NSG 316 EXAM 2

Cranial Nerve I: Olfactory Test

test sense of smell with familiar odor

Cranial Nerve II: Optic Test

test visual acuity and visual field with confrontation

Confrontation Test

gross measure of peripheral vision
-stand 2 fett from person
-have patient cover one eye, then cover your own eye opposite to the persons covered one
-hold finger as target midline between you and patient, slowly advance to periphery
-as person to say "now" as target is first seen

Confrontation Test: normal

50 degrees upward
90 degrees temporal
70 degrees down
60 degrees nasal

Cranial Nerve III, IV, VI: Oculomotor, Trochlear, Abducens Test

PERRLA
6 cardinal positions of gaze

PERRLA

pupils equal, round, reactive to light (direct and consensual) and accommodation

6 cardinal positions of gaze

right & up
right
right & down
left & up
left
left & down

nystagmus

back-and-forth oscillation of the eyes

nystagmus: amplitude

fine, medium or coarse movement

nystagmus: frequency

constant or fades after few beats

nystagmus: plane of movement

horizontal, vertical, rotary or combo

Cranial Nerve V: Trigeminal Test

Motor: asking the client to clench her teeth while you palpate the masseter (muscle of mastication)
Sensory- test light touch by having a client closer their eyes while you toucher her face gently with a wisp of cotton, patient identifies location

What does the corneal reflex test?

CN V sensory, CN VII motor

Corneal reflex test

-remove contacts, bring cotton wisp from side, lightly touch cornea
NORMALLY: patient blinks bilaterally

Cranial Nerve VII: Facial Test

Motor: have client smile, frown, puff out her cheeks, raise her eyebrows, close her eyes tightly
Sensory: anterior 2/3 taste (sugar, salt, lemon juice)

Cranial Nerve VIII: Vestibulocochlear Test

Whispered voice test

Cranial Nerve IX & X: Glossopharyngeal and Vagus Test

Motor: open mouth say "ahh" & gag reflex
NORMALLY: uvula and soft palate rise in midline
Sensory: CN IX does posterior 1/3 taste

Cranial Nerve XI: Accessory Test

shrug shoulders

Cranial Nerve XII: Hypoglossal Test

say "light, tight, dynamite"

screening neuro exam

perform on well persons who have no significant subjective findings

complete neuro exam

perform on person with neuro concerns

neuro recheck exam

perform on person with demonstrated neuro defect, who requires period ic assessment

ansomia

Decrease or loss of smell occurs bilaterally

hemianopsia; hemianopia

Defective vision or blindness in one half of the visual field

ptosis

drooping eyelid

paresthesias

tingling, prickling, "pins & needles" (sensory loss)

diplopia

double vision

dysphagia

difficulty swallowing

What are the test to evaluate cerebellar function?

Balance Test (Gait)
Romberg Test
Rapid Alternating Movements (RAM)

Balance Test (Gait)

-observe as the person walks 10 to 20 feet, turns and returns to the starting point
NORMALLY: gait is smooth, rhythmic and effortless opposing arm swing is coordinating

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed for ~20 seconds
NORMALLY: patient can maintain posture and balance

Rapid Alternating Movements (RAM)

pat the knees with both hands, turn hands over, then faster
NORMALLY: done with equal turning and quick rhythmic pace

flaccidity

decreased muscle tone (hypotonia), muscle feels limp, soft, flabby

spasticity

increased muscle tone (hypertonia)

rigidity

constant state of resistance; resists passive movement in any direction (dystonia)

cogwheel rigidity

Increased tone is released by degrees during passive range of motion so it feels like small, regular jerks.

paralysis

decreased or loss of motor power

hemiplegia

Spastic or flaccid paralysis of one side of the body

paraplegia

symmetric paralysis of both lower extremities

quadriplegia

paralysis of all four extremities

paresis

weakness of muscles rather than paralysis

tic

involuntary, compulsive, repetitive twitching of a muscle group

myoclonus

Rapid, sudden jerk or a short series of jerks at fairly regular intervals. (ex: hiccup)

fasciculation

rapid continuous twitching of resting muscle without movement of limb

chorea

sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face
irregular intervals, not rhythmic or repetitive

athetosis

slow, writhing involuntary movements

tremor

involuntary contraction of opposing muscle groups resulting in rhythmic movement of one or more joints

rest tremor

occurs when muscles are quiet and supported against gravity (hand in lap), coarse and slow, partly or completely disappears with voluntary movement

intention tremor

worse with voluntary movement (like reaching to a target)

spastic hemiparesis

Arm is immobile against the body, with flexion of the shoulder, elbow, wrist, and fingers and adduction of shoulder; does not swing freely. Leg is stiff and extended and circumducts with each step (drags toe in a semicircle).

cerebellar ataxia

staggering, wide-based gait; difficulty with turns; uncoordinated movement with positive Romberg sign

parkinsonian (festinating)

Posture is stooped; trunk is pitched forward; elbows, hips, and knees are flexed. Shuffling gait. Difficulty with any change in direction.

scissors

knees cross or are in contact, like holding an orange between the thighs.

steppage or foot drop

slapping quality, looks like walking up stairs with no stairs there

waddling

weak hip muscles- when the person takes a step, the opposite hip drops, which allows compensatory lateral movement of pelvis

short leg

Leg length discrepancy >2.5 cm (1 inch).

cerebral palsy

damage to cerebral cortex from a developmental defect (infancy and childhood), intrauterine meningitis or encephalitis, birth trauma, anoxia

muscular dystrophy

a chronic, progressive wasting of skeletal musculature producing weakness contracture and respiratory dysfunction or death

Parkinsonism

loss of dopamine-producing neurons causing motor tract disorder
symptoms: resting tremor, bradykinesia, cogwheel rigidity

cerebellar

A lesion in one hemisphere produces motor abnormalities on the ipsilateral side.

Multiple Sclerosis (MS)

chronic, progressive, immune mediated disease which axons experience inflammation, demyelination, degeneration and finally sclerosis

decorticate rigidity

upper: flexion of arm, wrist fingers, adduction of arms
lower: extension, internal rotation, plantar flexion

decerebrate rigidity

Upper: stiffly extended, adducted, internal rotation, palms pronated.
Lower extremities: stiffly extended, plantar flexion; teeth clenched; hyperextended back

flaccid quadriplegia

complete loss of muscle tone and paralysis of all four extremities (completely nonfunctional brainstem)

Opisthotonos

prolonged arching of back, with head and heels bent backward (meningeal irritation)

stereognosis

Test the persons ability to recognize objects by feeling their forms, sizes and weights

position (kinesthesia)

test person's ability to perceive passive movements of extremities

Tactile discrimination (fine touch)

measure the discrimination ability of the sensory cortex

Graphesthesia

ability to "read" a number by having it traced on the skin

two point discrimination

test ability to distinguish separation of two simultaneous pin points on skin

extinction

simultaneously touch both sides of body at the same time, both sensations should be felt

point location

touch skin and withdraw stimulus promptly; ask person to put finger where you touched

peripheral neuropathy

Loss of sensation involves all modalities; loss most severe distally at feet and hands

individual nerves or roots

Decrease or loss of all sensory modalities; corresponds to distribution of involved nerve

Spinal Cord Hemisection (Brown-Sequard Syndrome)

injury to one-half of the cord, causing contralateral loss of pain and temp
the ipsilateral side side of the lesion has paralysis and loss of vibration and touch sensation

Complete transection of spinal cord

Complete loss of all sensory modalities below level of lesion; associated with motor paralysis and loss of sphincter control

thalamus

loss of all sensory modality son the face, arm and leg on the side contrateral to lesion

cortex lesion

loss of discrimination on contralateral side; loss of graphesthesia, stereognosis, recognition of shapes and weights, finger findings

deep tendon reflexes (DTR)

measurement of stretch reflex reveals intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levels

DTR scale

0 - no response
1+ - diminished low normal or occurs w reinforcement
2+ - normal
3+ - brisker than average may indicate disease
4+ - hyperactive w/ clonus, very brisk, indicative of disease

Clonus

test when reflex are hyperactive

how do you test clonus?

support lower leg in one hand and with other hand move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing fort, hold stretch

what do you normally and abnormally see in a clonus test?

NORMALLY: you feel no further movement
ABNORMALLY: note rapid rhythmic contractions of calf and foot

Tempomandibular Joint (TMJ) assessment

note smooth movement without limitations or tenderness, clicking or popping when jaw opens and closes

how do you assess the thyroid gland?

ask client to take a sip of water, hold in mouth, the swallow while palpating thyroid gland
-one hand palpates and the other displaces

what is abnormal in palpating the thyroid gland?

an enlarged thyroid

What does the nurse do next if the thyroid gland is enlarged?

LISTEN FOR BRUIT (turbulent blood flow)
check the area they drain from for source of the problem

how do you examine lymph nodes?

gentle circular motion of finger, palpate lymph nodes

visual acuity test: snellen chart

person 20 feet from chart, ask to read smallest line possible

what does 10/20 vision mean

patient reads 10 feet way what a normal person reads 20 feet away

visual acuity: jaeger card

normal: 14/14 without hesitancy or moving card

Corneal Light Reflex (Hirschberg Test)

Assess the parallel alignment of the eye axes by shining a light toward the person's eyes.

what is normal for the corneal light reflex test?

light reflection on cornea should be in same spot on each eye

pupillary light reflex

normal constriction of pupils when bright light shines on retina

direct light reflex

constriction of the same-sided pupil

consensual light reflex

simultaneous constriction of the other pupil

red reflex

red glow that appears to fill the person's pupil caused by reflection of light of inner retina

what is a normal finding for the whispered voice test

person can repeat back a the combo of letters and numbers

tuning fork test

Measure bone and air conduction of sound

what is vestibular apparatus and what test is used?

a sensory organ for detecting sensations of equilibrium.
-romberg test