Neurologic and Sensory Systems


CHAPTER 10






Neurologic and Sensory Systems


 

 





LEARNING OUTCOMES






 


Upon completion of this chapter, the nurse will:



1.  Outline the areas to include when assessing the neurologic and sensory systems


2.  Identify appropriate questions to assess the neurologic and sensory systems


3.  Analyze approaches to gather more information about the neurologic and sensory systems


THE NEUROLOGIC SYSTEM


For many nurses the neurologic system can be overwhelming because this system interacts and controls all other body systems. As a review, the neurologic system is divided into:



  Central nervous system:


      Brain


      Spinal cord


  Peripheral nervous system:


      Cranial nerves


      Spinal nerves


Central Nervous System


The Brain


The brain contains the frontal, temporal, parietal, and occipital lobes. Each lobe is responsible for specific body functions.


 






















Lobe


Functions


Frontal


  Voluntary movement


  Speech


  Thinking


  Emotions


Temporal


  Interpretation of hearing


  Sense of smell


Parietal


  Conscious awareness


  Pain


  Temperature


Occipital


  Vision


 


Additional structures within “the brain” include the following:


 



















Structure


Function


Cerebellum


  Body movement


  Positioning


Diencephalon


  Thalamus


  Hypothalamus


  Autonomic control center to control:


      Blood pressure


      Heart rate


      Respiratory rate


      Temperature


Brain stem


  Midbrain


  Pons


  Medulla oblongata


  Site for 10 cranial nerves


  Controls vasoconstriction


  Regulates:


      Respiratory depth and rhythm


      Coughing


      Sneezing


      Swallowing


The Spinal Cord


The spinal cord is an extension of the medulla oblongata and ends around the first or second lumbar vertebra. This structure is the relay station for sensory and motor input, and the function is divided into cervical, thoracic, and lumbar sections.


Peripheral Nervous System


Cranial Nerves


Learning the cranial nerves for nursing school was not always an easy feat. There is no need to memorize them now. There are 12 cranial nerves, each with a specific function.


 














































Nerve


Function


I Olfactory


  Smell


II Optic


  Vision


III Oculomotor


  Pupil response


  Eye muscle movement


IV Trochlear


  Eye muscle movement


V Trigeminal


  Three branches:


      Ophthalmic: eye sensation


      Maxillary: lower eyelid, nose, upper teeth, and upper lip


      Mandibular: lower teeth, tongue, chin, and lower lip


VI Abducens


  Eye movement


VII Facial


  Taste


  Facial movement


  Tears


  Saliva


VIII Vestibulocochlear


  Two branches:


      Vestibular: balance


      Cochlear: hearing


IX Glossopharyngeal


  Gag reflex


  Swallowing


  Taste


X Vagus


  Throat


  Swallowing


  Receptor responses


XI Accessory


  Trapezius and sternocleidomastoid muscle movement


  Inner throat movement


XII Hypoglossal


  Tongue movement to swallow


  Chewing


  Speech


Spinal Nerves


There are 31 pairs of spinal nerves that correspond to the vertebral level.


 

























Vertebral Level


Nerves


Cervical


Nerves C1–C8


Thoracic


Nerves T1–T12


Lumbar


Nerves L1–L5


Sacral


Nerves S1–S5


Coccygeal


1 nerve


THE SENSORY SYSTEM


The sensory system contains the eyes and ears. Structures of the eye can be divided into three layers:



  Cornea


  Choroid


      Iris


      Pupil


  Retina


      Optic disc


      Macula


There are three parts to the ears, which include:



  External ear


      Ear canal


  Middle ear


      Tympanic membrane


      Eustachian tubes


  Inner ear


      Cochlea


ASSESSMENT OVERVIEW


As you can see, the neurologic and sensory systems contain a large number of structures and perform many body functions. You will be challenged to complete these assessments and will be limited in your ability to:



  Observe body movement and positioning


  Assess cranial and spinal nerve functioning


  Determine eye function and pupillary response


The one status that you will be able to assess thoroughly is that of hearing because you will be asking carefully structured, succinct questions in order to determine the functioning of these body systems. As with the previous body systems, the best approach might be to introduce this assessment by saying, “Let’s spend some time now talking about the nerves, vision, and hearing. Before we get started, are you having or have you had any problems with your nerves, eyes, or ears?” Plan your assessment according to the response.


QUESTIONS TO ASSESS THE NEUROLOGIC SYSTEM



















































































































Body Area


Question


Brain


Have you ever had an injury to your head? If so,


  When did this occur?


  How was it treated?


  Have you had many changes because of the injury?


Frontal lobe


Do you have any problems walking or moving your arms and legs?


 


(Observe the patient’s speech pattern. You will not be going into an in-depth assessment of thinking/reasoning/judgment but ask about activities of daily living and instrumental activities of daily living.)


Are you able to complete your own care needs such as:


  Bathing?


  Dressing?


  Toileting?


  Eating?


Are you able to perform routine activities such as:


  Cooking?


  Grocery shopping?


  Balancing a checkbook?


Temporal lobe


Have you had or are you experiencing any changes in your ability to smell things? If so, what are the changes?


  Do you have smoke alarms in your (home, apartment, room)?


 


(This lobe is responsible for the interpretation of hearing. If the patient/client is responding appropriately to your questions, it is unlikely that there are any issues with hearing interpretation.) If the patient/client is not responding appropriately to questions:


  Are you able to hear me?


  Can you understand what I am saying?


(Be advised that these are not appropriate questions for a patient with English as a second language or someone who recently relocated to the United States and has not mastered the English language. These questions are to assess if the spoken word is being appropriately transmitted to the temporal lobe for sensory interpretation and not to measure ability to comprehend a different language.)


Parietal lobe


Is the temperature of the room where you sitting right now comfortable to you?


  Is it too hot, too cold?


  Are you able to adjust your clothing or environment if it is too hot or too cold?


 


Are you having any pain right now? If so,


  Where is the pain?


  Describe what it feels like.


  How long does it last?


  What makes it better?


  What makes it worse?


Occipital lobe


Although we will spend more time on vision shortly, can you tell me if you have or have had any problems with your vision?


  Tell me some of the items around you right now.


Additional brain structures


Do you have any problems swallowing?


 


Do you ever feel like you aren’t stable on your feet when standing still or walking?


 


Do you have or have you had any issues with a cough or sneezing?


Cranial nerves


(If no issue with sense of smell, no need to repeat asking questions about CN I)


 


(If no issue with vision, no need to repeat asking questions about CN II, III, IV, and VI)


 


Do you have or have you had any problems with pain on the skin around your eyes, cheeks, or jaw? If so,


  Is the pain constant?


  Is it aggravated by something else, such as eating, drinking, talking, smoking, or cold air?


  What makes the pain better?


  Have you been treated for this face pain? If so,


  What is/was the treatment/medication?


  How often do you use the treatment/medication?


 


When you smile do both sides of your mouth move? If not, which side does not move?


  How long has this been going on?


 


Do you have any problems swallowing food or liquids? If so,


  What is the problem? How long has this been going on?


 


Have you had or are you having any problems with the taste of food? If so,


  What foods taste different?


  What is the taste that you are experiencing?


  How long has this been going on?


 


Have you had or are you having any problems chewing food? If so,


  What is the problem?


  How long has this been going on?


 


Have you had or are you having any problems with your tongue? If so,


  Describe the problem.


  How long has this been going on?


Spinal nerves


Are you having or have you had any pain that was caused by nerve irritation? Such as:


  Neck pain


  Arm pain


  Pain down the back of your leg


  Lower back pain


  Foot pain


If so,


  When does the pain occur?


  What makes it better?


  What makes it worse?


  What have you been told about the pain?


 


Have you had an injury to your neck or back at any time? If so,


  What was the injury?


  When did it happen?


  How was it treated?


  How does it feel right now?


  Is there anything that you have to do now to prevent it from happening again?


 


Have you had or currently have numbness or tingling of any body part. If so,


  Where is the numbness/tingling occurring?


  How long does it last?


  What makes it better?


  What makes it worse?


  What have you been told about the numbness/tingling?


 


Have you ever had any operations on your neck or back? If so,


  What was done?


  When was it done?


  Why was it done?


 


Have you had or currently have weakness of any arms or legs? If so,


  Which arm/leg?


  On the right side of the body?


  On the left side of the body?


  How long has this been going on?


  What has your doctor/health care provider told you about the weakness?


Has the weakness changed your ability to:


  Walk?


  Eat?


  Perform other activities?


Eyes


Do you have any problems seeing/with your vision? If so, what is the problem?


  Blurred vision


  Blind spots


  Floaters


 


Do you wear eyeglasses? For what reason?


  All of the time


  To read


  For distance


  When driving


 


Have you ever been told that you have an eye problem such as:


  Glaucoma?


  Cataracts (cloudy vision)?


  Macular degeneration (loss of central vison)?


 


Have you ever had eye surgery? If so, what was it for?


  Detached retina


  Laser surgery (to correct vision)


  Laser surgery (to stop bleeding from diabetic retinopathy)


 


Are you prescribed any medications for your eyes? If so,


  What is the name of the medicine?


  How many drops each time?


  How often are they used?


  What are they for?


 


Do you have any problems with:


  Eye tearing?


  Dry eyes?



How often do you see your eye doctor?


  When is your next appointment?


Ears


Are you having any problems with your ears right now? If so,


  What is the problem?


  Is the problem “buzzing” or “ringing” in the ears?


  How long has it been going on?


  What have you been doing about it?


 


How do you remove wax from your ears?


 


Are you having any problems with your hearing? If so,


  How long has this been going on?


  Do you use a hearing aid?


  What kind of hearing aid do you have?


 


Have you ever had surgery on your ears? If so,


  When was it done?


  What was it for?


  Did the surgery fix the problem?


ALGORITHM FOR ASSESSING THE NEUROLOGIC AND SENSORY SYSTEMS


If you are calling a patient/client who is experiencing a new set of symptoms, the following questions might be helpful.


 





















































































Finding


Action


Headache


Assess for the location of the headache:


  At the base of the neck (hypertension)


  Top of the head


  Temporal area


  Forehead (sinus)


  Behind the eyes (cluster, sinus)


 


Assess for when the headache started:


  Woke up with it in the morning (hypertension)


  Gradually during the day (migraine, tension)


  After sitting and working at a computer (tension)


 


Assess for any other symptoms:


  Eye pain with light (photophobia)


  Eye tearing (cluster headache)


  Nausea/vomiting (increasing intracranial pressure, Meniere’s disease)


 


Suspect:


  Headache associated with hypertension (assess further if patient/client has a history of this disorder)


  Tension headache if occurs after sitting/working in a hunched position


  Sinus headache if associated with forehead pain, nasal stuffiness


  Migraine headache if associated with photophobia


  Cluster headache if associated with eye tearing


  Increasing intracranial pressure if associated with nausea/vomiting:


      Assess for changes in level of responsiveness


  Meniere’s disease if associated with nausea/vomiting:


      Assess for hearing and dizziness


 


Encourage to seek medical attention for any new onset of symptoms


Pain


Assess for location of pain:


  Eye


  Leg


  Ear


  Back


 


Assess for when the pain started:


  After reading


  Sitting


  Walking


  Lifting an object or twisting


 


Assess for length of time pain has been occurring


 


Assess for what has been done to help the pain


 


Assess for any associated symptoms:


  Acute loss of vision (acute glaucoma, detached retina)


  Loss of hearing (ruptured eardrum)


  Limb numbness/tingling/weakness (nerve compression)


 


Suspect:


  Acute onset glaucoma, detached retina with loss of vision


  Acute onset ruptured tympanic membrane with loss of hearing


  Nerve compression with limb numbness/tingling/weakness


 


Encourage to seek medical attention for any new onset of symptoms


Change in vision


Assess for the change:


  Complete loss of vision in one/both eyes


  Loss of peripheral vision


  Loss of central vision


  Blurred vision


  Spots in vision


  Cloudy vision


  “Yellow haze” or “halo” vision


 


Assess for length of time vision change has occurred:


  Sudden


  Gradual


  Upon waking up in the morning


  Over the course of the day


 


Assess for any associated symptoms:


  Eye pain


  Tearing


  Eye drainage/mucus


  “Red” eyes


 


Suspect:


  Acute onset glaucoma with eye pain


  Macular degeneration with loss of central vision


  Glaucoma with loss of peripheral vision


  Cataracts with cloudy vision


  Floaters with “spots” in vision


  Medication adverse effect (digitalis/digoxin) with yellow or halo vision


  Infection with red eyes and drainage


  Metabolic disorder (diabetes) with blurred vision


(Conduct additional assessments if indicated)


 


Encourage to seek medical attention for any new onset of symptoms


Ears Ringing (Tinnitus)/Acute onset of deafness


Assess when the ear ringing/deafness started


(Assess medications if noticed after starting/taking a specific medication such as ototoxic antibiotics or over-the-counter aspirin)


 


Assess activities being done when the ear ringing/deafness started:


  Listening to loud music


  Loud bang/gunshot/bomb


  Swimming/water in the ears


  Cleaning the ears with an ear swab or other object


 


Assess for any other symptoms:


  Nausea/vomiting


  Pain in or around the ear


  Drainage/bleeding from the ear


 


Suspect:


  Acute irritation if occurring after loud music, loud noise


  Acute ear infection if associated with water in the ears/swimming


  Tympanic membrane rupture if associated with cleaning the ears


  Medication adverse effect if associated with medications


 


Encourage to seek medical attention for any new onset of symptoms


Onset of paralysis


Access if paralysis is on one side (both arm and leg) or just one limb


 


Assess when the paralysis started


 


Suspect acute stroke and refer for immediate medical attention


 


See Chapter 17 for additional information about neurologic and sensory system disorders.


TIPS FOR ASSESSING THE NEUROLOGIC AND SENSORY SYSTEMS


  Begin the assessment with asking if the client has experienced any new changes or symptoms.


  Use terms such as “feeling” or “numbness” to describe a problem with the cranial and/or peripheral nerves. Clients may become confused if the term “nerves” is used and think the assessment will focus on “nervousness” or “anxiety.”


  An acute onset of any new symptom should be investigated immediately.


  Any onset of slurred speech or confusion could indicate a stroke. Obtain medical assistance for the client.


  Emphasize that any acute change in vision or hearing needs immediate attention. Acute loss of vision in one eye could indicate a detached retina, requiring immediate surgery.


  Take the time and further assess any symptoms that might be attributed to a problem in another body system.


 

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Oct 5, 2017 | Posted by in NURSING | Comments Off on Neurologic and Sensory Systems
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