Transcript Neurological Assessment File

Jane E. Binetti DNP MSN RN
 Generally
part of any overall physical
 Past Medical History
• If neuro problems are suspected:
 Avoid suggesting what the problem is
 History of the illness is important for the pt. to recall
 May not be a reliable historian
 Medications
 Surgery
or treatments
• Cancer therapies


Developmental progression
Functional ability
• ADL’s
• Falls

Generally, six primary nerve functions
are assessed:
• Mental status, cranial nerves, motor, sensory,
cerebellar function, and reflexes
 Mental
Status reflects functional ability
• General appearance
• Cognition
 A and O
 Language
 Memory
• Mood and affect
• 12 Pair
• I Olfactory
• II Optic
• III Oculomotor
• IV Trochlear
• V Trigeminal
• VI Abducens
• VII Facial
• VIII Acoustic
(vestibulocochler)
• IX Glossopharangeal
• X Vagus
• XI Spinal accessory
• XII Hypoglossal
 CN I = Olfactory
• Ability to smell
• Chronic infections and smoking decrease ability
• Aberrancy could be tumor, basilar fracture
 CN II = Optic
• Tests visual fields
• One eye at a time
• Stare at nose, while identifying peripheral objects
• Snellen Eye Chart
• Aberrancy lesions on optic nerve or anywhere it
tracks through the brain
 CN III = Oculomotor
• Constriction and accommodation
• PERRL or PERRLA
• Convergence
• Ptosis
 CN IV = Trochlear
 CN VI

= Abducens
All are tested together
• Follow a finger left/right and up/down
• Disconjugate gaze
• Nystagmus
 Oculocephalic
reflex:
• With eyelids open, turn
the head
• Normal reflex = eyes move
in opposite direction
• Abnormal = eyes move
with head
 Oculovestibular
reflex:
• Cold water test (caloric)
 V = Trigeminal Nerve
• Tested with eyes closed
• Sensory with pin
• Motor with teeth clenching
• Corneal reflex is sensory with V
 VII = Facial Nerve
• Corneal reflex is motor with VII
• Blink to threat
• Raise brows
• Shut eyes tight
• Purse lips, smile/frown
 CN VIII
= Acoustic / Vestibulocochlear
• Eyes closed, MD uses ticking watch, or whispers a
directive
• More diagnostic are:
 Weber: tuning fork for equilateral hearing
 Rinne: tuning fork for bone vs air conduction
 Audiometry (ABR)
 Typically for auditory dysfunction like vertigo or tinnitus
 CN
IX = Glossopharyngeal
• Responsible for tongue and swallowing
• Palate and uvula should rise
 CN
X = Vagus
• Responsible for pharynx, larynx, gi, cardiac, lungs
 Tested
together: both innervate the pharynx
• IX reflects sensory piece of Gag reflex
• X is motor piece causing retching
 CN XI = Accessory Nerve
• Accessory muscles
• Shrug shoulders
• Turn your head against resistance
 CN XII = Hypoglossal Nerve
• Stick your tongue out
• Midline
• Up and down
• Side to side against a
tongue blade
 Information
on bulk power of muscle, and
coordination and balance
• Resistance, grasp
• Pronator drift
• Balance and coordination
• Finger to nose testing
• Patient should normally have symmetrical
strength and motion
 Hypotonia
- flaccid
 Hypertonia - spastic
 Myoclonus – muscle spasms
 Athetosis – slow writhing movements
 Chorea – involuntary, purposeless
 Dystonia – impaired tone
 Patient
should be able to discriminate:
• Touch with eyes closed
• Sharp vs dull
• Temperature differences
• Vibration
• Positional sense
 Finger placement
 Romberg test
• Cortical sensorium
 Graphesthesia, stereognosis

Tendons attached to skeletal muscles
have receptors that will react
• Tapped with reflex hammer
• Range is 0/5 – 5/5 with 2/5 as “normal”
• Arreflexia to hyperreflexia with clonus
• Generally Biceps or Patellar reflexes are tested
 Triceps, Brachioradialis and Achilles may be used
Jane E. Binetti DNP RN

Common complaint
• Can be functional
• Often benign but can be key assessment


Causes can be intracranial and
extracranial
Not all cranial tissue is sensitive to pain

Based on diagnostic criteria:
• Primary headaches include
 Tension
 Migraine
 Cluster headaches
• Secondary headaches are caused by:
 Sinus infections
 Neck injuries
 Strokes
 Medication overuse can also cause headaches

A patient can have more than one kind

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
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
Most common headache reported
Gradual onset of band-like tightening
Not affected by activity
Episodic vs. Chronic – minutes to days
Cause
• Once thought to be head/neck muscle
contraction
• EBP suggests neurovascular
 Abnormal neuron sensitivity
 Symptoms
• No nausea, band like pressure
• Photophobia, phonophobia
• Palpable neck tension
 Diagnostics
• Patient history
 Treatment
• Typically non-opiod analgesics
• ASA or Tylenol


Usually unilateral, throbbing, recurring
headache
Typically related to trigger
• Foods
• Weather
• Stress
• Hormones
• Fatigue

Risk factors:
• Most common onset 20-30
• 17% females and 6% males in US
• Family history – most have first degree family
• Low socioeconomics
• Heavy workload
• Low education level
• Frequent tension headaches
 IHS
Sub Classifications of Migraines
• Without Aura
 Most common type
 Formally called “common” migraine
• With Aura
 Only about 10% of patients
 Formally called “classic” migraine
 Auras
are sensory signals
• Visual, auditory or motor symptoms
 Sounds, smells, patterns of light, scotomas, weakness,
sensation of movement
 Prodromes
are physical signals
• Photophobia
• Hyperactivity, irritability
• Food cravings
 Migraine
can last hours to days
 Patients withdraw to quiet, dark places
 Throbbing pain matches the pulse
 Some people are incapacitated by them,
but others work through them
 Some feel they worsen over time
 Done
by History
 Patients may keep diaries to find
triggers
 Neuro exam may be “normal”
• Diagnostic tests may not show anything
 CT
and MRI are not routine
• Variation of usual symptoms may be cause for
secondary causes to be ruled out
 Mild:
• Non opioids usually work well
 ASA
 Acetaminophen
 Ibuprofen
 Combination meds with caffeine
• Other behavioral therapies
 Moderate
to severe:
• Triptans are first line therapy
• Reduce neurogenic inflammation of vessels
 Cause vasoconstriction
• Best taken preemptively at onset
 Sumatriptan (Imitrex)
 Rizatriptan (Maxalt)
 Zolmitriptan (Zomig)
 Sumatriptan/Naproxen (Treximet) combination
• Watch your cardiac patients! - vasoconstriction
 Topiramate (Topamax)
• Antiseizure drug taken daily as preventative
• Can cause seizures if stopped abruptly
• Push fluids to avoid calculi
• Can cause drowsiness
 Beta adrenergic blockers:
• Propranolol (Inderal)
• Atenolol (Tenormin)
 Alpha adrenergic blockers:
• Ergotamine (Ergomar)
• Dihydroergotamine (DHE)
 Analgesic/Anti-inflammatory
• Cambia (Diclofenac)
 Analgesic
combinations
• Fiorinal (Butalbital/Aspirin/Caffeine)
• Fioricet (Butalbital/Acetaminophen/Caffeine)
 Corticosteroids
• Dexamethasone (Decadron)
 Tricyclics
 SSRIs
 Alpha
and Beta adrenergic blockers
 Anti-seizure meds
 Ca channel blockers
 Biofeedback
 Relaxation
 Cognitive behavioral therapy
 Rare
headache ~ 0.1% of population
 Exacerbate and remit
 Cause:
• Not clearly known
 Triggers: ETOH, weather, odors
• Trigeminal nerve
• Dysfunction of intracranial vessels
• Sympathetic nervous system
• ? hypothalamus
A
pt complaining of sharp, stabbing pain
 Lasts minutes to hours
 Many a day/many days
 Cluster is weeks to months long
• Sharp head pain:
eye, forehead, cheek
• Tearing, swelling,
pallor, flushing even
ptosis
 Primarily
by History
 Keeping a diary is helpful
 Other tests done to rule out a more
significant cause:
• CT, MRI, MRA, LP
• R/O tumor, aneurysm, infection, neuro disease
 Clusters
often happen suddenly at night
and are brief, meds are little help
• Hi flow O2 is helpful
 100% at 6-8L for 10 minutes
 Can repeat after 5 minute breaks
 Pt at home would need O2 supply
 Triptans
can be useful
 Prohylactic tx:
• Verapamil, lithium, ergotamine, NSAIDS
• Intranasal lidocaine spray
 For
refractory Cluster Headaches:
• Nerve blocks
• Ablation
• Percutaneous radiofrequency
• Deep brain stimulation
• Overuse of
analgesics or any
meds used for tx can
cause rebound
• Avoidance of overuse
and ensuring slow
withdrawal is helpful
• Avoidance of triggers
•Hunger
•Fatigue
 Help
pts:
• With life style changes, diet, smoking
• Relaxation/distraction/meditation/yoga
• Identify and avoid triggers
• Management
 Early identification
 Compliance with treatment
 Stress management