Chapter 3: Cultural Competence: Cultural Care
The Spinning Woman Illusion
--Nobuyuki Kayahara
J Carley MSN, MA, RN, CNE
Fall, 2009
JARVIS , C. (2008)
Physical Examination & Health Assessment
Chapter
232004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Elsevier items and derived
items © 2008,
Slide 3-1
Unit Objectives
•1. Describe the anatomic structures of the central
nervous system and brain.
•2. Identify the 12 cranial nerves and their function
•3. Complete the Glasgow Coma scale, the Rancho Los
Amigos scale, and the mini mental state exam as
appropriate for case studies.
4. Explain how to prepare the client for a neurological
examination
5. Discuss the appropriate equipment necessary for
examining the neurological system.
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23-2
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23-3
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23-4
Peripheral nerves go from spinal cord
to arms, hands, legs, and feet
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23-5
Autonomic nerves go to the stomach,
intestines, and other parts of the
digestive system
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23-6
Cranial nerves go from brain to
eyes, mouth, ears, and other parts of
head (and others…e.g., Vagus)
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23-7
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23-8
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23-9
Central Nervous System
(CNS)
 Cerebral cortex  Hypothalamus
- Frontal lobe
 Cerebellum
- Parietal lobe
- Occipital lobe
 Brainstem
- Wernicke’s area
- Broca’s area
 Basal ganglia
 Thalamus
- Midbrain
- Pons
- Medulla
 Spinal cord
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2310
Cerebral Cortex
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2311
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2312
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2313
[PRODUCTION NOTE: Please insert Figure 23-2 (from Jarvis Physical
Examination and Health Assessment, 5e, ISBN: 978-1-4160-3243-4)]
CNS
© Pat Thomas,
2006.
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2314
I
Olfactory
II
Optic
III
Oculomotor
IV
Trochlear,
VI
Abducens
V
Trigeminal
VII
Cranial
Nerves
Facial
VIII Acoustic (vestibulocochlear)
IX
Glossopharyngeal
X
Vagus
XI
Spinal accessory
XII
Hypoglossal
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2315
Cranial Nerves - Introduction
Interactive quiz to identify the cranial nerve function.
Olfactory I
Optic II
Oculomotor III
Trochlear IV
Trigeminal V
Abducens VI
Facial VII
Auditory (vestibulocochlear) VIII
Glossopharyngeal IX
Vagus X
Spinal Accessory XI
Hypoglossal XII
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2316
CNS Pathways
 Sensory pathways
- Spinothalamic tract
- Posterior (dorsal) column
 Motor pathways
- Corticospinal or pyramidal
tract
- Extrapyramidal tracts
- Cerebellar system
 Upper motor neurons
 Lower motor neurons
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2317
Sensory Pathways
© Pat Thomas, 2006.
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2318
Motor Pathways
© Pat Thomas, 2006.
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2319
Reflex Arc
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2320
Subjective Data






Headache
Head injury
Dizziness or Vertigo
Seizures
Tremors
Weakness
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2321
Subjective Data
 In-coordination / “uncoordinated”
 Numbness or tingling
 Difficulty swallowing
 Difficulty speaking (Dysphasia)
 Environmental/occupational hazards
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2322
Objective Data
 Equipment needed
- Penlight
- Tongue blade
- Toothpick
- Cotton swab / Cotton ball
- Tuning fork (128 or 256 Hz)
- Percussion hammer
- Familiar aromatic substance
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2323
Motor System
 Muscles
- Size
- Strength
- Tone
- Involuntary movements
 Cerebellar function
- Balance tests
- Coordination
- Skilled movements
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2324
Romberg Test
 Proprioceptive pathway
Negative
- ve
Positive
+ ve
Normal
Abnormal
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2325
Ambulation
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2326
Describe…
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2327
Abnormal Ambulation
Asymmetrical Spastic Diplegia
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2328
Neuro Check (Crani Check)
 Level Of Consciousness (LOC)
Person
Place
Time




Oriented x
3
Motor function
Pupillary response
Vital signs
Glasgow Coma Scale (GCS)
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2329
IntraCranial Pressure = ICP
Pressure within the cranial cavity influenced by brain mass,
the circulatory system, CSF dynamics, and skull rigidity
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2330
Increased
ICP (IICP)
Critical event / Life threatening
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2331
CT scan showing intracranial
hemorrhage with cerebral
edema, midline shift, and
increased intracranial pressure
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2332
Glasgow Coma Scale
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2333
The GCS is the most
widely used method of
defining a patient's level
of consciousness (LOC)
34
35
Expanded
Neuro
Assessment
Tool
36
Mini-Mental Status Exam
Rancho Los Amigos Scale
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2337
EARLY Signs of
↑ ICP
The most important
neurologic “vital sign”
!!!!!!!!!!!!!!!!!!!!!!!!!
1. LOC changes ******MOST IMPORTANT****
2. Pupils sluggish / Impaired eye movement
3. Limb strength changes
4. Headache
38
Pupils
LATE Signs of
.
ICP
.
“Call the
neurosurgeon”
1. Further decreased LOC
2. Cushing’s Triad
3. Abnormal respiration patterns
anisicoria
“fixed & dilated
4. Pupils asymmetrical / Dilated
5. Projectile vomiting
“Call the
chaplain.”
6. Hemiplegia / decorticate or decerebrate posturing
39
Late Sign of IICP
Cushing’s “Triad”


Blood Pressure
(Widening Pulse Pressure)

Temperature

Pulse
40
Abnormal Postures
 Flaccid quadriplegia
 Decorticate rigidity
 Decerebrate rigidity
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2341
“Toward the Core”
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2342
43
Pupil Responses
Dilated ?
Consenusal ?
Shape ?
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2344
Rapidly Alternating
Movement (RAM) Evaluation
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2345
Finger to Nose Test
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2346
Heel to Shin Coordination Test
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2347
Test Deep Tendon Reflexes
Technique
Grading
Babinski’s sign
Biceps reflex
Triceps reflex
Brachioradialis reflex
Quadriceps reflex
Achilles reflex (“ankle jerk”)
Abdominal reflexes
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2348
Reflexes
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2349
Babinski Reflex
Negative
- ve
Normal
Positive
+ ve
Abnormal
A normal response, B Babinski reflex
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2350
Testing the DTR’s provides
data about the
INTACTNESS of the
REFLEX ARC at specific
levels in the spinal cord.
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2351
Abnormalities in Muscle Movement




Paralysis
Fasciculations
Flaccidity
Ataxia
 Rest tremor
 Intention
tremor
 Paresthesia
 Coma
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2352
Sensory System

Alert, cooperative, and comfortable
 Spinothalamic tract
- Pain
- Temperature
- Light touch
 Posterior column tract
- Vibration
- Position (kinesthesia)
- Tactile discrimination
(stereognosis,
graphesthesia)
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2353
Aged – “Less” is Normal
- Walk slower
- More careful walking
- Decreased tactile sensation
- Lose ability to feel vibration
at ankles
- Decreased ability to smell
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2354
Cultural Considerations
“Epilepsy”
Uganda: contagious, untreatable
Greece: source of family shame
Mexican-American: evidence of physical
imbalance
Hutterites: having endured a trial by God
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2355
Narrative Charting
Denies any of the following: frequent or severe headaches; history of head
injury, dizziness, or vertigo. Denies weakness, numbness, or tingling; no
difficulty swallowing or speaking. No past history of stroke, meningitis, spinal
cord injury, or alcoholism.
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2356
Narrative Charting
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2357
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2358
Jarvis Page 679
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2359
Neuro Assessments
Neuro Assessment Practice:
 http://icarus.med.utoronto.ca/NeuroExam/

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2360
Which area of the brain is most likely
affected if the patient is having trouble
with the finger-to-nose test?
A.
B.
C.
D.
Cerebellum
Cerebrum
Hypothalmus
Brain stem
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2361
Vibratory sense is most
frequently affected in cases of?
A.
B.
C.
D.
Heart disease
Crohns’ disease
Lung Cancer
Diabetes
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2362
Brain Teasers
http://brainconnection.positscience.com/teasers/
Slide
2363
The Hermann Grid Illusion
This phenomena demonstrates a very important principle of perception: we don't
always see what's really there. Our perceptions depend upon how our visual system
responds to environmental stimuli and how our brain then interprets this
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information.1
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1
Bach, M. (n.d.). Grid illusions. http://www.michaelbach.de/ot/lum_herGrid/index.html
The Zollner Illusion
This illusion presents a series of oblique lines crossed with overlapping short lines. The oblique
lines look as if they are crooked and will diverge. In reality, all of the oblique lines are
parallel.This optical illusion demonstrates how the background of an image can distort the
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appearance of straight lines.
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The
End
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