1/3/2008. Karen Burke Priscilla LeMone Elaine Mohn-Brown. Medical-Surgical Nursing Care, 2e Karen Burke, Priscilla LeMone, and Elaine Mohn-Brown

Transkript

1 Medical-Surgical Nursing Care Second Edition Karen Burke Priscilla LeMone Elaine Mohn-Brown Chapter 37 The Nervous System and Assessment Nervous System Controls and integrates sensory, motor, and autonomic functions Maintains internal homeostasis Enables connection and response to external environment Neuron Working cell of the nervous system Carries impulses Sensory (afferent) Motor (efferent) Neurotransmitters (chemicals) Facilitate or hinder impulse transmission across synapse 1

2 Figure A neuron. Central Nervous System Brain Spinal cord Brain Control center of the nervous system 2

3 Figure The four major regions of the brain with an illustration of the meninges. Brain Cerebrum; sensation, movement Left hemisphere; speech, problem solving, reasoning, calculations Right hemisphere; visual, spatial Brain Diencephalon Thalamus; sensory relay Hypothalamus; regulatory center Brainstem: vital centers Cerebellum Involuntary muscle activity; fine motor Balance and posture 3

4 Spinal cord Spinal tracts Sensory and motor messages White matter and gray matter Peripheral Nervous System Cranial nerves Spinal nerves Somatic nervous system Autonomic nervous system Sympathetic Parasympathetic Peripheral Nervous System Link between CNS and the body Spinal nerves 31 pairs Sensory and motor fibers Involved in reflexes/reflex arc 4

5 Spinal Nerves Cranial Nerves Cell bodies in brain/brainstem Sensory function, motor function, or both Mainly control head and neck functions Autonomic Nervous System Maintains internal homeostasis Two divisions Sympathetic: flight or fight Parasympathetic: rest and digest 5

6 The Eye Sensory organ Converts patterns of light to nerve impulses sent to brain Brain interprets impulses, makes meaning of visual input Figure The external and accessory structures of the eye. Eyeball Three layers Outer: sclera, cornea Middle: iris, ciliary body, choroids Pupil, lens Inner: retina Rods, cones, optic disk (optic nerve) 6

7 Eyeball Two interior cavities Posterior Vitreous body Anterior Anterior chamber Aqueous humor; canal of Schlemm Posterior chamber The Ear Sensory organ Converts sound to vibrations then impulses Brain interprets impulses as sound Participates in maintaining balance, equilibrium, coordination of body movements Figure Structures of the external, middle, and inner ear. 7

8 External Ear Pinna Auditory canal Eardrum Middle Ear Auditory ossicles (bones) Malleus, incus, stapes Eustachian tube Labyrinth Vestibule Semicircular canals Cochlea Organ of Corti Inner Ear 8

9 Neurologic Assessment LOC always assessed first Altered LOC leads to inaccuracies Determine alternate sources of information Family, caregivers, health care professionals Subjective Past medical history Assessment Actual neurologic disorders/family history Medication use Symptom history; include pain assessment Social/environmental data Assessment Subjective Motor: loss of movement; altered balance, coordination Sensory: numbness, tingling, sight, touch Cognitive: memory, speech, intellect, mood 9

10 Subjective Eye Assessment PMH/family history related to the vision Changes in vision; use of corrective lenses; irritation Ear PMH/family history related to hearing Changes in hearing; tinnitus drainage Use of hearing aids Assessment Objective General survey Appearance, gait, balance, posture Vital signs Cranial nerve assessment Objective Cognitive functioning Assessment LOC, mental status, mood Sensory functioning Sight, sounds, touch Motor functioning Muscle strength, tone symmetry Reflexes 10

11 Objective Eye Assessment Snellen, Rossenbaum charts Inspection Ear Rinne, Webber, whisper tests Inspection Expected Alterations Related to Aging Slower movement and reflexes Forgetfulness Changes in sleep patterns Changes in motor skills Expected Alterations Related to Aging Ptosis Presbyopia Decreased tear production Changes in eyelids Hearing difficulties Increased production of cerumen 11

12 Unexpected Alterations Related to Aging Significant changes in Long/short-term term memory Mental status Coordination/motor skills Speech Pain perception Sleep Unexpected Alterations Related to Aging Significant changes in Orientation Psychologic status Electrolytes Complete blood count Liver function tests Renal panel Arterial blood gases Cultures Urinalysis Laboratory Test 12

13 Imaging Studies All radiographic studies Allergy assessment shellfish/iodine shellfish/iodine Hydration, renal function Pregnancy concerns Client teaching about procedure Imaging Studies Skull/spine x-rays Client teaching/explanation MRI Assess for implanted metal Client teaching: enclosed space; noise Imaging Studies CT scan ID shellfish/iodine allergy Assess disorientation Medicate for agitation Teach: warm sensation with contrast 13

14 Imaging Studies Cerebral angiography NPO prior Flushing with contrast media Close neurologic/vs monitoring post Pressure dressing/ice Report bleeding/swelling at site STAT Imaging Studies Myelography Post: elevate HOB, bed rest Close neurologic/vs monitoring Report leakage/bleeding at site STAT PET NPO 4 hours prior IV start Post: hydration Carotid duplex Imaging Studies 14

15 Electrographic Studies EEG, evoked potentials Wash hair prior EMG Discomfort with needle insertion Vision Tests Fluorescein stain Potential stinging; staining not permanent Visual fields Tiring Facial x-rays/ct scan Explain procedure Ultrasound Cornea anesthetized Hearing Tests Audiometry Explain procedure X-ray/CT scan Explain procedure Electronystagmography Post assessment; vomiting Aspiration precautions 15