neuro diag

7/29/2019 Neuro Diag

1/128

NEUROLOGIC

EXAMINATION
http://rds.yahoo.com/_ylt=A0S0206lxbpK6qEAi_CjzbkF/SIG=139kv794s/EXP=1253840677/**http%3A//www.kckmedical.com/ProductImages/Categories/instruments-percussion-hammers.jpghttp://rds.yahoo.com/_ylt=A0S020mhxLpKdWsBEYmjzbkF/SIG=122vp1ean/EXP=1253840417/**http%3A//www.fyeo.com/gfx/small/tunning-fork.jpg


2/128

HEALTH HISTORY

History of Present Illness

Important aspect of neurologicassessment

Initial Interview

Provides an excellent opportunity tosystematically explore the patients currentcondition and related eventswhile observing the:

Overall appearance Mental status Posture Movement

Affect


3/128

HEALTH HISTORY

Depending on the patients condition, the

nurse may rely on:

YES or NO answer

Review of Medical Records

Input from Family


4/128

HEALTH HISTORY INCLUDES:

Onset, character, severity, location duration

and frequency of signs and symptoms. Complaints

Precipitating, aggravating and relieving

factors Progression, remission and exacerbation

Presence or absence of similar signs and

symptoms among family members History of genetic disease


5/128

HEALTH HISTORY

Review of medical history including

the system-by-system evaluation ispart of the nursing history.

The nurse should be aware of historyof trauma or falls that may haveinvolved the head or spinal injury.

Questions about the use of alcohol,medications and illicit drugs are also

relevant.


6/128

PHYSICAL ASSESSMENT

General Observation of the client:

a. Posture, gait, coordination: performRomberg test

b. Personal hygiene and grooming

c. Evaluate speech and ability tocommunicate1. Place of speech: rapid, slow, halting2. Clarity: slurred or distinct

3. Tone: high-pitched, rough4. Vocabulary: appropriate choice of words

*** Facial features may suggest specific

syndromes in children


7/128

PHYSICAL ASSESSMENT

Mental Status

a. General appearance and behaviorb. Level of consciousness

1. Oriented to person, place and time2. Appropriate response to verbal and tactile

stimuli3. Memory, problem solving abilities.

c. Moodd. Thought content & intellectual

capacity


8/128

PHYSICAL ASSESSMENT

Assess Pupillary Status and Eye movement

a. Size of pupils should be equalb. Reaction of pupilsa. Accommodation: pupillary constriction to

accommodate near vision

b. Direct light reflex: constriction of pupil when lightis shone directly into the eyec. Consensual reflex: constriction of the pupil in the

opposite eye when the direct light reflex istested.

c. Evaluate ability to move eyea. Note nystagmusb. Ability of eyes to move togetherc. Resting position of iris should be at mid-position

of the eye socketd. PERRLA


9/128

Clinical Manifestation

The clinical manifestation of neurologic disease

are as varied as the disease processesthemselves. Symptoms may be:

Varied or intense

Fluctuating or permanent

Inconvenient or devastating

PAIN

SEIZURES

DIZZINESS a nd VERTIGO

VISUAL DISTURBANCES

WEAKNESS

ABNORMALSENSATION


10/128

Clinical ManifestationsPAIN unpleasant sensory perception & emotional experience associated with actual or

potential tissue damage

- Subjective-Acute

> lasts shorter & remits as pathology

resolves> trigeminal neuralgia, spinal disk disease

- Chronic or persistent

> Lasts longer than 6 months> degenerative and chronic neurologic cond.


11/128

Clinical Manifestations

SEIZURES- Are the result of abnormal paroxysmal

discharges in the cerebral cortex,

which manifests as alteration in

sensation, perception, movement or

consciousness

- May be long or short- The type of seizure activity is a direct

result of the brain affected.

- May be a first obvious sign of brainlesion


12/128


DIZZINESS AND VERTIGO

- Dizziness is an abnormal sensation ofimbalance or movement.

- Variety of causes: viral syndrome, hot

weather, roller coaster rides, middle earinfections

- About 50% of patients with dizziness have

vertigo (illusion of movement usuallyrotation).

- Vertigo is a manifestation of vestibular

dysfunction

Cli i l M if t ti


13/128


VISUAL DISTURBANCES

Visual defects that cause people to seekhealth care can range from decreased

visual acuity associated with aging to

sudden blindness caused by glaucoma

Normal vision depends on :

- functioning visual pathways thought theretina and optic chiasm

- radiations into the visual cortex in the

occipital lobes


14/128


WEAKNESS- common manifestation of neurologic

disease (muscle weakness)

- Coexists with other symptoms and can

affect variety of muscles causing

disability- Can be sudden or permanent or

progressive


15/128


ABNORMAL SENSATION- Numbness, loss of sensation or

abnormal sensation is a neurologic

manifestation of both cerebral andperipheral nervous system diseaseh

- Usually associated with pain or

weakness and is potentially disablingg- Both numbness and weakness can

significantly affect balance and

coordination

PHYSICAL EXAMINATION


16/128

PHYSICAL EXAMINATION The brain and the spinal cord cannot be

examined directly as other body systems Neurologic examination is an indirectevaluation that assesses the function ofspecific body part controlled

f

5 COMPONTENTS OF

NEURO ASSESSMENT

(1) Cerebral function(2) Cranial Nerves

(3) Motor system

(4) Sensory System(5) Reflexes


17/128

Assessing Cerebral Function

Cerebral abnormalities may cause:

- disturbance in mental status

- Intellectual function- Thought content

- Pattern of emotional behavior

- Alteration in perception, motor andlanguage ability

- Lifestyle change/s


18/128

Assessing Cerebral Function

Should be specific and non-judgemental

Avoid using the terms

inappropriateordemented

Specific records on observations

regarding orientation, level ofconsciouness, emotional state or thought

content


19/128

Assessing the Mental Status

Observe patients appearance & behavior

Note dress, grooming & personal hygiene

Posture, gesture, movements, facialexpression & motor activity

Assess manner of speech & level of

consciousness Assess orientation to time, place & person


20/128

Intellectual Function

A person with an average IQ can:

a. Recite 5 digits backwards

b. Serial 7s (Subtract 7 from 100,then 7 from that, and so forth)

Interpret proverbs

Ability to recognize similarities Situational analysis

Th ht C t t


21/128

Thought ContentDuring the interview, it is important to

assess the patients thought content. Are the patients thought

Spontaneous

Natural Clear

Relevant

Coherentf

Unusual thoughts likehallucinations, preoccupation with

death and morbid events, paranoidideation requires further evaluation


22/128

Emotional Status

Is the patients affect natural or even?

Does his or her mood fluctuate

normally?

Are verbal communications consistent

with nonverbal cues?

P ti


23/128

Perception

The examiner may consider more

specific areas of higher cortical function

Agnosia - inability to recognize objects

seen through the special senses a patient may see a pencil but knows not what to do with it

or what its called

Screening forvisualand tactile agnosiaprovides insight into the patients

cortical interpretation ability

Placing a familiar object (key) in the patients hand, have himidentify it with eyes closed

L Abilit


24/128

Language Ability

A person with normal neurologic function

can understand and communicate inspoken and written language.

Aphasia is a deficiency in language

function

Type of Aphasia Brain area involved

Auditory-receptive Temporal LobeVisual-receptive Parietal-occipital lobe

Expressive speaking Inferior posterior frontal areas

Expressive writing Posterior frontal area


25/128

Motor Ability

Ask the patient to perform a skilled act

(throw a ball, move a chair)

Performance requires

=>the ability to understand the activity

desired and normal motor strength

Failure signals cerebral dysfunction


26/128

ASSESSING THE

CRANIAL NERVES


27/128

CRANIAL NERVES

Oh

Oh

Oh

To

TouchA nd

Feel

AGirls

Vagina

So

Heavenly

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)

S

S

M

M

M/SM

M/S

SM/S

M/S

M

M


28/128

C i l N I Olf t N


29/128

Cranial Nerve I - Olfactory Nerve

Before testing nerve function, ensure

patency of each nostril by occluding inturn and asking patient to sniff

Once patency is established, ask patient

to close eyes Occlude one nostril and hold aromatic

substance (coffee) beneath nose

Ask patient to identify substance Repeat with other nostril

C i l N I Olf t


30/128

Cranial Nerve I - Olfactory

Normal:

Patient is able toidentify substance.

(Bear in mind thatsome substances maybe unfamiliar,especially to children)

Abnormal:

Anosmia - loss of senseof smell.

May be inherited and non-pathological: chronic rhinitis,

sinusitis, heavy smoking,zinc deficiency, or cocaineuse.

It may also indicate cranialnerve damage from facialfractures or head injuries,disorders of base of frontallobe such as a tumor, orartherosclerotic changes.

Cranial Nerve II - Optic Nerve


31/128

Cranial Nerve II - Optic Nerve

Use the snellen chart to check/test:

- distant vision- color

Client should be 20 feet distant from the chart

Use an object to occlude one eye

Evaluate the vision one eye at a time

Cranial Nerves III IV and VI


32/128

Testing eyemovements

Testing pupil

accommodation

Cranial Nerves III, IV and VI

=> Test for ocular rotations,

conjugate movements, nystagmus

** Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis

- using direct & consensual pupillary reaction to light

Normal:Abnormal:


33/128

Normal: Able to read without

difficulty

Visual acuity intact20/20, 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.

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 pupilsfinally become fixed and

CN V T i i l N


34/128

CN V - Trigeminal Nerve

a. Testing motor function:

- Askpatient to move jaw from side to

side against resistance and then clench

jaw as you palpate contraction of

temporal and masseter muscles, or tobite down on a tongue blade.

CN V - Trigeminal Nerve


35/128

Testing CN V

sensory function

CN V Trigeminal Nerve

b. Testing sensory function:

-Askpatient to close eyes- Touch the face with the wisp of cotton

- Instruct to tell you when he or she feels

sensation on the face.

- Repeat the test using sharp and dull

stimuli (toothpick or tongue blade)

- Instruct to say Sharp orDull

(Be random, dont establish a pattern)

Cranial Nerve V Trigeminal Nerve


36/128

Testing corneal reflex

Cranial Nerve V - Trigeminal Nerve

c. Testing corneal reflex:

- Gently touch cornea with cotton wisp.

oTouching cornea can cause abrasions.

oAlternative approach is to:

> puff air across cornea with a needlesssyringe, or

> gently touch eyelash

and look for blink reflex

Cont. CN V

Abnormal:


37/128

Normal: Full range of motion

(ROM) in jaw and15 strength.

Patient perceives

light touch and

superficial pain

bilaterally

Weak or absent contractionunilaterally:

- Lesion of nerve, cervical spine,

or brainstem

Inability to perceive light touchand superficial pain

- may indicate peripheral nervedamage.

Trigeminal Neuralgia:- Neuralgic pain of CN V caused

by the pressure of degenerationof a nerve

Corneal reflex test used inpatients with decreased LOC

- to evaluate integrity of brainstem.

Cranial Nerve VII - Facial Nerve


38/128

Testing CN VII motor function

a. Testing motor function:

- Ask patient to perform these movements:smile, frown, raise eyebrows, show upper

teeth, show lower teeth, puff out cheeks,

purse lips,close eyes tightly while nurse

tries to open them.

- Observe face for

flaccid paralysis

Cranial Nerve VII - Facial Nerve


39/128

Testing taste sensation

b. Testing sensory function:

- Test taste on anterior two-thirds of

tongue for sweet, sour, salty.F

Sweet: Tip of the tongueSour: Sides of back half of tongue

Salty: Anterior sides and tip of tongue

Bitter: Back of tongue

CN VII - Facial Nerve


40/128

CN VII Facial Nerve

Normal:

Facial nerve intact

Able to make faces.

Taste sensation onanterior tongue intact.

(Taste decreased inolder adults.)

Abnormal:

Asymmetrical or impairedmovement:

- Nerve damage, such asthat caused by Bells

palsy or stroke.

Impaired taste/loss oftaste:

- Damage to facial nerve,chemotherapy orradiation therapy to headand neck.

Cranial Nerve VIII - Acoustic Nerve


41/128

Watch tick test

a. Perform Weber and Rinne tests for hearing

b. Perform watch-tick test by holding watch closeto patients ear.

c. Perform Romberg test for balance

- Nurse at the back or side of the pt.

- Instruct client to stand straight, feet together,

hands at the side and eyes closed.

(Evaluates the balancing function of the CN VIII)

Cranial Nerve VIII - Acoustic Nerve


42/128

Cranial Nerve VIII Acoustic Nerve

Normal: Hearing intact.

Negative

Romberg test.

Abnormal:

Hearing loss,nystagmus, balancedisturbance,dizziness/vertigo:

- Acoustic nervedamage.

Nystagmus:- CN VIII, brainstem, or

cerebellum problem orphenytoin (Dilantin)toxicity.

Cranial Nerves IX and X

Gl h l & V N


43/128

Testing CN IX and

Xmotor function

Glossopharyngeal & Vagus Nerves

a. Observe ability to cough, swallow, andtalk.

b. Test motor function:

-Ask patient to open mouth and say ah

while you depress the tongue with a

tongue blade.

- Observe soft palate and uvula.

- Soft palate and uvula should rise medially.

CN IX and X


44/128

c. Test sensory function of CN IXand motor

function of CN X bystimulating gag reflex. Tell patient that you are going to touch interior

throat

Then lightly touch tip of tongue blade to posterior

pharyngeal wall.

Observe the pharyngeal movement.

Ask the client to drink a small amount of water*Note the ease & difficulty of swallowing

*Note quality of the voice or hoarseness

when speaking

CN IX and X Ab l


45/128

CN IX and X

Normal: Swallow and cough

reflex intact.

Speech clear.

Elevation andconstriction ofpharyngeal

musculature andtongue retractionindicate positive gagreflex

Abnormal:

Unilateral movement:

Contralateral nerve damage.- Damage to CNs IX and X also

impairs swallowing.

Changes in voice quality (e.g.,

hoarseness): CN X damage.

Diminished/absent gag reflex:

Nerve damage

- Risk for aspiration

Impaired taste on posterior

portion of tongue:

Problem with CN IX

CN XI - Spinal Accessory Nerve


46/128

p y

a. Test motor function of shoulder and

neck muscles:

=> Ask patient to shrug shoulders upwardagainst your resistance. (Trapieze

muscle)

=> Then ask her or him to turn head from

side to side against your resistance.(Strenoclaidomastoid muscle)

**Observe for symmetry of contraction and

muscle strength.

Cranial Nerve XI


47/128

Normal:

Movementsymmetrical, withpatient movingagainst resistance

without pain.

Full ROM of neckwith +5/5 strength.

Abnormal:

Asymmetrical Diminished

Absent movement

Pain unilateral or bilateral

weakness:

Peripheral nerve CN

XI damage.

CN XII - Hypoglossal Nerve


48/128

Testing CN XII

motor function

yp g

a. Have patient say d, l, n, t or a phrase

containing these letters.- The ability to say these letters requiresuse of the tongue.

b. Ask the patient to protrude the tongue.Observe any deviation from midline, tumors,lesions, or atrophy.

c. Now ask the patient to move thetongue from side to side.

Normal: Abnormal:


49/128

Can protrude

tongue medially. No atrophy,

tumors, or

lesions.

Asymmetrical/diminished/

absent movement/deviation

from midline/protruded

tongue: - Peripheral nerve

CN XII damage.

Tongue paralysis results in

dysarthria.

Examining the Motor System


50/128

g y Assessing the patients ability to flex or

extend the extremities against resistancetests muscle strength.

g

The evaluation of muscle strength

compares the sides of the body with eachother

This way, subtle differences in muscle strengthcan easily be detected and described.

f

MUSCLE STRENGTH


51/128

Muscle tone (tension present in a

muscle at rest) is evaluated by palpation Abnormalities in tone include:

Spasticity (increased muscle tone)

Rigidity (resistance to passive strength)

Flaccidity

British Medical Council

Method of Scoring

Balance and Coordination


52/128

Cerebellar influence on the motor system is

reflected in balance and coordination.

Coordination of the hands and extremities is

tested by:

Rapid, alternating movements

POINT TO POINT TESTING

Balance and Coordiantion


53/128

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.

Normal:

done with equal turning

and quick rhythmic

pace

Abnormal:Lack of coordinationDysdiadochokinesia- Slow, clumsy, and sloppy response- occurs with cerebellar disease

The patient is asked to

pronate and supinate

the hands as rapid as

possible

b. Finger-to-Finger test

With th k th t h h i d


54/128

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.

Normal: Movement is smooth

and accurate

Abnormal:Dysmetria

- clumsy movement withovershooting the mark

- occurs with cerebellar

disorder

Past-pointing- constant deviation to one

side



55/128

Coordination in the lower extremities is

tested by having the patient run heel downthe anterior surface of the tibia of the otherleg. Each leg is tested

Ataxia is incoordination of voluntarymuscle groups in action

Tremors are rhythmic, involuntarymovements

=>The presence of these movements suggestscerebellar disease

When abnormality is observed, a thorough

examination is indicated



56/128

The cerebellum is responsible for

balance and coordination.

Rombergs Test- screening test for balance

- the pt stands with feet togetherand arms at the side, first witheyes open and eyes closed for 20

to 30 secs

- slight sway is normal but loss ofbalance is abnormal and considered

(+) Romberg rest

Normal:

Negative Romberg

Abnormal:Sways falls widens base of


57/128

Negative Romberg

test

Sways, falls, widens base of

feet to avoid falling

Positive Romberg sign

-Loss of balance that occurs

when closing the eyes.

-Occurs with cerebellar

ataxia (multiple sclerosis,

alcohol intoxication)

-Loss of proprioception, and

loss of vestibular function

Perform Tandem Walking


58/128

- 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

Abnormal:Crooked line walk

Widens base to maintain balance

Staggering, reeling, loss of balanceAn ataxia that did not appear now.

Inability to tandem walk is sensitive for

an upper motor neuron lesion, such asmultiple sclerosis.

Hopping in place, alternating knee bends(some individuals cannot hop owing to aging or obesity)


59/128

(some individuals cannot hop owing to aging or obesity)

Examining the ReflexesM t fl i l t t ti f


60/128

Motor reflex are involuntary contraction of

muscles or muscle groups in response toabrupt stretching near the site of muscle

insertion

Technique:A reflex hammer is used toelicit a deep tendon reflex.

The tendon is struck briskly, and the

response is compared with the oppositeside of the body (right and left)

The response should be equal

Examining the Reflexes
http://rds.yahoo.com/_ylt=A0S0206lxbpK6qEAi_CjzbkF/SIG=139kv794s/EXP=1253840677/**http%3A//www.kckmedical.com/ProductImages/Categories/instruments-percussion-hammers.jpg


61/128

GRADING the REFLEXES The absence of reflex is significant,

although ankle jerks (achilles reflex) may

be absent on older people.

Some uses the terms:

PRESENTABSENT

DIMINISHED

REFLEXESDocumenting Reflex Findings


62/128

Use these grading scales to rate the strength of

each reflex in a deep tendon and superficial reflexassessment.

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


63/128

Documentation of reflex finding

ASSESSING REFLEXESBiceps Reflex


64/128

Biceps Reflex- is elicited by striking the biceps tendon of

the flexed elbow.- the examiner supports the forearm withone arm while placing the thumb againstthe tendon and striking the thumb with thereflex hammer.

Normal:

Flexion at the elbow andcontraction of the biceps

ASSESSING REFLEXESb T i R fl


65/128

b. Triceps Reflex

- flex pts arm to 90 angle and

positioned in front of the chest

Abduct patients arm and flex it at the elbow.

Support the arm with your non-dominant hand. Identify triceps tendon by

palpating 2.5 to 5cm

(1-2 in) above the elbow

Normal: Contraction of triceps with

extension at elbow

ASSESSING REFLEXES


66/128

c. Patellar Reflex

Have patient sit with legs dangling. Strike tendon directly below patella.

Normal: Contraction of

quadriceps with

extension of knee.

ASSESSING REFLEXESd A kl R fl


67/128

d. Ankle Reflex

- Achilles reflex- foot is dorsiflexed at the ankle and

the hammer strikes the stretched

Achilles tendon

Normal:

Plantar flexion of foot.

ASSESSING REFLEXES

e Test for Clonus


68/128

e. Test for Clonus

When reflexes are very hyperactive, aphenomenon called clonus may be elicited If a foot is abruptly dorsiflexed, it may

continue to beat two to three times before it

settles into a position of rest The presence of clonus always indicates the

presence of CNS disease and requiresfurther evaluation

Normal:No contraction

F. Superficial Reflexes

Abdominal Reflex


69/128

Abdominal Reflex

Stroke patients abdomen diagonally fromupper and lower quadrants toward umbilicus.

Contraction of rectus abdominis. Umbilicus

moves toward stimulus.

Perianal Reflex

Gently stroke skin around anus with gloved finger.


70/128

Normal:

Anus puckers.

Cremasteric Reflex

Gently stroke inner aspect of a males thigh.

Normal: Testes rise.

Bulbocavernosus Reflex Gently apply pressure over bulbocavernous

muscle on dorsal side of penis.

Normal:

Bulbocavernosus muscle contracts.

ASSESSING REFLEXES


71/128

BABINSKI REFLEX

Stroke sole of patients foot in an arcfrom lateral heel to medial ball.

Fanning of toes when stroked laterally

Normal in newborn (found until 16 24 mos) Indicates CNS disease of motor system

Normal: Flexion of all toes.

SENSORY EXAMINATION Highly subjective & requires cooperation of the pt


72/128

Highly subjective & requires cooperation of the pt

The examiner should be familiar with dermatomes Most sensory deficits results from peripheral

neuropathy and follow anatomic dermatomes

Assessment involves:

Tactile sensation

Superficial pain

Vibration Position sense

** during assessment, pt eyes are kept closed

SENSORY EXAMINATION

Tactile Sensation or Light Touch


73/128

Tactile Sensation or Light Touch

- Brush a light stimulus such as a cotton wispover patients skin in several locations, including

torso and extremities.

Normal:

Identifies areas

stimulated by light

touch.

Abnormal:Hypesthesia: diminished capacity for

physical sensation (esp. skin)

Hyperesthesia: Increased sensitivity

Paresthesia: Numbness & tingling

Anesthesia: Loss of sensation.

PAIN and TEMPERATURE- Stimulate skin lightly with sharp and dull ends of

h i k/ li


74/128

toothpick/ paper clip

- Apply stimuli randomly and ask patient to identifywhether sensation is sharp or dull.

- Touch patients skin with test tubes filled with hot or

cold water.

- Apply stimuli randomly, and ask patient to identifywhether sensation is hot or cold.

Sensory ExaminationVIBRATION and PROPRIOCEPTION

Pl ib ti t i f k fi


75/128

- Place a vibrating tuning fork over a finger

joint, and then over a toe joint.- Ask patient to tell you when vibration is felt

and when it stops.

- If patient is unable to detect vibration, testproximal areas as well.

Sensory Examination

l Abnormal:


76/128

Normal:

Vibratorysensation intactbilaterally in upper

and lowerextremities.

Abnormal:

Diminished/absentvibration sense:

- Peripheral nerve

damage caused by

alcoholism,

diabetes, or damage

to posterior columnof spinal cord.

StereognosisWith patients eyes closed, place a familiar


77/128

object, such as a coin or a button, in patients

hand, and ask patient to identify it. Test both hands using different objects.

Normal: Stereognosis

intact bilaterally.

Abnormal:Abnormal findings suggest alesion or other disorder

involving sensory cortex or adisorder affecting posterior

column.

Sensory Extinction Simultaneously touch both sides of patients


78/128

body at same point.

Ask patient to point to where she or he wastouched.

Normal:

Extinction intact.

Abnormal:

Identification of stimulus ononly one side suggests lesion

or other disorder involving

sensory cortical region inopposite hemisphere.


79/128

Assessing

Level of Consciousness

Level of Consciousness (LOC)

arousal; awareness of self or environmentd

Al t f ll k i t t t l d


80/128

Alert fully awake; appropriate responses to external and

internal stimuli; oriented to person, place and timesLethargic somnolent, drowsy, listless, indifferent tosurroundings, very sleepy, can be aroused from sleep butwhen stimulation ceases, falls back to sleep; may be

oriented or confusedd

Stuporous unconscious most of the time but makesspontaneous movements and response is evoked only by astrong, continuous, noxious stimuli; loud noises or sounds,bright light, pressure to sternum, response is usually apurposeful attempt to remove the stimulusf

Comatose absence of voluntary response to stimuli

including painful stimuli; no response, no eye openingscore of 7 or less on GCS

Glasgow Coma Scale- A standardized objective assessment that


81/128

j

defines the LOC by giving it a numeric value.- Most often after brain surgery

- Document as E_V_M_; for example, E4V5M6.

The three numbers are added; the total score reflects the

brain functional level.

A fully awake person = 15

Coma = 7 or less

The GCS assesses the functional state of the brain as a

whole, not of any particular site in the brain. (Juarez and Lyon,1995)


82/128

Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)

ASSESSING LEVEL OFCONSCIOUSNESS


83/128

a. Test orientation to time, place, and person

Normal:

Awake, alert, andoriented to time,place, and person(AAO x 3)

Responds to

external stimuli

Abnormal: Disorientation may be

physical in origin Disorientation can also

be psychiatric in origin(schizophrenia)

Lathargic or somnolent Obtunded

Stupor Coma

Abnormal FindingsAbnormalities in Muscle Movement

Paralysis


84/128

Paralysis

Loss or impairment of the ability to move a body part,usually as a result of damage to its nerve supply.

Loss of sensation over a region of the body.

Hemiplegiaparalysis of one side of the body

Paraplegiaparalysis of both lower limbs due to

spinal disease or injury

Quadriplegiaparalysis of all four limbs or of the entire

body below the neckParesis

partial motor paralysis

Abnormal Findings

Abnormalities in Muscle Movement
http://coursewareobjects.elsevier.com/objects/elr/Jarvis4e/icollection/images/23FT05A.jpghttp://coursewareobjects.elsevier.com/objects/elr/Jarvis4e/icollection/images/23FT05A.jpg


85/128


Fasciculations

Rapid, continuous twitching of resting

muscle

Abnormal Findings

http://coursewareobjects.elsevier.com/objects/elr/Jarvis4e/icollection/images/23FT05B.jpg


86/128


Tic

Repetitive twitching of a muscle group

Abnormal Findings

http://coursewareobjects.elsevier.com/objects/elr/Jarvis4e/icollection/images/23FT05C.jpg


87/128


Myoclonus

Rapid, sudden jerk at a fairly regular

intervals

Abnormal Findings

http://coursewareobjects.elsevier.com/objects/elr/Jarvis4e/icollection/images/23FT05D.jpg


88/128


Tremor

Involuntary contraction of opposing muscle

groups

Rest tremor

Intention tremor

Abnormal Findings

http://coursewareobjects.elsevier.com/objects/elr/Jarvis4e/icollection/images/23FT05F.jpg


89/128


Chorea

Sudden, rapid, jerky,

purposelessmovement involving

limbs, trunk, or face

Abnormal Findings

http://coursewareobjects.elsevier.com/objects/elr/Jarvis4e/icollection/images/23FT05G.jpg


90/128


Athetosis

Slow, twisting,

writhing,continuousmovement,

resembling asnake or worm

Neurologic Exam: Meningeal signsBrudzinskis sign- neck stiffness
http://coursewareobjects.elsevier.com/objects/elr/Jarvis4e/icollection/images/23FT05H.jpg


91/128

neck stiffness

- involuntary flexion of hips and kneeswhen flexing neck is positive sign for

meningeal irritation

Neurologic Exam: Meningeal signsPositive Kernigs sign

-excessive pain in the lower back


92/128

excessive pain in the lower back

when examiner attempts to straightenknees with client supine and knees

and hips flexed

Neurologic Exam: Meningeal


93/128

Decorticate posturing (up)

Decorticate posturing (down)


94/128

DIAGNOSTIC

EVALUATION

Computed Tomography Scan

Makes use of narrow x-ray beam to scan body partin successive layers


95/128

in successive layers Images provide cross-sectional views of the brain

displayed on an oscilloscope or TV monitor and isphotographed and stored digitally

Non-invasive and painless and has high degree indetecting brain lesions

Nursing Intervention:

Teach patient about the need to lie quietlythroughout the entire procedure Assess for iodine/shellfish allergy Monitor for side effect of IV or inhalation contrast

agents: flushing, nausea, vomiting

CT SCAN


96/128

Positron Emission Tomography (PET)

- Computer based nuclear imaging that produces


97/128

images of actual organ functioning.- Radioactive gas or substance is inhaled orinjected that emits positively charged particles.

- It permits measurement of blood flow, tissue

composition, brain metabolism thus evaluatesbrain function.

- Useful in showing metabolic changes in thebrain (Alzheimers disease), locating lesions(tumor, epiliptogenic lesions), identifyingblood flow and oxygen metabolism in stroke ptand new therapies for brain tumor.

Positron Emission Tomography (PET)

Key nursing interventions include patient


98/128

preparation, which involves explaining the test andteaching the patient about inhalation techniques and

the sensations (dizziness, light-headedness,

headache) may occur.

IV injection of radioactive substance produces

similar side effects.

Relaxation exercises may reduce anxiety during the

test.

PET Scan


99/128

Single Photon Emission ComputedTomography (SPECT)

3D imaging technique that uses radionuclides


100/128

g g q

and instruments to detect single photons.

Perfusion study that captures cerebral blood

flow at time of injection of radionuclide.

SPECT is useful in detecting extent &location of perfused areas of the brain,

allowing detection, localization and sizing ofstroke, detecting tumor progression andevaluation of perfusion before and after

neurosurgical procedures.

Single Photon Emission ComputedTomography (SPECT)

Nursing Intervention


101/128

g

Preparation and monitoring

Observe for allegeric reaction.

Pregnancy and breastfeeding are

contraindications.


102/128

Magnetic Resonance Imaging(MRI)

Uses a powerful magnetic


103/128

Uses a powerful magneticfield to obtain images ofdifferent areas of thebody

Can identify cerebralabnormality earlier andmore clearly than anyother diagnostic tests

Useful in monitoringtumors response totreatment, Dx of MS


104/128


105/128

Nursing Intervention: MRI

Relaxation techniques


106/128

Advise pt that she can speak with the staff bymeans of a microphone inside the scanner

ALL metal objects and magnetic cards areremoved (aneurysm clips, ortho-hardware,

pacemakers, artificial heart valves, IUD) Medication patches removed (cause burns)

Sedation for claustrophobic pt

Scanning process is painless, but the patienthears loud thumping of magnetic coils asmagnetic field is being pulsed.

Myelography Myelogram is an Xray of spinal subarachnoid space

taken with contrast agent (through Lumbar Tap)


107/128

g ( g p)

Shows distortion of spinal cord or spinal dural sac

caused by tumors, cysts, herniated vertebral disks

Nursing Intervention Meal before procedure is omited

After myelography, patient to lie in bed with head

elevated up to 45 and remain in bed for 3hrs

Encourage increased fluid intake

Monitor VS

Myelography


108/128

CEREBRAL ANGIOGRAPHY

X-ray study of the cerebral circulation with

contrast agent injected to selected artery.


109/128

g j y

Performed by threading a catheter through the

femoral artery in the groin and up to the desired

vessel.

Uses: Vascular disease, aneurysms, AVM

Digital Subtraction Angiography- X-ray images of areas in question are taken before and

after injection of contrast agent (peripheral vein) and then

compared

CEREBRAL ANGIOGRAM


110/128


111/128

Nursing Intervention: CEREBRAL ANGIOGRAPHYNURSING CARE PRE-TEST

1.) Check allergy to iodine

2.) Keep NPO after midnight or offer clear liquid breakfast only


112/128

3.) Explain that the client may have warm, flushed feeling and salty taste inmouth during procedure

4.) Take baseline vital signs and neuro check

5.) Administer sedation if ordered

NURSING CARE POST-TEST1.) Maintain pressure dressing over site if femoral or brachial artery used;

apply ice as ordered

2.) Maintain bed rest until next morning as ordered

3.) Monitor vital signs, neuro checks frequently; report any changes

immediately4.) Check site frequently for bleeding or hematoma; if carotid artery used;

assess for swelling of neck, difficulty swallowing or breathing

5.) Check pulse, color, and temperature of extremity distal to site used.

6.) Keep extremity extended and avoid flexion

Non-invasive Carotid Flow Studies

Uses ultrasound and doppler measurements of

arterial blood flow to evaluate carotid and deep


113/128

orbital circulation. The graph produced indicates blood velocity.

( velocity = stenosis or partial obstruction)

Carotid doppler permits evaluation of

Carotid ultrasonography arterial blood flow and

Oculoplethysmography detection of atrialOpthalmodensinometry stenosis, occlusion and

plaques

Transcranial Doppler

Uses the same noninvasive techniques as


114/128

Carotid flow studies except it records bloodflow velocities of intracranial vessels

Flow velocity is measured through thin area

of temporal and occipital bones of the skull. A hand-held doppler probe emits a pulsed

beam; the signal is reflected by a moving

RBC within the blood vessel Helpful in assessing vasospasm, altered cerebral

blood flow in occlusive vascular dse or stroke


115/128

Electroencephalography (EEG)

Represents a record of electricalactivity generated by the brain

h h l d li d h


116/128

through electrodes applied on thescalp

Used to diagnose seizure

disorders, coma Tumors, brain abscess, blood

clots may cause abnormalpatterns in electrical activity

Used in making a determinationof BRAIN DEATH


117/128

Electroencephalography (EEG)

Nursing Intervention

Withhold medications that may interfere with the results-

ti l t d ti d ti l t


118/128

anticonvulsants, sedatives and stimulants Wash hair thoroughly before procedure

Instruct adult client to sleep no more than 5 hrs the night

before.

Coffee, tea, chocolate and cola drinks are omitted Meal itself is not omitted because an altered glucose level

alters brain wave patterns

It takes 45min-1hour; 12 hours for sleep EEG

Standard EEG - water-soluble lubricant

Sleep EEG - collodion glue for electrode contact (acetone

for removal)

Diagnostic EvaluationElectromyography (EMG)- obtained by inserting needle electrode into the skeletal

l t h i th l t i l t ti l f th


119/128

muscle to measure changes in the electrical potential of themuscles and the nerves leading to them.Determine presence of neuromuscular disorders & myopathies.

Nerve Conduction Studies

-A peripheral nerve is stimulated at several points along

its course and recording the muscle action potential or

sensory action potential.Useful in studying peripheral neuropathies.

Lumbar Puncture and CSF examination

Spinal tap - a needle is inserted into the subarachnoidspace through the 3rd and 4th or 4th and 5th

l b i t f t ithd i l fl id


120/128

lumbar interface to withdraw spinal fluidhPURPOSES1. Measures CSF pressure

(normal opening pressure 60-150mmH2O)

2. Obtain specimens for lab analysis, cytology, C&S(protein - normally not present, sugar - normally present)

3. Check color of CSF (normally clear) and check forblood

4. Inject air, dye, or drugs into the spinal canal

- CSF pressure in lateral recumbent position is70-200mm H20

Lumbar Puncture and CSF examination

CONTRAINDICATION

INCREASED ICP

COAGULOPATHY & DECREASED PLATELETS


121/128

COAGULOPATHY & DECREASED PLATELETS SPINAL DEFORMITIES ( SCOLIOSIS, KYPHOSIS)

Lumbar Puncture GuidelinesNURSING CARE PRE-TEST

1.) Have client empty bladder

2 ) Position client in a lateral recumbent position with head


122/128

2.) Position client in a lateral recumbent position with headand neck flexed onto the chest and knees pulled up.

3.) Explain the need to remain still during the procedure

NURSING CARE POST-TEST

1.) Ensure labeling of CSF specimens in proper sequence

2.) Keep client flat for 12-24 hours as ordered

3.) Force fluids

4.) Check puncture site for bleeding, leakage of CSF

5.) Assess sensation and movement in lower extremities

6.) Monitor vital signs

7.) Administer analgesics for headache as ordered


123/128

Queckenstendts Test lumbar manometric test

performed by compressing jugular veins during Spinal

tap


124/128

tap in pressure caused by compression is noted; then

released and read every 10secs interval.

a slow rise and fall in pressure indicated a partial blockdue to lesion compressing the spinal subarachnoid path.

no pressure change => complete block is indicated.

Contraindicated: if intracranial lesion is suspected.

CSF Analysis CSF should be clear and colorless

Pink, blood-tinged, or glossy bloody CSF

indicates cerebral contusion laceration or


125/128

indicates cerebral contusion, laceration or

subarachnoid hemorrhage

Specimens are obtained for: cell count,

culture and glucose and protein testing

Post Lumbar Headache Mild to severe, may occur few hours to several

days after the procedure.

i h bbi bif l i i l h d h


126/128

It is throbbing bifrontal or occipital headache,

dull or deep in character

Cause:leak at puncture site, fluid continues toescape into the tissues by way of the needle

track from the spinal canal

May be avoided if small-gauged needle is used

and if pt remains prone

after the procedure.

sources Dillon, Patricia. Nursing Health Assessment. 2nd

Ed. F.A. Davis. 2007

J i C l Ph i l E i ti d H lth


127/128

Jarvis, Carolyn. Physical Examination and Health

Assessment. 3rd ed. New York: W.B. Saunder

Company.2000

Bickley. Lyn and Hoekenan, Robert. Bates Guide

to Physical Examination and History Taking. 7th

ed. New York: Lippincott Williams and Wilkins.

1999

Estes, Mary Ellen Zator. Health Assessment &

Physical Examination. 3rd ed. Delmar Learning.

2006


128/128

THANK YOU!!!

neuro diag

Documents