assessment of neurological function michelle gardner rn, msn
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ASSESSMENT OF NEUROLOGICAL FUNCTIONMICHELLE GARDNER RN, MSN
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
NEUROLOGIC OVERVIEW• Central nervous system (CNS) - brain and spinal cord
• Peripheral nervous system - cranial/spinal nerves - autonomic nervous system
• Basic functional unit neuron
Function of the Nervous System
•Control all motor, sensory, autonomic, cognitive, and
behavioral activities
NEURON
NEUROTRANSMITTERS
Central Nervous System The Braincerebrumbrain stemcerebellum
Protective Structures
Spinal Cord
Peripheral Nervous System
Include •Cranial nerves•Spinal nerves•Autonomic nervous system
CRANIAL NERVES
Dermatome Distribution
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
Neurological Assessment
Health history•History of the present illness-DETAILS•Review the medical records• Input from witness/family member
Neurological Assessment
Common symptoms• Pain• Seizures• Dizziness/vertigo• Visual disturbances• Muscle weakness• Abnormal sensations
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
CT scan
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
Magnetic Resonance Imaging
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
Electroencephalography -EEG
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.
Cerebral Angiography
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
Electromyography
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.
Lumbar Puncture
Lumber PunctureCerebrospinal 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
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
Altered LOC -• Altered LOC is not a disorder but the result
of a pathology • Full consciousness
• Confusion
• Disorientation
• Obtundation
• Coma
PathophysiologyA-E-I-O-U =• Alcohol, Epilepsy, Insulin, Opium, Uremia
TIPSS =• Tumor, Injury, Psychiatric, Stroke, Sepsis
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
POSTURING
Decorticate Posturing Decerebrate Posturing
Interdisciplinary Care
• Must begin immediatelyFocus• identify the underlying cause• preserve function• prevent deterioration
Diagnostic Procedures• CT scan/MRI • EEG • Cerebral angiography
• Laboratory tests - blood glucose - electrolytes - ABG - liver function test - toxicology screening
Potential Complications• Respiratory distress or failure• Pneumonia• Aspiration• Pressure ulcer• Deep vein thrombosis (DVT)• Contractures
Ineffective Airway Clearance
• Assess/monitor• Positioning to prevent obstruction of upper airway—HOB elevated 30°• Suctioning, and CPT• Monitor ABG analysis
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
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
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
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.
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
Increased Intracranial Pressure• Sustained elevated pressure within the cranial cavity• Caused by – head trauma, tumors stroke hemorrhage infection *cerebral edema
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.
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)
Increased Intracranial Pressure
Clinical Manifestations• Early sign – change in LOC•Motor responses•Vision & pupils•Vital signs•Other
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
Brain with intracranial shifts
Increased Intracranial Pressure
Diagnostic studies • CT scan/MRI• Serum Osmolality• ABG’s
Increased Intracranial Pressure
Complications• Brain stem herniation• Diabetes inisipidus• Syndrome of inappropriate antidiuretic hormone (SIADH)
Complications
Brain Stem Herniation• Displacement of brain tissue from its normal compartment presses down on the brain stem.• results in cessation of blood flow to the brain irreversible brain anoxia and brain death • Lethal complications of IICP
Complications
Diabetes Insipidus• decreased secretion of antidiuretic hormone (ADH)• S/S excessive urine output, decrease urine osmolality• treatment administer fluids, replace electrolytes, vasopressin therapy – desmopressin (DDAVP)
ComplicationsSyndrome of inappropriate antidiuretic hormone (SIADH)• increased secretion of ADH• S/S – volume overload, diminished urine output, serum sodium concentration decreased• treatment – fluid restriction (< 800mL/day – with no free water)
Increased Intracranial Pressure
Medical Management• Goal to relieve the increased ICP, decrease
cerebral edema, lower the volume of CSF or decrease cerebral blood volume
• Medication• ICP monitoring
Medication
Osmotic Diuretics• Mannitol (Osmitrol)
Loop diuretics• Furosemide (Lasix)
Other• Neuromuscular blocking agents• Antipyretics• Antihypertensive• Antiulcer
ICP Monitoring
Continuously assess ICP, the effects of medical therapy and nursing interventions• Identify increased pressure early on before
cerebral damage occurs.• ICP monitoring can be done with the use of: - intraventricular catheter - subarachnoid screw/bolt - epidural probe • Insertion and care of any ICP monitoring
device requires surgical aseptic technique – to reduce the risk of infection
ICP Monitoring
ICP Monitoring
Nursing Diagnosis/Interventions
Assessment• History of events leading up to the present illness• Pertinent medical history• Neurologic examination - evaluation of mental status - cranial nerve function - monitoring of vital signs - reflexes - sensory/motor function
Ineffective Tissue Perfusion - Cerebral
• Assess for and report manifestations of IICP• Monitor if patient on ventilator• Monitor ABG’s • Teach patient at risk - interventions to avoid• Monitor bladder distention and bowel
constipation• Plan/schedule nursing care• Provide quiet environment• Maintain fluid restriction
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