Neurologic and Reproductive Systems Overview

Neurologic System

Overview of the Nervous System

Central Nervous System (CNS)
  - Composed of the brain and spinal cord
  - Brain
    - Divided into hemispheres and lobes
  - Medulla
    - Contains all ascending and descending fiber tracts
    - Vital for autonomic centers, including the regulation of:
      - Respiration
      - Heart and gastrointestinal functions
    - Contains nuclei for cranial nerves VIII through XII
    - Features crossed representation (the left hemisphere controls the right side of the body and vice versa)
Peripheral Nervous System (PNS)
  - Comprises all nerve fibers outside of the brain and spinal cord
  - Contains:
    - 12 pairs of cranial nerves
    - 31 pairs of spinal nerves
      - Cervical nerves: 8 pairs
      - Thoracic nerves: 12 pairs
      - Lumbar nerves: 5 pairs
      - Sacral nerves: 5 pairs
      - Coccygeal nerves: 1 pair
  - Functions:
    - Carry sensory (afferent) messages to the CNS from sensory receptors
    - Transmit motor (efferent) messages from the CNS to muscles and glands

Reflexes

Types of Reflexes
  1. Stretch or deep tendon reflexes:
    - Should be able to elicit and grade reflexes
    - Grading scale:
      - 0: No reflex, hyporeflexia, abnormal condition
      - 1: Slight response, present but diminished
      - 2: Normal and active
      - 3: Increased response, may or may not be normal
      - 4: Hyperreflexia, very hyperactive response
    - Ensure to compare bilaterally
  2. Superficial (cutaneous) reflexes
  3. Babinski reflex:
    - Tested by using the hammer handle to stroke the underside of the patient's foot in an upward motion from heel to toe

Brain Structure

Cerebral Cortex:
- Outer grey matter layer
Lobes of the Brain:
  - Frontal Lobe:
    - Responsible for personality, behavior, emotions, and intellectual function
  - Parietal Lobe:
    - Contains the postcentral gyrus, which is the primary center for sensation
  - Temporal Lobe:
    - Located behind the ear; primary auditory reception center, with functions in hearing, taste, and smell
  - Occipital Lobe:
    - Primary visual receptor center
  - Wernicke Area:
    - Located in the temporal lobe; important for language comprehension

Cranial Nerves

Overview:
- Part of the peripheral nervous system with 12 cranial nerves
Cranial Nerve Functions:
  1. Olfactory Nerve (CN I):
    - Manages the sense of smell
    - Testing: Eyes closed, one nostril covered, have patient smell a familiar odor.
  2. Optic Nerve (CN II):
    - Controls vision
    - Testing: Visual acuity through Snellen chart reading.
  3. Oculomotor Nerve (CN III):
    - Manages eye movement and blinking
    - Testing: Check cardinal fields and pupil response (PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation).
  4. Trochlear Nerve (CN IV):
    - Controls up-and-down and back-and-forth eye movements
    - Testing: Check cardinal fields and pupil response (PERRLA).
  5. Trigeminal Nerve (CN V):
    - Manages facial sensations and jaw movements
    - Testing:
      - Sensory: Light touch on forehead, chin, and cheek
      - Motor: Patient clenching jaw and opening mouth.
  6. Abducens Nerve (CN VI):
    - Helps manage lateral eye movements
    - Testing: Check cardinal fields and pupil response (PERRLA).
  7. Facial Nerve (CN VII):
    - Controls facial expressions and contributes to taste
    - Testing:
      - Sensory: Taste familiar flavor (sugar/lemon) on anterior tongue
      - Motor: Raise eyebrows, close eyes tightly, and smile broadly.
  8. Auditory/Vestibular Nerve (CN VIII):
    - Controls hearing and balance
    - Testing:
      - Assess ability to hear a normal conversation and whisper test
      - Evaluate equilibrium using Romberg test.
  9. Glossopharyngeal Nerve (CN IX):
    - Controls taste and swallowing functions
    - Testing:
      - Sensory: Place a familiar flavor on the posterior part of the tongue
      - Motor: Assess swallowing ability and gag reflex.
  10. Vagus Nerve (CN X):
    - Manages functions of heart rate and digestion
    - Testing:
      - Sensory: Place a familiar flavor on the posterior tongue
      - Motor: Assess swallowing ability and gag reflex.
  11. Spinal Accessory Nerve (CN XI):
    - Regulates neck and shoulder muscle movement
    - Testing: Assess strength of trapezius and sternocleidomastoid muscles.
  12. Hypoglossal Nerve (CN XII):
    - Controls tongue movements
    - Testing: Motor function of tongue; have patient say “light, tight, dynamite.”

Aging and Neurologic Assessment

Aging Adult Characteristics:
  - Atrophy:
    - Wasting, shrinkage, or decrease in size of muscles, tissues, or organs due to factors such as disuse, malnutrition, or underlying disease.
  - Velocity of Nerve Conduction:
    - Decreases, resulting in a slower reaction time.
  - Sensory Changes:
    - Diminished touch, pain, taste, and smell
  - Motor System Slowing:
  - Cerebral Blood Flow:
    - Progressive decrease affecting oxygen supply.
Glasgow Coma Scale (GCS):
  - Assesses client responses in 3 areas:
    1. Eye opening
    2. Verbal response
    3. Motor response
  - Score Ranges:
    - Score of 15 indicates full consciousness, while 7 or less indicates coma or vegetative state.

Levels of Neurovascular Assessment

Components:
  - Level of Consciousness (LOC)
  - Orientation (A&O x4)
      - Person, Place, Time, Situation
  - Pupils (PERRLA)
  - Motor Strength
  - Sensation
  - Circulation

Levels of Consciousness

1. Alert:
- Awake, oriented, responds appropriately
2. Confused:
- Disoriented, unclear thinking
3. Somnolent:
- Drowsy, easily aroused, drifts back to sleep
4. Lethargic:
- Very drowsy, slow response, requires stimulation
5. Obtunded:
- Difficult to arouse, disoriented when awake
6. Stuporous:
- Responds only to painful stimuli
7. Comatose:
- No response to any stimuli

Mnemonic for Levels of Consciousness

All Carrots Sometimes Leave Orange Skin Carvings

Data Assessment

Subjective Data:
  - Headache
  - Dizziness
  - Numbness
  - Tingling
  - Confusion
  - Seizures
Objective Data:
  - LOC
  - GCS
  - Reflexes
  - Motor Strength
  - Sensory Findings

Motor vs Sensory Assessment

Motor Assessment:
  - Strength: Scale from 0 to 5
  - Tone
  - Coordination
  - Gait
Sensory Assessment:
  - Pain
  - Temperature
  - Touch
  - Vibration

Neuro Examinations

1. Screening Neurologic Exam:
  - For well persons with no significant findings in history
  - Tests Include:
    - Mental status
    - Cranial Nerves
    - Motor: gait, balance, knee flexion
    - Sensory: superficial pain, light touch, and vibrations in arms/legs
    - Reflexes: biceps, triceps, patellar, Achilles
2. Complete Neurologic Exam:
  - For clients presenting with neurological concerns
  - Tests Include:
    - Mental status
    - Cranial Nerves II to XII
    - Motor: muscle size, strength, tone, rapid alternating movements, gait, balance
    - Sensory: superficial pain, light touch, vibration, position sense, stereognosis, graphesthesia, two-point discrimination
    - Reflexes: DTRs, biceps, triceps, brachioradialis, patellar, Achilles, superficial, plantar
3. Neurologic Recheck Exam:
- For hospitalized patients post-trauma or with neurological deficits

Stroke Information

Definition:
- Medical emergency characterized by the acute stoppage of blood supply to the brain; 5th most common cause of death in the US.
Risk Factors:
  - Age
  - Diet
  - Exercise
  - Hypertension
  - Obesity
  - Hyperglycemia
  - Hyperlipidemia
  - Renal dysfunction
Types of Strokes:
  - Ischemic:
    - Caused by blockage
  - Hemorrhagic:
    - Involves vascular bleeding
Stroke Symptoms - FAST:
  - F: Face drooping
  - A: Arm weakness
  - S: Speech difficulties
  - T: Time to call emergency services

Dementia vs. Delirium

Dementia:
  - Gradual, chronic, irreversibly progressive loss of memory and cognitive abilities affecting daily life
  - Types include Alzheimer’s, Vascular dementia, Lewy body dementia, and Frontotemporal dementia
  - Warning Signs:
    - Memory loss
    - Difficulty performing familiar tasks
    - Problems with language
    - Disorientation to time and place
    - Poor or decreased judgment
    - Difficulty keeping track of things
    - Misplacing items
    - Mood and behavior changes
    - Challenges understanding visual and spatial information
    - Withdrawal from social activities
Delirium:
- Acute, sudden onset condition, often reversible

Male Genitourinary System

Scrotum:
  - Loose protective sac; continuation of the abdominal wall
  - Comprised of thin skin in folds (rugae) and underlying cremaster muscle
  - Cremaster Muscle:
    - Regulates scrotal size in response to temperature
  - Features a septum dividing the sac into two halves, each containing a testis that produces sperm

Testes

Solid oval structures, suspended vertically by the spermatic cord
Left testis is often lower due to the longer left spermatic cord

Lymphatics

Lymphatics of the penis and scrotum drain into inguinal lymph nodes
Lymphatics of the testes drain into the abdomen (not accessible to clinical examination)

Genetics and Environment Influencing Male GU

Chronic Kidney Disease (CKD):
  - Risk factors: hypertension (HTN) and diabetes
  - Hypertension:
    - Higher prevalence among African Americans, American Indians, and Hispanics
Bladder Cancer:
- Fourth most common cancer in men; incidence differs by ethnicity
- Risk factors include smoking (assess for painless hematuria)
Sexually Transmitted Infections (STIs):
- Often asymptomatic; testing recommended for all sexually active individuals due to increased transmission risks associated with unprotected sex

Subjective Data for Male GU Assessment

Frequency, urgency, and nocturia
Dysuria
Hesitancy and straining during urination
Urine color changes
Past medical history (penis pain, lesions, discharge)
Scrotum self-care practices, presence of lumps

Objective Data for Male GU Assessment

Inspect anatomy
Assess for edema
Palpate inguinal lymph nodes
Evaluate urinary function

Health Promotion

Testicular Self-Exam (TSE):
  - T: Timing, once a month
  - S: Shower; warm water relaxes the scrotal sac
  - E: Examine; check for changes and report concerns immediately

Anus, Rectum, and Prostate

Benign Prostatic Hypertrophy (BPH):
- Symptoms include urinary frequency, urgency, weak stream, and nocturia
- Examination reveals an enlarged, smooth prostate
Prostate Cancer:
  - Risk Factors:
    - Age, African ancestry, family history (brother or father), and inherited mutations (BRCA1 and BRCA2)
  - Screening Recommendations:
    - Average risk: starting at 50 years old
    - High risk: begin screening earlier based on family history
    - PSA Testing:
      - Screening controversial
Colorectal Cancer:
  - Symptoms include blood in stool and anemia
  - Risk Factors:
    - Age, irritable bowel disease (IBD), type 2 diabetes mellitus (T2DM), diet
  - Screening Guidelines:
    - Begin at 45 years old; if first colonoscopy is negative, schedule next in 10 years; screen younger if symptomatic

Subjective Data for Anus, Rectum, and Prostate

Usual bowel routine
Changes in bowel habits
Rectal bleeding or blood in stool
Medications including laxatives and stool softeners
Rectal conditions (pruritus, hemorrhoids, fissure, fistula)
Family history concerning rectal conditions

Anus Assessment - Objective Data

Spread buttocks wide apart for inspection of the perianal region
Inspect the sacrococcygeal area, which should appear smooth and even

Female Genitourinary System

Aging Adult Changes:
  - Menopause:
    - Ovaries atrophy, vagina shortens, narrows, and becomes less elastic
  - Menopause Symptoms:
    - Irregular periods, vaginal dryness, hot flashes, sore or tender breasts, chills, night sweats, sleep disturbances, headaches, weight gain and slowed metabolism, mood changes, thinning hair, dry skin, memory issues
  - Human Papillomavirus (HPV):
    - HPV vaccine protects against infection often spread through sexual contact; recommended for individuals ages 11-12, adults up to 45, and males and females over 13 (2 doses required)
Cervical Cancer:
  - Develops when cervical cells grow uncontrollably; regular pap smears are vital for screening
  - Risk Factors:
    - Absence of HPV vaccination, lack of cervical cancer screening, previous dysplasias, immunosuppression, smoking or tobacco use

Subjective Data for Female GU Assessment

Menstrual history
Obstetric history
Menopause
Acute pelvic pain
Urinary symptoms
Vaginal discharge characteristics
Past medical history, sexual activity, contraceptive use, STIs

Objective Data for Female GU Assessment

Inspect external genitalia for anatomy, skin color, and hair distribution

Substance Use

Alcohol:
  - Most widely used and abused psychoactive drug in the U.S.; 3rd leading cause of preventable death
  - Dependence or Alcoholism:
    - Chronic, progressive disease that is treatable but not curable
Binge Drinking Guidelines:
- Women: 4 or more drinks on any day or 8 or more per week
- Men: 5 or more drinks on any day or 15 or more per week
Diseases Associated with Heavy Drinking:
  - Liver diseases
  - Cardiovascular (CV) diseases including cardiomyopathy, heart failure, dysrhythmias, hypertension
  - Various cancers
  - Adolescents:
    - Alcohol slows brain development and reduces maturity; associated with high-risk behaviors including sexual risks, academic issues, trauma injuries, and continuation of alcohol-related diseases in later life
  - Pregnancy:
    - Alcohol poses dangers to mother and fetus; risk of developing Fetal Alcohol Spectrum Disorder (FASD), leading to physical deformities and behavioral issues; no safe amount of alcohol for pregnant women has been established
  - Aging Processes:
    - Decreased metabolic functions of the liver, body water, and kidney function increase risks for falls, depression, gastrointestinal problems, and fatal overdoses

Subjective Data for Substance Use Assessment

All questions should be asked in a non-judgmental manner

Screening Tools for Alcohol Use

AUDIT:
- Covers three domains with a maximum score of 40 (alcohol consumption, drinking behavior or dependence, adverse consequences)
- Advantages: sensitive to current vs past alcohol issues, minimally biased based on gender and culture
CAGE:
  - Best for detecting long-term issues; questions include:
    1. Have you ever felt you ought to cut down on drinking?
    2. Have people annoyed you by criticizing your drinking?
    3. Have you ever felt bad or guilty about your drinking?
    4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener)
TWEAK:
- Designed for pregnant women, includes sections on tolerance, worry, eye-opener, amnesia, and cut down
SMAST-G:
- Short Michigan Alcoholism Screening Test for older adults reporting social or regular drinking

Clinical Data for Alcoholism

Objective Data:
  - Clinical Biomarkers:
    - Gamma glutamyl transferase (GGT): chronic drinking of more than 4 drinks per day for 4-8 weeks significantly elevates levels
    - Mean corpuscular volume (MCV): not sensitive enough to use as the sole biomarker
    - Aspartate aminotransferase (AST): chronic drinking causes elevation levels

Alcohol Withdrawal Symptoms

Symptoms include craving, irritability, anorexia, abdominal discomfort, fatigue, chills, muscle cramps, palpitations, tachycardia, hypertension, fever, disorientation, slurred speech, staggered gait, and poor dexterity

Other Substances

Definition: Non-medical agents intended to alter mood or behavior
Intoxication: Characterized by maladaptive behavior (CNS)
Abuse: Inability to stop substance use leading to impaired life functioning
Dependence: Physiologic dependence on substances
Tolerance: Needing more of the substance for the same effect
Withdrawal: Cessation leads to a syndrome of physiologic symptoms

Illicit Drug Use

Types of illicit drugs include:
  1. Marijuana
  2. Cocaine
  3. Heroin
  4. Hallucinogens
  5. Inhalants
  6. Methamphetamine
  7. Nonmedical use of psychotherapeutics
Consequences:
  - Health implications
  - Relationship issues
  - Job and career futures
  - School performance
  - Risk of addiction and potential death

Diagnosing Substance Abuse

Both abuse and addiction are viewed as diseases of the brain; not tied to a singular case, rather they involve complex interactions between genetic, environmental, and developmental factors
Substance use activates reward pathways in the brain, releasing dopamine; prolonged use leads to desensitization of these pathways

Family Violence and Human Trafficking

Types of Violence:
  1. Intimate Partner Violence (IPV):
    - Encompasses physical, sexual violence, stalking, and psychological aggression; also relevant in teen dating scenarios
  - Characteristics of abusers include:
    - Sense of entitlement, controlling and manipulative behaviors, charm, and often involve being uninvolved parents
  - Domestic violence is learned behavior, not determined solely by illness, genetics, alcohol, or relationship issues
Barriers to Treatment:
  - Social stressors
  - Legal standing
  - Lack of access to culturally appropriate care

Objective Data for Family Violence

Use RADAR protocol for domestic violence interventions:
  - R: Routinely screen female patients
  - A: Ask direct questions
  - D: Document findings
  - A: Assess patient safety
  - R: Respond, review options, and refer
Child Abuse and Neglect:
- Most common maltreatment is neglect, followed by physical abuse; nurses are mandatory reporters and must document accurately using the child's words to describe injuries
Elder Abuse and Neglect:
- 60% of abusers are family members; forms include physical, sexual, psychological, neglect, and financial abuse
Human Trafficking:
- Involves sexual exploitation, forced labor, debt bondage, and domestic servitude; indicators include inconsistent stories, fear/anxiety in behavior, lack of awareness of time and location, and having restricted legal documents.

Documentation of Abuse

Provide detail in documentation, including:
  - Non-biased progress notes
  - Use language provided by the patient to describe injuries
  - Ensure thorough physical exam documentation
  - Digital photographic evidence in medical records obtained with patient consent