ASSESSING THE SENSORY-NEUROLOGICAL SYSTEM

Outcomes Identify pertinent neuro/sensory

history questions. Obtain a neuro/sensory history. Perform a neuro/sensory physical

assessment.

(Continued)

Outcomes Document pertinent neuro/

sensory assessment findings.

Identify actual/potential health problems stated as nursing diagnosis.

Differentiate between normal and abnormal findings.

Structures Cerebrum Cortex Frontal lobe Temporal lobe Limbic system Parietal lobe Occipital lobe RAS Thalamus Hypothalamus Cerebellum Brainstem Midbrain Medulla Meninges Ventricles

FunctionsWhat are the functions of…

Cerebrum: Largest part of brain

Cortex: Outer layer of cerebrum; controls

most conscious processesFrontal Lobe:

Emotional expression, Broca’s area (expressive language) (Continued)

FunctionsWhat are the functions of…

Temporal lobe:

Hearing, taste, smell, memory, Wernike’s (language comprehension)

Limbic system: Emotions, sexual arousal, behavioral

expression, recent memory (Continued)

FunctionsWhat are the functions of…

Parietal: Sensory input

Occipital lobe: Vision and spatial relationships

RAS: Wakefulness

(Continued)

FunctionsWhat are the functions of…

Thalamus: Clusters multiple sensory stimuli

Hypothalamus: Controls autonomic nervous system

and pituitary glandCerebellum:

Coordination, equilibrium(Continued)

FunctionsWhat are the functions of…

Brainstem: Involuntary survival behaviors;

includes midbrain, medulla and pons

Midbrain: Visual, auditory, pupils, and eye

movements(Continued)

FunctionsWhat are the functions of…

Medulla: Regulates heart, respiratory rates,

B/P, and protective reflexesPons:

Helps with respiratory function, facial sensation and movement

(Continued)

FunctionsWhat are the functions of…

Meninges: 3 layers (pia, arachnoid, dura);

protect brain and spinal cordVentricles:

4 cavities; capillaries produce and reabsorb CSF

(Continued)

Relationship to Other SystemsWhat is the relationship of the neurologic/

sensory system to other systems? Integumentary Respiratory HEENT Musculoskeletal Lymphatic Genitourinary Cardiovascular Endocrine Hematological Gastrointestinal

DevelopmentalVariationsWhat developmental variations of the

neurologic/sensory system might you seen with:

ChildrenPregnant clientsOlder adults

Cultural Variations

What cultural variations of the neurologic/sensory system might be seen with:

African Americans Irish Native Americans

HistoryWhat can the history tell you about the neurologic/sensory system?

Biographical data Current health status Past health history Family history Review of systems Psychosocial history

SymptomsWhat symptoms would signal a problem with the neurologic/sensory system? Headache Mental status change Dizziness, vertigo, syncope Numbness or loss of sensation Deficits of the 5 senses

Physical AssessmentApproach: inspection, palpation, and

auscultation Position: sittingTools: stethoscope, B/P cuff, penlight,

gloves, cotton, sharp object, coin, fragrance, sweet and sour substance, tongue blade, test tubes, reflex hammer, ophthalmoscope

General Survey and head-to-toe scan

Cerebral Function Behavior Level of consciousness: time, place,

person Glasgow Coma Scale Memory: immediate, recent, remote Mathematical ability Thought process Judgement General knowledge Communication

Sensory FunctionSuperficial sensations: Light touch Pain Temperature

Deep sensations: Vibratory sensations Kinesthetics

(Continued)

Sensory FunctionDiscriminatory sensations: Stereognosis Graphesthesia 2 point discrimination Point localization Extinction

Deep Tendon Reflexes Biceps Triceps Brachioradialis Patellar Achilles

Superficial Reflexes Plantar Abdominal Anal Cremasteric Bulbocavernosus

Protective Reflexes

Gag Cough Swallow Blink Corneal

Primitive Reflexes

Babinski Sucking Grasp Rooting Snout Glabellar

Meningeal Signs

Nuchal rigidity

Kernig’s Sign

Brudzinski’s Sign

Motor Function Finger-to-nose Heel-to-shin Rapid alternating movements Romberg Gait: heel-to-toe