Neurological Assessment PDF

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NUR 4110: Review of Neurological Assessment

Components of a Neurological Assessment 1. 2. 3. 4. 5. 6. 7. 8. 9.

Interview Level of consciousness Pupillary assessment Cranial nerve testing Vital signs Motor function Sensory function Tone Cerebral function

Interview to identify the presence of=>           

Headache Difficulty with speech Altered consciousness Confusion, disorientation Decrease din sensation, tingling, pain Motor weakness, decreased strength Change in vision Difficulty swallowing Altered gait, balance Dizziness Tremors, twitches

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Consciousness is the most sensitive indicator of neurological change

Level of Consciousness

Consciousness

Arousal

Awareness

** Awareness: the patient can interact with and interpret their environment ** Arousal: function of the brain stem (doesn’t have anything to do with the “thinking brain” Reasons for altered consciousness 1. 2. 3. 4.

Decreased cerebral metabolism (hypoxia, hypoglycemia) Drugs (alcohol, barbiturates) Hypotension (decreased cerebral blood flow) Structural lesions (infarctions, hemorrhages, tumors)

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Glasgow Coma Scale Evaluation   

Eye opening Motor function Speech

Pupillary Assessment     

Size, shape, reactivity to light, comparison of one pupil to the other Size (pinpoint, small, large, dilated) Shape (normally round) Reactivity (sluggish, nonreactive/fixed) Extraocular eye movement (Normal: blink periodically, eyes move together, no nystagmus)

Vital Signs   



Changes in vital signs are not consistent early warning signals Respiratory and cardiac centers located in brainstem Respiratory o Assess rate, rhythm and characteristics of inspiration/expiration o Assess gas exchange, tissue perfusion, airway clearance, risk for aspiration o Ensure patent airway  What causes changes in respirations from a neurological standpoint?  Increased ICP  Spinal cord injury Cardiac o Assess rate, rhythm, quality of pulse, cardiac output, arrhythmias  What causes changes in pulse form a neurological standpoint?  Tachycardia: Multiple trauma/hemorrhage  Bradycardia: Increased ICP, SCI o Asses BP  What can cause changes in blood pressure from a neurological standpoint?  Hypertension: increased ICP (widening pulse pressure)/Cushing’s Triad (HTN, bradycardia, apnea)

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Motor function  

Muscle size, tone, strength, involuntary movements Grade strength o 5= full ROM against gravity/resistance (normal) o 4= Full ROM against gravity/moderate o 3= Full ROM against gravity only, moderate muscle weakness o 2= Full ROM when gravity is eliminated, severe weakness o 1= Muscle contraction is palpated, but no movement, very severe weakness o 0= Complete paralysis

Sensory function    

Pain/temperature sensation Position sense (proprioception) Light touch Sensory tests (stereognosis, graphesthesis, two-point discrimination)

Tone 

Reflex response o 0= no response o 1+= diminished response o 2+= average, normal o 3+= brisker than normal o 4+= very brisk, hyperactive

Cerebellar function    

Finger to finger test Finger to nose test Tandem walking Romberg test

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Diagnostic Evaluation

Computerized tomography Education regarding procedure Need to lie quietly throughout procedure Relaxation techniques Monitoring if sedation administered IV contrast agent/allergy and renal function assessment (increased IVF/PO) MRI  With or without contrast  Can identify cerebral abnormality earlier and more clearly than other tests  Provides information about chemical changes within cells (diagnosis of brain tumor, CVA, MS)  Magnetic substances in the body may be dislodged by magnet: history of any metal fragments/objects (aneurysm clips. Orthopedic hardware, pacemakers, artificial heart valves, intrauterine devices)  No metal objects brought into room (oxygen tanks, IV poles, ventilators, stethoscopes)  Assess girth of patient  Education 3. Positron Emission Tomography  Produces images of actual organ functioning (measures blood flow, tissue composition, metabolism)  Inhalation or injection of radioactive substance  Educate about inhalation techniques and side effects (dizziness) that may occur  Relaxation exercise may reduce anxiety during test

1.      2.

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4. Cerebral angiography  X-ray study of cerebral circulation with a contrast magnet injected into artery  Determines vessel patency, pre4sence of collateral circulation, vascular anomalies  Renal function evaluation – BUN & Cr- good kidney function to excrete contrast  Preparation of site/fluoroscopy  Void before test  Educate patient about warm sensation that might occur once contrast is injected  Local anesthetic to minimize pain at insertion site & to reduce arterial spasm  Assess for complications: new onset altered LOC, weakness, sensory deficits, speech disturbances, embolism or arterial dissection.  Fluids given to get rid of contrast

5. Noninvasive carotid flow studies a. Carotid Doppler: detects arterial stenosis, occlusion, plaques b. Transcranial Doppler: arterial flow measures through temporal and occipital bones of skull= assesses vasospasm, brain death c. EEG: records electrical activity in brain //hold the following 24-48 hrs before  Avoid caffeine, cola, chocolate prior to exam (stimulating effect)  Deprive body of sleep night before EEG  Avoid sedatives 6. Lumbar puncture a. Insertion of needle into lumbar subarachnoid (bw 3rd/4th vertebrae) space to withdraw CSF b. Obtain a culture, measure and reduce CSF pressure, determine presence of absence of blood in the CSF c. Administer medications intrathecal d. Risky in presence of intracranial mass lesion (brain may herniate downward)

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CSF fluid analysis:  Should be clear and colorless  Pink, blood tinged- could indicate hemorrhage  Specimens sent to lab right away!  Obtain specimen for culture, glucose, protein  Post-lumbar puncture headache: caused by leakage at the puncture site  Pain lessens when lying down  Headache can be avoided if small gauge is used or if pt remains PRONE after procedure.  Managed by rest, analgesic agents, hydration  See pages 1969- 1970 and Table A-5 in Appendix A on the Point for normal values of CSF

KG Fall 2015

LUMBAR PUNCTURE PRE PROCEDURE Determine whether written consent has been obtained. • Explain the procedure to the patient and describe the sensations that are likely during the procedure (a sensation of cold as the site is cleaned with solution, a needle prick when local anesthetic agent is injected). • Determine whether the pt has any ? or misconceptions about the procedure; reassure the pt that the needle will not enter the spinal cord or cause paralysis. • Instruct the patient to void before the procedure. DURING Procedure • The pt is positioned on one side at the edge of the bed with the back toward the physician; the thighs&legs are flexed as much as possible to increase the space between the spinous processes of the vertebrae, for easier entry into the subarachnoid space. • A small pillow may be placed under the pts head to maintain the spine in a horizontal position; a pillow may be placed between the legs to prevent the upper leg from rolling • The nurse assists the pt to maintain the position to avoid sudden movement • The nurse describes the procedure step by step to the patient as it proceeds. • The physician cleanses the puncture site with an antiseptic agent solution and drapes site. • Then he injects local anesthetic agent to numb the puncture site and then inserts a spinal needle into the area. A pressure reading may be obtained. • A specimen of CSF is removed and usually collected in 3 test tubes, labeled in order of collection. The needle is withdrawn.sent to the lab immediately. Post-procedure • Instruct the patient to lie prone (for 2 to 3 hours) to separate the alignment of the dural and arachnoid needle punctures in the meninges, to reduce leakage of CSF. • Monitor the pt for complications of lumbar puncture; notify PCP if they occur. • Encourage increased fluid intake to reduce the risk of headache.

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