

Function         =  MOTOR

I.

Olfactory nerves and tract

Entirely Sensory

SMELL

II.

Optic Nerve

Entirely Sensory

VISION

III.

Oculomotor nerve

Mixed, primarily motor

CONTROLS MOVEMENTS OF THE EYEBALL AND UPPER EYELIDS

ACCOMMODATION OF LENS FOR NEAR VISION

CONSTRICTION OF PUPIL

Muscle sense

IV.

Trochlear nerve

Mixed, Primarily motor

CONTROLS MOVEMENT OF THE EYE

Muscle sense

V.

Trigeminal nerve

Ophthalmic branch

Maxillary branch

Mandibular branch

Mixed

CHEWING

CONVEYS SENSATION FOR TOUCH, PAIN AND TEMPERATURE

Muscle sense

VI.

Abducens nerve

Mixed, Primarily motor

MOVEMENT OF THE EYEBALL

Muscle sense

VII.

Facial nerve

Mixed cranial nerve

FACIAL EXPRESSION

SECRETION OF SALIVA AND TEARS

Muscle sense

VIII.

Vestibulocochlear nerve

Vestibular branch

Cochlear branch

Sensory cranial nerve

Vestibular branch: CONVEYS IMPULSES ASSOCIATED WITH EQUILIBRIUM

Cochlear branch: CONVEYS IMPULSES ASSOCIATED WITH HEARING

IX.

Glossopharyngeal nerve

Mixed cranial nerve

SECRETION OF SALIVA

TASTE, REGULATION OF BP

Muscle sense

X.

Vagus nerve

Mixed

SMOOTH MUSCLE CONTRACTION AND RELAXATION

SECRETION OF DIGESTIVE FLUIDS

SENSATION FROM VISCERAL ORGANS SUPPLIED

Muscle sense

XI.

Accessory nerve

Mixed, primarily motor

Cranial portion mediates swallowing mvmts

Spinal portion mediates mvmts of head

Muscle sense

XII.

Hypoglossal nerve

Mixed, primarily motor

Mvmts of tongue during speech/swallowing

Muscle sense

 

2.      Describe how each cranial nerve is assessed.

 

Function/region

Cranial Nerve

Test/Observation

Olfactory

I

Smell (e.g., coffee, vanilla, peppermint)

Have pt. close both eyes and sniff a readily recognized odor.

Vision

II

Acuity, fields, color, fundus

Have pt. close one eye, look at bridge of your nose, and indicate when an object (finger, pencil) presented from the periphery of each of the four visual field quadrants is seen. Repeat for other eye

Visual acuity

Oculomotor

III

Check for pupillary constriction and for convergence (eyes turning inward) and accommodation (pupils constricting with near vision)

Damage can show drooping eyelid (ptosis), pupillary abnormalities, and muscle weakness.

Eye movements and eyelids

III,  IV,  VI

Range and quality of eye movements, saccades, pursuits, nystagmus (fine, rapid jerking mvmts of the eyes), ptosis

Sensation

V

FOR DECREASED LEVEL OF CONSCIOUSNESS PTS. ONLY =Corneal reflexes (corneal sensation when wisp strand applied to cornea), facial sensation.  Have pt identify light touch (cotton), and pinprick in each of the three division (ophthalmic, maxillary, and mandibular of the nerve on both sides of the face. Pts. Eyes should be closed.

Muscles of mastication

V

Clench teeth

Facial strength

VII

Observe degree of expression of emotions, eye or lip closure strength.  ASK pt to raise the eyebrows, close the eyes tightly, purse the lips and draw back the corners of the mouth in an exaggerated smile and frown.  FOR DECREASED LEVEL OF CONSCIOUSNESS PTS. ONLY = corneal reflex (eye blink when cotton wisp strand to the cornea)

Hearing

VIII

Localize voice, attend to finger rub. Have pt close the eyes and indicate when a ticking watch or the rustling of the examiner’s fingertips is heard as the stimulus is brought closer to the ear. Each ear is tested individually. (for more precise assessment of hearing , an audiometer is used). Vestibular portion not routinely tested unless pt. c/o of dizziness, vertigo, or unsteadiness. In this case, caloric testing, is done

Mouth, Pharynx

VII,  IX,  X,  XII

Swallowing, speech quality (nasal deficits in labial, lingual, or palatal sound production), symmetric palatal elevation, tongue protrusion, gag reflex, have pt. say “ah” and to note the bilateral symmetry of elevation of the soft palate. Put hands on either sides of throat and ask pt to swallow. Any asymmetry is noted.

Head control

XI

Head position and movement, shoulder shrug against resistance and to turn the head to either side against resistance.

 

 

 

 

 

 

3.      Describe the components of the mental status assessment.

Normal Neuro Exam Shows:  Alert and oriented, orderly thought processes, appropriate mood and affect.

 

A.  General appearance and behavior:

Includes motor activity, body posture, dress and hygiene, facial expression, and speech.

B.     State of consciousness:

AOX3, memory, general knowledge, insight, problem solving and calculation.  The nurse should consider whether the patient’s plans and goals match the physical and mental capabilities.

C.    Mood and affect:

Note agitation, anger, depression, or euphoria and the appropriateness of these states. Questions should be directed to bring out the feelings of the patient.

D.    Thought content:

Note illusions, hallucinations, delusions, or paranoia.

E.     Intellectual capacity:

Note retardation, dementia, and intelligence.

 

 

4.      Describe the components and use of the Glascow Coma Scale.

 

 Activity           Best response                       Activity                        Best response

EYE OPENING                                              VERBAL

Spontaneous             4                                  Oriented                                 5

To speech                  3                                  Confused                               4

To pain                       2                                  Inappropriate words              3

None                           1                                  Nonspecific sounds              2

                                                                        None                                       1

MOTOR

Follows commands               6

Localizes pain                       5

Withdraws to pain                 4

Abnormal flexion                   3

Abnormal extension              2

None                                       1

 

5.      Describe the assessment of the motor system.

 

Muscle bulk                                                   Tone: high, normal, low

Strength                                                         -  Axial tone

Movement quality and functionality          -  Limb tone

Normal Neuro Exam Shows: Normal motor gait and station; normal tandem walk; negative Romberg test; normal and symmetric muscle bulk, tone, strength, smooth performance of finger-nose, heel-shin movements.

6.      Describe the assessment of the sensory system.

Normal Neuro Exam Shows: Intact sensation to light touch, position sense, vibration, pinprick, heat and cold, two-point discrimination; intact stereognosis and graphesthesia.

 

·        always have patients eyes closed to avoid visual clues

·        apply stimulus so that patient doesn’t expect it

·        give no verbal clues

·        touching 4 extremities is sufficient

 

A.  Light touch: 

Gently strokes a cotton wisp over each of the four extremities and asks the patient to indicate when the stimulus is felt by saying, “touch”

B.     Pain and temperature:

Applying the sharp end of a pin to the skin tests pain

Applying tubes of warm and cold water to the skin and asking the patient to identify the stimuli with the eyes closed tests temperature.

C.    Vibration sense:

Apply a vibrating c128 tuning fork to the fingernails and the bony prominences of the hands, legs and feet with the patient’s eyes closed. Ask patient do they feel a vibration or “buzz”. Then ask the patient when the vibration ceases.

D.    Position sense:

This is assessed by placing the thumb and forefinger on either side of the patient’s forefinger or great toe and gently moving the finger up or down. The patient is asked which direction the digit is moved.

-         The test of the lower extremities is the Romberg test.  The patient is asked to stand with the feet together then close his or her eyes. If the patient is able to maintain balance with the eyes open, but falls or sways with the eyes closed then it is a (+) Romberg test.

E.     Cortical sensory function:

-         Placing the two points of a calibrated compass on the tips of the fingers and toes assesses two-point discrimination. Have pt. identify how many objects are touching them.

-         Having the patient identify numbers traced on the palm of the hands tests Graphesthesia.

-         Having the patient identify the size and shape of easily recognized objects placed into their hands (e.g., coins, keys, and a safety pin) tests Stereognosis.

 

 

7.      Describe the assessment of normal reflexes.

Normal Neuro Exam shows: biceps, triceps, brachioradialis, patellar, and Archilles tendon reflexes 2 + bilaterally; downgoing toes with plantar stimulation.

 

Assessed as follows using a reflex hammer

0 =  absent                

1 = weak response

2 = normal response

3 = exaggerated response

4 = hyperreflexia with clonus

 

8.      Identify diagnostic studies used in assessing neuro status.

Cerebrospinal fluid analysis

·        Lumbar puncture

 

Radiologic

·        skull and spine x-rays

·        Cerebral angiography (when vascular lesions or tumors are suspected)

·        CT scan – computed tomography (identifies disruptions in the blood-brain barrier and enhances visualizations of blood vessels)

·        Myelography (used to detect spinal lesions, ruptured disk, tumor)

·        MRI – magnetic resonance imaging (evaluates brain and spinal cord edema, hemorrhage, infarction, blood vessels, neoplasms, and one lesions)

·        PET – position emission tomography (determines regional metabolism in the brain)

 

Electrographic

·        EEG – electroencephalgraphy

·        Electromyography/ Nerve conduction

·        Evoked potentials

·        Visual evoked potentials

·        Brainstem auditory evoked potentials

·        Somatosensory evoked potentials

 

Ultrasound

·        Carotid duplex studies

·        Transcranial Doppler