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Neuro Assessment

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MS 104

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Neuro Assessment

  1. 1. NEUROLOGIC EXAMINATION Presented by: Reyna Paredes
  2. 2. HEALTH HISTORY <ul><li>History of Present Illness </li></ul><ul><ul><li>Important aspect of neurologic assessment </li></ul></ul><ul><li>Initial Interview </li></ul><ul><li>Provides an excellent opportunity to systematically explore the patient’s current condition and related events </li></ul><ul><li>while observing the: </li></ul><ul><ul><li>Overall appearance </li></ul></ul><ul><ul><li>Mental status </li></ul></ul><ul><ul><li>Posture </li></ul></ul><ul><ul><li>Movement </li></ul></ul><ul><ul><li>Affect </li></ul></ul>
  3. 3. HEALTH HISTORY <ul><li>Depending on the patients condition, the nurse may rely on: </li></ul><ul><li>YES or NO answer </li></ul><ul><li>Review of Medical Records </li></ul><ul><li>Input from Family </li></ul>
  4. 4. HEALTH HISTORY INCLUDES: <ul><li>Onset, character, severity, location duration and frequency of signs and symptoms. </li></ul><ul><li>Complaints </li></ul><ul><li>Precipitating, aggravating and relieving factors </li></ul><ul><li>Progression, remission and exacerbation </li></ul><ul><li>Presence or absence of similar signs and symptoms among family members </li></ul><ul><li>History of genetic disease </li></ul>
  5. 5. HEALTH HISTORY <ul><li>Review of medical history including the system-by-system evaluation is part of the nursing history. </li></ul><ul><li>The nurse should be aware of history of trauma or falls that may have involved the head or spinal injury. </li></ul><ul><li>Questions about the use of alcohol, medications and illicit drugs are also relevant. </li></ul>
  6. 6. PHYSICAL ASSESSMENT <ul><li>General Observation of the client: </li></ul><ul><ul><li>Posture, gait, coordination: perform Romberg test </li></ul></ul><ul><ul><li>Personal hygiene and grooming </li></ul></ul><ul><ul><li>Evaluate speech and ability to communicate </li></ul></ul><ul><ul><ul><li>Place of speech: rapid, slow, halting </li></ul></ul></ul><ul><ul><ul><li>Clarity: slurred or distinct </li></ul></ul></ul><ul><ul><ul><li>Tone: high-pitched, rough </li></ul></ul></ul><ul><ul><ul><li>Vocabulary: appropriate choice of words </li></ul></ul></ul><ul><ul><ul><li>*** Facial features may suggest specific syndromes in children </li></ul></ul></ul>
  7. 7. PHYSICAL ASSESSMENT <ul><li>Mental Status </li></ul><ul><li>General appearance and behavior </li></ul><ul><li>Level of consciousness </li></ul><ul><ul><li>Oriented to person, place and time </li></ul></ul><ul><ul><li>Appropriate response to verbal and tactile stimuli </li></ul></ul><ul><ul><li>Memory, problem solving abilities. </li></ul></ul><ul><li>Mood </li></ul><ul><li>Thought content & intellectual capacity </li></ul>
  8. 8. PHYSICAL ASSESSMENT <ul><li>Assess Pupillary Status and Eye movement </li></ul><ul><li>Size of pupils should be equal </li></ul><ul><li>Reaction of pupils </li></ul><ul><ul><ul><li>Accommodation : pupillary constriction to accommodate near vision </li></ul></ul></ul><ul><ul><ul><li>Direct light reflex : constriction of pupil when light is shone directly into the eye </li></ul></ul></ul><ul><ul><ul><li>Consensual reflex : constriction of the pupil in the opposite eye when the direct light reflex is tested. </li></ul></ul></ul><ul><li>Evaluate ability to move eye </li></ul><ul><ul><ul><li>Note nystagmus </li></ul></ul></ul><ul><ul><ul><li>Ability of eyes to move together </li></ul></ul></ul><ul><ul><ul><li>Resting position of iris should be at mid-position of the eye socket </li></ul></ul></ul><ul><li>PERRLA </li></ul>
  9. 9. Clinical Manifestation <ul><li>The clinical manifestation of neurologic disease are as varied as the disease processes themselves. Symptoms may be: </li></ul><ul><ul><li>Varied or intense </li></ul></ul><ul><ul><li>Fluctuating or permanent </li></ul></ul><ul><ul><li>Inconvenient or devastating </li></ul></ul><ul><li>PAIN </li></ul><ul><li>SEIZURES </li></ul><ul><li>DIZZINESS a nd VERTIGO </li></ul><ul><li>VISUAL DISTURBANCES </li></ul><ul><li>WEAKNESS </li></ul><ul><li>ABNORMALSENSATION </li></ul>
  10. 10. Clinical Manifestations <ul><li>PAIN </li></ul><ul><li>unpleasant sensory perception & emotional </li></ul><ul><li>experience associated with actual or potential tissue damage </li></ul><ul><li>- Subjective </li></ul><ul><li>- Acute </li></ul><ul><li> > lasts shorter & remits as pathology resolves </li></ul><ul><li>> trigeminal neuralgia, spinal disk disease </li></ul><ul><li>- Chronic or persistent </li></ul><ul><li> > Lasts longer than 6 months </li></ul><ul><li> > degenerative and chronic neurologic cond. </li></ul>
  11. 11. Clinical Manifestations <ul><li>SEIZURES </li></ul><ul><li>Are the result of abnormal paroxysmal discharges in the cerebral cortex, which manifests as alteration in sensation, perception, movement or consciousness </li></ul><ul><li>May be long or short </li></ul><ul><li>The type of seizure activity is a direct result of the brain affected. </li></ul><ul><li>May be a first obvious sign of brain lesion </li></ul>
  12. 12. Clinical Manifestations <ul><li>DIZZINESS AND VERTIGO </li></ul><ul><li>Dizziness is an abnormal sensation of imbalance or movement. </li></ul><ul><li>Variety of causes : viral syndrome, hot weather, roller coaster rides, middle ear infections </li></ul><ul><li>About 50% of patients with dizziness have vertigo (illusion of movement usually rotation). </li></ul><ul><li>Vertigo is a manifestation of vestibular dysfunction </li></ul>
  13. 13. Clinical Manifestations <ul><li>VISUAL DISTURBANCES </li></ul><ul><li>Visual defects that cause people to seek health care can range from decreased visual acuity associated with aging to sudden blindness caused by glaucoma </li></ul><ul><li>Normal vision depends on : </li></ul><ul><li>- functioning visual pathways thought the retina and optic chiasm </li></ul><ul><li>- radiations into the visual cortex in the occipital lobes </li></ul>
  14. 14. Clinical Manifestations <ul><li>WEAKNESS </li></ul><ul><li>common manifestation of neurologic disease (muscle weakness) </li></ul><ul><li>Coexists with other symptoms and can affect variety of muscles causing disability </li></ul><ul><li>Can be sudden or permanent or progressive </li></ul>
  15. 15. Clinical Manifestations <ul><li>ABNORMAL SENSATION </li></ul><ul><li>Numbness, loss of sensation or abnormal sensation is a neurologic manifestation of both cerebral and peripheral nervous system disease </li></ul><ul><li>h </li></ul><ul><li>Usually associated with pain or weakness and is potentially disabling </li></ul><ul><li>g </li></ul><ul><li>Both numbness and weakness can significantly affect balance and coordination </li></ul>
  16. 16. PHYSICAL EXAMINATION <ul><li>The brain and the spinal cord cannot be examined directly as other body systems </li></ul><ul><li>Neurologic examination is an indirect evaluation that assesses the function of specific body part controlled </li></ul><ul><li>f </li></ul><ul><li>5 COMPONTENTS OF </li></ul><ul><li>NEURO ASSESSMENT </li></ul><ul><li>(1) Cerebral function </li></ul><ul><li>(2) Cranial Nerves </li></ul><ul><li>(3) Motor system </li></ul><ul><li>(4) Sensory System </li></ul><ul><li>(5) Reflexes </li></ul>
  17. 17. Assessing Cerebral Function <ul><li>Cerebral abnormalities may cause: </li></ul><ul><li>- disturbance in mental status </li></ul><ul><li>- Intellectual function </li></ul><ul><li>- Thought content </li></ul><ul><li>Pattern of emotional behavior </li></ul><ul><li>Alteration in perception, motor and language ability </li></ul><ul><li>Lifestyle change/s </li></ul>
  18. 18. Assessing Cerebral Function <ul><li>Should be specific and non-judgemental </li></ul><ul><li>Avoid using the terms </li></ul><ul><li>“ inappropriate” or “demented” </li></ul><ul><li>Specific records on observations regarding orientation, level of consciouness, emotional state or thought content </li></ul>
  19. 19. Assessing the Mental Status <ul><li>Observe patient’s appearance & behavior </li></ul><ul><li>Note dress, grooming & personal hygiene </li></ul><ul><li>Posture, gesture, movements, facial expression & motor activity </li></ul><ul><li>Assess manner of speech & level of consciousness </li></ul><ul><li>Assess orientation to time, place & person </li></ul>
  20. 20. Intellectual Function <ul><li>A person with an average IQ can: </li></ul><ul><ul><li>Recite 5 digits backwards </li></ul></ul><ul><ul><li>Serial 7’s (Subtract 7 from 100, then 7 from that, and so forth) </li></ul></ul><ul><li>Interpret proverbs </li></ul><ul><li>Ability to recognize similarities </li></ul><ul><li>Situational analysis </li></ul>
  21. 21. Thought Content <ul><li>During the interview, it is important to </li></ul><ul><li>assess the patient’s thought content. </li></ul><ul><li>Are the patient’s thought… </li></ul><ul><ul><li>Spontaneous </li></ul></ul><ul><ul><li>Natural </li></ul></ul><ul><ul><li>Clear </li></ul></ul><ul><ul><li>Relevant </li></ul></ul><ul><ul><li>Coherent </li></ul></ul><ul><ul><li>f </li></ul></ul><ul><li>Unusual thoughts like… hallucinations, preoccupation with death and morbid events, paranoid ideation requires further evaluation </li></ul>
  22. 22. Emotional Status <ul><li>Is the patient’s affect natural or even? </li></ul><ul><li>Does his or her mood fluctuate normally? </li></ul><ul><li>Are verbal communications consistent with nonverbal cues? </li></ul>
  23. 23. Perception <ul><li>The examiner may consider more specific areas of higher cortical function </li></ul><ul><li>Agnosia - inability to recognize objects seen through the special senses </li></ul><ul><ul><li>a patient may see a pencil but knows not what to do with it or what it’s called </li></ul></ul><ul><li>Screening for visual and tactile agnosia provides insight into the patient’s cortical interpretation ability </li></ul><ul><ul><li>Placing a familiar object (key) in the patient’s hand, have him identify it with eyes closed </li></ul></ul>
  24. 24. Language Ability <ul><li>A person with normal neurologic function can understand and communicate in spoken and written language. </li></ul><ul><li>Aphasia is a deficiency in language function </li></ul>Posterior frontal area Expressive writing Inferior posterior frontal areas Expressive speaking Parietal-occipital lobe Visual-receptive Temporal Lobe Auditory-receptive Brain area involved Type of Aphasia
  25. 25. Motor Ability <ul><li>Ask the patient to perform a skilled act </li></ul><ul><li>(throw a ball, move a chair) </li></ul><ul><li>Performance requires </li></ul><ul><li> => the ability to understand the activity desired and normal motor strength </li></ul><ul><li>Failure signals cerebral dysfunction </li></ul>
  27. 27. CARNIAL NERVES On Old Olympus Towering Tops A Finn And German Viewed Some Hops Olfactory (I) Optic (II) Occulamotor (III) Trochlear (IV) Trigemenal (V) Abducens (VI) Facial (VII) Acoustic (VIII) Glossopharyngeal (IX) Vagus (X) Spinal Accessory (XI) Hypoglossal (XII) M S M M M/S M M/S S M/S M/S M M
  28. 28. Cranial Nerve I - Olfactory Nerve <ul><li>Before testing nerve function, ensure patency of each nostril by occluding in turn and asking patient to sniff </li></ul><ul><li>Once patency is established, ask patient to close eyes </li></ul><ul><li>Occlude one nostril and hold aromatic substance (coffee) beneath nose </li></ul><ul><li>Ask patient to identify substance </li></ul><ul><li>Repeat with other nostril </li></ul>
  29. 29. Cranial Nerve I - Olfactory <ul><li>Normal: </li></ul><ul><li>■ Patient is able to identify substance. </li></ul><ul><li>(Bear in mind that some substances may be unfamiliar, especially to children) </li></ul><ul><li>Abnormal: </li></ul><ul><li>■ Anosmia - loss of sense of smell. </li></ul><ul><li>May be inherited and non-pathological: chronic rhinitis, sinusitis, heavy smoking, zinc deficiency, or cocaine use. </li></ul><ul><li>It may also indicate cranial nerve damage from facial fractures or head injuries, disorders of base of frontal lobe such as a tumor, or artherosclerotic changes. </li></ul>
  30. 30. Cranial Nerve II - Optic Nerve <ul><li>Use the snellen chart to check/test: </li></ul><ul><li>- distant vision </li></ul><ul><li>- color </li></ul><ul><li>Client should be 20 feet distant from the chart </li></ul><ul><li>Use an object to occlude one eye </li></ul><ul><li>Evaluate the vision one eye at a time </li></ul>
  31. 31. Cranial Nerves III, IV and VI <ul><li>=> Test for ocular rotations, </li></ul><ul><li>conjugate movements, nystagmus </li></ul><ul><li>** Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis - using direct & consensual pupillary reaction to light </li></ul>Testing eye movements Testing pupil accommodation
  32. 32. Normal: ■ Able to read without difficulty ■ Visual acuity intact 20/20, both eyes Hippus phenomenon: Brisk constriction of pupils in reaction to light, followed by dilation and constriction - may be normal or sign of early CN III compression. Abnormal: ■ CN II deficits - can occur with stroke or brain tumor. ■ Changes in pupillary reactions - can signal CN III deficits. ■ Increased ICP causes changes in pupillary reaction As pressure increases, response becomes more sluggish until pupils finally become fixed and dilated.
  33. 33. CN V - Trigeminal Nerve <ul><li>Testing motor function: </li></ul><ul><li>- Ask patient to move jaw from side to side against resistance and then clench jaw as you palpate contraction of temporal and masseter muscles, or to bite down on a tongue blade. </li></ul>
  34. 34. CN V - Trigeminal Nerve <ul><li>b. Testing sensory function: </li></ul><ul><li>- Ask patient to close eyes </li></ul><ul><li>- Touch the face with the wisp of cotton </li></ul><ul><li>- Instruct to tell you when he or she feels sensation on the face. </li></ul><ul><li>- Repeat the test using sharp and dull stimuli (toothpick or tongue blade) </li></ul><ul><li>- Instruct to say “ Sharp” or “Dull” </li></ul><ul><li>(Be random, don’t establish a pattern) </li></ul>Testing CN V – sensory function
  35. 35. Cranial Nerve V - Trigeminal Nerve <ul><li>c. Testing corneal reflex: </li></ul><ul><li>- Gently touch cornea with cotton wisp. </li></ul><ul><ul><li>Touching cornea can cause abrasions. </li></ul></ul><ul><ul><li>Alternative approach is to: </li></ul></ul><ul><ul><li>> puff air across cornea with a needless syringe, or </li></ul></ul><ul><li> > gently touch eyelash </li></ul><ul><li>and look for blink reflex </li></ul>Testing corneal reflex
  36. 36. <ul><li>Normal: </li></ul><ul><li>Full range of motion (ROM) in jaw and 15 strength. </li></ul><ul><li>Patient perceives light touch and superficial pain bilaterally </li></ul><ul><li>Abnormal: </li></ul><ul><li>Weak or absent contraction unilaterally: </li></ul><ul><li>Lesion of nerve, cervical spine, or brainstem </li></ul><ul><li>Inability to perceive light touch and superficial pain </li></ul><ul><li>may indicate peripheral nerve damage. </li></ul><ul><li>■ Trigeminal Neuralgia: </li></ul><ul><li>Neuralgic pain of CN V caused by the pressure of degeneration of a nerve </li></ul><ul><li>■ Corneal reflex test used in patients with decreased LOC </li></ul><ul><li>- to evaluate integrity of brainstem. </li></ul>Cont. CN V
  37. 37. Cranial Nerve VII - Facial Nerve <ul><li>Testing motor function: </li></ul><ul><li>- Ask patient to perform these movements: </li></ul><ul><li>smile, frown, raise eyebrows, show upper teeth, show lower teeth, puff out cheeks, purse lips, close eyes tightly while nurse tries to open them. </li></ul><ul><li>- Observe face for </li></ul><ul><li>flaccid paralysis </li></ul>Testing CN VII – motor function
  38. 38. Cranial Nerve VII - Facial Nerve <ul><li>b. Testing sensory function: </li></ul><ul><li>- Test taste on anterior two-thirds of tongue for sweet, sour, salty. </li></ul><ul><li>F </li></ul><ul><li>Sweet: Tip of the tongue </li></ul><ul><li>Sour: Sides of back half of tongue </li></ul><ul><li>Salty: Anterior sides and tip of tongue </li></ul><ul><li>Bitter: Back of tongue </li></ul>Testing taste sensation
  39. 39. CN VII - Facial Nerve <ul><li>Normal: </li></ul><ul><li>Facial nerve intact </li></ul><ul><li>Able to make faces. </li></ul><ul><li>Taste sensation on anterior tongue intact. </li></ul><ul><li>(Taste decreased in older adults.) </li></ul><ul><li>Abnormal: </li></ul><ul><li>Asymmetrical or impaired movement: </li></ul><ul><li>Nerve damage, such as that caused by Bell’s palsy or stroke. </li></ul><ul><li>Impaired taste/loss of taste: </li></ul><ul><li>- Damage to facial nerve, chemotherapy or radiation therapy to head and neck. </li></ul>
  40. 40. Cranial Nerve VIII - Acoustic Nerve <ul><li>Perform Weber and Rinne tests for hearing </li></ul><ul><li>Perform watch-tick test by holding watch close to patient’s ear. </li></ul><ul><li>Perform Romberg test for balance </li></ul><ul><li>- Nurse at the back or side of the pt. </li></ul><ul><li>- Instruct client to stand straight, feet together, hands at the side and eyes closed. </li></ul><ul><li>(Evaluates the balancing function of the CN VIII) </li></ul>Watch tick test
  41. 41. Cranial Nerve VIII - Acoustic Nerve <ul><li>Normal: </li></ul><ul><li>Hearing intact. </li></ul><ul><li>Negative Romberg test. </li></ul><ul><li>Abnormal: </li></ul><ul><li>Hearing loss, nystagmus, balance disturbance, dizziness/vertigo: </li></ul><ul><li>- Acoustic nerve damage. </li></ul><ul><li>■ Nystagmus: </li></ul><ul><li>- CN VIII, brainstem, or cerebellum problem or phenytoin (Dilantin) toxicity. </li></ul>
  42. 42. Cranial Nerves IX and X Glossopharyngeal & Vagus Nerves <ul><li>a. Observe ability to cough, swallow, and talk. </li></ul><ul><li>b. Test motor function : </li></ul><ul><li>- Ask patient to open mouth and say “ah” while you depress the tongue with a tongue blade. </li></ul><ul><li>- Observe soft palate and uvula. </li></ul><ul><li>- Soft palate and uvula should rise medially. </li></ul>Testing CN IX and X – motor function
  43. 43. CN IX and X <ul><li>c. Test sensory function of CN IX a nd motor function of CN X by stimulating gag reflex . </li></ul><ul><li>Tell patient that you are going to touch interior throat </li></ul><ul><li>Then lightly touch tip of tongue blade to posterior pharyngeal wall. </li></ul><ul><li>Observe the pharyngeal movement. </li></ul><ul><li>Ask the client to drink a small amount of water </li></ul><ul><li>*Note the ease & difficulty of swallowing </li></ul><ul><li>*Note quality of the voice or hoarseness when speaking </li></ul>
  44. 44. CN IX and X <ul><li>Normal: </li></ul><ul><li>Swallow and cough reflex intact. </li></ul><ul><li>Speech clear. </li></ul><ul><li>Elevation and constriction of pharyngeal musculature and tongue retraction indicate positive gag reflex </li></ul><ul><li>Abnormal: </li></ul><ul><li>Unilateral movement: </li></ul><ul><li>Contralateral nerve damage . </li></ul><ul><li>Damage to CNs IX and X also impairs swallowing. </li></ul><ul><li>■ Changes in voice quality (e.g., hoarseness): CN X damage. </li></ul><ul><li>■ Diminished/absent gag reflex: Nerve damage </li></ul><ul><li>Risk for aspiration </li></ul><ul><li>■ Impaired taste on posterior portion of tongue : </li></ul><ul><li>Problem with CN IX </li></ul>
  45. 45. CN XI - Spinal Accessory Nerve <ul><li>Test motor function of shoulder and </li></ul><ul><li>neck muscles: </li></ul><ul><li>=> Ask patient to shrug shoulders upward against your resistance. (Trapieze muscle) </li></ul><ul><li>=> Then ask her or him to turn head from side to side against your resistance. </li></ul><ul><li>(Strenoclaidomastoid muscle) </li></ul><ul><li>**Observe for symmetry of contraction and muscle strength. </li></ul>
  46. 46. Cranial Nerve XI <ul><li>Normal: </li></ul><ul><li>Movement symmetrical, with patient moving against resistance without pain. </li></ul><ul><li>■ Full ROM of neck with +5/5 strength . </li></ul><ul><li>Abnormal: </li></ul><ul><li>Asymmetrical </li></ul><ul><li>Diminished </li></ul><ul><li>Absent movement </li></ul><ul><li>Pain </li></ul><ul><li>unilateral or bilateral weakness: Peripheral nerve CN XI damage. </li></ul>
  47. 47. CN XII - Hypoglossal Nerve <ul><li>a. Have patient say “ d, l, n, t ” or a phrase containing these letters. </li></ul><ul><li>- The ability to say these letters requires use of the tongue. </li></ul><ul><li>b. Ask the patient to protrude the tongue. </li></ul><ul><li>Observe any deviation from midline, tumors, lesions, or atrophy. </li></ul><ul><li>c. Now ask the patient to move the </li></ul><ul><li>tongue from side to side. </li></ul>Testing CN XII – motor function
  48. 48. <ul><li>Normal: </li></ul><ul><li>Can protrude tongue medially. </li></ul><ul><li>No atrophy, tumors, or lesions. </li></ul><ul><li>Abnormal: </li></ul><ul><li>Asymmetrical/diminished/ </li></ul><ul><li>absent movement/deviation from midline/protruded tongue: - Peripheral nerve CN XII damage. </li></ul><ul><li>■ Tongue paralysis results in dysarthria. </li></ul>
  49. 49. Examining the Motor System <ul><li>Assessing the patient’s ability to flex or extend the extremities against resistance tests muscle strength. </li></ul><ul><li>g </li></ul><ul><li>The evaluation of muscle strength compares the sides of the body with each other </li></ul><ul><li>This way, subtle differences in muscle strength can easily be detected and described. </li></ul><ul><li>f </li></ul>
  50. 50. MUSCLE STRENGTH <ul><li>Muscle tone (tension present in a muscle at rest) is evaluated by palpation </li></ul><ul><li>Abnormalities in tone include: </li></ul><ul><ul><li>Spasticity (increased muscle tone) </li></ul></ul><ul><ul><li>Rigidity (resistance to passive strength) </li></ul></ul><ul><ul><li>Flaccidity </li></ul></ul>British Medical Council Method of Scoring
  51. 51. Balance and Coordination <ul><li>Cerebellar influence on the motor system is reflected in balance and coordination. </li></ul><ul><li>Coordination of the hands and extremities is tested by: </li></ul><ul><ul><li>Rapid, alternating movements </li></ul></ul><ul><ul><li>POINT TO POINT TESTING </li></ul></ul>
  52. 52. Balance and Coordiantion a. Rapid Alternating Movements (RAM) Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the knees with the backs of the hands. Then ask to do this faster. <ul><li>Normal: </li></ul><ul><li>done with equal turning and quick rhythmic pace </li></ul><ul><li>Abnormal: </li></ul><ul><li>Lack of coordination </li></ul><ul><li>Dysdiadochokinesia </li></ul><ul><li>- Slow, clumsy, and sloppy response </li></ul><ul><li>- occurs with cerebellar disease </li></ul>The patient is asked to pronate and supinate the hands as rapid as possible
  53. 53. b. Finger-to-Finger test With the persons eyes open, ask that he or she use index finger to touch your finger, then his or her own nose. After a few times move your finger to a different spot. <ul><li>Normal: </li></ul><ul><li>Movement is smooth and accurate </li></ul><ul><li>Abnormal: </li></ul><ul><li>Dysmetria </li></ul><ul><li>- clumsy movement with overshooting the mark </li></ul><ul><li>- occurs with cerebellar disorder </li></ul><ul><li>Past-pointing </li></ul><ul><li>- constant deviation to one side </li></ul>
  54. 54. Balance and Coordination <ul><li>Coordination in the lower extremities is tested by having the patient run heel down the anterior surface of the tibia of the other leg. Each leg is tested </li></ul><ul><li>Ataxia is incoordination of voluntary muscle groups in action </li></ul><ul><li>Tremors are rhythmic, involuntary movements </li></ul><ul><ul><li>=>The presence of these movements suggests cerebellar disease </li></ul></ul><ul><li>When abnormality is observed, a thorough examination is indicated </li></ul>
  55. 55. Balance and Coordination <ul><li>The cerebellum is responsible for </li></ul><ul><li>balance and coordination . </li></ul><ul><li>Romberg’s Test </li></ul><ul><li>- screening test for balance </li></ul><ul><li>- the pt stands with feet together </li></ul><ul><li> and arms at the side, first with </li></ul><ul><li> eyes open and eyes closed for 20 </li></ul><ul><li> to 30 secs </li></ul><ul><li>- slight sway is normal but loss of </li></ul><ul><li> balance is abnormal and considered </li></ul><ul><li> (+) Romberg rest </li></ul>
  56. 56. <ul><li>Normal: </li></ul><ul><li>Negative Romberg test </li></ul><ul><li>Abnormal: </li></ul><ul><li>Sways, falls, widens base of feet to avoid falling </li></ul><ul><li>Positive Romberg sign </li></ul><ul><ul><li>Loss of balance that occurs when closing the eyes. </li></ul></ul><ul><ul><li>Occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication) </li></ul></ul><ul><ul><li>Loss of proprioception, and loss of vestibular function </li></ul></ul>
  57. 57. Perform Tandem Walking - ask the person to walk a straight line in a heel-to-toe fashion. - This decreases the base of support and will accentuate any problem with coordination. Normal: Person can walk straight & stay balanced <ul><li>Abnormal: </li></ul><ul><li>Crooked line walk </li></ul><ul><li>Widens base to maintain balance </li></ul><ul><li>Staggering, reeling, loss of balance </li></ul><ul><li>An ataxia that did not appear now. </li></ul><ul><li>Inability to tandem walk is sensitive for an upper motor neuron lesion, such as multiple sclerosis. </li></ul>
  58. 58. Hopping in place, alternating knee bends ( some individuals cannot hop owing to aging or obesity)
  59. 59. Examining the Reflexes <ul><li>Motor reflex are involuntary contraction of muscles or muscle groups in response to abrupt stretching near the site of muscle insertion </li></ul><ul><li>Technique: A reflex hammer is used to elicit a deep tendon reflex . </li></ul><ul><li>The tendon is struck briskly, and the response is compared with the opposite side of the body (right and left) </li></ul><ul><li>The response should be equal </li></ul>
  60. 60. Examining the Reflexes <ul><li>GRADING the REFLEXES </li></ul><ul><li>The absence of reflex is significant, although ankle jerks (achilles reflex) may be absent on older people. </li></ul><ul><li>Some uses the terms: </li></ul><ul><ul><li>PRESENT </li></ul></ul><ul><ul><li>ABSENT </li></ul></ul><ul><ul><li>DIMINISHED </li></ul></ul>
  61. 61. REFLEXES <ul><li>Documenting Reflex Findings </li></ul><ul><li>Use these grading scales to rate the strength of each reflex in a deep tendon and superficial reflex assessment. </li></ul>Deep tendon reflex grades 0 absent + present but diminished + + normal + + + increased but not necessarily pathologic + + + + hyperactive or clonic (involuntary contraction and relaxation of skeletal muscle) Superficial reflex grades 0 absent + present
  62. 62. <ul><li>Documentation of reflex finding </li></ul>
  63. 63. ASSESSING REFLEXES <ul><li>Biceps Reflex </li></ul><ul><li>- is elicited by striking the biceps tendon of the flexed elbow. </li></ul><ul><li>- the examiner supports the forearm with one arm while placing the thumb against the tendon and striking the thumb with the reflex hammer. </li></ul><ul><li>Normal: </li></ul><ul><li>■ Flexion at the elbow and </li></ul><ul><li>contraction of the biceps </li></ul>
  64. 64. ASSESSING REFLEXES <ul><li>b. Triceps Reflex </li></ul><ul><li>flex pt’s arm to 90° angle and </li></ul><ul><li>positioned in front of the chest </li></ul><ul><li>■ Abduct patient’s arm and flex it at the elbow. </li></ul><ul><li>■ Support the arm with your non-dominant hand. </li></ul><ul><li>■ Identify triceps tendon by </li></ul><ul><li>palpating 2.5 to 5cm </li></ul><ul><li>(1-2 in) above the elbow </li></ul><ul><li>Normal: </li></ul><ul><li>■ Contraction of triceps with </li></ul><ul><li>extension at elbow </li></ul>
  65. 65. ASSESSING REFLEXES <ul><li>c. Patellar Reflex </li></ul><ul><li>■ Have patient sit with legs dangling. </li></ul><ul><li>■ Strike tendon directly below patella. </li></ul><ul><li>Normal: </li></ul><ul><li>■ Contraction of </li></ul><ul><li>quadriceps with </li></ul><ul><li>extension of knee. </li></ul>
  66. 66. ASSESSING REFLEXES <ul><li>d. Ankle Reflex </li></ul><ul><li>- Achilles reflex </li></ul><ul><li>- foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon </li></ul><ul><li>Normal: </li></ul><ul><li>■ Plantar flexion of foot. </li></ul>
  67. 67. ASSESSING REFLEXES <ul><li>e. Test for Clonus </li></ul><ul><li>When reflexes are very hyperactive, a phenomenon called clonus may be elicited </li></ul><ul><li>If a foot is abruptly dorsiflexed, it may continue to “beat” two to three times before it settles into a position of rest </li></ul><ul><li>The presence of clonus always indicates the presence of CNS disease and requires further evaluation </li></ul><ul><li>Normal: </li></ul><ul><li>■ No contraction </li></ul>
  68. 68. F. Superficial Reflexes Abdominal Reflex ■ Stroke patient’s abdomen diagonally from upper and lower quadrants toward umbilicus. ■ Contraction of rectus abdominis. Umbilicus moves toward stimulus.
  69. 69. Perianal Reflex ■ Gently stroke skin around anus with gloved finger. Normal: ■ Anus puckers. Cremasteric Reflex ■ Gently stroke inner aspect of a male’s thigh. Normal: ■ Testes rise. Bulbocavernosus Reflex ■ Gently apply pressure over bulbocavernous muscle on dorsal side of penis. Normal: ■ Bulbocavernosus muscle contracts.
  70. 70. ASSESSING REFLEXES <ul><li>BABINSKI REFLEX </li></ul><ul><li>■ Stroke sole of patient’s foot in an arc from lateral heel to medial ball. </li></ul><ul><li>Fanning of toes when stroked laterally </li></ul><ul><li>Normal in newborn (found until 16 – 24 mos) </li></ul><ul><li>Indicates CNS disease of motor system </li></ul><ul><li>Normal: </li></ul><ul><li>■ Flexion of all toes. </li></ul>
  71. 71. SENSORY EXAMINATION <ul><li>Highly subjective & requires cooperation of the pt </li></ul><ul><li>The examiner should be familiar with dermatomes </li></ul><ul><li>Most sensory deficits results from peripheral neuropathy and follow anatomic dermatomes </li></ul><ul><li>Assessment involves: </li></ul><ul><li>Tactile sensation </li></ul><ul><li>Superficial pain </li></ul><ul><li>Vibration </li></ul><ul><li>Position sense </li></ul><ul><li>** during assessment, pt eyes are kept closed </li></ul>
  72. 72. SENSORY EXAMINATION Tactile Sensation or Light Touch - Brush a light stimulus such as a cotton wisp over patient’s skin in several locations, including torso and extremities. <ul><li>Normal: </li></ul><ul><li>Identifies areas stimulated by light touch. </li></ul><ul><li>Abnormal: </li></ul><ul><li>Hypesthesia: diminished capacity for </li></ul><ul><li>physical sensation (esp. skin) </li></ul><ul><li>■ Hyperesthesia : Increased sensitivity </li></ul><ul><li>■ Paresthesia : Numbness & tingling </li></ul><ul><li>■ Anesthesia : Loss of sensation . </li></ul>
  73. 73. <ul><li>PAIN and TEMPERATURE </li></ul><ul><li>Stimulate skin lightly with sharp and dull ends of toothpick/ paper clip </li></ul><ul><li>Apply stimuli randomly and ask patient to identify whether sensation is sharp or dull. </li></ul><ul><li>Touch patient’s skin with test tubes filled with hot or cold water. </li></ul><ul><li>Apply stimuli randomly, and ask patient to identify whether sensation is hot or cold. </li></ul>
  74. 74. Sensory Examination <ul><li>VIBRATION and PROPRIOCEPTION </li></ul><ul><li>- Place a vibrating tuning fork over a finger joint, and then over a toe joint. </li></ul><ul><li>- Ask patient to tell you when vibration is felt and when it stops. </li></ul><ul><li>- If patient is unable to detect vibration, test proximal areas as well. </li></ul>
  75. 75. Sensory Examination <ul><li>Normal: </li></ul><ul><li>Vibratory sensation intact bilaterally in upper and lower extremities. </li></ul><ul><li>Abnormal: </li></ul><ul><li>Diminished/absent vibration sense: </li></ul><ul><li>- Peripheral nerve damage caused by alcoholism, diabetes, or damage to posterior column of spinal cord. </li></ul>
  76. 76. Stereognosis With patient’s eyes closed, place a familiar object, such as a coin or a button, in patient’s hand, and ask patient to identify it. ■ Test both hands using different objects. <ul><li>Normal: </li></ul><ul><li>Stereognosis intact bilaterally. </li></ul>Abnormal: ■ Abnormal findings suggest a lesion or other disorder involving sensory cortex or a disorder affecting posterior column.
  77. 77. Sensory Extinction ■ Simultaneously touch both sides of patient’s body at same point. ■ Ask patient to point to where she or he was touched. <ul><li>Normal: </li></ul><ul><li>Extinction intact. </li></ul><ul><li>Abnormal: </li></ul><ul><li>Identification of stimulus on only one side suggests lesion or other disorder involving sensory cortical region in opposite hemisphere. </li></ul>
  78. 78. Assessing Level of Consciousness
  79. 79. <ul><li>Level of Consciousness (LOC) </li></ul><ul><li>– arousal; awareness of self or environment </li></ul><ul><li>d </li></ul><ul><li>Alert – fully awake; appropriate responses to external and internal stimuli; oriented to person, place and time </li></ul><ul><li>s </li></ul><ul><li>Lethargic – somnolent, drowsy, listless, indifferent to surroundings, very sleepy, can be aroused from sleep but when stimulation ceases, falls back to sleep; may be oriented or confused </li></ul><ul><li>d </li></ul><ul><li>Stuporous – unconscious most of the time but makes spontaneous movements and response is evoked only by a strong, continuous, noxious stimuli; loud noises or sounds, bright light, pressure to sternum, response is usually a purposeful attempt to remove the stimulus </li></ul><ul><li>f </li></ul><ul><li>Comatose – absence of voluntary response to stimuli including painful stimuli; no response, no eye opening – score of 7 or less on GCS </li></ul>
  80. 80. Glasgow Coma Scale <ul><li>A standardized objective assessment that defines the LOC by giving it a numeric value. </li></ul><ul><li>Most often after brain surgery </li></ul><ul><li>Document as E_V_M_ ; for example, E4V5M6 . </li></ul><ul><li>The three numbers are added; the total score reflects the brain functional level. </li></ul><ul><li>A fully awake person = 15 </li></ul><ul><li>Coma = 7 or less </li></ul><ul><li>The GCS assesses the functional state of the brain as a </li></ul><ul><li>whole, not of any particular site in the brain. (Juarez and Lyon,1995) </li></ul>
  81. 81. Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)
  82. 82. ASSESSING LEVEL OF CONSCIOUSNESS <ul><li>Normal: </li></ul><ul><li>Awake, alert, and oriented to time, place, and person (AAO x 3) </li></ul><ul><li>Responds to external stimuli </li></ul><ul><li>Abnormal: </li></ul><ul><li>Disorientation may be physical in origin </li></ul><ul><li>Disorientation can also be psychiatric in origin (schizophrenia) </li></ul><ul><li>Lathargic or somnolent </li></ul><ul><li>Obtunded </li></ul><ul><li>Stupor </li></ul><ul><li>Coma </li></ul><ul><li>Test orientation to time, place, and person </li></ul>
  83. 83. Abnormal Findings Abnormalities in Muscle Movement <ul><li>Paralysis </li></ul><ul><li>Loss or impairment of the ability to move a body part, usually as a result of damage to its nerve supply. </li></ul><ul><li>Loss of sensation over a region of the body. </li></ul><ul><li>Hemiplegia </li></ul><ul><ul><li>paralysis of one side of the body </li></ul></ul><ul><ul><li>Paraplegia </li></ul></ul><ul><ul><li>paralysis of both lower limbs due to spinal disease or injury </li></ul></ul><ul><ul><li>Quadriplegia </li></ul></ul><ul><ul><li>paralysis of all four limbs or of the entire body below the neck </li></ul></ul><ul><ul><li>Paresis </li></ul></ul><ul><ul><li>partial motor paralysis </li></ul></ul>
  84. 84. Abnormal Findings Abnormalities in Muscle Movement <ul><li>Fasciculations </li></ul><ul><ul><li>Rapid, continuous twitching of resting muscle </li></ul></ul>
  85. 85. Abnormal Findings Abnormalities in Muscle Movement <ul><li>Tic </li></ul><ul><ul><li>Repetitive twitching of a muscle group </li></ul></ul>
  86. 86. Abnormal Findings Abnormalities in Muscle Movement <ul><li>Myoclonus </li></ul><ul><ul><li>Rapid, sudden jerk at a fairly regular intervals </li></ul></ul>
  87. 87. Abnormal Findings Abnormalities in Muscle Movement <ul><li>Tremor </li></ul><ul><ul><li>Involuntary contraction of opposing muscle groups </li></ul></ul><ul><li>Rest tremor </li></ul><ul><li>Intention tremor </li></ul>
  88. 88. Abnormal Findings Abnormalities in Muscle Movement <ul><li>Chorea </li></ul><ul><li>Sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face </li></ul>
  89. 89. Abnormal Findings Abnormalities in Muscle Movement <ul><li>Athetosis </li></ul><ul><li>Slow, twisting, writhing, continuous movement, resembling a snake or worm </li></ul>
  90. 90. Neurologic Exam: Meningeal signs Brudzinski’s sign - neck stiffness - involuntary flexion of hips and knees when flexing neck is positive sign for meningeal irritation
  91. 91. Neurologic Exam: Meningeal signs Positive Kernig’s sign -excessive pain in the lower back when examiner attempts to straighten knees with client supine and knees and hips flexed
  92. 92. Neurologic Exam: Meningeal <ul><ul><ul><li>Decorticate posturing (up) </li></ul></ul></ul><ul><ul><ul><li>Decorticate posturing (down) </li></ul></ul></ul>
  94. 94. Computed Tomography Scan <ul><li>Makes use of narrow x-ray beam to scan body part in successive layers </li></ul><ul><li>Images provide cross-sectional views of the brain displayed on an oscilloscope or TV monitor and is photographed and stored digitally </li></ul><ul><li>Non-invasive and painless and has high degree in detecting brain lesions </li></ul><ul><li>Nursing Intervention: </li></ul><ul><li>Teach patient about the need to lie quietly throughout the entire procedure </li></ul><ul><li>Assess for iodine/shellfish allergy </li></ul><ul><li>Monitor for side effect of IV or inhalation contrast agents: flushing, nausea, vomiting </li></ul>
  95. 95. CT SCAN
  96. 96. Positron Emission Tomography (PET) <ul><li>Computer based nuclear imaging that produces </li></ul><ul><li>images of actual organ functioning. </li></ul><ul><li>- Radioactive gas or substance is inhaled or injected that emits positively charged particles. </li></ul><ul><li>- It permits measurement of blood flow, tissue composition, brain metabolism thus evaluates brain function. </li></ul><ul><li>Useful in showing metabolic changes in the brain (Alzheimer’s disease), locating lesions (tumor, epiliptogenic lesions), identifying blood flow and oxygen metabolism in stroke pt and new therapies for brain tumor. </li></ul>
  97. 97. Positron Emission Tomography (PET) <ul><li>Key nursing interventions include patient preparation, which involves explaining the test and teaching the patient about inhalation techniques and the sensations (dizziness, light-headedness, headache) may occur. </li></ul><ul><li>IV injection of radioactive substance produces similar side effects. </li></ul><ul><li>Relaxation exercises may reduce anxiety during the test. </li></ul>
  98. 98. PET Scan
  99. 99. Single Photon Emission Computed Tomography (SPECT) <ul><li>3D imaging technique that uses radionuclides and instruments to detect single photons. </li></ul><ul><li>Perfusion study that captures cerebral blood flow at time of injection of radionuclide. </li></ul><ul><li>SPECT is useful in detecting extent & location of perfused areas of the brain, allowing detection, localization and sizing of stroke, detecting tumor progression and evaluation of perfusion before and after neurosurgical procedures. </li></ul>
  100. 100. Single Photon Emission Computed Tomography (SPECT) <ul><li>Nursing Intervention </li></ul><ul><li>Preparation and monitoring </li></ul><ul><li>Observe for allegeric reaction. </li></ul><ul><li>Pregnancy and breastfeeding are contraindications. </li></ul>
  101. 101. SPECT
  102. 102. Magnetic Resonance Imaging (MRI) <ul><li>Uses a powerful magnetic field to obtain images of different areas of the body </li></ul><ul><li>Can identify cerebral abnormality earlier and more clearly than any other diagnostic tests </li></ul><ul><li>Useful in monitoring tumor’s response to treatment, Dx of MS </li></ul>
  103. 105. Nursing Intervention: MRI <ul><li>Relaxation techniques </li></ul><ul><li>Advise pt that she can speak with the staff by means of a microphone inside the scanner </li></ul><ul><li>ALL metal objects and magnetic cards are removed (aneurysm clips, ortho-hardware, pacemakers, artificial heart valves, IUD) </li></ul><ul><li>Medication patches removed (cause burns) </li></ul><ul><li>Sedation for claustrophobic pt </li></ul><ul><li>Scanning process is painless, but the patient hears loud thumping of magnetic coils as magnetic field is being pulsed. </li></ul>
  104. 106. Myelography <ul><li>Myelogram is an Xray of spinal subarachnoid space taken with contrast agent (through Lumbar Tap) </li></ul><ul><li>Shows distortion of spinal cord or spinal dural sac caused by tumors, cysts, herniated vertebral disks </li></ul><ul><li>Nursing Intervention </li></ul><ul><li>Meal before procedure is omited </li></ul><ul><li>After myelography, patient to lie in bed with head elevated up to 45º and remain in bed for 3hrs </li></ul><ul><li>Encourage increased fluid intake </li></ul><ul><li>Monitor VS </li></ul>
  105. 107. Myelography
  106. 108. CEREBRAL ANGIOGRAPHY <ul><li>X-ray study of the cerebral circulation with contrast agent injected to selected artery. </li></ul><ul><li>Performed by threading a catheter through the femoral artery in the groin and up to the desired vessel. </li></ul><ul><li>Uses: Vascular disease, aneurysms, AVM </li></ul><ul><li>Digital Subtraction Angiography </li></ul><ul><li>X-ray images of areas in question are taken before and after injection of contrast agent (peripheral vein) and then compared </li></ul>
  108. 111. Nursing Intervention: CEREBRAL ANGIOGRAPHY <ul><li>NURSING CARE PRE-TEST </li></ul><ul><li>1.) Check allergy to iodine </li></ul><ul><li>2.) Keep NPO after midnight or offer clear liquid breakfast only </li></ul><ul><li>3.) Explain that the client may have warm, flushed feeling and salty taste in mouth during procedure </li></ul><ul><li>4.) Take baseline vital signs and neuro check </li></ul><ul><li>5.) Administer sedation if ordered </li></ul><ul><li>NURSING CARE POST-TEST </li></ul><ul><li>1.) Maintain pressure dressing over site if femoral or brachial artery used; apply ice as ordered </li></ul><ul><li>2.) Maintain bed rest until next morning as ordered </li></ul><ul><li>3.) Monitor vital signs, neuro checks frequently; report any changes immediately </li></ul><ul><li>4.) Check site frequently for bleeding or hematoma; if carotid artery used; assess for swelling of neck, difficulty swallowing or breathing </li></ul><ul><li>5.) Check pulse, color, and temperature of extremity distal to site used. </li></ul><ul><li>6.) Keep extremity extended and avoid flexion </li></ul>
  109. 112. Non-invasive Carotid Flow Studies <ul><li>Uses ultrasound and doppler measurements of arterial blood flow to evaluate carotid and deep orbital circulation. </li></ul><ul><li>The graph produced indicates blood velocity. </li></ul><ul><li>(  velocity = stenosis or partial obstruction) </li></ul><ul><li>Carotid doppler permits evaluation of </li></ul><ul><li>Carotid ultrasonography arterial blood flow and </li></ul><ul><li>Oculoplethysmography detection of atrial </li></ul><ul><li>Opthalmodensinometry stenosis, occlusion and </li></ul><ul><li>plaques </li></ul>
  110. 113. Transcranial Doppler <ul><li>Uses the same noninvasive techniques as Carotid flow studies except it records blood flow velocities of intracranial vessels </li></ul><ul><li>Flow velocity is measured through thin area of temporal and occipital bones of the skull. </li></ul><ul><li>A hand-held doppler probe emits a pulsed beam; the signal is reflected by a moving RBC within the blood vessel </li></ul><ul><li>Helpful in assessing vasospasm, altered cerebral blood flow in occlusive vascular dse or stroke </li></ul>
  111. 115. Electroencephalography (EEG) <ul><li>Represents a record of electrical activity generated by the brain through electrodes applied on the scalp </li></ul><ul><li>Used to diagnose seizure disorders, coma </li></ul><ul><li>Tumors, brain abscess, blood clots may cause abnormal patterns in electrical activity </li></ul><ul><li>Used in making a determination of BRAIN DEATH </li></ul>
  112. 117. Electroencephalography (EEG) <ul><li>Nursing Intervention </li></ul><ul><li>Withhold medications that may interfere with the results- anticonvulsants , sedatives and stimulants </li></ul><ul><li>Wash hair thoroughly before procedure </li></ul><ul><li>Instruct adult client to sleep no more than 5 hrs the night before. </li></ul><ul><li>Coffee, tea, chocolate and cola drinks are omitted </li></ul><ul><li>Meal itself is not omitted because an altered glucose level alters brain wave patterns </li></ul><ul><li>It takes 45min-1hour; 12 hours for sleep EEG </li></ul><ul><li>Standard EEG - water-soluble lubricant </li></ul><ul><li>Sleep EEG - collodion glue for electrode contact (acetone for removal) </li></ul>
  113. 118. Diagnostic Evaluation <ul><li>Electromyography (EMG) </li></ul><ul><li>obtained by inserting needle electrode into the skeletal muscle to measure changes in the electrical potential of the muscles and the nerves leading to them. </li></ul><ul><li>Determine presence of neuromuscular disorders & myopathies. </li></ul><ul><li>Nerve Conduction Studies </li></ul><ul><li>A peripheral nerve is stimulated at several points along its course and recording the muscle action potential or sensory action potential. </li></ul><ul><li>Useful in studying peripheral neuropathies. </li></ul>
  114. 119. Lumbar Puncture and CSF examination <ul><li>Spinal tap - a needle is inserted into the subarachnoid space through the 3rd and 4th or 4th and 5th lumbar interface to withdraw spinal fluid </li></ul><ul><li>h </li></ul><ul><li>PURPOSES </li></ul><ul><li>1. Measures CSF pressure </li></ul><ul><li>(normal opening pressure 60-150mmH 2 O) </li></ul><ul><li>Obtain specimens for lab analysis, cytology, C&S </li></ul><ul><li>(protein - normally not present, sugar - normally present) </li></ul><ul><li>3. Check color of CSF (normally clear) and check for blood </li></ul><ul><li>4. Inject air, dye, or drugs into the spinal canal </li></ul><ul><li>CSF pressure in lateral recumbent position is </li></ul><ul><li>70-200mm H 2 0 </li></ul>
  115. 120. Lumbar Puncture and CSF examination <ul><li>CONTRAINDICATION </li></ul><ul><li>INCREASED ICP </li></ul><ul><li>COAGULOPATHY & DECREASED PLATELETS </li></ul><ul><li>SPINAL DEFORMITIES ( SCOLIOSIS, KYPHOSIS) </li></ul>
  116. 121. Lumbar Puncture Guidelines <ul><li>NURSING CARE PRE-TEST </li></ul><ul><li>1.) Have client empty bladder </li></ul><ul><li>2.) Position client in a lateral recumbent position with head and neck flexed onto the chest and knees pulled up. </li></ul><ul><li>3.) Explain the need to remain still during the procedure </li></ul><ul><li>NURSING CARE POST-TEST </li></ul><ul><li>1.) Ensure labeling of CSF specimens in proper sequence </li></ul><ul><li>2.) Keep client flat for 12-24 hours as ordered </li></ul><ul><li>3.) Force fluids </li></ul><ul><li>4.) Check puncture site for bleeding, leakage of CSF </li></ul><ul><li>5.) Assess sensation and movement in lower extremities </li></ul><ul><li>6.) Monitor vital signs </li></ul><ul><li>7.) Administer analgesics for headache as ordered </li></ul>
  117. 123. Queckenstendt’s Test <ul><li>lumbar manometric test </li></ul><ul><li>performed by compressing jugular veins during Spinal tap </li></ul><ul><li> in pressure caused by compression is noted; then released and read every 10secs interval. </li></ul><ul><li>a slow rise and fall in pressure indicated a partial block due to lesion compressing the spinal subarachnoid path. </li></ul><ul><li>no pressure change => complete block is indicated. </li></ul><ul><li>Contraindicated : if intracranial lesion is suspected. </li></ul>
  118. 124. CSF Analysis <ul><li>CSF should be clear and colorless </li></ul><ul><li>Pink, blood-tinged, or glossy bloody CSF indicates cerebral contusion, laceration or subarachnoid hemorrhage </li></ul><ul><li>Specimens are obtained for: cell count, culture and glucose and protein testing </li></ul>
  119. 125. Post Lumbar Headache <ul><li>Mild to severe, may occur few hours to several days after the procedure. </li></ul><ul><li>It is throbbing bifrontal or occipital headache, dull or deep in character </li></ul><ul><li>Cause: leak at puncture site, fluid continues to escape into the tissues by way of the needle track from the spinal canal </li></ul><ul><li>May be avoided if small-gauged needle is used and if pt remains prone </li></ul><ul><li>after the procedure. </li></ul>
  120. 126. sources <ul><li>Dillon, Patricia. Nursing Health Assessment. 2 nd Ed. F.A. Davis. 2007 </li></ul><ul><li>Jarvis, Carolyn. Physical Examination and Health Assessment. 3 rd ed. New York: W.B. Saunder Company.2000 </li></ul><ul><li>Bickley. Lyn and Hoekenan, Robert. Bate’s Guide to Physical Examination and History Taking. 7 th ed. New York: Lippincott Williams and Wilkins. 1999 </li></ul><ul><li>Estes, Mary Ellen Zator. Health Assessment & Physical Examination. 3 rd ed. Delmar Learning. 2006 </li></ul>
  121. 127. THANK YOU!!!
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MS 104


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