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Cranial Nerve 1
Olfactory Nerve- smell
Cranial Nerve 2
Optic Nerve- vision
Cranial Nerve 3
occulomotor- eye movement
Cranial Nerve 4
trochlear- eye movement
Cranial Nerve 5
trigeminal- mastication and sensation
How to test for function of cranial nerve 5?
touch jaw as they chew or clench their teeth
touch light sensation to personâs face, cheeks, and chin to test for sensation
Cranial Nerve 6
abducens- eye movement
Cranial Nerve 7
facial- face movement and sensation
How do you test cranial nerve 7?
note face symmetry
have person puff cheeks
Cranial Nerve 8
Acoustic nerve (vestibulocochlear)- hearing
How to test for cranial nerve 8?
whisper voice test or move fingers by the ear
Cranial Nerve 9
Glossopharyngeal- uvula, soft palate, and tonsillar pillar movement, posterior 1/3 of taste buds (not tested for)
Cranial Nerve 10
Vagus- controls specific body functions such as digestion, HR, and immune system
Cranial Nerve 11
Accessory- shoulder movement
How do you test for cranial nerve 11?
shrug shoulders up equally against resistance
rotate head against resistance
Cranial Nerve 12
Hypoglossal- tounge novement
How to test for cranial nerve 12?
ask patient to say âlight tight dynamiteâ
stick tongue out and see if it is midline
The four unrelated words test
pick 4 words with semantic and phonetic diversity, ask person to remember the four words
ask for the recall of all 4 words at 5, 10, 30 mins
Normal 4 word recall response under 60 years old
accuratly recall 3-4 words at each interval
4 word recall in aging adults
people older than 80 average two or four words recalled over 5 minutes and improves over 10 and 30 mins
What happens with Aphasia?
loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular accident
A-B-C-T of mental exams
A- Appearance
B- Behavior
C- cognitive
T- thought process
Mini-Cog aging adult test
consists of three item recall test and clock drawing test
tests for cognitive impairment
those with dementia or other impairments will not be able to complete
What happens to the neuro aspect of the body with an aging adult?
atrophy with steady loss of neuron structure in the brain and spinal cord
velocity of nerve conduction decreases making the reaction time slower in some older persons
diminished sensation of touch, pain, taste, and smell
What 2 ethnic groups have higher rate for stroke?
African Americans and Hispanics
91% of strokes are due to what?
modifiable factors
ex. smoking, diet, high BP
Perform a ______ on well persons with no significant findings from history
screening neurologic examination
Perform a ______ on persons with neurologic concerns
Complete neurologic examination
Perform _______ on persons with demonstrated neurologic deficits who require periodic assessments
Neurologic recheck examination
What tests the personâs ability to recognize objects by feeling their forms, sizes, and weights?
Stereogenosis
Whatâs the ability to âreadâ a number by having it traced on skin?
Graphesthesia
What is it called when at the same time touch both sides of the body; both sides should feel sensation?
Extinction
What is it called when the skin is touched and withdraw stimulus promptly; ask the person to put finger where you touched?
Point Location
What is it called when testing the posterior dorsal column tract?
Spinal Dorsal nerve is intact
How are specific muscle groups palpated or tested?
Always bilaterally
Rapid Alternating Movements
finger nose finger test
heel to shin test
What is the Romberg Test?
A balance test where the person is asked to stand up with feet together and arms at their sides. Close eyes and hold position for 20 seconds maintaining posture.
What is a DTRs 4-point scale used for?
reflex response is graded this way
0= no response
4= very brisk and hyperactive, indicative of a disease
What is reinforcement when testing reflex?
alternate technique to help elicit reflexes by performing an isometric exercise in a different muscle group
What is the clonus test?
test for when reflexes are hyperactive
support lower leg in one hand with with the other, move foot up and down to relax the muscle; then stretch muscle by briskly dorsiflexing foot; hold the stretch. Note: normal response: you would feel no further movement
A patient presents with, rapid rhythmic contractions of calf muscle and movement of foot. The nurse knows this is a sign of?
Clonus present
What are the three things the Glasgow Coma scale tests for?
eye-opening response
motor response
verbal response
F.A.S.T. plan from American Stroke Association
F=Face drooping
A=Arm weakness
S= speech difficulty
T= Time to call 911
What are risk factors that can increase a Pt risk for stroke?
HTN
Cigarettes
Heart Disorders
An 80 year old women presents with memory loss, trouble seeing, changes in personality, and losing track of time. The nurse suspects she has what?
Alzheimers
Ischemic strokes can be defined to be a sudden interruption of blood flow. Which pt would be identified as having an ischemic stoke?
embolic
tumor
thrombotic
Both embolic and thrombotic
Hemorrhagic strokes involve acute rupture and bleeding. Which conditions can result in a hemorrhagic stroke?
congenital malformations
tumor
cocaine abuse
distributed coagulation cascade
ALL of the above
What is repetitive movement of the jaw, lips, or tongue?
Dyskinesias
RAMS in aging adult
rapid alternating movements, difficult to perform
Plantar reflex in aging adult
may be absent or difficult to interpret
Abnormality in Cranial Nerve 1
cant smell well (anosmia)
Abnormality in Cranial Nerve 2
absent or defect in central vision
bad peripheral vision
absent light reflex
papilledema
optic atrophy
Abnormality in Cranial Nerve 3
dilated pupil, pitosis, eye turns out and slightly down
failure to move up, in, down
absent light reflex
Abnormality in Cranial Nerve 4
failure to turn eye down or out
Abnormality in Cranial Nerve 5
NO BLINKING
absent touch and pain (parathesias)
weakness of masseter or temporalis muscles
Abnormality in Cranial Nerve 6
failure to move laterally, diplopia on lateral gaze
Abnormality in Cranial Nerve 7
absent or asymmetric facial movement
loss of taste
Abnormality in Cranial Nerve 8
decrease or loss of hearing
Abnormality in Cranial Nerve 9
no gag reflex
Abnormality in Cranial Nerve 10
uvula deviates to the side
no gag reflex
hoarse voice
cant swallow and fluid goes up nose
Abnormality in Cranial Nerve 11
unable to shrug shoulders
Abnormality in Cranial Nerve 12
tongue deviate to the side and the tongue movement is slowed
Fasciculations
muscle twitches when a single peripheral nerve is overactive
Myoclonus
sudden, brief twitching
chorea
involuntary, irregular or unpredictable movements
athetosis
slow, writhing, and continuous worm-like movement of the limbs or trunk
Reasons for a ischemic stroke
sudden interruption of blood flow
thrombotic
embolic
Reasons for a hemorrhagic stroke
acute rupture and bleeding
congenital malformations
disturbed coagulation cascade
tumor
cocaine abuse
Examples of abnormal gaits
spastic hemiparesis- one side of body contacted constantly
cerebellar ataxia- poor muscle control causing clumsiness
parkinsonian
scissors- knees go together while walking
steppage or footdrop
waddling
short leg
hemiplegia
paralysis of one side of the body
paraplegia
paralysis of the legs and lower body, typically caused by spinal injury or disease
peripheral neuropathy
common in diabetes patients, loss of sensation involves all modalities; loss most severe at feet and hands
Babinski reflex
plantar foot stimulates extension of upward movement. children under 2 have positive sign but if older, it could mean there is a disorder
oppenheim reflex
drawing two knuckles down the patients chin will cause the patient to have dorsiflexion of the big toe (bad)
gordon hoffmann reflex
An extensor plantar response when the calf muscle is squeezed
Kernig reflex
the appearance of resistance or pain during extension of the patientâs knees beyond 135 degrees
Brudzinski reflex
severe neck stiffness causes a patientâs hips and knees to flex when the neck is flexed
snout reflex
protrusion of the lips elicited by tapping the midline of the upper lip