Transcript neuroassess

NEUROLOGICAL SYSTEM
ASSESSMENT
PYRAMID POINTS
• Risk factors associated with neurological
disorders
• Neurological assessment
• Cranial nerve assessment
• Glasgow coma scale
• Preprocedure and postprocedure nursing care
and client education
• Positioning a client following a diagnostic
procedure
ASSESSMENT OF RISK FACTORS
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Trauma
Hemorrhage
Tumors
Infection
Toxicity
Metabolic disorders
ASSESSMENT OF RISK FACTORS
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Hypoxic conditions
Deficiency conditions
Hypertension
Cigarette smoking
Stress
ASSESSMENT OF CRANIAL NERVE I
OLFACTORY
• Cranial nerve I: (olfactory) sensory, smell
• Have the client close eyes and occlude one
nostril with finger
• Ask the client to identify nonirritating odors such
as coffee, tea, cloves, soap, chewing gum, and
peppermint
• Repeat the test on the other nostril
CRANIAL NERVE I
OLFACTORY
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
ASSESSMENT OF CRANIAL NERVE II
OPTIC
• Cranial nerve II: (optic) sensory, vision
• Assess visual acuity with a Snellen chart or
newspaper or ask the client to count how many
fingers the examiner is holding up
• Check visual fields by confrontation
• Have the client sit directly in front of examiner
and stare at examiner's nose
• Examiner slowly moves his or her finger from the
periphery towards the center until the client says
it can be seen
• Check color vision by asking the client to name
the color of several nearby objects
CRANIAL NERVE II
OPTIC
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
CRANIAL NERVE II: OPTIC
ASSESSING VISUAL FIELDS
From Leahy, J. & Kizilay, P. (1998). Foundations of nursing practice. Philadelphia: W.B. Saunders
ASSESSMENT OF CRANIAL NERVES III, IV, VI
OCULOMOTOR, TROCHLEAR, ABDUCENS
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Cranial nerve III (oculomotor)
Cranial nerve IV (trochlear)
Cranial nerve VI (abducens)
The motor functions of these nerves overlap;
therefore, they need to be tested together
• First, inspect the eyelids for ptosis (drooping),
then assess ocular movements and note any eye
deviation
• Test accommodation and direct and consensual
light reflexes
ASSESSMENT OF CRANIAL NERVES III, IV, VI
OCULOMOTOR, TROCHLEAR, ABDUCENS
• Cranial nerve III: (oculomotor) motor
– Assesses pupillary constriction, upper eyelid
elevation, and most eye movement
• Cranial nerve IV: (trochlear) motor
– Assesses downward and inward eye
movement
• Cranial nerve VI: (abducens)
– Assesses lateral eye movement
CRANIAL NERVE III
OCULOMOTOR
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
CRANIAL NERVE IV
TROCHLEAR
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
CRANIAL NERVE VI
ABDUCENS
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
ASSESSMENT OF CRANIAL NERVE V
TRIGEMINAL
• Cranial nerve V: (trigeminal) sensory and motor
• Assesses sensation to the cornea, nasal and oral
mucosa, facial skin, and mastication
• To test motor function, ask the client to close
jaws tightly then try to separate the clenched jaw
• Test the corneal reflex by lightly touching the
client's cornea with a cotton wisp
• Check sensory function by asking the client to
close the eyes, then lightly touch the forehead,
cheeks, and chin noting if the touch can be felt
equally on both sides
CRANIAL NERVE V
TRIGEMINAL
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
ASSESSMENT OF THE CORNEAL REFLEX
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.
ASSESSMENT OF CRANIAL NERVE VII
FACIAL
• Cranial nerve VII: (facial) sensory and motor
• Tests taste perception on the anterior two-thirds
of the tongue
• Have the client show the teeth
• Attempt to close the client's eyes against
resistance and ask the client to puff out his or her
cheeks
• Place sugar, salt, or vinegar on the front of the
tongue and have the client identify these
substances by their tastes
CRANIAL NERVE VII
FACIAL
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
ASSESSMENT OF CRANIAL NERVE VIII
ACOUSTIC
• Cranial nerve VIII: (acoustic) sensory
• The ability to hear tests the cochlear portion
• The sense of equilibrium tests the vestibular
portion
• Check the client's ability to hear a watch ticking
or a whisper
• Observe the client's balance and observe for
swaying when walking or standing
CRANIAL NERVE VIII
ACOUSTIC
From Leahy, J. & Kizilay, P. (1998). Foundations of nursing practice. Philadelphia: W.B. Saunders
ASSESSMENT OF CRANIAL NERVE IX
GLOSSOPHARYNGEAL
• Cranial nerve IX: (glossopharyngeal) sensory and
motor
• Assesses swallowing ability
• Assesses sensation to the pharyngeal soft palate
and tonsillar mucosa, and taste perception on the
posterior third of the tongue and salivation
CRANIAL NERVE IX
GLOSSOPHARYNGEAL
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
ASSESSMENT OF CRANIAL NERVE X
VAGUS
• Cranial nerve X: (vagus) sensory and motor
• Assesses swallowing and phonation, sensation
to the exterior ear's posterior wall, and sensation
behind the ear
• Assesses sensation to the thoracic and
abdominal viscera
CRANIAL NERVE X
VAGUS
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
ASSESSMENT OF CRANIAL NERVES IX AND X
GLOSSOPHARYNGEAL AND VAGUS
• Cranial nerve IX: (glossopharyngeal)
• Cranial nerve X: (vagus)
• Have the client identify a taste at the back of the
tongue
• Inspect the soft palate and observe for
symmetrical elevation when the client says "aah"
• Touch the posterior pharyngeal wall with a
tongue depressor to elicit a gag reflex
ASSESSMENT OF CRANIAL NERVES IX AND X
GLOSSOPHARYNGEAL AND VAGUS
From Leahy, J. & Kizilay, P. (1998). Foundations of nursing practice. Philadelphia: W.B. Saunders
ASSESSMENT OF CRANIAL NERVE XI
SPINAL ACCESSORY
• Cranial nerve XI: (spinal accessory) motor
• Assesses uvula and soft palate movement,
sternocleidomastoid, and trapezius muscle
• Assesses upper portion of the trapezius muscle,
which governs shoulder movement and neck
rotation
• Palpate and inspect the sternocleidomastoid
muscle as the client pushes the chin against the
examiner’s hand
• Palpate and inspect the trapezius muscle as the
client shrugs the shoulders against the
examiner’s resistance
CRANIAL NERVE XI
SPINAL ACCESSORY
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
ASSESSMENT OF CRANIAL NERVE XI
SPINAL ACCESSORY
From Leahy, J. & Kizilay, P. (1998). Foundations of nursing practice. Philadelphia: W.B. Saunders
ASSESSMENT OF CRANIAL NERVE XII
HYPOGLOSSAL
• Cranial nerve XII: (hypoglossal) motor
• Assesses tongue movements involved in
swallowing and speech
• Observe the tongue for asymmetry, atrophy,
deviation to one side, and fasciculations
• Ask the client to push the tongue against a
tongue depressor, then have the client move the
tongue rapidly in and out and from side to side
CRANIAL NERVE XII
HYPOGLOSSAL
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
ASSESSMENT OF LEVEL OF CONSCIOUSNESS
• Assesses cerebral function
• Assess client behavior to determine level of
consciousness such as confusion, delirium,
unconsciousness, stupor, and coma
ASSESSMENT OF RESPIRATIONS
• CHEYNE-STOKES
– Rhythmical with periods of apnea
– Can indicate a metabolic dysfunction or
dysfunction in the cerebral hemisphere or
basal ganglia
• NEUROGENIC HYPERVENTILATION
– Regular, rapid, deep, sustained respirations
– Indicates a dysfunction to the low midbrain
and middle pons
ASSESSMENT OF RESPIRATIONS
• APNEUSTIC
– Irregular respirations with pauses at the end of
inspiration and expiration
– Indicates a dysfunction to the middle or caudal
pons
• ATAXIC
– Totally irregular in rhythm and depth
– Indicates a dysfunction in the medulla
ASSESSMENT OF RESPIRATIONS
• CLUSTER
– Clusters of breaths with irregularly spaced
pauses
– Indicates a dysfunction in the medulla and
pons
ASSESSMENT OF PUPILS
• Size
• Equality
• Reactions to light described as brisk, slow, or
fixed
• Unusual eye movements
• Unilateral pupil dilation indicates compression of
the third cranial nerve
• Mid-position, fixed pupil indicates midbrain injury
• Pinpoint, fixed pupil indicates pontine damage
RESPIRATORY PATTERNS AND PUPIL
APPEARANCES
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
ASSESSMENT OF TEMPERATURE
• An elevated temperature increases the brain's
metabolic rate
• A rapid rise in temperature indicates a
dysfunction of the hypothalamus or brain stem
• A slow rise in temperature may indicate infection
ASSESSMENT OF MOTOR FUNCTION
• Muscle tone including strength and equality
• Voluntary and involuntary movements
• Purposeful and nonpurposeful movements
ASSESSMENT FOR POSTURING
• POSTURING
– Indicates a deterioration of the condition
• FLEXION (DECORTICATE POSTURING)
– Client flexes one or both arms on the chest
and may stiffly extend the legs
– Indicates a nonfunctioning cortex
ASSESSMENT FOR POSTURING
• EXTENSOR (DECEREBRATE POSTURING)
– Client stiffly extends one or both arms and
possibly the legs
– Indicates a brain stem lesion
• FLACCID POSTURING
– Client displays no motor response in any
extremity
POSTURING
From Ignatavicius, D. & Workman, M. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.
ASSESSMENT OF REFLEXES
• BABINSKI’S REFLEX
– Dorsiflexion of the ankle and great toe with
fanning of the other toes
– Indicates a disruption of the pyramidal tract
• CORNEAL REFLEX
– Loss of the blink reflex
– Indicates a dysfunction of cranial nerve V
• GAG REFLEX
– Loss of the gag reflex
– Indicates a dysfunction of cranial nerves IX
and X
BABINSKI’S REFLEX IN AN ADULT
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
CORNEAL REFLEX
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.
GAG REFLEX
From Leahy, J. & Kizilay, P. (1998). Foundations of nursing practice. Philadelphia: W.B. Saunders
ASSESSMENT OF MENINGEAL IRRITATION
• Nuchal rigidity
• Irritability
• Fever
ASSESSMENT OF MENINGEAL IRRITATION
• KERNIG’S SIGN
– Flexion of the thigh and knee to right angles,
and when extended, causes spasm of
hamstring and pain
• BRUDZINSKI’S SIGN
– Flexion of the head causes flexion of both
thighs at the hips, and knee flexion
NUCHAL RIGIDITY
KERNIG’S AND BRUDZINSKI’S SIGNS
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for
clinical practice, ed 2, Philadelphia: W.B. Saunders.
ASSESSMENT OF THE AUTONOMIC SYSTEM
• SYMPATHETIC FUNCTIONS/ADRENERGIC
RESPONSES
– Increased pulse and blood pressure
– Dilated pupils
– Decreased peristalsis
– Increased perspiration
ASSESSMENT OF THE AUTONOMIC SYSTEM
• PARASYMPATHETIC FUNCTION/CHOLINERGIC
RESPONSES
– Decreased pulse and blood pressure
– Constricted pupils
– Increased salivation
– Increased peristalsis
– Dilated blood vessels
– Bladder contraction
ASSESSMENT OF SENSORY FUNCTION
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Touch
Pressure
Pain
Bladder control
Bowel control
GLASGOW COMA SCALE
• A method of assessing a client's neurological
condition
• A scoring system based on a scale of 1 to 15
points
• A score below 8 indicates coma is present
• Eye opening is the most important indicator
SKULL AND SPINAL X-RAY
• DESCRIPTION
– X-rays of the skull reveal the size and shape of
the skull bones, suture separation in infants,
fractures or bony defects, erosion, or
calcification
– Spinal x-rays identify fractures, dislocation,
compression, curvature, erosion, narrowed
spinal cord, and degenerative processes
SKULL AND SPINAL X-RAY
• PREPROCEDURE
– Provide support for the confused, combative,
or ventilator-dependent client
– Maintain immobilization of the neck if a spinal
fracture is suspected
– Remove metal items from body parts
– If the client has thick and heavy hair, this
should be documented, because it may affect
interpretation of the x-ray film
• POSTPROCEDURE
– Maintain immobilization until results are
known
COMPUTED TOMOGRAPHY (CT) SCAN
• DESCRIPTION
– A type of brain scanning that may or may not
require an injection of a dye
– Used to detect intracranial bleeding, spaceoccupying lesions, cerebral edema,
infarctions, hydrocephalus, cerebral atrophy,
and shifts of brain structures
POSITIONING FOR CT SCAN
From Perkin GD et al (1986) Atlas of clinical neurology. London: Gower Medical Publishing.
CT SCAN OF THE BRAIN
From Seeley RS, Stephens TD, Tate P (1995) Anatomy and Physiology (3rd ed.)
New York: The McGraw-Hill Companies; Howard Sochurek.
COMPUTED TOMOGRAPHY (CT) SCAN
• PREPROCEDURE
– Obtain a consent if a dye is used
– Assess for allergies to iodine, contrast dyes,
or shellfish if a dye is used
– Instruct the client in the need to lie still and flat
during the test
– Instruct the client to hold his or her breath
when requested
– Initiate an IV if prescribed
COMPUTED TOMOGRAPHY (CT) SCAN
• PREPROCEDURE
– Remove objects from the head such as wigs,
barrettes, earrings, and hairpins
– Assess for claustrophobia
– Inform the client of possible mechanical noises
as the scanning occurs and that there may be a
hot, flushed sensation and a metallic taste in the
mouth when the dye is injected
– Note that some clients may be given the dye
even if they report an allergy, and are pretreated
with an antihistamine and corticosteroids prior
to the injection, to reduce the severity of a
reaction
COMPUTED TOMOGRAPHY (CT) SCAN
• POSTPROCEDURE
– Provide replacement fluids because diuresis
from the dye is expected
– Monitor for an allergic reaction to dye
– Assess dye injection site for bleeding or
hematoma, and monitor extremity for color,
warmth, and the presence of distal pulses
MAGNETIC RESONANCE IMAGING (MRI)
• DESCRIPTION
– A noninvasive procedure that identifies types
of tissues, tumors, and vascular abnormalities
– Similar to the CT scan but provides more
detailed pictures and does not expose the
client to ionizing radiation
CLINICAL SETTING FOR AN MRI
From Mourad LA (1991) Orthopedic disorders. St. Louis: Mosby.
MAGNETIC RESONANCE IMAGE
From Crossman AR, Neary D (1995). Neuroanatomy: an illustrated color text. Edinburgh:
Churchill Livingstone.
MAGNETIC RESONANCE IMAGING (MRI)
• PREPROCEDURE
– Remove all metal objects from the client
– Determine if the client has a pacemaker,
implanted defibrillator, or metal implants such
as a hip prosthesis or vascular clips because
these clients cannot have this test performed
– Remove IV fluid pumps during the test
MAGNETIC RESONANCE IMAGING (MRI)
• PREPROCEDURE
– Provide precautions for the client attached to a
pulse oximetry because it can cause a burn
during testing if coiled around the body or a
body part
– Provide an assessment of the client with
claustrophobia
– Administer medication as prescribed for the
client with claustrophobia
MAGNETIC RESONANCE IMAGING (MRI)
• PREPROCEDURE
– Determine if a contrast agent is to be used and
follow the prescription related to the
administration of food, fluids, and medications
– Instruct the client that he or she will need to
remain still during the procedure
• POSTPROCEDURE
– Client may resume normal activities
– Expect diuresis if a contrast agent was used
LUMBAR PUNCTURE
• DESCRIPTION
– Insertion of a spinal needle through L3-L4
interspace into the lumbar subarachnoid space
to obtain cerebrospinal fluid (CSF); measure
CSF fluid or pressure; or to instill air, dye, or
medications
– Contraindicated in clients with increased
intracranial pressure, because the procedure
will cause a rapid decrease in pressure within
the CSF around the spinal cord, leading to
brain herniation
LUMBAR PUNCTURE
• PREPROCEDURE
– Obtain a consent
– Have the client empty his or her bladder
LUMBAR PUNCTURE
• DURING THE PROCEDURE
– Position the client in a lateral recumbent
position and have the client draw knees up to
the abdomen and chin onto the chest
– Assist with the collection of specimens (label
the specimens in sequence)
– Maintain strict asepsis
LUMBAR PUNCTURE
From Herlihy B, Maebius NK: The human body in health and illness, Philadelphia, 2000, W.B. Saunders.
LUMBAR PUNCTURE
• POSTPROCEDURE
– Monitor vital signs and neurological signs
– Position the client flat as prescribed
– Force fluids
– Monitor I&O
MYELOGRAM
• DESCRIPTION
– Injection of dye or air into the subarachnoid
space to detect abnormalities of the spinal
cord and vertebrae
POSITIONING FOR A MYELOGRAM
From Chipps EM, Clanin NJ, Campbell VG (1992) Neurologic disorders.
St. Louis: Mosby. Courtesy of Doctors Hospital, Columbus, OH.
NORMAL MYELOGRAM
OF THE LUMBAR SPINE
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.
MYELOGRAM
• PREPROCEDURE
– Obtain a signed consent form
– Provide hydration for at least 12 hours before
the test
– Assess for allergies to iodine
– If the client is taking a phenothiazine, hold the
medication because this medication lowers the
seizure threshold
– Premedicate for sedation as prescribed
MYELOGRAM
• POSTPROCEDURE
– Vital signs and neurological assessment
frequently as prescribed
– If a water-based dye is used, elevate the head
15 to 30 degrees for 8 hours as prescribed
– If an oil-based dye is used, keep the client flat
6 to 8 hours as prescribed
– If air is used, keep the head lower than the
trunk as prescribed
MYELOGRAM
• POSTPROCEDURE
– Administer analgesics for headache or
backache as prescribed
– Force fluids
– Monitor I&O
– Assess for bladder distention and voiding
CEREBRAL ANGIOGRAPHY
• DESCRIPTION
– Injection of a contrast through the femoral
artery into the carotid arteries to visualize the
cerebral arteries and assess for lesions
CEREBRAL ANGIOGRAPHY
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.
CEREBRAL ANGIOGRAPHY
• PREPROCEDURE
– Obtain a consent
– Assess the client for allergies to iodine and
shellfish
– Encourage hydration for 2 days before the test
– NPO 4 to 6 hours prior to the test as
prescribed
– Obtain a baseline neurological assessment
– Mark the peripheral pulses
CEREBRAL ANGIOGRAPHY
• PREPROCEDURE
– Remove metal items from the hair
– Administer premedication as prescribed
CEREBRAL ANGIOGRAPHY
• POSTPROCEDURE
– Monitor neurological status and vital signs
frequently until stable
– Monitor for swelling in the neck and for
difficulty swallowing and notify the physician if
these symptoms occur
– Maintain bed rest for 12 hours as prescribed
– Elevate the head of the bed 15 to 30 degrees
only if prescribed
CEREBRAL ANGIOGRAPHY
• POSTPROCEDURE
– Keep the bed flat if the femoral artery is used
as prescribed
– Assess peripheral pulses
– Immobilize the puncture site for 12 hours as
prescribed
– Apply sandbags and a pressure dressing to
the injection site as prescribed
– Place ice to the puncture site as prescribed
– Force fluids
ELECTROENCEPHALOGRAPHY (EEG)
• DESCRIPTION
– A graphic recording of the electrical activity of
the superficial layers of the cerebral cortex
ELECTROENCEPHALOGRAPHY
From Chipps EM, Clanin NJ, Campbell VG (1992) Neurologic disorders. St. Louis: Mosby.
ELECTROENCEPHALOGRAPHY
NORMAL AND INTRACRANIAL TUMOR
Thompson JM et al. Mosby’s Clinical Nursing, ed. 4, St. Louis, 1997, Mosby.
ELECTROENCEPHALOGRAPHY (EEG)
• PREPROCEDURE
– Wash the client's hair
– Inform the client that electrodes are attached
to the head and that electricity does not enter
the head
– Withhold stimulants, antidepressants,
tranquilizers, and anticonvulsants for 24 to 48
hours prior to the test as prescribed
– Allow the client to have breakfast if prescribed
– Premedicate for sedation as prescribed
ELECTROENCEPHALOGRAPHY (EEG)
• POSTPROCEDURE
– Wash the client's hair
– Maintain siderails and safety precautions if the
client was sedated
CALORIC TESTING
(OCULOVESTIBULAR TESTING)
• DESCRIPTION
– Provides information about the function of the
vestibular portion of cranial nerve VIII and aids
in the diagnosis of cerebellum and brain stem
lesions
CALORIC TESTING
(OCULOVESTIBULAR TESTING)
• PROCEDURE
– Patency of the external canal is confirmed
– Cold or warm water is introduced into the
external auditory canal
– Stimulation of the auditory canal with warm
water produces a horizontal nystagmus toward
the side of the irrigated ear when the vestibular
cranial nerve VIII is normal
– Stimulation of the auditory canal with cold
water produces a horizontal nystagmus away
from the side of the irrigated ear if the brain
stem is intact