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Neurologic Nursing 1


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Neurologic Nursing 1

  2. 2. On completion of this chapter, the learner will be able to:1. Describe the structures and functions of the central andperipheral nervous systems.2. Differentiate between pathologic changes that affect motorcontrol and those that affect sensory pathways.3. Compare the functioning of the sympathetic andparasympathetic nervous systems.4. Describe the significance of physical assessment to thediagnosis of neurologic dysfunction.
  3. 3. Continued…5. Describe changes in neurologic function associated withaging and their impact on neurologic assessment findings.6. Describe diagnostic tests used for assessment ofsuspected neurologic disorders and the related nursingimplications.
  4. 4. 1. MOTOR NEURONSTake nerve impulses from the CNS to muscles, organs, orglands2. SENSORY NEURONSTake nerve impulses from sensory receptors to the CNS3. INTERNEURONSConvey nerve impulses between various parts of the CNS
  5. 5. There are two types of receptors: direct and indirect.• DIRECT RECEPTORS are also known as inotropic becausethey are linked to ion channels and allow passage of ionswhen opened. They can be excitatory or inhibitory and arerapid-acting (measured in milliseconds).• INDIRECT RECEPTORS affect metabolic processes in thecell, which can take from seconds to hours to occur
  6. 6.  Over average lifetime, brain shrinks 10% Most cell death occurs in temporal lobes By age 90, frontal cortex has lost half its neurons Number of dendritic branches decreases Decreased levels of neurotransmitters Fading memory Slowed responses and reflexes Increased risk of falling Changes in sleep patterns that result in fewer sleepinghours
  7. 7.  Pain Seizures Dizziness Vertigo Visual disturbances Weakness Abnormal sensation
  8. 8. • An assessment of mental status begins by observing thepatient’s appearance and behavior, noting dress, grooming,and personal hygiene.• Posture, gestures, movements, facial expressions, andmotor activity often provide important information about thepatient.• The patient’s manner of speech and level of consciousnessare also assessed.• Assessing orientation to time, place, and person assists inevaluating mental status.
  9. 9. • A person with an average IQ can repeat seven digitswithout faltering and can recite five digits backward.• The examiner might ask the patient to count backward from100 or to subtract 7 from 100, then 7 from that, and so forth(called serial 7s).• The capacity to interpret well-known proverbs testsabstract reasoning, which is a higher intellectual function.• Questions designed to assess the integrative capacityinclude the ability to recognize similarities.• Can the patient make judgments about situations.
  10. 10. • Are the patient’s thoughts spontaneous, natural, clear,relevant, and coherent?• Does the patient have any fixed ideas, illusions, orpreoccupations?• What are his or her insights into these thoughts?• Preoccupation with death or morbid events, hallucinations,and paranoid ideation are examples of unusual thoughts orperceptions that require further evaluation.
  11. 11. • Is the patient’s affect (external manifestation of mood)natural and even, or irritable and angry, anxious, apatheticor flat, or euphoric?• Does his or her mood fluctuate normally, or does thepatient unpredictably swing from joy to sadness during theinterview?• Is affect appropriate to words and thought content?• Are verbal communications consistent with nonverbalcues?
  12. 12. • Agnosia is the inability to interpret or recognize objectsseen through the special senses.• Placing a familiar object (eg, key, coin) in the patient’s handand having him or her identify it with both eyes closed is aneasy way to assess tactile interpretation.
  13. 13. • Assessment of cortical motor integration is carried out byasking the patient to perform a skilled act.• Successful performance requires the ability to understandthe activity desired and normal motor strength.• Failure signals cerebral dysfunction.
  14. 14. • The person with normal neurologic function can understandand communicate in spoken and written language.• Does the patient answer questions appropriately?• Can he or she read a sentence from a newspaper andexplain its meaning?• Can the patient write his or her name or copy a simplefigure that the examiner has drawn?• A deficiency in language function is called aphasia.
  15. 15. • Issues to consider include the limitations imposed on thepatient by any deficit and the patient’s role in society,including family and community roles.• The plan of care that the nurse develops needs to addressand support adaptation to the neurologic deficit andcontinued function to the extent possible within thepatient’s support system.
  16. 16. • Interpretation and documentation of neurologicabnormalities, particularly mental status abnormalities,should be specific and nonjudgmental.• Lengthy descriptions and the use of terms such as―inappropriate‖ or ―demented‖ should be avoided.• The examiner records and reports specific observationsregarding orientation, level of consciousness, emotionalstate, or thought content, all of which permit comparison byothers over time.
  17. 17. • The patient is instructed to walk across the room while theexaminer observes posture and gait.• The muscles are inspected, and palpated if necessary, fortheir size and symmetry. Any evidence of atrophy orinvoluntary movements (tremors, tics) is noted.• MUSCLE TONE (the tension present in a muscle at rest)is evaluated by palpating various muscle groups at restand during passive movement.• Resistance to these movements is assessed anddocumented. Abnormalities in tone include spasticity,rigidity, and flaccidity.
  18. 18. • Assessing the patient’s ability to flex or extend theextremities against resistance tests muscle strength.• The evaluation of muscle strength compares the sides ofthe body to each other.• Distal and proximal strength in both upper and lowerextremities is recorded using the five-point scale.
  19. 19. • Cerebellar influence on the motor system is reflected inbalance control and coordination.• Coordination in the hands and upper extremities is tested byhaving the patient perform rapid, alternating movements andpoint-to-point testing.• First, the patient is instructed to pat his or her thigh as fastas possible with each hand separately. Then the patient isinstructed to alternately pronate and supinate the hand asrapidly as possible. Lastly, the patient is asked to touch eachof the fingers with the thumb in a consecutive motion.• Speed, symmetry, and degree of difficulty are noted.
  20. 20. • Coordination in the lower extremities is tested by having thepatient run the heel down the anterior surface of the tibia ofthe other leg.• Ataxia is defined as incoordination of voluntary muscleaction, particularly of the muscle groups used in activitiessuch as walking or reaching for objects.• The presence of ataxia or tremors during these movementssuggests cerebellar disease.• It is advisable to perform a simple screening of the upperand lower extremities by having the patient perform eitherrapid, alternating movements or point-to-point testing.
  21. 21. • The Romberg test is a screening test for balance. Thepatient stands with feet together and arms at the side, firstwith eyes open and then with both eyes closed for 20 to 30seconds.• Slight swaying is normal, but a loss of balance is abnormaland is considered a positive Romberg test.• Additional cerebellar tests for balance in the ambulatorypatient include hopping in place, alternating knee bends,and heel-to-toe walking (both forward and backward).
  22. 22. • Deep tendon reflex responses are often graded on a scaleof 0 to 4+.• A 4+ indicates a hyperactive reflex, often indicatingpathology; 3+ indicates a response that is more brisk thanaverage but may be normal or indicative of disease; 2+indicates an average or normal response; 1+ indicates ahypoactive or diminished response; and 0 indicates noresponse.
  23. 23. • When reflexes are very hyperactive, a phenomenon calledclonus may be elicited.• The major superficial reflexes include corneal, gag orswallowing, upper/lower abdominal, cremasteric (men only),plantar, and perianal.• These reflexes are graded differently than the motor reflexesand are noted to be present (+) or absent (-). Of these, onlythree are tested commonly.
  24. 24. • Assessment of the sensory system involves tests for tactilesensation, superficial pain, vibration, and position sense(proprioception).• Tactile sensation is assessed by lightly touching a cottonwisp to corresponding areas on each side of the body.• Determining the patient’s sensitivity to a sharp object canassess superficial pain perception.• Vibration and proprioception are transmitted together in theposterior part of the cord.• Vibration may be evaluated through the use of a low-frequency (128- or 256-Hz) tuning fork.
  25. 25. • Position sense or proprioception may be determined byasking the patient to close both eyes and indicate, as thegreat toe is alternately moved up and down, in whichdirection movement has taken place.• Integration of sensation in the brain may be performed bytesting two-point discrimination—when the patient istouched with two sharp objects simultaneously, are theyperceived as two or as one• Another test of higher cortical sensory ability isstereognosis. The patient is instructed to close both eyesand identify a variety of objects that are placed in one handby the examiner.
  26. 26. • Preparation includes teaching the patient about the need tolie quietly throughout the procedure.• A review of relaxation techniques may be helpful forclaustrophobic patients.• Sedation can be used if agitation, restlessness, or confusionwill interfere with a successful study.• If a contrast agent is used, the patient must be assessedbefore the CT scan for an iodine/shellfish allergy, as thecontrast agent is iodine-based.
  27. 27. • An intravenous line for injection of the contrast agent and aperiod of fasting (usually 4 hours) are required prior to thestudy.• Patients who receive an intravenous or inhalation contrastagent are monitored during and after the procedure forallergic reactions and other side effects, including flushing,nausea, and vomiting.
  28. 28. • Key nursing interventions include patient preparation, whichinvolves explaining the test and teaching the patient aboutinhalation techniques and the sensations (eg, dizziness,lightheadedness, and headache) that may occur.• The intravenous injection of the radioactive substanceproduces similar side effects.• Relaxation exercises may reduce anxiety during the test.
  29. 29. • Teaching about what to expect before the test can allayanxiety and ensure patient cooperation during the test.• Premenopausal women are advised to practice effectivecontraception before and for several days after testing, andthe woman who is breastfeeding is instructed to stop nursingfor the period of time recommended by the nuclear medicinedepartment.• The nurse may need to accompany and monitor the patientduring transport to the nuclear medicine department for thescan.• Patients are monitored during and after the procedure forallergic reactions to the radiopharmaceutical agent
  30. 30. • Patient preparation should include teaching relaxationtechniques and informing the patient that he or she will beable to talk to the staff by means of a microphone locatedinside the scanner.• Before the patient enters the room where the MRI is to beperformed, all metal objects and credit cards are removed.No metal objects may be brought into the room where theMRI is located.• A patient history is obtained to determine the presence ofany metal objects (eg, aneurysm clips, orthopedic hardware,pacemakers, artificial heart valves, intrauterine devices).
  31. 31. • These objects could malfunction, be dislodged, or heat upas they absorb energy.• Cochlear implants will be inactivated by MRI; therefore,other imaging procedures are considered.• The scanning process is painless, but the patient hears loudthumping of the magnetic coils as the magnetic field is beingpulsed.• Patients may experience claustrophobia; sedation may beprescribed in these circumstances.
  32. 32. • The patient should be well hydrated, and clear liquids areusually permitted up to the time of a regular arteriogram orDSA.• Before going to the x-ray department, the patient isinstructed to void.• The locations of the appropriate peripheral pulses aremarked with a felt-tip pen.• The patient is instructed to remain immobile during theangiogram process and is told to expect a brief feeling ofwarmth in the face, behind the eyes, or in the jaw, teeth,tongue, and lips, and a metallic taste when the contrastagent is injected.
  33. 33. • Nursing care after cerebral angiography includesobservation for signs and symptoms of altered cerebralblood flow.• Signs of minor arterial blockage include alterations in thelevel of responsiveness and consciousness, weakness onone side of the body, motor or sensory deficits, and speechdisturbances.• The injection site is observed for hematoma formation, andan ice bag may be applied intermittently to the puncture siteto relieve swelling and discomfort.
  34. 34. • Because a hematoma at the puncture site or embolization toa distant artery affects the peripheral pulses, these pulsesare monitored frequently.• The color and temperature of the involved extremity areassessed to detect possible embolism.
  35. 35. • The patient is informed about what to expect during theprocedure and should be aware that changes in positionmay be made during the procedure.• A sedative may be prescribed to help the patient cope withthis lengthy test.• After myelography, the patient lies in bed with the head ofthe bed elevated 30 to 45 degrees for 3 hours or asprescribed by the physician.• The patient is encouraged to drink liberal amounts of fluidfor rehydration and replacement of CSF and to decrease theincidence of post lumbar puncture headache.
  36. 36. • The blood pressure, pulse, respiratory rate, and temperatureare monitored, as well as the patient’s ability to void.• Untoward signs include headache, fever, stiff neck,photophobia (sensitivity to light), seizures, and signs ofchemical or bacterial meningitis.
  37. 37. • The patient is informed that this is a noninvasive test, that ahand-held transducer will be placed over the neck and orbitsof the eyes, and that some type of water-soluble jelly is usedon the transducer.
  38. 38. • To increase the chances of recording seizure activity, it issometimes recommended that the patient be deprived ofsleep on the night before the EEG.• Antiseizure agents, tranquilizers, stimulants, anddepressants should be withheld 24 to 48 hours before anEEG.• Coffee, tea, chocolate, and cola drinks are omitted in themeal before the test because of their stimulating effect.• The patient is informed that the standard EEG takes 45 to60 minutes, 12 hours for a sleep EEG.
  39. 39. • The patient is assured that the procedure does not cause anelectric shock and that the EEG is a diagnostic test, not aform of treatment.• Sedation is not advisable as it may lower the seizurethreshold in patients with a seizure disorder and alter brainwave activity in all patients.• Routine EEGs use a water-soluble lubricant for electrodecontact, which at the conclusion of the study can be wipedoff and removed by shampooing.• Sleep EEGs involve the use of collodion glue for electrodecontact, which requires acetone for removal.
  40. 40. • In evoked potential studies, electrodes are applied to thescalp and an external stimulus is applied to peripheralsensory receptors to elicit changes in the brain waves.• Evoked changes are detected with the aid of computerizeddevices that extract the signal, display it on anoscilloscope, and store the data on magnetic tape or disk.• In clinical practice, the visual, auditory, and somatosensorysystems are most often tested.
  41. 41. • There is no specific patient preparation other than to explainthe procedure and to reassure the patient and encouragehim or her to relax.• The patient is advised to remain perfectly still throughout therecording to prevent artifacts (signals not generated by thebrain) that interfere with the recording and interpretation ofthe test.
  42. 42. • The procedure is explained and the patient is warned toexpect a sensation similar to that of an intramuscularinjection as the needle is inserted into the muscle.• The muscles examined may ache for a short time after theprocedure.
  43. 43. • Nerve conduction studies are performed by stimulating aperipheral nerve at several points along its course andrecording the muscle action potential or the sensoryaction potential that results.• Surface or needle electrodes are placed on the skin overthe nerve to stimulate the nerve fibers.• This test is useful in the study of peripheral neuropathies.
  44. 44. • A lumbar manometric test (Queckenstedt’s test) may beperformed by compressing the jugular veins on each sideof the neck during the lumbar puncture.• The increase in pressure caused by the compression isnoted; then the pressure is released and pressurereadings are made at 10-second intervals.• A slow rise and fall in pressure indicates a partial blockdue to a lesion compressing the spinal subarachnoidpathways.
  45. 45. • If there is no pressure change, a complete block isindicated.• This test is not performed if an intracranial lesion issuspected.
  46. 46. • The CSF should be clear and colorless. Pink, blood-tinged, or grossly bloody CSF may indicate a cerebralcontusion, laceration, or subarachnoid hemorrhage.• Usually, specimens are obtained for cell count, culture,and glucose and protein testing.• The specimens should be sent to the laboratoryimmediately because changes will take place and alter theresult if the specimens are allowed to stand.
  47. 47. • It is a throbbing bifrontal or occipital headache, dull anddeep in character. It is particularly severe on sitting orstanding but lessens or disappears when the patient liesdown.• Post–lumbar puncture headache may be avoided if a smallgauge needle is used and if the patient remains proneafter the procedure.
  48. 48. • When a large volume of fluid (more than 20 mL) isremoved, the patient is positioned prone for 2 hours, thenflat in a side-lying position for 2 to 3 hours, and thensupine or prone for 6 more hours.• The postpuncture headache is usually managed by bedrest, analgesic agents, and hydration.• If the headache persists, the epidural blood patchtechnique may be used.
  49. 49. • Herniation of the intracranial contents, spinal epiduralabscess, spinal epidural hematoma, and meningitis arerare but serious complications of lumbar puncture.• Other complications include temporary voiding problems,slight elevation of temperature, backache or spasms, andstiffness of the neck.
  50. 50. • Herniation of the intracranial contents, spinal epiduralabscess, spinal epidural hematoma, and meningitis arerare but serious complications of lumbar puncture.• Other complications include temporary voiding problems,slight elevation of temperature, backache or spasms, andstiffness of the neck.