NEUROLOGICAL Study Guide NR 304 Sept Oct 2013

Key Vocabulary: Agnosia: loss of ability to recognize objects, persons, sounds, shapes,
or smells while the specific sense is not defective nor is there any significant memory
loss.
Agraphia: inability to write resulting from brain disease. Agraphia can exist on its own
or combine with other issues.
Aphasia: a disturbance of the comprehension and formulation of language caused by
dysfunction in specific brain regions. Having difficulty remembering words to losing the
ability to speak, read, or write.
Apraxia: unable to perform tasks or movements when asked, even though: The request
or command is understood
Ataxia: (Ataxic gait): Loss of voluntary coordination. Uncoordinated movement is due to
a muscle control problem that causes an inability to coordinate movements. It leads wide
base, uneven steps, feet slapping, tendency to sway, and an unsteady gait (walking style).
Clonus: Rhythmically alternating flexion and extension, confirms upper motor neuron
disease.
Dysphagia: Difficulty with swallowing
Fasciculation: small, spontaneous twitches
Nystagmus: Constant involuntary movement of the eyeball.
Tremors (involuntary and intention): Rhythmic or alternating involuntary movement
from the contraction of opposing muscle groups. Vary in degree, seen with Parkinsons,
multiple sclerosis, and alcoholics.
Tic: habit involuntary spasmodic movement of the muscle is seen in a muscle under
voluntary control. Usually face, neck, shoulders. Increases during stress.
Rigidity: aching muscles and muscle stiffness or weakness
Flaccidity:
Paralysis: loss of muscle function for one or more muscles
Paraplegia: impairment in motor or sensory function of the lower extremities.
Paresthesia: a sensation of tingling, tickling, prickling, pricking, or burning of a person's skin with
no apparent long-term physical effect.

Nuchal rigidity: Stiffness of the neck

Spasticity: condition in which muscles are continuously tight or stiff.
Developmental Considerations
Elderly
List the expected changes in the neurological system as a result of aging: Reduced/slowing gait,
diminished senses, reduced gag reflex. Memory is NOT a normal change.

Cranial Nerves oh, oh, oh to touch and feel very good vagina after humping
S= sensory
M= motor
Cranial Nerve Nerve How to assess:
Normal
Type
briefly
Finding
I Olfactory
Have pt smell
Correctly
Senso something common. identifies
ry
Lemon, cinnamon
scents in
both nares.
II Optic- Vision
Pt do the snellen
20/20 vision
S
chart
III Oculomotor
M

IV Trochlear
M
V Trigeminal

S/M

VI Abducens

S/M

VII Facial
S/M

VIII
Vestibulocochl S
ear

Pupillary reflex &

extrinsic eye
movement.
PERRLA
Eye muscle
movement, Cover
uncover test.
Sensory impulses
feeling, Motor
teeth clenching,
movement of jaw.

Extrinsic muscle
movement of eye.
Ex: * move penlight
in a star formation.
Taste, facial
movements smiling,
closing eyes,
frowning, tears/
salvia.
Vestibular branch=
sense of balance.
Cochlear= sense of
hearing.
EX: Rombergs test :
2

Abnormal
Finding/Cause
Unilateral/
bilateral
anosmia.(loss
of smell)

PERRLA
Indirect and
Direct, No
eyelid
drooping

Ability to
chew, and
feel
sensations.
Ability to feel
sharp/dull
sensation
over
forehead.
Able to follow
without any
twitches
Ability to do
listed. Plus
puff out
cheeks,
wrinkle
forehead
Ears

Loss of facial
sensation,
cant chew,
decrease in
blinking.

Diplopia: Dbl
vision.
Strabismus:
cross eyed
Bells Palsy
(stroke on 1
side of face),
decreased
ability to
distinguish
tastes.
Deaf, vertigo
(dizzy),
tinnitus

IX
Glossopharyn
geal

S/M

X Vagus
S/M

XI Accessory

XII
Hypoglossal

stand straight/arms
at side (no sway)
Gag/swallowing
reflex. Taste on
posterior third of
tongue.
Muscles for throat
and mouth for
swallowing and
talking. Responsible
for pressoreceptors
& chemoreceptor
activity.
Movement of the
trapezius and
sternocleidomastoid
muscles, some
movement of larynx,
pharynx, and soft
plate.
Movement of tongue
to swallow,
movement of food
for chewing, and
speech.

Gags &
swallows,
uvula/ soft
palate rises
symmetricall
y
Talks &
Swallows

Loss of gag
and taste,
difficulty
swallowing.

Shrugs/ turns
head L and R

Cant shrug,
or turn head
to left and
right.

Tongues
moves side to
side and up
and down
against
resistance.

Difficulty with
speech,
swallowing,
inability to
protrude
tongue.

Loss of voice,
impaired
voice and
difficulty
swallowing.

Which cranial Nerves can be assessed together? III, IV,VI (3,4,6) Oculomotor, Trochlear,
Abducens. All test visual fields, PERRLA, Cover uncover test, six cardinal field of gaze (star
test)
PERRLA assesses which cranial nerve? III Oculomotor
Describe papilledema: swelling of the optic nerve as it enters the retina. Symptom: increase
intracranial pressure.
- Significance? Can be indicative of brain tumors or intracranial hemorrhage.
Functions of brain by region:
Brainstem::

Alertness, Arousal, Breathing, Blood Pressure, Digestion, Heart Rate, Other Autonomic
Functions

Relays Information Between the Peripheral Nerves and Spinal Cord to the Upper Parts of the
Brain

Frontal lobe: Speech, Motor cortex

Temporal: Smell, Hearing, Auditory association area
Occipital: Visual association area
Parietal: Somatosensory association area, speech, taste, reading

Explain the sensory and motor reflex arc? Autonomic reflex arc (affecting inner organs)
and somatic reflex arc (affecting muscles). Example: Knee Reflex test (no thinking
required)

Explain why an unconscious patient has normal reflex responses? Reflex has nothing
to do with the brain; reflexes are mediated in spinal cord.

What is a Dermatome? An area of skin innervated by the cutaneous branch of one spinal
nerve. (All spinal nerve except C1).

What type of viral infection reactivates itself in a nerve dermatome? Shingles (herpes
zoster)

What does the following positive Review of System(symptoms) suggest:

o
o
o
o
o

Syncope: Brief loss of consciousness, usually sudden.

Loss of balance /falling: + Rombergs Sign
Diplopia: (double vision) + for muscle weakness within the eye lid
Dysphasia: (trouble swallowing) Example: Diminished or absent gag reflex
Severe Morning Headache:

Abnormal speech patterns

o Aphasia: Global, Expressive or Receptive (define each)
o Word Salad: incoherent mixture of words, phrases, disconnected content
o Echolalia: imitation, repeating others words

Components and order of neuro exam:

1- mental status/loc 2- cranial nerves 3- motor and cerebellum 4- sensory 5-reflexes.

Mental Status exam:

o Appearance
o Behavior: Body language, affect, tremors, facial affect, etc
o Cognition: LOC, orientation, abstract reasoning, judgment
4

o Thought Processes
o MiniMental exam: cognitive assessment
o Four unrelated words test for new memory

Grading of reflexes:
o 0+ No Response
1+ Diminished
2+ Normal
3+ Brisk, Above Normal
4+ Hyperactive,
What is normal? 2+
What is hyperreflexia? Defined as overactive or overresponsive reflexes.
Examples of this can include twitching or spastic tendencies, which are
indicative of upper motor neuron disease
When will you observe? Common cause spinal cord injury

What is the maneuver to distract client when trying to elicit reflexes? The
Jendrassik maneuver is a medical maneuver wherein the patient clenches the teeth,
flexes both sets of fingers into a hook-like form and interlocks those sets of fingers
together

+Babinski in adults: What does the finding indicate? Present in a child older than 2 years or
in an adult, it is often a sign of a brain or nervous system disorder. Fanning of toes only normal in
children.

What is the difference between the Planar reflex and the Babinski sign? Picture Above
Assess Sensory Function
o What is Anesthesia? Absence of sensation.
o What is Parasthesia? A sensation of tingling, tickling, prickling, pricking, or burning of a
person's skin with no apparent long-term physical effect.

o Sterognosis? the ability to perceive and recognize the form of an object using
cues from texture, size, spatial properties, and temperature
o Graphesthesia? Is the ability to recognize writing on the skin purely by the sensation
of touch.

o What conditions have decreased or absent sensation?

Peripheral Neuropathy associated with DM2

Decerebrate: Posturing and extensor. Pt extends one or both arms, possibly legs.
Indicates a brain stem lesion.
Decorticate: Posturing and flexor. Pt flexes one or both arms on the chest and may
stiffly extend legs. Indicates a nonfunctioning cortex.

Major signs and symptoms

Myasthenia Gravis: an autoimmune neuromuscular disease leading to fluctuating
muscle weakness and fatigue. Muscles that control eye and eyelid movement, facial expressions,
chewing, talking, and swallowing are especially susceptible
Multiple Sclerosis: First attack typically 20 40 yrs old. Symptoms: unsteadiness,
tingling, blurred vision, slurred speech, and difficulty urinating.
Bells palsy: form of facial paralysis resulting from a dysfunction of the cranial nerve VII
(the facial nerve) causing an inability to control facial muscles on the affected side.
Physical findings on exam

What is the difference between a Rest tremor and intention tremors? Intention
tremors are common among individuals with multiple sclerosis. Intention tremor: Triggered by
movement toward a target (for example, reaching for a glass). Resting tremor: Occurring mainly at rest

Assessing balance in elderly safely:

Rhomberg: stand with arms together and feet together, pt closes eyes for 20 seconds.
Should complete without swaying or falling or moving feet apart.
heel to shin, alternating hand movements Normal versus abnormal

Glascow coma scale:

o What are the categories of assessment? Best eye opening, Best motor response,
Best verbal response.
o What parameters require immediate referral? Scoring below an 8 indicates coma.

Seizures: general vs partial describe each?

Abnormal gait r/t neurological abnormality: describe each

o Parkinsons: Stooped posture walks with short shuffle, steps, pill rolling finger
movements.
o Ataxic gait: wide base, uneven steps, feet slapping, and swaying. Seen in
Multiple Sclerosis or drug/alcohol intoxication.
o Scissor gait: spastic lower limbs and movement in a stiff jerky manner. Knees
come together crossing one in front of the other, short, progressive slow steps.
Also seen with MS.
o Steppage gait: foot drop flexes and raises the knee. (pretending there is a step
but really isnt one) then flops foot to the ground. Seen with progressive muscular
atrophy.

Definitions:
obtunded: Decreased alertness
stuporous: Sleep like state but not unresponsive
Comatose: No response to stimuli
lethargic: Drowsy but arouses when stimulated (awake)
Delirium: confusion often due to change in routine or environment

Problems: What are the key subjective and objective findings of the following
conditions?
o Stoke (infarct versus hemorrhagic)

Ischemic Stroke
In everyday life, blood clotting is beneficial. When you are bleeding from a wound, blood clots
work to slow and eventually stop the bleeding. In the case of stroke, however, blood clots are
dangerous because they can block arteries and cut off blood flow, a process called ischemia.
An ischemic stroke can occur in two ways: embolic and thrombotic strokes.

Embolic Stroke
In an embolic stroke, a blood clot forms somewhere in the body (usually the heart) and travels
through the bloodstream to your brain. Once in your brain, the clot eventually travels to a
blood vessel small enough to block its passage. The clot lodges there, blocking the blood
vessel and causing a stroke. The medical word for this type of blood clot is embolus.

Thrombotic Stroke
In the second type of blood-clot stroke, blood flow is impaired because of a blockage to one or
more of the arteries supplying blood to the brain. The process leading to this blockage is
known as thrombosis. Strokes caused in this way are called thrombotic strokes. That's
because the medical word for a clot that forms on a blood-vessel deposit is thrombus.

Blood-clot strokes can also happen as the result of unhealthy blood vessels clogged with a
buildup of fatty deposits and cholesterol. Your body regards these buildups as multiple, tiny
and repeated injuries to the blood vessel wall. So your body reacts to these injuries just as it
would if you were bleeding from a wound; it responds by forming clots. Two types of
thrombosis can cause stroke: large vessel thrombosis and small vessel disease (or lacunar
infarction.)

Hemorrhagic Stroke
Strokes caused by the breakage or "blowout" of a blood vessel in the brain are called
hemorrhagic strokes. The medical word for this type of breakage is hemorrhage. Hemorrhages
can be caused by a number of disorders which affect the blood vessels, including longstanding high blood pressure and cerebral aneurysms. An aneurysm is a weak or thin spot on
a blood vessel wall. These weak spots are usually present at birth. Aneurysms develop over a
number of years and usually don't cause detectable problems until they break. There are two
types of hemorrhagic stroke: subarachnoid and intracerebral.

In an intracerebral hemorrhage, bleeding occurs from vessels within the brain itself.
Hypertension (high blood pressure) is the primary cause of this type of hemorrhage.

In a subarachnoid hemorrhage, an aneurysm bursts in a large artery on or near the thin,

delicate membrane surrounding the brain. Blood spills into the area around the brain, which is
filled with a protective fluid, causing the brain to be surrounded by blood-contaminated fluid.

Meningitis: It's easy to mistake the early signs and symptoms of meningitis for the flu (influenza).
Meningitis signs and symptoms may develop over several hours or over one or two days.

The signs and symptoms that may occur in anyone older than age of 2 include:
Sudden high fever
Severe headache that isn't easily confused with other types of headache
Stiff neck
Vomiting or nausea with headache
Confusion or difficulty concentrating
Seizures
Sleepiness or difficulty waking up
Sensitivity to light
Lack of interest in drinking and eating
Skin rash in some cases, such as in meningococcal meningitis
Signs in newborns
Newborns and infants may not have the classic signs and symptoms of headache and stiff neck. Instead,
signs of meningitis in this age group may include:
High fever
Constant crying
Excessive sleepiness or irritability

Inactivity or sluggishness
Poor feeding
A bulge in the soft spot on top of a baby's head (fontanel)
Stiffness in a baby's body and neck
Infants with meningitis may be difficult to comfort, and may even cry harder when picked up.

Brain tumor: New onset or change in pattern of headaches

Headaches that gradually become more frequent and more severe

Unexplained nausea or vomiting

Vision problems, such as blurred vision, double vision or loss of peripheral vision

Gradual loss of sensation or movement in an arm or a leg

Difficulty with balance

Speech difficulties

Confusion in everyday matters

Personality or behavior changes

Seizures, especially in someone who doesn't have a history of seizures

Hearing problems

o Parkinsons: Poor posture, trouble with walking, flat facial expression

o Multiple Sclerosis: ataxic gait, muscle weakness and balance disturbance

Describe Brudzinski Sign: flex the neck. Observe hips and knees for reaction. Normal =
hips and knees will remain relaxed and motionless. Positive = pain and flexion at the hips
is an abnormal exam.
Describe Kernig Sign: Flex knee and hip, straighten knee. No pain with normal exam.
Positive is an increased resistance to knee extension and back pain.

Differentiate between TIA and CVA

While transient ischemic attack (TIA) is often labeled mini-stroke, it is more accurately characterized as a warning
stroke, a warning you should take very seriously.
TIA is caused by a clot; the only difference between a stroke and TIA is that with TIA the blockage is transient
(temporary). TIA symptoms occur rapidly and last a relatively short time. Most TIAs last less than five minutes; the

average is about a minute. Unlike a stroke, when a TIA is over, usually causes no permanent injury to the brain.
View a detailed animation of TIA.

What assessment would the nurse expect to perform for a client with TIA and syncope? Glasgow
scale. Tests the LOC of the pt on a continuum from alertness to coma and tests three body
functions: verbal response, motor response, and eye response. A maximum total score of 15
indicates that the pt is alert, responsive, and oriented. A total score fo 3, the lowest possible
score, indicates a nonresponsive comatose pt.
Describe the Romberg test and what it is used for? Used to test Cranial Nerve VIII (8). Pt
stands straight legs together, hands at side, eyes closed. If they sway or need to spread feet it is a
positive test.

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