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  • 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

Transcript

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