Transcript LWW PPT Slide Template Master

Chapter 33:
Patient Assessment:
Nervous System
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Objectives
• Gather baseline data in an organized fashion
• Correlate and look for trends in data
• Analyze and develop nursing diagnoses
• Determine how deficit affects activities of daily living
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Equipment Needed
• Reflex hammer (deep tendon reflexes)
• Ophthalmoscope and/or flashlight (pupil checks)
• Tuning fork (hearing evaluation)
• Monofilament (sensation)
• Otoscope (hearing evaluation)
• Blood pressure cuff (identify hypertension)
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Understanding Age-Related Changes
With age, all of the following may be diminished:
– Taste and smell
– Hearing and visual acuity
– Muscle mass
– Sensitivity to touch and pain
– Deep tendon reflexes
• In addition, you may see:
– Tremors of head and tongue
– Slow and uncertain gait
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Comprehensive History
• Chief problem
• Past medical history
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Chief Problem: OPQRST Method
O = Onset
R = Radiation
P = Precipitating factors
S = Severity; on a 1-to10 scale
Q = quality; describe
your symptoms in your
own words
T = Timing; how long
does it last; does it
occur at any particular
time of day?
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Past Medical History: Head to Toe
• Neurological: TIA, stroke, seizures, headache, change in LOR, speech
pattern, pain
• Cardiovascular: CAD, MI, HTN, PVD, syncope, rhythm disturbances
(atrial fibrillation)
• Respiratory: COPD, shortness of breath, recent infections
• Musculoskeletal: Guillain-Barré, myasthenia gravis, ability to carry out
ADLs
• Others
–
Medications: antiseizure meds, antihypertensives,
anticoagulants, antiplatelets
–
Surgeries
–
Social behaviors: ETOH, drugs, cigarette smoking
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Physical Assessment
• Level of responsiveness (LOR)
• Motor strength
• Vital signs
• Cranial nerve assessment
• Deep tendon reflexes (DTRs)
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Level of Responsiveness
• A good, thorough inspection will give you the most
information.
• Gross bedside mental status checks
– AVPU (gross check for Awake, Verbal stimulus, Pain,
and Unresponsive
– A+O x3 (“Who you are, Where you are, What time is
it?”)
– Glasgow Coma Scale
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Glasgow Coma Scale
• Done according to responses:
– Best eye
– Best motor
– Best verbal
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Question
The nurse is assessing a stroke patient using the Glasgow
Coma Scale (GCS). The patient opens his eyes
spontaneously and obeys commands but does not know
who he is, where he is, or what time it is. His GCS total
score would be:
A. 8
B. 13
C. 14
D. 15
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Answer
C. 14
Rationale: His eye response is a 4. His motor response is a
6. His verbal response is a 4. This is a total of 14 on the
GCS scale.
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Motor Responses
• Strength with and without resistance
• More primitive responses:
– Localizing
– Withdrawing
– Decorticate rigidity
– Decerebrate rigidity
(See Figure 33-1.)
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Motor and Cerebellar Functions
• Cogwheeling
• Ataxia
• Romberg tests
• Finger-to-nose test
• Heel-to-shin test
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Vital Signs
• Temperature: of note are very high temps unresponsive to
antipyretics
• Pulse: increased ICP can cause tachycardias, but bradycardias
are late signs of impending herniation down the brain stem
• Respirations: can be early signs
– Snoring/stridor = airway obstruction (partial)
– Cheyne Stokes = cerebellar dysfunction
• Blood pressure: patient is usually hypertensive due to
autoregulation mechanisms. Hypotension after herniation
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Question
Which of the following might be an early indication of
increased ICP?
A. Respiratory changes
B. Widening of the pulse pressure
C. Extremely high temperature
D. Bradycardia
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Answer
A. Respiratory changes
Rationale: The brain is quick to respond to changes in
carbon dioxide, so respiratory changes would occur first.
All of the others are late signs and might indicate
herniation of the brain down the tentorium and then
brain stem.
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The 12 Cranial Nerves
• Olfactory
• Facial
• Optic
• Acoustic
• Oculomotor
• Glossopharyngeal
• Trochlear
• Vagus
• Trigeminal
• Spinal accessory
• Abducens
• Hypoglossal
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More Detailed View:
Oculomotor (CN III)
• Controls pupil size and reaction to light
• Trend pupil size in millimeters by using a chart/pupil stick
• Direct response
• Consensual response
• Accommodation
• Charting: PERRLA
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Pathological Pupils
• Large
– Fear
– Fits (seizures)
– Fast living: drug abuse
• Small
– Drugs
– Drops
– Dead (almost)
• The “blown” pupil (ipsilateral dilation)
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Question
A “blown” pupil is one that is bilaterally large but
responsive.
A. True
B. False
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Answer
B. False
Rationale: A “blown” pupil is one that is fixed and dilated
on the same side as the problem. This is caused by a
decreased blood supply from pressure exerted from the
lesion causing the increased ICP. The opposite pupil is
reactive initially but then also becomes fixed and dilated
as pressure is unrelieved.
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Eye Tests for Brain Stem Functioning
• Doll’s eyes (oculocephalic pupils)
• Caloric ice test (oculovestibular pupils)
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More Detailed View:
Acoustic (CN VIII)
• Whisper test
• Rinne
• Weber
• Otoscopic examination
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Percussion: Deep Tendon Reflexes and
Primitive and Abnormal Reflexes
• Biceps
• Babinski’s reflex
• Triceps
• Brudzinski's sign
• Brachioradialis
• Kernig’s sign
• Patellar
• Achilles
• Documentation with stick
man
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Documentation
Mental status: Well-groomed. Slightly slumped posture. Gazed at
floor throughout interview. Responds to questions. A+O x3.
Recent and remote memory intact.
Cranial nerves: Vision 20/30 in both eyes with glasses. PERRLA
at 4 mm. EOMs intact; clenches jaw, frowns, and smiles
without difficulty. Able to shrug shoulders. Tongue is midline.
Cerebellar: Finger-to-nose, heel-to-shin alternating movements
coordinated but slow. Romberg negative in bed. Cannot do
others due to bed rest status.
DTRs: Bilaterally symmetrical. Negative Babinski.
Other: Vital signs stable; 98.7-78-18 and BP 120/78.
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Neurodiagnostic Studies
• Cerebral x-rays
• Computed tomography (CT scan)
• Magnetic resonance imaging (MRI)
• Cerebral angiography
• Other studies
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Common Brain Tests
• Cerebral and spinal x-ray
– Must be done to rule out spinal cord injury in all brain AND
spinal cord problems
– MUST maintain cervical spine precautions
– Will show air in the brain
• CT scan
– With or without contrast medium
– Superior to MRI for bony disturbances
(See Figure 33-10)
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Question
A patient is scheduled for a CT with contrast for a
previously stable brain tumor. Which of the following lab
values should be brought to the physician’s attention?
A. Serum potassium 3.5–5.0 mEq/L
B. Serum sodium 145 mEq/L
C. Creatinine 3
D. BUN 30
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Answer
C. Creatinine 3
Rationale: A creatinine of 3 tells the nurse the kidney won’t
be able to excrete the contrast without help. All the other
lab values are normal and wouldn’t affect this test.
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Neurodiagnostic Tests
• MRI
– Very fine cross-sections of tissues
– Strong magnetic waves are used, so any metallic
substances contraindicate procedure
– Nurse screens for presence of pacemakers, metallic
heart valves, orthopedic pins, and fragments from
traumatic injury
• Cerebral angiography: inject dye to see vascular system
• Other tests: PET, DSSA, EEG, LP
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