Neurological Assessment & Diagnostic Studies NET 2420 Neuro Lecture Handout S. Compton RN, MSN
Nursing History <ul><li>Current Health History </li></ul><ul><ul><li>Headaches, memory and concentration, visual disturban...
Complete Neurological  Assessment 5 Components <ul><li>Cerebral Function  </li></ul><ul><li>Cranial Nerve Function: I-XII ...
Neuro Check <ul><li>Level of consciousness (LOC) </li></ul><ul><li>Pupil response and size </li></ul><ul><li>Verbal respon...
Cerebral Function <ul><li>Level of consciousness:  </li></ul><ul><ul><li>Level of  arousal:  Subcortical RAS </li></ul></u...
Cerebral Function: Verbal Responsiveness and Speech <ul><li>Dysarthria: difficulty with mechanics of speech </li></ul><ul>...
Mini-Mental State <ul><li>Widely used tool </li></ul><ul><li>Assesses only cognitive abilities </li></ul><ul><ul><li>LOC, ...
Cranial Nerves (CNs) Smeltzer & Bare Table 60-5  p 1837 <ul><li>CN I- Olfactory </li></ul><ul><li>CN II- Ophthalmic </li><...
Cranial Nerve I <ul><li>Olfactory nerve (sensory) </li></ul><ul><ul><li>Vulnerable to damage in frontal head, basilar, and...
Cranial Nerve II <ul><li>Optic nerve (sensory) </li></ul><ul><ul><li>Visual acuity, visual fields, ophthalmic exam of reti...
Visual Field Defects
Cranial Nerve III <ul><li>Oculomotor nerve (motor) </li></ul><ul><ul><li>Elevation of eyelid </li></ul></ul><ul><ul><li>Mu...
CN III, CN IV, CN VI <ul><li>Oculomotor, trochlear, abducens nerves (motor) </li></ul><ul><ul><li>Assess EOM’s </li></ul><...
CN V: Trigeminal Nerve  (sensory and motor) <ul><li>Sensory:  three branches: </li></ul><ul><ul><li>Opthalmic, Maxillary, ...
CN VII: Facial Nerve (sensory and motor) <ul><li>Sensory:  taste to anterior 2/3 of tongue </li></ul><ul><li>Motor:  Facia...
CN VIII: Acoustic Nerve (sensory) <ul><li>Vestibulocochlear nerve: </li></ul><ul><ul><li>Hearing (cochlear) and balance (v...
CN IX and CN X   <ul><li>Glossopharyngeal and Vagus  </li></ul><ul><li>Sensory and motor </li></ul><ul><li>Assess together...
CN XI: Spinal Accessory Nerve   <ul><li>Motor </li></ul><ul><li>Shrug shoulders   trapezius </li></ul><ul><li>Turn head ...
CN XII: Hypoglossal Nerve <ul><li>Motor </li></ul><ul><li>Tongue movements, strength </li></ul><ul><li>Speech sounds: d, l...
Motor Assessment <ul><li>Assess muscle strength, tone, size </li></ul><ul><ul><li>Observe for decreased fine motor movemen...
Cerebellar Function <ul><li>Balance: </li></ul><ul><ul><li>Tandem, heel-toe walking </li></ul></ul><ul><ul><li>Romberg tes...
Cerebellar Function:  Abnormal Findings <ul><li>Ataxia: incoordination of voluntary muscle action </li></ul><ul><li>Dysdia...
Gait Disturbances   <ul><li>Spastic Hemiparesis </li></ul><ul><li>Spastic Paresis </li></ul><ul><li>(Scissors Gait) </li><...
Deep Tendon Reflexes  Assessing Spinal Cord Level <ul><li>Biceps C5C6 </li></ul><ul><li>Brachioradialis C5C6 </li></ul><ul...
Grading Reflexes <ul><li>Grade 0-4+  </li></ul><ul><ul><li>0    reflex absent </li></ul></ul><ul><ul><li>2+    “normal” ...
Superficial Reflexes <ul><li>Graded as PRESENT or ABSENT </li></ul><ul><li>Corneal Reflex (CN V) </li></ul><ul><ul><li>Pre...
Plantar Reflex: Babinski Response   <ul><li>Stroke lateral aspect of sole of foot </li></ul><ul><li>NORMAL response    pl...
Grasp Reflex: Significance <ul><li>COMA: Stimulation of palm of hand </li></ul><ul><ul><li>POSITIVE: Pt will grasp firmly ...
Sensory Function <ul><li>Assessing dorsal columns or parietal lobe  </li></ul><ul><ul><li>Light touch, position sense, vib...
Gerontologic Considerations <ul><li>Smeltzer & Bare  p 1841 </li></ul><ul><li>Structural changes </li></ul><ul><ul><li>Dec...
Anatomical Planes
Skull and Spinal X-rays <ul><li>C-spine films routinely ordered in multiple trauma to rule out cervical fracture </li></ul...
Computerized Tomography <ul><li>Cross sectional images brain and spine using radiation and computer </li></ul><ul><li>More...
CT: Patient Preparation <ul><li>Pt must be as motionless as possible </li></ul><ul><ul><li>Confused combative client/ pedi...
PET Scan <ul><li>Images of actual organ functioning </li></ul><ul><li>Inhaled or injected radioactive substance </li></ul>...
MRI: Nursing Considerations <ul><li>Use of electromagnet and radio waves </li></ul><ul><li>Check patient history!! </li></...
Cerebral Angiography <ul><li>Injection of contrast medium into cerebral circulation </li></ul><ul><li>Useful in detecting ...
Cerebral Angiography:  Procedure & Patient Preparation <ul><li>Injection of contrast medium into cerebral circulation </li...
MR Angiography (MRA) <ul><li>Utilization of MR technology to view vasculature </li></ul><ul><li>Same restrictions as MRI <...
Myelogram <ul><li>Injection of contrast medium into subarachnoid space   x-ray visualization </li></ul><ul><li>Useful for...
Patient Preparation <ul><li>Inpatient procedure/ 23 HR </li></ul><ul><li>Consent form </li></ul><ul><li>NPO 4-8 hours prio...
Post-procedure Care <ul><li>Amipaque: not aspirated   absorbed by body  </li></ul><ul><ul><li>HOB 30-60 degrees for 24 ho...
EEG <ul><li>Amplifies and  </li></ul><ul><li>records electrical  </li></ul><ul><li>activity in brain </li></ul><ul><li>Use...
EEG Preparation Use of Evoked Potentials <ul><li>Preparation:  </li></ul><ul><ul><li>Avoidance of caffeine prior to exam <...
Electromyography (EMG)  and  Nerve Conduction Velocities (NCV) <ul><li>EMG: Needle electrodes inserted into skeletal muscl...
Lumbar Puncture <ul><li>Insertion of needle into subarachnoid space between L2 and S1 </li></ul><ul><li>Withdrawal of smal...
Lumbar Puncture <ul><li>Patient preparation: </li></ul><ul><ul><li>No diet or fluid restrictions </li></ul></ul><ul><ul><l...
Lumbar Puncture <ul><li>CSF in three labeled tubes </li></ul><ul><ul><li>Protein and glucose </li></ul></ul><ul><ul><li>Cu...
Post-Lumbar Puncture Headache <ul><li>Most common complication </li></ul><ul><li>CSF leaks from needle track    depleted ...
CSF Fluid Analysis   <ul><li>Pressure: Normal: 70-180 mmH2O  (5-15mmHg) </li></ul><ul><ul><li>Increased: SAH, brain tumor,...
CSF Fluid Analysis <ul><li>Cell Count: 0-5 monos and no RBC’s </li></ul><ul><ul><li>Elevated monos   infection, abcess, t...
Upcoming SlideShare
Loading in …5
×

Neurological Assessment

3,942
-1

Published on

0 Comments
10 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
3,942
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
144
Comments
0
Likes
10
Embeds 0
No embeds

No notes for slide
  • If CVA or tumor causes cortex (UMN) damage, pt. Will still be able to wrinkle forehead If facial nerve damage, unable to wrinkle forehead or close eye
  • Neurological Assessment

    1. 1. Neurological Assessment & Diagnostic Studies NET 2420 Neuro Lecture Handout S. Compton RN, MSN
    2. 2. Nursing History <ul><li>Current Health History </li></ul><ul><ul><li>Headaches, memory and concentration, visual disturbances, hearing, balance, dizzy spells, speech, muscle strength, abnormal sensations </li></ul></ul><ul><li>Past Health History </li></ul><ul><ul><li>Head injury, spinal cord injury, surgery, seizures </li></ul></ul><ul><li>Family History </li></ul><ul><ul><li>Neurological diseases, headaches, HTN, stroke, DM </li></ul></ul><ul><li>Social History and Habits </li></ul><ul><ul><li>Diet, vitamin deficiencies, ability to read or concentrate, exposure to toxins or chemicals, alcohol or drug use, sexual difficulties, sleep problems </li></ul></ul><ul><li>Medication History-neuro as well as all others </li></ul>
    3. 3. Complete Neurological Assessment 5 Components <ul><li>Cerebral Function </li></ul><ul><li>Cranial Nerve Function: I-XII </li></ul><ul><li>Cerebellar and Motor Function </li></ul><ul><li>Sensory System </li></ul><ul><li>Reflexes </li></ul>
    4. 4. Neuro Check <ul><li>Level of consciousness (LOC) </li></ul><ul><li>Pupil response and size </li></ul><ul><li>Verbal responsiveness </li></ul><ul><li>Extremity strength and movement </li></ul><ul><li>Vital signs </li></ul><ul><li>Establishing BASELINE and regularly re-evaluating key indictors reveals trends and detects changes  warning signs of problems </li></ul>
    5. 5. Cerebral Function <ul><li>Level of consciousness: </li></ul><ul><ul><li>Level of arousal: Subcortical RAS </li></ul></ul><ul><ul><ul><li>Alert  lethargic  unresponsive </li></ul></ul></ul><ul><ul><ul><li>Auditory  tactile  painful stimuli to elicit response </li></ul></ul></ul><ul><ul><li>Level of orientation: Cortex activity </li></ul></ul><ul><ul><ul><li>Person, place, time </li></ul></ul></ul><ul><li>Speech </li></ul><ul><ul><li>Quality: Clear, slurred </li></ul></ul><ul><ul><li>Verbal responses appropriate or nonsensical </li></ul></ul><ul><ul><li>Ability to understand and follow commands </li></ul></ul><ul><ul><li>Awareness of and difficulties with communication </li></ul></ul>
    6. 6. Cerebral Function: Verbal Responsiveness and Speech <ul><li>Dysarthria: difficulty with mechanics of speech </li></ul><ul><li>Aphasia: </li></ul><ul><ul><li>TEMPORAL-receptive </li></ul></ul><ul><ul><ul><li>Inability to understand or process speech  Wernicke’s </li></ul></ul></ul><ul><ul><ul><li>Auditory: spoken word </li></ul></ul></ul><ul><ul><ul><li>Visual: written word </li></ul></ul></ul><ul><ul><li>FRONTAL-expressive </li></ul></ul><ul><ul><ul><li>Inability to form or use language  Broca’s Area </li></ul></ul></ul><ul><ul><ul><li>Spoken OR written or BOTH </li></ul></ul></ul><ul><ul><li>GLOBAL: both receptive and expressive </li></ul></ul>
    7. 7. Mini-Mental State <ul><li>Widely used tool </li></ul><ul><li>Assesses only cognitive abilities </li></ul><ul><ul><li>LOC, abstract reasoning, arithmetic calculations, writing ability, memory and judgment </li></ul></ul><ul><li>Objective score based on results </li></ul>
    8. 8. Cranial Nerves (CNs) Smeltzer & Bare Table 60-5 p 1837 <ul><li>CN I- Olfactory </li></ul><ul><li>CN II- Ophthalmic </li></ul><ul><li>CN III- Occulomotor* </li></ul><ul><li>CN IV- Trochlear* </li></ul><ul><li>CN V- Trigeminal </li></ul><ul><li>CN VI- Abducens* </li></ul><ul><li>CN VII- Facial </li></ul><ul><li>CN VIII- Vestibulocochlear </li></ul><ul><li>CN IX- Glossopharyngeal </li></ul><ul><li>CN X- Vagus </li></ul><ul><li>CN XI- Spinal Accessory </li></ul><ul><li>CN XII- Hypoglossal </li></ul>
    9. 9. Cranial Nerve I <ul><li>Olfactory nerve (sensory) </li></ul><ul><ul><li>Vulnerable to damage in frontal head, basilar, and facial injuries </li></ul></ul><ul><ul><li>Performed one nostril at a time </li></ul></ul><ul><ul><li>Able to correctly identify smells </li></ul></ul>
    10. 10. Cranial Nerve II <ul><li>Optic nerve (sensory) </li></ul><ul><ul><li>Visual acuity, visual fields, ophthalmic exam of retinal structures </li></ul></ul><ul><ul><li>Area and extent of visual field loss depends on location of problem </li></ul></ul>
    11. 11. Visual Field Defects
    12. 12. Cranial Nerve III <ul><li>Oculomotor nerve (motor) </li></ul><ul><ul><li>Elevation of eyelid </li></ul></ul><ul><ul><li>Muscles of eye </li></ul></ul><ul><ul><li>(with IV and VI) </li></ul></ul><ul><ul><li>Assess pupil size, shape, response to light and accommodation  parasympathetic inervation </li></ul></ul><ul><ul><li>Assesses midbrain </li></ul></ul><ul><ul><li>Normal response: PERRLA-> pupils equal round reactive to light and accommodation </li></ul></ul><ul><ul><ul><li>How do you test for accommodation? </li></ul></ul></ul><ul><ul><ul><li>If PERRL, usually no need to test </li></ul></ul></ul>
    13. 13. CN III, CN IV, CN VI <ul><li>Oculomotor, trochlear, abducens nerves (motor) </li></ul><ul><ul><li>Assess EOM’s </li></ul></ul><ul><ul><li>Assesses midbrain and pons </li></ul></ul>
    14. 14. CN V: Trigeminal Nerve (sensory and motor) <ul><li>Sensory: three branches: </li></ul><ul><ul><li>Opthalmic, Maxillary, Mandibular </li></ul></ul><ul><li>Motor: </li></ul><ul><ul><li>Muscles of mastication </li></ul></ul><ul><ul><ul><li>Palpate temporal and masseter muscles </li></ul></ul></ul><ul><ul><ul><li>Open mouth  symmetry </li></ul></ul></ul><ul><ul><li>Corneal reflex </li></ul></ul><ul><ul><ul><li>? Contact wearers </li></ul></ul></ul>
    15. 15. CN VII: Facial Nerve (sensory and motor) <ul><li>Sensory: taste to anterior 2/3 of tongue </li></ul><ul><li>Motor: Facial expression and secretion of saliva </li></ul><ul><ul><li>Wrinkle forehead, raise and lower eyebrows, smile and show teeth, puff cheeks, close eyes </li></ul></ul><ul><ul><li>Observe for symmetry </li></ul></ul><ul><li>UMN problems vs. facial nerve paralysis </li></ul>
    16. 16. CN VIII: Acoustic Nerve (sensory) <ul><li>Vestibulocochlear nerve: </li></ul><ul><ul><li>Hearing (cochlear) and balance (vestibular) </li></ul></ul><ul><li>Testing: Tuning Fork: Weber and Rinne tests </li></ul><ul><ul><li>Weber: tuning fork to center of forehead: </li></ul></ul><ul><ul><ul><li>NORMAL: hear equally in both ears </li></ul></ul></ul><ul><ul><li>RINNE: tuning fork to mastoid process then auditory canal </li></ul></ul><ul><ul><ul><li>NORMAL: hear air conduction 2X as long as bone (Rinne positive) </li></ul></ul></ul>
    17. 17. CN IX and CN X <ul><li>Glossopharyngeal and Vagus </li></ul><ul><li>Sensory and motor </li></ul><ul><li>Assess together </li></ul><ul><ul><li>Taste posterior 1/3 of tongue </li></ul></ul><ul><ul><li>Swallowing, gag reflex </li></ul></ul><ul><ul><li>Movement of pharynx (ahhhhh) </li></ul></ul><ul><li>Assesses medulla </li></ul>
    18. 18. CN XI: Spinal Accessory Nerve <ul><li>Motor </li></ul><ul><li>Shrug shoulders  trapezius </li></ul><ul><li>Turn head  sternocleidomastoid </li></ul>
    19. 19. CN XII: Hypoglossal Nerve <ul><li>Motor </li></ul><ul><li>Tongue movements, strength </li></ul><ul><li>Speech sounds: d, l, n, t </li></ul>
    20. 20. Motor Assessment <ul><li>Assess muscle strength, tone, size </li></ul><ul><ul><li>Observe for decreased fine motor movements </li></ul></ul><ul><ul><li>Finger grasp, arm strength </li></ul></ul><ul><ul><li>Compare side to side </li></ul></ul><ul><li>Can indicate UMN problems: </li></ul><ul><ul><li>Degenerative cerebral disease, trauma or ischemia </li></ul></ul><ul><li>Can indicate LMN disease: </li></ul><ul><ul><li>Problems within spinal cord: cord compression or injury </li></ul></ul>
    21. 21. Cerebellar Function <ul><li>Balance: </li></ul><ul><ul><li>Tandem, heel-toe walking </li></ul></ul><ul><ul><li>Romberg test (feet together, eyes closed) </li></ul></ul><ul><li>Coordination: </li></ul><ul><ul><li>Rapid alternating movements </li></ul></ul><ul><ul><li>Finger to nose to finger test </li></ul></ul><ul><ul><li>Heel down shin </li></ul></ul>
    22. 22. Cerebellar Function: Abnormal Findings <ul><li>Ataxia: incoordination of voluntary muscle action </li></ul><ul><li>Dysdiadochokinesia: inability to do rapid alternating movement </li></ul><ul><li>Dysmetria: past pointing </li></ul><ul><li>Positive Romberg’s sign </li></ul><ul><ul><li>Pt sways badly or loses balance  positive Romberg sign </li></ul></ul><ul><ul><ul><li>If cerebellar, pt sways with eyes open or closed </li></ul></ul></ul><ul><ul><ul><li>If proprioceptive ( posterior columns) patient OK with eyes open </li></ul></ul></ul>
    23. 23. Gait Disturbances <ul><li>Spastic Hemiparesis </li></ul><ul><li>Spastic Paresis </li></ul><ul><li>(Scissors Gait) </li></ul><ul><li>Foot Drop </li></ul><ul><li>Sensory Ataxia </li></ul><ul><li>(+ Romberg’s eyes closed) </li></ul><ul><li>Cerebellar Ataxia </li></ul><ul><li>(+ Romberg’s eyes open or closed) </li></ul><ul><li>F. Parkinsonian </li></ul>
    24. 24. Deep Tendon Reflexes Assessing Spinal Cord Level <ul><li>Biceps C5C6 </li></ul><ul><li>Brachioradialis C5C6 </li></ul><ul><li>Triceps C7C8 </li></ul><ul><li>Abdominal T8T9T10 </li></ul><ul><li>Patellar (knee-jerk) L2L3L4 </li></ul><ul><li>Achilles S1S2 </li></ul>
    25. 25. Grading Reflexes <ul><li>Grade 0-4+ </li></ul><ul><ul><li>0  reflex absent </li></ul></ul><ul><ul><li>2+  “normal” </li></ul></ul><ul><ul><li>4+  CLONUS  UMN disease </li></ul></ul><ul><li>Compare side to side </li></ul><ul><li>Many variations </li></ul><ul><li>Patient must be relaxed </li></ul>
    26. 26. Superficial Reflexes <ul><li>Graded as PRESENT or ABSENT </li></ul><ul><li>Corneal Reflex (CN V) </li></ul><ul><ul><li>Present  Brisk blink </li></ul></ul><ul><ul><li>Loss in stroke, coma, CONTACT WEARERS </li></ul></ul><ul><ul><li>EYE PROTECTION </li></ul></ul><ul><li>Gag Reflex (CN X) </li></ul><ul><ul><li>Present  Elevation of uvula bilaterally </li></ul></ul><ul><ul><li>Loss in stroke </li></ul></ul><ul><ul><li>ASPIRATION PRECAUTIONS </li></ul></ul>
    27. 27. Plantar Reflex: Babinski Response <ul><li>Stroke lateral aspect of sole of foot </li></ul><ul><li>NORMAL response  plantar FLEXION </li></ul><ul><li>BABINSKI response  pathological in adult </li></ul><ul><ul><li>POSITIVE BABINSKI: Dorsiflexion of great toe with fanning of other toes </li></ul></ul><ul><ul><li>Indicates upper motor neuron disease </li></ul></ul>
    28. 28. Grasp Reflex: Significance <ul><li>COMA: Stimulation of palm of hand </li></ul><ul><ul><li>POSITIVE: Pt will grasp firmly </li></ul></ul><ul><ul><li>Will not let go to command </li></ul></ul><ul><ul><li>Indicates frontal lobe damage, thalamic degeneration, cerebral atrophy </li></ul></ul>
    29. 29. Sensory Function <ul><li>Assessing dorsal columns or parietal lobe </li></ul><ul><ul><li>Light touch, position sense, vibration </li></ul></ul><ul><ul><li>Stereognosis: able to identify object placed in hand </li></ul></ul><ul><ul><li>Graphesthesia </li></ul></ul><ul><ul><li>Extinction: touch one or both sides of body </li></ul></ul><ul><ul><li>Two point discrimination </li></ul></ul><ul><li>Spinothalamic tracts and parietal lobe </li></ul><ul><ul><li>Pain and temperature </li></ul></ul><ul><ul><ul><li>Sharp or dull </li></ul></ul></ul>
    30. 30. Gerontologic Considerations <ul><li>Smeltzer & Bare p 1841 </li></ul><ul><li>Structural changes </li></ul><ul><ul><li>Decreased conduction </li></ul></ul><ul><li>Muscle atrophy </li></ul><ul><li>Diminished reflexes </li></ul><ul><li>Sensory alterations </li></ul><ul><li>Mental status changes </li></ul><ul><li>BUT….CANNOT ATTRIBUTE NEUROLOGIC CHANGES TO AGE WITHOUT THOROUGH ASSESSMENT!!!! </li></ul>
    31. 31. Anatomical Planes
    32. 32. Skull and Spinal X-rays <ul><li>C-spine films routinely ordered in multiple trauma to rule out cervical fracture </li></ul><ul><li>X-rays used to evaluate skull, spinal abnormalities, pituitary tumor </li></ul><ul><li>Frequently ordered to evaluate low back pain </li></ul>
    33. 33. Computerized Tomography <ul><li>Cross sectional images brain and spine using radiation and computer </li></ul><ul><li>More specific views of bone and tissue than X-rays </li></ul><ul><li>Useful in detecting tumors, hemorrhages, hematomas, ventricular enlargement </li></ul><ul><li>May be used with IV contrast enhancement </li></ul>
    34. 34. CT: Patient Preparation <ul><li>Pt must be as motionless as possible </li></ul><ul><ul><li>Confused combative client/ pediatric considerations </li></ul></ul><ul><li>If contrast used: </li></ul><ul><ul><li>?? allergies to shellfish </li></ul></ul><ul><ul><li>NPO for 4 hours prior to test </li></ul></ul><ul><ul><li>IV started in radiology (if not already in place) </li></ul></ul><ul><li>Should remove wigs, hairpins, clips and jewelry  interfere with image seen </li></ul><ul><li>Test should take 30-60 minutes </li></ul><ul><li>Post-test: resume diet and encourage fluids if IV contrast used </li></ul>
    35. 35. PET Scan <ul><li>Images of actual organ functioning </li></ul><ul><li>Inhaled or injected radioactive substance </li></ul><ul><li>Shows metabolic changes </li></ul><ul><ul><li>Alzheimer’s </li></ul></ul><ul><ul><li>Brain tumors </li></ul></ul><ul><ul><li>O2 uptake after stroke </li></ul></ul>
    36. 36. MRI: Nursing Considerations <ul><li>Use of electromagnet and radio waves </li></ul><ul><li>Check patient history!! </li></ul><ul><ul><li>PATIENTS WHO CANNOT HAVE MRI: </li></ul></ul><ul><ul><ul><li>Pacemakers </li></ul></ul></ul><ul><ul><ul><li>Metal implants, plates, screws, or clips (old aneurysm surgeries!) </li></ul></ul></ul><ul><ul><ul><li>IUD’s, metal heart valves </li></ul></ul></ul><ul><li>SAFETY: </li></ul><ul><ul><li>IV pumps, portable oxygen tanks cannot be in scan area </li></ul></ul><ul><li>Patient Preparations and teaching: </li></ul><ul><ul><li>No metals: jewelry, credit cards, eyemakeup </li></ul></ul><ul><ul><li>Process takes 45 minutes to 1 hour  pt. must lie still </li></ul></ul><ul><ul><li>MRI machine makes loud beating noise </li></ul></ul><ul><ul><li>Closed MRI: tight space: problems with claustophobia? </li></ul></ul><ul><ul><ul><li>May need Valium pre-test/ some cannot tolerate </li></ul></ul></ul>
    37. 37. Cerebral Angiography <ul><li>Injection of contrast medium into cerebral circulation </li></ul><ul><li>Useful in detecting cause of stroke, headaches, seizures </li></ul><ul><li>Femoral access most commonly used vessel </li></ul><ul><li>Risk: stroke </li></ul>
    38. 38. Cerebral Angiography: Procedure & Patient Preparation <ul><li>Injection of contrast medium into cerebral circulation </li></ul><ul><ul><li>Useful in detecting cause of stroke, headaches, seizures </li></ul></ul><ul><li>NPO solids 6-10 hours </li></ul><ul><ul><li>Clear liquids/ water encouraged 24 hours prior </li></ul></ul><ul><li>Assess PT/ PTT </li></ul><ul><ul><li>Stop anticoagulants prior to test (usually) </li></ul></ul><ul><li>Contrast dye precautions/ informed consent </li></ul><ul><li>Patient AWAKE; slight sedation </li></ul><ul><li>Femoral puncture  mark peripheral pulses </li></ul><ul><li>Burning or flushing with contrast injection expected </li></ul><ul><li>Procedure will take 1-2 hours </li></ul><ul><li>http://www.heartcenteronline.com/myheartdr/common/artprn_rev.cfm?filename=&ARTID=560 </li></ul>
    39. 39. MR Angiography (MRA) <ul><li>Utilization of MR technology to view vasculature </li></ul><ul><li>Same restrictions as MRI </li></ul><ul><li>May use contrast material (gadolinium) but is not iodine based </li></ul>
    40. 40. Myelogram <ul><li>Injection of contrast medium into subarachnoid space  x-ray visualization </li></ul><ul><li>Useful for visualizing obstructions within spinal canal </li></ul><ul><ul><li>Dye bathes nerve roots  any compressin of nerve roots visualized </li></ul></ul><ul><ul><li>Helpful in diagnoses of herniated discs and spinal cord tumor </li></ul></ul>
    41. 41. Patient Preparation <ul><li>Inpatient procedure/ 23 HR </li></ul><ul><li>Consent form </li></ul><ul><li>NPO 4-8 hours prior </li></ul><ul><li>Probably mild sedation given; IV started </li></ul><ul><li>Lumbar puncture in radiology  CSF aspirated </li></ul><ul><li>Either water based (Amipaque) or oil based (Pantopaque) dye used </li></ul><ul><ul><li>Hold phenothiazines (Phenergan), TCA’s, SSRI’s 48 hours </li></ul></ul><ul><ul><ul><li>Lower seizure threshhold </li></ul></ul></ul><ul><ul><li>X-ray table tilted </li></ul></ul><ul><li>CT performed at end </li></ul>
    42. 42. Post-procedure Care <ul><li>Amipaque: not aspirated  absorbed by body </li></ul><ul><ul><li>HOB 30-60 degrees for 24 hours </li></ul></ul><ul><li>Pantopaque: aspirated at end of visualization </li></ul><ul><ul><li>Patient flat for 24 hours (rarely used) </li></ul></ul><ul><li>Quiet activity, little stimulation </li></ul><ul><li>Push fluids, monitor I and O, BUN, Creatinine </li></ul><ul><li>BP, RR, pulse temperature monitored </li></ul><ul><li>May experience nausea, headache  should diminish  no Phenergan or Compazine! </li></ul><ul><li>No neck stiffness or confusion should occur </li></ul>
    43. 43. EEG <ul><li>Amplifies and </li></ul><ul><li>records electrical </li></ul><ul><li>activity in brain </li></ul><ul><li>Uses: </li></ul><ul><ul><li>Detecting areas of abnormal or absent brain activity </li></ul></ul><ul><ul><ul><li>Brain tumors, hematomas, seizure activity </li></ul></ul></ul><ul><ul><ul><li>Determination of brain death in comatose patient </li></ul></ul></ul>
    44. 44. EEG Preparation Use of Evoked Potentials <ul><li>Preparation: </li></ul><ul><ul><li>Avoidance of caffeine prior to exam </li></ul></ul><ul><ul><li>No gels, sprays in hair </li></ul></ul><ul><ul><li>Must be quiet and still as possible </li></ul></ul><ul><li>Evoked Potentials: </li></ul><ul><ul><li>Auditory, sensory, visual: record brain activity in response to stimuli </li></ul></ul><ul><ul><li>Diagnostic for various disorders </li></ul></ul>
    45. 45. Electromyography (EMG) and Nerve Conduction Velocities (NCV) <ul><li>EMG: Needle electrodes inserted into skeletal muscles  patient relaxes and contracts various muscles and action potential recorded </li></ul><ul><li>NCV: Nerve stimulated with electrical impulse </li></ul><ul><li>Useful in studying patients with cervical or lumbar disc disease, myasthenia gravis, muscular dystrophy (LMN diseases) </li></ul><ul><li>Patient should be taught to expect some mild discomfort </li></ul>
    46. 46. Lumbar Puncture <ul><li>Insertion of needle into subarachnoid space between L2 and S1 </li></ul><ul><li>Withdrawal of small amount CSF for diagnostic evaluation </li></ul><ul><li>Measurement of CSF pressure </li></ul><ul><ul><li>Should not be performed if evidence of greatly increased CSF pressure (papilledema) </li></ul></ul>
    47. 47. Lumbar Puncture <ul><li>Patient preparation: </li></ul><ul><ul><li>No diet or fluid restrictions </li></ul></ul><ul><ul><li>Empty bowel and bladder before </li></ul></ul><ul><ul><li>Careful instructions regarding cooperation during test </li></ul></ul><ul><ul><li>Signed consent required </li></ul></ul><ul><li>Positioning </li></ul><ul><li>Chart 60-4 p 1847 </li></ul>
    48. 48. Lumbar Puncture <ul><li>CSF in three labeled tubes </li></ul><ul><ul><li>Protein and glucose </li></ul></ul><ul><ul><li>Culture </li></ul></ul><ul><ul><li>Blood cell counts </li></ul></ul><ul><li>Post-procedure care: </li></ul><ul><ul><li>Prone with pillow under abdomen for 1 hr </li></ul></ul><ul><ul><li>Flat in bed 6-24 hours (30 degrees) </li></ul></ul><ul><ul><li>Increased fluid intake </li></ul></ul><ul><ul><li>Observe site for swelling, leakage </li></ul></ul><ul><ul><li>Observe for post spinal headache </li></ul></ul>
    49. 49. Post-Lumbar Puncture Headache <ul><li>Most common complication </li></ul><ul><li>CSF leaks from needle track  depleted </li></ul><ul><li>Increases when patient upright </li></ul><ul><li>AVOID: use small gauge needle/ keep prone after </li></ul><ul><li>Treatment: bedrest, analgesics, hydration </li></ul><ul><ul><li>Persistent: Blood patch </li></ul></ul>
    50. 50. CSF Fluid Analysis <ul><li>Pressure: Normal: 70-180 mmH2O (5-15mmHg) </li></ul><ul><ul><li>Increased: SAH, brain tumor, viral meningitis </li></ul></ul><ul><li>Appearance: clear and colorless </li></ul><ul><ul><li>Bloody: SAH or traumatic tap (will clear) </li></ul></ul><ul><ul><li>Cloudy: infection </li></ul></ul><ul><ul><li>Orange or yellow: RBC breakdown, elevated protein </li></ul></ul>
    51. 51. CSF Fluid Analysis <ul><li>Cell Count: 0-5 monos and no RBC’s </li></ul><ul><ul><li>Elevated monos  infection, abcess, tumor, infarction, chronic illness (MS) </li></ul></ul><ul><ul><li>RBC’s  SAH or traumatic tap </li></ul></ul><ul><li>Protein: 15-45 mg/dl </li></ul><ul><ul><li>Lower than plasma because of BBB </li></ul></ul><ul><ul><li>Elevated: infection, tumor, MS, degenerative brain disease </li></ul></ul><ul><li>Glucose: 50-75 mg/dl </li></ul><ul><ul><li>Elevated: DM or diabetic coma </li></ul></ul><ul><ul><li>Decreased: acute bacterial meningitis, tumor </li></ul></ul>
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×