ASSESSMENT OF NEUROLOGICAL FUNCTION MICHELLE GARDNER RN, MSN

1. ASSESSMENT OF NEUROLOGICAL FUNCTIONMICHELLE GARDNER RN, MSN

2. OBJECTIVES • Review the structures and functions of the central and peripheral nervous systems • Describe the significance of physical assessment to the diagnosis of neurologic dysfunction. • Describe diagnostic tests used for assessment of suspected neurologic disorders and related nursing implications • Describe the needs of patients with various neurologic dysfunctions

3. NEUROLOGIC OVERVIEW • Central nervous system (CNS) - brain and spinal cord • Peripheral nervous system - cranial/spinal nerves - autonomic nervous system • Basic functional unit neuron

4. Function of the Nervous System • Control all motor, sensory, autonomic, cognitive, and behavioral activities

5. NEURON

6. NEUROTRANSMITTERS

7. Central Nervous System • The Brain cerebrum brain stem cerebellum

8. Protective Structures

9. Spinal Cord

10. Peripheral Nervous System Include • Cranial nerves • Spinal nerves • Autonomic nervous system

11. CRANIAL NERVES

12. Dermatome Distribution

13. Autonomic Nervous System (ANS) • Functions to regulate activities of internal organs and to maintain and restore internal homeostasis. • Sympathetic NS - “fight or flight responses • Parasympathetic NS - controls most visceral functions - serves to conserve and restore the energy stores in the body

14. Neurological Assessment Health history • History of the present illness-DETAILS • Review the medical records • Input from witness/family member

15. Neurological Assessment Common symptoms • Pain • Seizures • Dizziness/vertigo • Visual disturbances • Muscle weakness • Abnormal sensations

16. Diagnostic Evaluation • CT scan (Computer Tomography) • MRI (Magnetic Resonance Imaging) • PET (Positron Emission Tomography) • Cerebral angiography • Electroencephalography (EEG) • Electromyography (EMG) • Lumbar puncture – analysis of CSF

17. CT scan

18. CT Scan • Computer – assisted x-ray of multiple cross sections of the brain to detect problems hemorrhage, brain atrophy, infection, tumor and other abnormalities. • Contrast media may be used • Assess for contraindications to contrast media shell fish/iodine/dye allergy • Explain appearance of scanner • Instruct client to remain still during the procedure. • Evaluate renal function

19. Magnetic Resonance Imaging

20. Magnetic Resonance Imaging (MRI) • Imaging of brain, spinal cord  by means of magnetic energy. • Used to detect strokes, tumors, seizures, trauma • Not an invasive procedure • Has greater contrast in images of soft tissue structures than CT scan. • Contrast media may be used to enhance images. • Screen client for metal parts

21. Electroencephalography -EEG

22. Electroencephalography -EEG • Electrical activity of the brain is recorded by scalp electrodes to evaluate seizure disorders, cerebral diseases, brain death. • Procedure is noninvasive and without danger of electrical shock. • Medication may be withheld • Resume medication and wash electrode paste out of hair after the test.

23. Cerebral Angiography

24. Cerebral Angiography • X-ray visualization of intracranial/extracranial blood vessels viewed to detect vascular lesions and tumors of the brain. • Contrast medium is used/explain procedure. • Assess client for stroke risk before procedure • Monitor neurological signs and VS • Report any neurological changes

25. Electromyography

26. Electromyography EMG • Electrical activity associated with nerve and skeletal muscle is recorded by insertion of needle electrodes to detect muscle and peripheral nerve disease. • Inform client that pain and discomfort may be associated with procedure  insertion of needles.

27. Lumbar Puncture

28. Lumber Puncture Cerebrospinal fluid analysis • CSF is aspirated by needle insertion in L3-4 or L4-5 interspace to assess many CNS diseases • Client assumes and maintains lateral recumbent position • Ensure strict aseptic technique • Post procedure- headache • CONTRAINDICATED with patients with ICP

29. Consciousness • Person is aware of self and the environment and is able to respond appropriately to stimuli • Full consciousness requires both alertness and full cognition

30. Altered LOC - • Altered LOC is not a disorder but the result of a pathology • Full consciousness • Confusion • Disorientation • Obtundation • Coma

31. Pathophysiology A-E-I-O-U = • Alcohol, Epilepsy, Insulin, Opium, Uremia TIPSS = • Tumor, Injury, Psychiatric, Stroke, Sepsis

32. LOC – Assessment • Assess verbal response and orientation • Alertness • Motor responses • Respiratory status • Eye signs • Reflexes • Posturing • Glasgow Coma Scale • Client is at risk for alterations in every body system

33. POSTURING Decorticate Posturing Decerebrate Posturing

34. Interdisciplinary Care • Must begin immediately Focus • identify the underlying cause • preserve function • prevent deterioration

35. Diagnostic Procedures • CT scan/MRI • EEG • Cerebral angiography • Laboratory tests - blood glucose - electrolytes - ABG - liver function test - toxicology screening

36. Potential Complications • Respiratory distress or failure • Pneumonia • Aspiration • Pressure ulcer • Deep vein thrombosis (DVT) • Contractures

37. Ineffective Airway Clearance • Assess/monitor • Positioning to prevent obstruction of upper airway—HOB elevated 30° • Suctioning, and CPT • Monitor ABG analysis

38. Impaired Physical Mobility • Frequent turning; use turning schedule • Passive ROM • Use of splints, foam boots, trochanter rolls, and specialty beds as needed • Clean eyes with cotton balls moistened with saline • Use artificial tears as prescribed

39. Risk for Imbalanced Nutrition - • Assess swallowing/gag reflex • Monitor and report manifestations of aspiration • Provide interventions to prevent aspiration • Monitor nutritional status • Assess the need for alternative methods of nutritional support - collaboration dietitian

40. Communication/Family Support • Encourage the family to talk to and touch patient • Maintain normal day/night pattern of activity • Orient the patient frequently • Note: When arousing from coma, a patient may experience a period of agitation; minimize stimulation at this time • Allow family to ventilate and provide support to them • Reinforce and provide consistent information to family • Referral to support groups and services for family

41. Increased Intracranial Pressure • Skull is like a closed box  (3) essential volume components - brain tissue (80%) - blood (12%) - cerebrospinal fluid (8%) • These components equal a state of equilibrium and produce ICP. • ICP measured in the lateral ventricles  normal pressure 10-15mmHg. 15mmHg being the upper limit.

42. Increased Intracranial Pressure Monroe-Kellie hypothesis • A state of equilibrium exist: if the volume of any of the three components increases, the volume of the others must decrease to maintain normal pressures within the cranial cavity . • Brain tissue has limited space to expand, compensation is accomplished by - displacing/shifting CSF, - increasing the absorption/diminishing the producing CSF - decrease cerebral blood volume

43. Increased Intracranial Pressure • Sustained elevated pressure within the cranial cavity • Caused by – head trauma, tumors stroke hemorrhage infection *cerebral edema

44. Increased Intracranial Pressure • Compensatory mechanism that compensate for increased ICP  autoregulation and decreased production/flow of CSF . • Autoregulation – the brain’s ability to change the diameter of the blood vessels to maintain a constant cerebral blood flow.

45. Increased Intracranial Pressure ICP is increased by: • Endotracheal or oral tracheal suctioning • Coughing • Blowing nose forcefully • Head of bed less than 30 degrees • Increased intra-abdominal pressure(restrictive clothing, Valsalva)

46. Increased Intracranial Pressure Clinical Manifestations • Early sign – change in LOC • Motor responses • Vision & pupils • Vital signs • Other

47. Clinical Manifestations - late • Cushing’s triad: bradycardia, severe hypertension, bradypnea • projectile vomiting • further deterioration of LOCstupor to coma • decortication, decerebration • respiratory abnormalitiesCheyne-Stokes breathing • Headache

48. Brain with intracranial shifts

49. Increased Intracranial Pressure Diagnostic studies • CT scan/MRI • Serum Osmolality • ABG’s

50. Increased Intracranial Pressure Complications • Brain stem herniation • Diabetes inisipidus • Syndrome of inappropriate antidiuretic hormone (SIADH)