neurological assessment- romeo rivera
TRANSCRIPT
ASSESSMENT OF THE NEUROLOGIC SYSTEM-assessment of the neurologic system is a challenge
because of the complexity of the nervous system. Neurologic assessment becomes multifaceted and lengthy.
Perception-conscious recognition and interpretation (awareness) of the sensory stimuli that serve as a basis for understanding, learning and knowing or for the motivation of a particular action or reaction
Coordination-when action or reaction towards a stimulus is occurring in a purposeful, orderly fashion, appropriate response to a stimulus
3 essential components of skull:1. Brain tissue-78%2. Blood -12 %3. CSF-10%
Monro-Kellie HypothesisIf volume added to the cranial vault equals the volume
displaced from it, the total intracranial volume will not change
Normal ICP: 60-150 mmH20 or 0-15 mmHg
Cerebral Blood FlowAmount of blood in milliliters passing through 100g of brain tissue in 1 minuteGlobal CBF-approximately 50 ml/minBrain needs constant supply of oxygen and glucose (20% of body’s oxygen, 25% of body’s glucose)
More than 10 minutes of oxygen deprivation-brain death
Mean arterial pressure at which autoregulation is effective (70-105 mmHg)
-Upper limit is 150 mmHg
MAP SBP 2 (DBP) 3
Cerebral perfusion pressure needed to ensure blood flow to the brain
CPPMAP-ICP -30 mmHg is incompatible with life
Cranium and Cerebral column
Cranial meningesDura materArachnoidPia mater
Falx cerebri-divides the left from right hemispheres
Subdural-more bleeding
NEUROLOGIC ASSESSMENTComprehensive History Taking1. Biographical and demographic data- it includes personal
profile of the patient, source of history and the clients mental status
2. Current health
a. Chief complaint- obtains a detailed description of the event that have led the client to seek care. Use open ended question.
b. Symptom analysis-3. Past health historya. Childhood infectious disease and immunizations
Rubella and rubeola Meningitis Herpes simplex virus cytomegalovirus influenza
b. Major illnesses and hospitalizations Pernicious anemia Cancer DM Infections Hypertension Liver and renal disease F & E imbalances Acid-Base Imbalances Head trauma Seizures and stroke
c. Medications- CNS stimulants Sedatives and hypnotics Antideppressives Analgesics Anti hypertensive and stroke
d. Growth and development
Mental Status Examination
An indication of how patient is functioning as a whole and how the patient is adapting to the environment
1. General appearance-2. Intellectual capacity or performance- consists of fund
of knowledge and calculation activity3. LOC-the most sensitive indicator of changes in the
neurologic status-begin by observing spontaneous behavior-visual cue -verbal cues-tactile-Noxious agent- use of central stimulus rather than peripheral (nail bed pressure) because it may elicit a reflexa. sterna pressureb. supraorbital ridge pressurec. sternocleidomastoid muscle pinch
4. Orientation- to time, place and event or situation5. Memory- retrograde (long-term memory) and
anterograde (recent memory or short-term)6. Mood/affect7. Judgment/Insight- include reasoning, abstract
thinking, problem solving and the clients’ perception of the situation.
8. Language/communication
MENTAL STATUS ASSESSMENT WITH ABNORMAL FINDINGS
Unilateral neglect (lack of caring of the other side of the body); strokes involving middle cerebral artery.
Poor hygiene and grooming: dementing disordersAbnormal gait and posture: transient ischemic attacks(TIAs) , strokes, and Parkinson’s diseaseEmotional swings, personality changes: strokesAphasia-defective or absent language function: TIA’s, strokes involving anterior/posterior artery; general term for impairment of languageDysphonia- change in tone of voiceDysarthria- (different in speaking); is indistinctness of words in word articulation resulting from interference with the peripheral speech mechanisms (e.g. muscles of the tongue, palate, pharynx, or lips) [Phipps, 1998, p. 1901]Decreased level of consciousnessConfusion, Coma
COGNITIVE FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS
Disorientation to time and place: stroke of right cerebral hemisphere
1. Memory deficits2. Emotional defense
CRANIAL NERVE ASSESSMENTSCranial I (Olfactory): Anosmia
1. lesions of frontal lobes2. impaired blood flow to middle cerebral artery.
Cranial II (Optic)1. blindness in eye: strokes of internal carotid
artery, TIA’s2. Homonymous hemianopia - impaired vision or
blindness in one side of both eyes; blockage of posterior cerebral artery.
3. Impaired vision: strokes of anterior cerebral artery; brain tumors
Note:Visual acuity-mediated by the cones of the retinaField of vision or peripheral vision-portion of space in which objects are visible during the fixation of vision in one direction. The receptors for peripheral fields are the rod neurons of the retina. (Phipps, 1998, p. 1906)
Cranial nerve III, IV, VI (Oculomotor, Trochlear, Abducens)-motor nerves that arise from the brainstem
1. Nystagmus –- involuntary eye movement; strokes of anterior, inferior, superior, cerebellar arteries
2. Constricted pupils: may signify impaired blood flow to vertebralbasilar arteries.
3. Ptosis (eyelid falldown); dropping of the upper eyelid over the globe—strokes of posterior inferior cerebellar artery; myasthenia gravis, palsy of CN III
Cranial nerve V (Trigeminal)—largest cranial nerve with motor and sensory components: changes in facial sensations; impaired blood flow to carotid artery
1. Decreased sensation of face and cornea on same side of body; strokes of posterior inferior cerebral artery
2. Lip and mouth numbness3. Loss of facial sensation: contraction of masseter and
temporal muscles, lesions CN V4. Severe facial pain: trigeminal neuralgia (tic dorlourex)Cranial VII (Facial nerve)—mixed nerve concerned with
facial movement and sensation of taste
1. Loss of ability to taste2. Decreased movement of facial muscles3. Inability to close eyes, flat nasolabial fold, paralysis
of lower face, inability to wrinkle the forehead 4. Eyelid weakness; paralysis of lower face; paralysis of
upper motor neuron5. Pain, paralysis, sagging of facial muscles: affected
side in Bell’s palsyCranial VIII (Acoustic)—composed of a cochlear
division related to hearing and a vestibular division related to equilibrium (Phipps, 1998, p. 1909)
Decreased hearing or deafness: strokes of vertebralbasilar arteries or tumors of CN VIII
Cranial IX(Glossopharyngeal) and cranial X (Vagus)—chief function of cranial nerve IX is sensory to the pharynx and taste to the posterior third of tongue; cranial nerve X is the chief motor nerve to the soft palatal, pharyngeal and laryngeal muscles (Phipps, 1998, p. 1909)
1. Dysphagia (difficulty swallowing)2. Unilateral loss of gag reflex
Cranial XI (Spinal accessory)—motor nerve that supplies the sternocleidomastoid muscle and upper part of trapezius muscles
1. Muscle weakness2. Cortralateral hemiparesis: strokes affecting middle
cerebral artery and internal arteryCranial XII (Hypoglossal)1. Atrophy, fasciculations (twitches): LMN disease2. Tongue deviation toward involved side of the body
SENSORY FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS
Altered sensation occurs with variety of neurologic pathology
Altered sense of position: lesions of posterior column of spinal cord
Inability to discriminate fine touch: injury to posterior columns
MOTOR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS
Muscle atrophy: LMNs diseaseTremors (groups, large of muscle fibers)-
Parkinson’s disease (tremors at rest), multiple sclerosis (tremors observed in activity)
Fasciculations (single muscle fiber): disease or trauma to LMN, side effects of medications, fever, sodium deficiency, anemia
Flaccidity (decreased muscle tone): disease or trauma to LMN and early stroke
Spasticity (increased muscle tone): disease of corticospinal motor tract
Muscle rigidity: disease of EP motor tractCogwheel rigidity (muscular movement with small
regular jerky movement; parkinson’s diseaseMuscle weakness-in arms, legs, hands: TIAsHemiplegia-paralysis of half of body verticallyFlaccid paralysis: strokes of anterior spinal artery,
multiple sclerosis or myasthenia gravisTotal loss of motor function: below level of injurySpasticity of muscle: incomplete cord injuries
CEREBELLAR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS
Ataxia (lack of coordination and clumsiness of movement, staggering, wide-based and unbalanced gait)
Steppage gait (client drags or lifts foot high, then slaps foot onto floor; inability to walk on heels; disease of LMN
Sensory ataxia (client walks on heels before bringing down toes and feet are held wide apart; gait worsens with eyes closed
Parkinsonian gait (stooped over position while walking with shuffling gait with arms held close to the side)
Romberg’s test (Positive)- With feet approximated, the patient stands with eyes open and then closed; if closing the eyes increases the unsteadiness, a loss of proprioceptive control is indicated
REFLEXHyperactive: reflexesDecreased reflexesClonus of foot (Hyperactive, rhythmic dorsiflexion
and plantar flexion of foot)Superficial reflexes (such as abdominal) and
cremasteric reflex Positive Babinski reflex (dorsiflexion of big toe)
(plantiflexion- Normal)
Special Neurologic Assessment
Brudzinski’s sign (pain, resistance, flexion of hips and knees when head flexed to chest with client supine)
Positive Kernig’s sign-excessive pain when examiner attempts to straighten knees with client supine and knees and hips flexed
Decorticate posturing (up)- decorticate response, mummy baby, flexor posturing- damage to mesencephalic region and the corticospinal tract
Decerebrate posturing (down)- extensor posturing- the head is arched back, the arms are extended by the sides, and the legs are extended.
Decerebrate posturing indicates brain stem damage or rather damage below the level of the red nucleus (eg. mid-collicular lesion)
#Altered Level of consciousness1. Consciousness
Requires:1. Arousal: alertness; dependent upon reticular
activating system (RAS); system of neurons in thalamus and upper brain stem
2. Cognition: complex process, involving all mental activities; controlled by cerebral hemispheres
Process that affect LOC:a. Increased ICPb. Stroke, hematoma, intracranial hemorrhagec. Tumorsd. Infectionse. Demyelinating disorders
Systemic Conditions affecting LOC Hypoglycemia F/E imbalance Accumulated waste products from liver or renal
failure Drugs affecting CNS: alcohol, analgesics,
anesthetics Seizure activity: exhausts energy metabolites Level of Consciousness
AlertLethargic-very sleepyObtunded
StuporousComa Death
Client Assessment with Decreased LOCa. Increased stimulation required to elicit response from
clientb. More difficult to arouse; client agitated and confused
when awakenedc. Orientation changes: losses orientation to time first,
then place, persond. Continuous stimulation required to maintain
wakefulnesse. Client has no response, even to painful stimulation
Loss of Simultaneous Eye MovementLoss of normal reflex functioning:1. Doll’s eye movement: eye movement in opposite
direction of head rotation (normal function of brain stem)
2. Oculocephalic reflex: eye move upward with passive flexion of neck; downward with passive neck extension (normal function)
3. Oculovestibular response (cold caloric testing): instillation of cold water in ear canal cause nystagmus (lateral tonic deviation of eyes) toward stimulus (normal function)
Glasgow Coma Scale
1 2 3 4 5 6
Eyes
Does not open eyes
Opens eyes in response to painful
stimuli
Opens eyes in response to
voice
Opens eyes spontaneously
N/A N/A
Verbal
Makes no sounds
Incomprehensible sounds
Utters inappropriate
words
Confused, disoriented
Oriented, converses normally
N/A
Mot
or
Makes no movements
Extension to painful stimuli
(decerebrate response)
Abnormal flexion to
painful stimuli (decorticate response)
Flexion / Withdrawal to painful stimuli
Localizes painful stimuli
Obeys commands
Interpretation
Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".
Generally, brain injury is classified as:
Severe, with GCS ≤ 8 Moderate, GCS 9 - 12 Minor, GCS ≥ 13.
Intubation and severe facial/eye swelling or damage makes it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. 'E1c' where 'c' = closed, or 'V1t' where t = tube.
A composite might be 'GCS 5tc'. This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for 'abnormal flexion'. Often the 1 is left out, so the scale reads Ec or Vt.
MOTOR FUNCTION ASSESSMENTa. Client follows verbal commandsb. Pushes away purposely from noxious stimulic. Movements are more generalized and less purposeful
(withdrawal, grimacing)d. Reflexive motor responsese. Flaccid with little or no motor response
COMA
Use CPOMR to evaluate the lesion C: Conscious P: Pupil O: Ocular movementM: Motor responseR: Respiratory pattern
Irreversible coma - vegetative statePermanent condition of complete unawareness of
self and environment, death of cerebral hemispheres with continued function of brain stem and cerebellum
Client does not respond meaningfully to environment but has sleep-wake cycles and retains ability to chew, swallow and cough
Eyes may wander but cannot track objectsMinimally conscious state: client aware of
environment, can follow simple commands,
indicates yes/no responses; make meaningful movements (blink, smile)
Often results from severe head injury or global anoxia
Locked-in syndrome1. Client is alert and fully aware of environment; intact
cognitive abilities but unable to communicate through speech or movement because of blocked efferent pathways from brain
2. Motor paralysis but cranial nerves may be intact allowing client to communicate through eye movement and blinking
3. Occurs with hemorrhage or infarction of pons, disorders of lower motor neurons or muscles
Brain Death1. Cessation and irreversibility of all brain functions2. General criteria:
a. Absent motor and reflex movementsb. Apneac. Fixed and dilated pupilsd. No ocular responses to head turning and caloric stimulatione. Flat EEG
ICP Increased blood volume, increased brain volume,
increased CSF volume Normal pressure: 5-15 mmHg, with pressure
tranducer with head elevated 30˚; 60-180
cmH20, water manometer with client lateral recumbent
Manifestations:Decreasing level of sensorium-most sensitive,
reliable and earliest indicator: due to cerebral hypoxia, interference with RAS function
Increasing BP, decreasing pulsePupillary changes (a reflection of tissue shiftsCushing’s triad-increasing systolic pressure,
widening pulse pressure and bradycardia (final compensatory mechanism to maintain CSF)
Papilledema-due to the compression of optic discRespiratory changes-dependent on site of pressureMotor changes-dependent on site of pressure;
usually starts contralaterally; then hemiplegia, decortication or decerebation depending on pressure on brain stem
Late signs: coma, apnea, unilateral pupil changes
ICP monitoring Continuous intracranial pressure monitor is used for
continual assessment of ICP and to monitor effects of medical therapy and nursing interventions
STROKE
Right brain damage Left brain damageParalyzed left
sideParalyzed right
side
Spatial-perceptual deficits
Tend to deny or minimize problems
Impaired judgment
Impaired time concepts
Short term span
Impaired speech/language
Impaired right and left discrimination
Aware of deficits, depression, anxiety
Impaired comprehension
Slow performance, cautious
SPINAL CORD INJURYA. Early symptoms of spinal shock
Absence of reflexes below level of lesionFlaccid paralysis below level of injury
Hypotonia results in bowel and bladder distentionInability to perspire in affected partsHypotension
B. Later symptoms of spinal cord injuryReflex hyperexcitabilityState of diminished reflex hyperexcitability below
site in all instances of cord damage following hyperreflexia
In total cord damage-loss of motor and sensory function is permanent
Sacral region-atonic bladder and bowel with impairment of sphincter control
Lumbar region- spastic bladder and loss of bladder and anal sphincter control
Thoracic-trunk below the diaphragmCervical-from neck down, if above C4 respirations
and depressedIn partial cord damage, depends on the type of
neurons affected (spastic vs. flaccid)
MUSCLE FUNCTION AFTER SPINAL CORD INJURY (((log-rolling)
Spinal Cord Injury
Muscle Functioning remaining
Muscle Function
LossCervical, above C4
None All including respiration
C5 Neck, scapular elevation
Arm, chest, all below
chestC6-C7 Neck, some
chest movement, some arm movement
Some arm, fingers, some
chest movement all below chest
Thoracic Neck, arms (full), some
chest
Trunk, all below chest
Lumbo-sacral
Neck, arms, chest, turnk
Legs