Complex-Neurological/Mental status

What parts of the body are part of the central nervous system?

Brain & spinal cord

What parts are part of the Peripheral Nervous System?

All the nerve fibers outside of the brain and spinal cord.

What neurological components does the brain consist of?

• The brain is a network of interconnecting neurons that control and integrate the body’s activities. ​

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• Neurons communicate with one another at synapses.

What are the three most important parts of the brain?

• Cerebrum​

• Brainstem​

• Cerebellum

What does the Cerebral cortex, which forms outside the cerebrum, contribute to?

• Motor & Sensory function

• Intellect

• Language

• Visual imaging

• Auditory processing

• Language comprehension & Expression

What does the Left hemisphere of the central cortex control?

• Language ​

• Analytical abilities

What does the Right Hemisphere of the Central Cortex control?

• Visual-spatial skills​

• Emotion​

• Intuition ​

• Musical and Artistic abilities

What does the Frontal lobe control?

Cognition, language, voluntary motor function

What happens in the Broca’s area and what happens if this gets damaged?

• verbal expression, writing ability​

• Damage to the left side of the brain: expressive aphasia ​

What does the Temporal lobe control?

Auditory input

What does Wernicke’s area control and what happens if this gets damaged?

• language is processed here (spoken and written words)​

• Damage to the left side of the brain: receptive aphasia

What does the Occipital lobe control?

Vision (interpret and integrate stimuli)

What does the Parietal lobe control?

Sensory (touch, pressure, pain)

What does the Thalamus do?

relays both the motor and sensory stimuli to the cerebral cortex. ​

What does the hypothalamus do?

controls vitals, sleep, the pituitary gland, and ANS.

What does the Hippocampus and amygdala, part of the limbic system, do?

• Primarily focuses on self-preservation

  • Remembering good or bad events

  • Mood and emotional responses to events

  • Mediates fear, aggression, sex, and affection

What does the Brain stem control?

• Vital to intact neurological functioning ​

• The cell bodies of cranial nerves III – XII​

• Contains the vital autonomic centers for respiratory, cardiac, and vasomotor functions ​

• Regulates smooth breathing rhythm​

• Controls involuntary functions

What does the Cerebellum control?

• Coordinates voluntary movement, posture, muscle tone, ​and maintains special orientation and equilibrium. ​

• Balance and coordination ​

• Integrates information from the cerebral cortex, inner ear, ​muscles, and joints.

What does the Anterolateral tract (Spinothalamic), a sensory pathway, do?

transmits pain, temperature, itch, and crude touch sensations.

What does the Posterior (Dorsal) columns (Sensory pathway) do?

conduct the sensations of position, vibration, and finely localized touch. ​

What does the motor pathway, the Corticospinal (pyramidal) tract do?

mediates voluntary, skilled, discrete, purposeful movements like writing. ​

What does the motor pathway, the Extrapyramidal (outside of the pyramidal) do?

maintains muscle tone and control of body movements like walking and reflexes.

What are the Cranial Nerves?

• Consists of 12 pairs of nerves

• Exits the Brain verses the spinal cord

• Could contain sensory fibers, motor fibers, or both

• Cranial Nerves supply primarily the head and neck, except for the Vagus nerve

• The Vagus nerve travels to the heart and abdomen

What is the Vasovagal response?

The body’s reflex reaction where the vagus nerve becomes ​

too active causing the blood pressure and heart rate to drop suddenly.

What are the symptoms of the vagal response?

• Dizziness or light-headedness

• Blurred or tunnel vision

• Diaphoresis

• Turning pale

• Nausea

• Fainting

• cold & clammy skin

• Ringing in ears (tinnitus)

• Feeling warm

What can activation of the vagal response lead to?

• The patient can pass out, but only lasts a few seconds. ​

• A mini-seizure

What can cause activation of the vagal response?

• Stress (fear, trauma, blood draw, pain)​

• Standing up too quickly​

• Excess heat​

• Prolonged exercise ​

• Straining during bowel movement

What can the nurse do for a pt experiencing an active vagal response?

• Lay the patient down or assist down ​

• Raise the legs higher than the upper body ​

• Don’t forget to reassure the patient ​

What is a good Cranial nerve mnemonic that can be used to remember the CN names?

• Only = Olfactory

• One = Optic

• Of = Oculomotor

• The = Trochlear

• Two = Trigeminal

• Athletes = Abducens

• Felt = Facial

• Very = Vestibulocochlear

• Good = Glossopharyngeal

• Victorious = Vagus

• And = Accessory

• Healthy = Hypoglossal

What is a good mnemonic to remember whether the CN is Sensory, Motor, or Both?

• Some = (S) Olfactory

• Say = (S) Optic

• Marry = (M) Oculomotor

• Money = (M) Trochlear

• But = (B) Trigeminal

• My = (M) Abducens

• Brother = (B) Facial

• Says = (S) Vestibulocochlear

• Big = (B) Glossopharyngeal

• Brains = (B) Vagus

• Matter = (M) Accessory

• Most = (M) Hypoglossal

What are Spinal Nerves?

• 31 spinal nerves ​

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• Named for the region they exit from the spinal cord: cervical, thoracic, lumbar, sacral, and coccygeal.​

• Each sensory nerve supplies a particular segment of the body. This area is called a dermatome. The area where the dermatome is located can indicate which nerve is causing the problem. ​

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• Dermatomes are especially useful in determining the location of damage in spinal cord injuries.

What are reflexes and why are they important?

• Reflexes are the basic defense mechanisms of the nervous system. ​

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• Involuntary- permits a quick reaction to potentially painful or damaging situations. *​

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• Helps the body maintain balance and muscle tone.​

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• Deep tendon reflexes

What is the Process of a Reflex?

• Tapping the tendon stretches the muscle spindles wrapped around the muscle.

• This activates the sensory fibers to carry messages to the spinal cord.

• Synapses in the cord with the motor neuron.

• Motor fibers then leave and travel back to the muscle, stimulating a sudden contraction. ​

​Note: muscle must be strong enough to ​cause the contraction

Does the brain shrink in the older adult?

Yes. The aging process causes degeneration or wasting away of neuron structures in the brain.

What structural changes does the brain go through as you age?

• Reduced cognitive abilities

• Reduced response to stimuli

• Delayed reflexes

• Decreased ability to perform multiple tasks at the same time

What does peripheral nerve function and impulse conduction decrease?

• Poor balance

• Risk for falls and injuries

• Light touch

• Pain sensations

What are some cultural variations and health disparities in relation to strokes?

• African Americans are twice as likely to die from a stroke than White Americans.

• This may be due to higher rates of BP, obesity, ​diabetes, and smoking.

• Hispanics and Native Americans are also ​at a higher risk.

• At-risk populations are likely to delay care, stop treatment once they feel better and avoid visits to their PCP.

• African Americans and Hispanics are more likely​ to have functional limitations post-stroke.

• Recovery of motor functions is associated with caregiver and support systems. Stroke survivors who receive more attention and therapy recover faster.

What does the Autonomic Nervous System consist of?

• Sympathetic NS

• Parasympathetic NS

What is the Primary function of the Autonomic Nervous System?

Maintain homeostasis of the body

Involuntary

What happens when the Sympathetic NS is activated?

• Neurotransmitter: Norepinephrine & Epinephrine

• Fight, Flight, or Freeze

• Increases

  • HR, RR, BP, Pupil Dilation

• Decreases

  • Digestion

  • Urine production

What happens when the parasympathetic system is activated?

• Neurotransmitter: Acetylcholine

• Rest and Digest

• Increases

  • Digestion

• Decreases

  • HR, RR, BP, Pupil Dilation

What Neurological Assessment of risk factors is needed?

• Biographical Information ​

• Past Medical History ​

• Lifestyle and Personal Habits ​

• Medications Family History

What s/s might you see with Neurological impairment?

• HA, localized or general weakness, involuntary movements or tremors

• Balance/coordination difficulties, Dizziness or Vertigo

• Difficulty Swallowing, Intellectual changes, Speech/language Difficulties

• Changes in senses of taste, touch, or smell

• Lost, Double, or Blurred vision, Hearing loss or tinnitus

How would you test a person’s mental status?

• Level of Consciousness

  • Are they awake or alert?

• Cognitive function

  • Orientation (person, place, time, situation)

  • Affect (does the objective observation meet the emotional state)

  • Remote and recent memory

  • New learning (4 unrelated words)

• Thought process and perceptions

  • Making sense w/ responses to questions

How would you test Pupillary Response?

• PERRLA

• Pupils equal, round, reactive to light, and accommodation

• Purposeful gaze (eye contact and drifting)

• Pupillary size (w/ light and without)

What term describes abnormal flexion?

Decorticate posturing

What are some abnormal movements?

• Reflex posturing

• Tics, tremors, myoclonus, seizures

What term describes abnormal extension?

Decerebrate posturing

How do you assess CN I (Olfactory)?

Have pt smell a strong sent and have them identify sent

How do you test CN II (Optic)?

Eye screening test

How do you test CN III (Oculomotor), CN IV (Trochlear), CN VI (Abducens)?

• Have pt follow finger w/ eyes that moves to all directions

• Shine a light in eyes (PERRLA)

How would you test CN V (Trigeminal)?

• Motor: palpate temporal & masseter muscles as pt clenches teeth

  • try to separate jaw by pushing down on chin

• Sensory: Test light sensation w/ cotton ball over

  • forehead (ophthalmic)

  • cheeks (Maxillary)

  • chin (mandibular)

How would you test CN VII (Facial)?

Instruct pt to:

• Crease up forehead

• Keep eyes closed against resistance

• Smile and reveal teeth

• Puff out cheeks

How do you test CN VIII (Acoustic)?

Whisper test

How would you test CN IX (Glossopharyngeal) & CN X (Vagus)?

Open up mouth, stick out tongue, say aww.

Check that thingy in back of throat is midline and not deviated

How do you test CN XI (Accessory)

• ask pt to scrunch up shoulders against resistance

• Ask pt to turn head sideways against resistance

How do you test CN XII (Hypoglossal)?

Ask pt to stick out tongue

How do you assess muscle bulk and tone?

• Inspect and palpate chosen muscles to for atrophy

• Assess the degree of resistance to passive stretch

  • Look for spasticity or rigidity

What are the most commonly tested muscle groups?

• deltoids, ​biceps, triceps, hamstrings, and quadriceps. ​

What are some Coordination and Skilled movement tests?

• Finger-Nose-Finger

• Rapid Alternating Movements (flip hands up and down)

  • Finger to finger

• Heel-to-Shin

What is the Rhomberg test?

Tests cerebellar function

Stand still, close eyes, see if pt stays still or loses balance

How do you test Sensory function (Spinothalamic)?

Light touch

Superficial pain sensation (sharp vs. dull touch)

How do you test Dorsal sensory function?

• Point Localization​

  • Closes eyes​

  • Using finger, touch:​

    • hands​

    • lower arms​

    • abdomen​

    • lower legs​

    • feet​

  • Identify sensation location

What is the Stereognosis test?

have pt close their eyes, put an object in hand and have them guess what it is

What is the graphesthesia test?

have pt close eyes, trace numbers on hand and have pt state which number

How do you do the 2-point discrimination?

have two points on hand and move it closer and closer until pt can’t distinguish b/w points

What does the Measurement Of The Stretch Reflexes Reveal?

• An involuntary muscle contraction​

• The intactness of the reflex arc at specific spinal levels

What does the reflex response depend on?

• The force of the stimulus

• Accurate location of the striking area over the tendon

• Patient’s relaxation level

What is Clonus?

• A set of rapid, rhythmic contractions of the same muscle.

• Test when reflexes are hyperactive (4+)

• The most common site to test is the ankle/Achilles reflex.

• Clonus indicates some insult to the central nervous system ​versus the peripheral nervous system.

• It is significant when you also have other abnormal signs​ such as weakness, spasticity, or Babinski sign.