2. Lumbar Puncture
• introduction of hollow needle with stylet
into the lumbar subarachnoid space of the
spinal canal between L1/L5 and of
withdrawal of CSF fluid for diagnostic and
therapeutic purposes.
3. Purpose:
• Measures CSF pressure (normal opening
pressure 60-150mm H20)
• Obtain specimen for laboratory analysis
• Check color of CSF (normally clear) and
check for blood
• Inject air, dye, or drugs into the spinal
canal.
4.
5.
6.
7.
8. Nursing Care
• Pretest
– Have client empty
bladder
– Position client in
lateral recumbent
position with head and
neck, flexed on the
chest and knees
pulled up.
– Explain the need to
remain still during the
procedure.
9. • Post test
– Ensure labelling of CSF specimens in proper
sequence
– Keep client flat for 12-24hours as ordered
– Forced fluids
– Check puncture site for bleeding, leakage of
CSF
– Assess sensation and movement in lower
extremities
– Monitor vital signs
– Administer analgesics for headache as
ordered.
12. Nursing Care
• Same as for lumbar puncture
• Observe for cyanosis, dyspnea and apnea
13. X-ray of the Skull
• – films examined for signs of fracture,
erosion of the bone including size of sella
turcica. Reveals configuration, destiny,
vascular markings.
16. Purpose –
localization of
tumors, abscesses,
aneurysms,
hematomas, and
occlusions.
Potential
Complications:
Anaphylactic
reaction to dye, local
haemorrhage,
vasospasm, adverse
intracranial
pressure.
17.
18. Nursing Care
• Pre Test
– Check allergies for iodine
– Take baseline assessment
– Measure neck circumference
– NPO after midnight or clear liquid
– Explain the warm flushed feeling and salty
taste in mouth may be felt during the
procedure.
19. Post Test
• Have emergency equipment available.
• Monitor neurological status and vital signs
for shock, LOC, hemiparesis, hemiplegia
and aphasia.
• Administer ice collar/cap intermittently to
relive swelling and discomfort.
• Maintain pressure dressing
• Maintain bed rest until next morning as
ordered.
20. Pneumoencephalograph
• introduction of air or oxygen into the
subarachnoid space by lumbar or cisternal
puncture to outline the ventricular system
and intracranial subarachnoid space for x-
ray study. Demonstrates intracranial
subarachnoid space and ventricular
system. Localize intracranial lesion.
21. Ventriculography
• introduction of air or O2 directly into the
lateral ventricles by ventricular puncture
thru an opening made in the frontal,
parietal or occipital regions for special x-
ray study of the brain.
22. • Purpose: - to visualize ventricles, localized
tumors.
• Potential Complications
– Headache
– Nausea and vomiting
– Meningitis
– Increased intracranial pressure
• Nursing Care
• Post Test
– Monitor Vital signs
– Check neurological status
– Elevate head of bed (15-20 degrees)
23. BRAIN SCANNING
(RADIONUCLIEDE IMAGING
STUDIES)
• – intravenous injection of radioactive
compound and the application of a
scintillation scanner in the patient’s brain –
there’s an increase uptake or radioactive
materials at the site of pathology.
24. • Purpose: use to detect intracranial
masses, vascular lesions, infarct and
hemorhage.
• Nursing Care
– Check for allergy
– Keep NPO 4-6 hours before exam
30. • Noninvasive procedure that identifies
tumors and vascular abnormalities and
provide a more detailed picture.
• Remove all metals from the body
• Pacemakers, implanted defibrillator, metal
implants and vascular clips are
contraindicated for the procedure.
31. • Pulse oximeters are not allowed because
it can burn during testing
• Assess for claustrophobia
• Client may resume normal activities after
the procedure.
32.
33. Computed Tomography Scan
• Brain scan that may or may not require a
contrast dye.
• Used to detect space-occupying lesions,
bleeding, edema, hydrocephalus and
atrophy.
• Assess for allergies to iodine, dyes, or
shellfish.
34. • Instruct the need to lie still and flat during
the entire procedure.
• Assess for claustrophobia.
• Inform of possible mechanical noises
• There may be a hot, flushed sensation and
metallic taste in the mouth when dye is
injected.
• Provide fluids after the procedure for
diuresis
35.
36.
37. Myelogram
Injection of air or dye in the subarachnoid
space to detect abnormalities of the spinal
cord and vertebrae.
Obtain informed consent.
Hydrate patient 12 hours prior to the test
Assess for allergies to iodine
Pre-medicate for sedation
38. Water based dye (most often used):
elevate the head of bed 15 to 30 degrees
for 6 to 8 hours.
Oil based dye: keep the head lower 6 to 8
hours.
If air is used: keep the head lower that the
trunk for 48 hours.
42. LEVEL OF CONSCIOUSNESS
• – ask questions about his present, past,
illness and not the general level of
consciousness most sensitive indicator of
changes in the neurologic status.
• Orientation to time, place and person
• Speech, clear , garbled, ramping
• Ability to follow commands
45. Objective evaluation
of level of
consciousness, motor
and verbal response
A standard system for
assessing the degree
of neurologic
assessment in
critically ill patients.
Score – 15 (patient is
awake and oriented)
7 or below (coma)
Lowest score 3 –
deep coma
46.
47. Abnormal Posturing
• Decerebrate – extension and adduction of
arms, hyperextension of legs
• Decorticate – flexion adduction internal
rotation of arms, extension of leg (damage
to corticospinal tracts, cerebral
hemispheres)
48.
49. Mood – may have diagnostic
significance
• schizophrenia
54. • Memory – maybe revealed by volume of
detail that he can provide in relating the
health history.
• Cortex – attempt to conceal memory
details by:
– Circumlocation – talking around an issue
without really answering the question.
– Confabulation – relating imaginary
experiences rather than admitting ability to
remember past events.
55. Complex Function
– Higher function should be evaluated
– To ascertain the level of patient’s cerebral
functioning
• Ability to reason abstractly tested by asking patient
to explain proverb, ability to perform mathematical
calculations
56. • Speech
–Note quality of articulation, manner of
syllabication, aptness of his word choice,
strength of his voice, comprehension of
questions.
–Impaired articulation results of infarction
of the dominant cerebral hemispheres,
cerebellar dysfunction, lesion of the
brain stem, dysfunction of 5,7, 9 or 10th
or 12th cranial nerve.
• Reading
• Writing
57. VITAL SIGNS – respiratory
patterns help localize possible
lesion
58. – Cheyne-stoke respiration
» Regular rhythmic, alternating between
hyperventilation and apnea
» Maybe caused by structural cerebral
dysfunction of metabolic problems such as
diabetic coma.
59. – Central neurogenic hyperventilation
» Sustained rapid, regular respiration (rate of
25/min) with normal blood oxygen levels
» Usually due to brainstem dysfunction
– Apneustic breathing
» Prolonged inspiratory phase, followed by a 2-3
second pause.
» Usually indicates dysfunction of respiratory
center in pons.
– Ataxic breathing – breathing pattern completely
irregular indicates damage to respiratory center of
the medulla
– Biots respiration
» Irregular breathing
» Deep and shallow breathing randomly
60.
61. PUPILS (PERRLA) – pupils
equal, round, reactive to light
and accommodation
64. • Affected pupil is usually on the same side
(ipsilateral) as the brain lesion, whereas
the motor and sensory deficits are usually
on the opposite side (contralateral)
• Observe size, shape and equality of pupils
• Reaction to light papillary constriction
• Corneal reflex – blink reflex in response to
light stroking of cornea
• Oculocephalic reflex (doll’s eyes) –
present in unconscious patient with intact
brainstem
65.
66. MOTOR FUNCTION
• Muscle size
– Inspect major muscle groups bilaterally for
symmetry
– Inspect the trunk and intercostals and
abdominal muscles.
67. Muscle
strength
Five Point Scale –
Muscle Strength
5/5 Normal full
strength muscle is
able to move
through full range of
motion against the
effects of gravity and
applied resistance.
68. 4/5 Muscle is able to
move actively
through full range of
motion against the
effect of gravity with
weakness to applied
resistance.
3/5 Muscle is able to
move actively
against the effect of
gravity alone
69. 2/5 Muscle is able to
move with support
against the gravity
1/5 Muscle contraction
is palpable and visible
trace or flicker
movement occurs.
0/5 Muscle contraction
or movement is
undetectable.
70. • Muscle tone – assessed while moving
each extremity through passive range of
motion.
– Increased muscle tone – muscle are restless
to movement, rigid or spastic
– Decreased muscle tone – muscles are soft,
flabby or flaccid
71. • Muscle coordination – testing rapid
alternating movements. Point to point
maneuvers and maintenance of truncal
balance and head position
• Gait and Station – assess by having client
stand still. Walk and walk in tandem.
72. • Pain
– Response seen when painful stimuli are
applied, tested by a pin which the patient is
pricked over various parts of skin surface
– Localization – the client pushes the stimuli
away
– Flexion – client pulls away from the stimuli
– Decorticate posturing (abnormal extension) –
indicates damage to the cerebellum
– No response – no visible movement to painful
stimuli
73. • Touch – tested by a cotton wisps on as
applicator or by a camel’s hair brush or
even by examiners which is brought
gingerly and lightly down the skin
• Heat and Cold
– Patient with eyes closed is asked to identify
hot and cold over various parts of the body
– Tested by means of test tubes containing hot
water and cracked ice.
74. REFLEXES
• Normal Reflexes
– Pupillary reflex
– Corneal reflex
• Tested by a means of a curved hair attached to a
stick enabling the examiner to touch to cornea
without stimulating the hair being seen
• Result: quick wink reflex.
75.
76.
77. –Biceps reflex
•Examined by placing the elbow of
the arm to be examined in the
hand of the examiner. The
examiner. The examiners thumb
being placed over the biceps
tendon and struck briskly with a
reflex hammer
•Result : Flexion of arms
78.
79.
80. Brachial reflex
Elicited by the
lower third of the
radius with the
forearm midway
between
pronation and
supination
Result: flexion of
the forearm on
the arm and
flexion of the
finger and hand
81. – Triceps
• Taken by holding the arm of the patient
supported by the elbow with the arm partly
extended, the triceps tendon being tapped
by the reflex hammer.
• Result: An extension movement of the arm
• In supine position: The arm is drawn across
the chest, the forearm slightly flexed and
the triceps tendon is tapped.
82.
83. – Patellar reflex
• Taken by tapping the patellar tendon with the leg
partly extended
• If it is taken in bed, placing a rolled pillow under the
knee facilities taking the reflex.
84.
85.
86. – Achilles reflex – maybe taken with patient
lying on his face, the knees flexed , the feet
held in slightly dorsiflexed by the examiners
hand and Achilles tendon struck in order to
produce plantar flexion.
87.
88. –Plantar reflex
• Sole of the
feet is
stimulated with
a blunt object
carried along
its outer and
inner sides
• Result: Flexion
of the toes
89. – Abdominal reflex
• Running an object along the upper and lower
abdominal quadrants on either side.
• Result: Movement of the abdominal musculature
and a pull of umbilicus toward stimulated side
• Medium tension of abdominal muscle – most
favourable
94. Abnormal Reflexes – indicative
of meningeal irritation
– Babinski reflex – tested by gently scrapping
the sole of the foot with a blunt point:
produces dorsiflexion of the great toe and
fanning of the other toes
– Brudzinski’s sign – flexing the head results
pain and involuntary flexion at hip and knee
joints
– Kernig’s sign – passive extension of the leg
with the thigh flexed is restricted and
considerably causes pain
95.
96.
97.
98. CEREBRAL DYSFUNCTION
• APHASIA – loss of language ability
• Types:
• Expressive or motor – inability to send
messages due to damaged Broca’s center
– Complete – patient will be unable to formulate
any spoken language
– Incomplete – words uttered or terms of
profanity and vulgarity
99. • Receptive aphasia
– Inability to comprehend messages received
from others and can relate either to written or
spoken language
– Lesion in posterior or temporal portion of
dominant hemisphere
• Global aphasia
– Loss of all speech function
– Destruction of both motor and sensory speech
areas in the dominant hemisphere
– Seen in occlusion of left carotid or middle
cerebral artery, massive cerebral
haemorrhage or blood transfusion
100. • AGNOSIA – inability to recognize objects due to parietal lobe
lesion
• Visual agnosia – unable to identify and understand the function
of familiar objects he can see.
• Tactile agnosia
– Due to parietal lobe lesion
– Unable to identify and comprehend the use of an object he
can touch and manipulate
– Test for agnosia: consists of pointing to or placing in the
patient’s hand such as object as coin, button, key, safety pin
and asking him to name the item and explain what is its use
for.
101. • APRAXIA – loss of previously acquired
ability to perform such simple skilled acts
tying one’s shoelace, buttoning a coat,
opening and closing a safety pin and
fastening a belt buckle.
102. CEREBELLAR SYSTEM
• ARMS
– Finger – nose test
• Patient is asked to place the index finger of each
hand on the nose
• This test may be varied by asking the patient
several times quickly to touch the nose in rapid
succession.
103. • Finger-finger test
– Patient is asked to place the index of his hand
on the examiner’s index finger
– Repeated several times in rapid succession.
104.
105. • Pronation – supination test
–With the arms extended in front of him,
the patient is asked to pronate and
supinate rapidly, using the elbow as
fulcrum. Under normal circumstances,
the movement are of equal amplitude,
smooth and even there’s no tendency
on the part of the arms to drift outward
or inward during the movement
–Beat and rhythm are well maintained
106.
107.
108. • Patting test – patient requested to pat
rapidly with each hand the examiner’s
hand or his own leg. Under normal
condition this is performed smoothly with
even amplitude and a smooth rhythm.
109. • LEGS
• Heel Test – with the patient in supine
position the heel of one foot is placed on
the opposite knee. This is done smoothly
without tremor and with accuracy.
• Heel-toe test – the patient is asked in
supine position the heel to toe along a
straight line. This can be done normally
without faltering or lose balance.
110.
111.
112. • TRUNK
• Gait
• Good method of determining trunk
coordination
• Patient should be given plenty of room and
asked to walk briskly with the eyes open
and closed and to turn quickly.
• May be asked to walk around a chair, to sit
and rise quickly from a chair.
113. • Station: tested by asking the patient to
stand with the leg close together, first with
eyes open then closed.
• Tandem Romberg – asked to stand with
one feet directly in front of the other.
114.
115.
116.
117.
118.
119.
120.
121. EVALUATION OF BRAIN STEM
FUNCTIONING
• Spontaneous motion of eyes
• Oculocephalic reflex (Doll’s Eye)
– Doll’s Phenomenon
• Eyes deviate conjugately in the direction opposite
to head turning.
• Tested by briskly turning the head from side to side
while holding the eyes open.
122. – Normal response if present – normal for eyes
to deviate conjugately in the direction
opposite to the head turning.
– Abnormal response if absent – abnormal
movement of the eyes in the same direction
as the head is turned.
123. • Occulovestibular test
– Ice H20 test – done by slowly injecting ice
water into the external auditory canal until eye
deviation or nystagmus occurs.
– Implications – slow conjugate deviation of
eyes towards irrigated ear where they remain
30-120 seconds is considered a response of a
comatose person with intact brain stem.
– Abnormal movement such as jerky
movements indicates brain stem lesion .
