Ch. 41 - Assessment of the Nervous System

neurotransmitters can be

excitatory or inhibitory

brain (3 parts)

forebrain, cerebellum, brainstem

frontal lobe

emotional expression, problem solving, memory, language, judgement, sexual behaviors

behavior issues, no filter

parietal/temporal lobes

thinking, speech

occipital lobe

vision

cerebellum

balance, coordination, hearing

cranial nerves (12)

1 = olfactory

2 = optic

3 = oculomotor

4 = trochlear

5 = trigeminal

6 = abducens

7 = facial

8 = vestibulocochlear

9 = glossopharyngeal

10 = vagus

11 = spinal accessory

12 = hypoglossal

olfactory

1 - smell

optic

2 - vision

oculomotor

3 - eye movement and pupil reflex

trochlear

4 - eye movement (down and in)

trigeminal

5 - face sensation and chewing

abducens

6 - eye movement

facial

7 - face movement and taste

vestibulocochlear

8 - hearing and balance

glosspharyngeal

9 - throat sensation, taste and swallowing

vagus

10 - movement, sensation and abdominal organs

spinal accessory

11 - neck movement

hypoglossal

12 - tongue

sympathetic nervous system

fight or flight

parasympathetic nervous system

rest and digest

____ is very important; it recharges the brain

sleep

neurologic changes with age (3)

mobility, sensory perception, cognition

mental status

who they are, where they are, why they are here, birthday, grade school

motor function

pull and push (both extremities at same time)

cerebellar function

cooridination

decorticate posturing

arms and feet in

decerebrate posturing

arms extended and out, feet in

WORSE

Glasgow Coma Scale (3)

eye opening, motor responses, verbal responses

glasgow coma scale

high score?

low score?

coma?

high = 15

low = 3

<8 is coma

____ is common with neurologic decline

depression

labs (5)

sodium, CSF, CBC, ABGs, ammonia

most common test?

CT

lumbar punctures

done at bedside

sample of CSF (between L4 and L5)

can have headache, assess injection site (halo)

The emergency department nurse is caring for a 78-year old patient whose daughter reports a decrease in cognition. Which nursing statement directed to the patient helps the nurse to assess cognition?

a"Tell me what this fable means to you."

b"Please count backward from 100 by 7s."

c"Tell me how you were transported to the hospital today."

d"I will write a word on this paper, and you copy it."

a. tell me what this fable means to you

tests abstract reasoning (part of cognition)

The nurse is caring for an older adult who is usually alert and oriented. When the patient exhibits a change in mental status, for which most cause does the nurse initially assess?

a. Infection

b. Use of sedatives

c. Oxygen insufficiency

d. Electrolyte imbalance

c. oxygen insufficiency

The nurse is caring for a 30-year-old patient who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention?

a. Enable the bed alarm safety system.

b. Place all items directly in front of the patient.

c. Use a picture board to assist with communication.

d. Instruct the patient to use a call light prior to getting out of bed.

a. enable the bed alarm safety system

Frontal lobe injuries may interfere with the patient's ability to regulate behavior based on judgment and foresight and also may affect reasoning, concentration, and abstraction. He may not be able to reason through how to use the call light. Enabling the bed alarm is important to reduce fall risk. Placing items in front of the patient would be helpful for parietal injuries involving spatial perception deficits, and a communication board would be indicated for an injury to the temporal lobe.

____ cells provide protection, structure and nutrition for the neurons

neuroglia cells

proprioception

The ability to tell where one's body is in space.

40 

40