Download - Neurological Assessment
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Neurological Assessment & Diagnostic Studies
NET 2420Neuro Lecture HandoutS. Compton RN, MSN
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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
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Complete Neurological Assessment
5 Components
• Cerebral Function • Cranial Nerve Function: I-XII• Cerebellar and Motor Function• Sensory System• Reflexes
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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
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Cerebral Function• Level of consciousness:
– Level of arousal: Subcortical RAS• Alert lethargic unresponsive• Auditorytactile 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
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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
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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
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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
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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
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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
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Visual Field Defects
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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
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CN III, CN IV, CN VI
• Oculomotor, trochlear, abducens nerves (motor)– Assess EOM’s– Assesses midbrain and pons
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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
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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
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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)
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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
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CN XI: Spinal Accessory Nerve • Motor
• Shrug shoulders trapezius• Turn head sternocleidomastoid
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CN XII: Hypoglossal Nerve
• Motor• Tongue movements, strength
• Speech sounds: d, l, n, t
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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
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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
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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
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Gait Disturbances
A. Spastic HemiparesisB. Spastic Paresis (Scissors Gait)C. Foot DropD. Sensory Ataxia (+ Romberg’s eyes
closed)E. Cerebellar Ataxia
(+ Romberg’s eyes open or closed)
F. Parkinsonian
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Deep Tendon Reflexes Assessing Spinal Cord Level
• BicepsC5C6
• BrachioradialisC5C6
• TricepsC7C8
• AbdominalT8T9T10
• Patellar (knee-jerk)L2L3L4
• AchillesS1S2
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Grading Reflexes
• Grade 0-4+ – 0 reflex absent– 2+ “normal”– 4+ CLONUS UMN
disease
• Compare side to side• Many variations• Patient must be
relaxed
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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
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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
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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
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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
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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!!!!
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Anatomical Planes
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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
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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
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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
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PET Scan
• Images of actual organ functioning
• Inhaled or injected radioactive substance
• Shows metabolic changes– Alzheimer’s– Brain tumors– O2 uptake after stroke
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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
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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
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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/com
mon/artprn_rev.cfm?filename=&ARTID=560
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MR Angiography (MRA)
• Utilization of MR technology to view vasculature
• Same restrictions as MRI• May use contrast material
(gadolinium) but is not iodine based
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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
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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
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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
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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
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EEG PreparationUse 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
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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
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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)
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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
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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
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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
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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
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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