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NEUROLOGIC EXAMINATION
HEALTH HISTORY
• History of Present IllnessImportant aspect of neurologic
assessment• Initial Interview Provides an excellent opportunity to
systematically explore the patient’s current condition and related eventswhile observing the: Overall appearance Mental status Posture Movement Affect
HEALTH HISTORY
Depending on the patients condition, the nurse may rely on:
YES or NO answer Review of Medical Records Input from Family
HEALTH HISTORY INCLUDES:• Onset, character, severity, location duration
and frequency of signs and symptoms.• Complaints• Precipitating, aggravating and relieving
factors• Progression, remission and exacerbation• Presence or absence of similar signs and
symptoms among family members• History of genetic disease
HEALTH HISTORY
Review of medical history including the system-by-system evaluation is part of the nursing history.
The nurse should be aware of history of trauma or falls that may have involved the head or spinal injury.
Questions about the use of alcohol, medications and illicit drugs are also relevant.
PHYSICAL ASSESSMENT
General Observation of the client:a. Posture, gait, coordination: perform
Romberg testb. Personal hygiene and groomingc. Evaluate speech and ability to
communicate1. Pace of speech: rapid, slow, halting2. Clarity: slurred or distinct3. Tone: high-pitched, rough4. Vocabulary: appropriate choice of words
*** Facial features may suggest specific syndromes in children
PHYSICAL ASSESSMENTMental Status
a. General appearance and behavior
b. Level of consciousness1. Oriented to person, place and time2. Appropriate response to verbal and tactile
stimuli3. Memory, problem solving abilities.
c. Moodd. Thought content & intellectual
capacity
PHYSICAL ASSESSMENT
Assess Pupillary Status and Eye movementa. Size of pupils should be equalb. Reaction of pupils
a. Accommodation: pupillary constriction to accommodate near vision
b. Direct light reflex: constriction of pupil when light is shone directly into the eye
c. Consensual reflex: constriction of the pupil in the opposite eye when the direct light reflex is tested.
c. Evaluate ability to move eyea. Note nystagmusb. Ability of eyes to move togetherc. Resting position of iris should be at mid-position
of the eye socketd. PERRLA
Clinical ManifestationThe clinical manifestation of neurologic disease are as varied as the disease processes themselves. Symptoms may be:• Varied or intense• Fluctuating or permanent• Inconvenient or devastating
PAINSEIZURESDIZZINESS a nd VERTIGOVISUAL DISTURBANCESWEAKNESSABNORMALSENSATION
Clinical ManifestationsPAIN• unpleasant sensory perception & emotional• experience associated with actual or
potential tissue damage- Subjective- Acute > lasts shorter & remits as pathology resolves
> trigeminal neuralgia, spinal disk disease - Chronic or persistent > Lasts longer than 6 months > degenerative and chronic neurologic cond.
Clinical ManifestationsSEIZURES- Are the result of abnormal paroxysmal
discharges in the cerebral cortex, which manifests as alteration in sensation, perception, movement or consciousness
- May be long or short - The type of seizure activity is a direct
result of the brain affected.- May be a first obvious sign of brain
lesion
Clinical ManifestationsDIZZINESS AND VERTIGO- Dizziness is an abnormal sensation of
imbalance or movement. - Variety of causes: viral syndrome, hot
weather, roller coaster rides, middle ear infections
- About 50% of patients with dizziness have vertigo (illusion of movement usually rotation).
- Vertigo is a manifestation of vestibular dysfunction
Clinical ManifestationsVISUAL DISTURBANCESVisual defects that cause people to seek
health care can range from decreased visual acuity associated with aging to sudden blindness caused by glaucoma
Normal vision depends on :- functioning visual pathways thought the retina and optic chiasm - radiations into the visual cortex in the occipital lobes
Clinical Manifestations
WEAKNESS- common manifestation of neurologic
disease (muscle weakness)- Coexists with other symptoms and can
affect variety of muscles causing disability
- Can be sudden or permanent or progressive
Clinical Manifestations
ABNORMAL SENSATION- Numbness, loss of sensation or
abnormal sensation is a neurologic manifestation of both cerebral and peripheral nervous system disease
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- Usually associated with pain or weakness and is potentially disabling
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- Both numbness and weakness can significantly affect balance and coordination
PHYSICAL EXAMINATION• The brain and the spinal cord cannot be
examined directly as other body systems• Neurologic examination is an indirect
evaluation that assesses the function of specific body part controlled
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5 COMPONTENTS OF NEURO ASSESSMENT
(1) Cerebral function(2) Cranial Nerves(3) Motor system(4) Sensory System(5) Reflexes
Assessing Cerebral Function
Cerebral abnormalities may cause:
- disturbance in mental status
- Intellectual function
- Thought content
- Pattern of emotional behavior
- Alteration in perception, motor and language ability
- Lifestyle change/s
Assessing Cerebral Function
• Should be specific and non-judgemental• Avoid using the terms
“inappropriate” or “demented”
• Specific records on observations regarding orientation, level of consciouness, emotional state or thought content
Assessing the Mental Status
• Observe patient’s appearance & behavior
• Note dress, grooming & personal hygiene
• Posture, gesture, movements, facial expression & motor activity
• Assess manner of speech & level of consciousness
• Assess orientation to time, place & person
Intellectual Function
A person with an average IQ can:a. Recite 5 digits backwardsb. Serial 7’s (Subtract 7 from 100,
then 7 from that, and so forth)• Interpret proverbs• Ability to recognize similarities• Situational analysis
Thought ContentDuring the interview, it is important toassess the patient’s thought content.• Are the patient’s thought…
Spontaneous Natural Clear Relevant Coherentf
• Unusual thoughts like… hallucinations, preoccupation with death and morbid events, paranoid ideation requires further evaluation
Emotional Status
• Is the patient’s affect natural or even?• Does his or her mood fluctuate
normally?• Are verbal communications consistent
with nonverbal cues?
Perception
The examiner may consider more specific areas of higher cortical function
• Agnosia - inability to recognize objects seen through the special senses– a patient may see a pencil but knows not what to do with
it or what it’s called
• Screening for visual and tactile agnosia provides insight into the patient’s cortical interpretation ability– Placing a familiar object (key) in the patient’s hand, have him
identify it with eyes closed
Language Ability• A person with normal neurologic function
can understand and communicate in spoken and written language.
• Aphasia is a deficiency in language function Type of Aphasia Brain area involved
Auditory-receptive Temporal Lobe
Visual-receptive Parietal-occipital lobe
Expressive speaking Inferior posterior frontal areas
Expressive writing Posterior frontal area
Motor Ability
• Ask the patient to perform a skilled act (throw a ball, move a chair)
• Performance requires
=> the ability to understand the activity desired and normal motor strength
• Failure signals cerebral dysfunction
ASSESSING THE ASSESSING THE CRANIAL NERVESCRANIAL NERVES
CRANIAL NERVESCRANIAL NERVESOn OldOlympus Towering Tops A Finn And German Viewed Some Hops
Olfactory (I)Optic (II)Occulamotor (III) Trochlear (IV)Trigemenal (V)Abducens (VI)Facial (VII)Acoustic (VIII)Glossopharyngeal (IX)Vagus (X)Spinal Accessory (XI)Hypoglossal (XII)
M SM MM/S M M/S S M/S M/S M M
Cranial Nerve I - Olfactory Nerve Before testing nerve function, ensure
patency of each nostril by occluding in turn and asking patient to sniff
Once patency is established, ask patient to close eyes
Occlude one nostril and hold aromatic substance (coffee) beneath nose
Ask patient to identify substance Repeat with other nostril
Cranial Nerve I - OlfactoryNormal:
■ Patient is able to identify substance.
(Bear in mind that some substances may be unfamiliar, especially to children)
Abnormal:■ Anosmia - loss of sense
of smell. • May be inherited and non-
pathological: chronic rhinitis, sinusitis, heavy smoking, zinc deficiency, or cocaine use.
• It may also indicate cranial nerve damage from facial fractures or head injuries, disorders of base of frontal lobe such as a tumor, or artherosclerotic changes.
Cranial Nerve II - Optic Nerve
Use the snellen chart to check/test:- distant vision- color
Client should be 20 feet distant from the chartUse an object to occlude one eyeEvaluate the vision one eye at a time
Testing eye movements
Testing pupil accommodation
Cranial Nerves III, IV and VI
=> Test for ocular rotations,
conjugate movements, nystagmus** Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis
- using direct & consensual pupillary reaction to light
Normal:■ Able to read without
difficulty■ Visual acuity intact
20/20, both eyesHippus phenomenon:
Brisk constriction of pupils in reaction to light, followed by dilation and constriction
- may be normal or sign of early CN III compression.
Abnormal:
■ CN II deficits - can occur with stroke or brain tumor.
■ Changes in pupillary reactions - can signal CN III deficits.
■ Increased ICP causes changes in pupillary reactionAs pressure increases, response becomes more sluggish until pupils finally become fixed and dilated.
CN V - Trigeminal Nerve
a. Testing motor function: - Ask patient to move jaw from side to side against resistance and then clench jaw as you palpate contraction of temporal and masseter muscles, or to bite down on a tongue blade.
Testing CN V – sensory function
CN V - Trigeminal Nerveb. Testing sensory function:
- Ask patient to close eyes- Touch the face with the wisp of cotton- Instruct to tell you when he or she feels sensation on the face. - Repeat the test using sharp and dull stimuli (toothpick or tongue blade)
- Instruct to say “Sharp” or “Dull”(Be random, don’t establish a pattern)
Testing corneal reflex
Cranial Nerve V - Trigeminal Nerve
c. Testing corneal reflex: - Gently touch cornea with cotton wisp. o Touching cornea can cause
abrasions.oAlternative approach is to: > puff air across cornea with a needless
syringe, or > gently touch eyelash
and look for blink reflex
Cont. CN V
Normal: Full range of motion
(ROM) in jaw and 15 strength.
Patient perceives light touch and superficial pain bilaterally
Abnormal: Weak or absent contraction
unilaterally: - Lesion of nerve, cervical spine,
or brainstem
Inability to perceive light touch and superficial pain
- may indicate peripheral nerve damage.
■ Trigeminal Neuralgia:- Neuralgic pain of CN V caused
by the pressure of degeneration of a nerve
■ Corneal reflex test used in patients with decreased LOC
- to evaluate integrity of brainstem.
Testing CN VII – motor function
Cranial Nerve VII - Facial Nerve
a. Testing motor function: - Ask patient to perform these movements: smile, frown, raise eyebrows, show upper teeth, show lower teeth, puff out cheeks, purse lips, close eyes tightly while nurse tries to open them.
- Observe face for flaccid paralysis
Testing taste sensation
Cranial Nerve VII - Facial Nerve
b. Testing sensory function:
• - Test taste on anterior two-thirds of tongue for sweet, sour, salty.
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Sweet: Tip of the tongue
Sour: Sides of back half of tongue
Salty: Anterior sides and tip of tongue
Bitter: Back of tongue
CN VII - Facial Nerve
Normal:• Facial nerve intact• Able to make faces.
• Taste sensation on anterior tongue intact.
• (Taste decreased in older adults.)
Abnormal:Asymmetrical or impaired
movement: - Nerve damage, such as
that caused by Bell’s palsy or stroke.
Impaired taste/loss of taste:
- Damage to facial nerve, chemotherapy or radiation therapy to head and neck.
Watch tick test
Cranial Nerve VIII - Acoustic Nerve
a. Perform Weber and Rinne tests for hearingb. Perform watch-tick test by holding watch close
to patient’s ear.
c. Perform Romberg test for balance- Nurse at the back or side of the pt.- Instruct client to stand straight, feet together, hands at the side and eyes closed.
(Evaluates the balancing function of the CN VIII)
Cranial Nerve VIII - Acoustic Nerve
Normal: Hearing intact. Negative
Romberg test.
Abnormal: Hearing loss,
nystagmus, balance disturbance, dizziness/vertigo: - Acoustic nerve damage.
■ Nystagmus: - CN VIII, brainstem, or cerebellum problem or phenytoin (Dilantin) toxicity.
Testing CN IX and X – motor function
Cranial Nerves IX and X Glossopharyngeal & Vagus Nerves
a. Observe ability to cough, swallow, and talk.
b. Test motor function: - Ask patient to open mouth and say “ah”
while you depress the tongue with a tongue blade. - Observe soft palate and uvula.
- Soft palate and uvula should rise medially.
CN IX and X
c. Test sensory function of CN IX and motor function of CN X by stimulating gag reflex.
Tell patient that you are going to touch interior throat
Then lightly touch tip of tongue blade to posterior pharyngeal wall.
Observe the pharyngeal movement.
Ask the client to drink a small amount of water*Note the ease & difficulty of swallowing*Note quality of the voice or hoarseness
when speaking
CN IX and XNormal: Swallow and cough
reflex intact.
Speech clear.
Elevation and constriction of pharyngeal musculature and tongue retraction indicate positive gag reflex
Abnormal: Unilateral movement:
Contralateral nerve damage.- Damage to CNs IX and X also
impairs swallowing.
■ Changes in voice quality (e.g., hoarseness): CN X damage.
■ Diminished/absent gag reflex: Nerve damage
- Risk for aspiration
■ Impaired taste on posterior portion of tongue: Problem with CN IX
CN XI - Spinal Accessory Nerve
a. Test motor function of shoulder and neck muscles:
=> Ask patient to shrug shoulders upward against your resistance. (Trapieze muscle)
=> Then ask her or him to turn head from side to side against your resistance. (Strenoclaidomastoid muscle)
**Observe for symmetry of contraction and muscle strength.
Cranial Nerve XINormal: Movement
symmetrical, with patient moving against resistance without pain.
■ Full ROM of neck with +5/5 strength.
Abnormal: Asymmetrical Diminished Absent movement Pain unilateral or bilateral
weakness: Peripheral nerve CN XI damage.
Testing CN XII – motor function
CN XII - Hypoglossal Nerve
a. Have patient say “d, l, n, t” or a phrase containing these letters. - The ability to say these letters requires use of the tongue.
b. Ask the patient to protrude the tongue. Observe any deviation from midline, tumors, lesions, or atrophy.
c. Now ask the patient to move the tongue from side to side.
Normal: Can protrude
tongue medially.
No atrophy, tumors, or lesions.
Abnormal:Asymmetrical/diminished/absent movement/deviation from midline/protruded tongue: - Peripheral nerve CN XII damage.
■ Tongue paralysis results in dysarthria.
Examining the Motor System• Assessing the patient’s ability to flex or
extend the extremities against resistance tests muscle strength.
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• The evaluation of muscle strength compares the sides of the body with each other
• This way, subtle differences in muscle strength can easily be detected and described.
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MUSCLE STRENGTH• Muscle tone (tension present in a
muscle at rest) is evaluated by palpation
• Abnormalities in tone include:– Spasticity (increased muscle tone)– Rigidity (resistance to passive strength) – Flaccidity
British Medical CouncilMethod of Scoring
Balance and Coordination• Cerebellar influence on the motor system is
reflected in balance and coordination.
• Coordination of the hands and extremities is tested by:– Rapid, alternating movements
– POINT TO POINT TESTING
Balance and Coordiantiona. Rapid Alternating Movements (RAM)
Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the knees with the backs of the hands.Then ask to do this faster.
Normal: done with equal turning
and quick rhythmic pace
Abnormal:Lack of coordinationDysdiadochokinesia- Slow, clumsy, and sloppy response - occurs with cerebellar disease
The patient is asked to pronate and supinate the hands as rapid as possible
b. Finger-to-Finger testWith the persons eyes open, ask that he or she use index finger to touch your finger, then his or her own nose.After a few times move your finger to a different spot.
Normal: Movement is smooth
and accurate
Abnormal:Dysmetria
- clumsy movement with overshooting the mark
- occurs with cerebellar disorderPast-pointing
- constant deviation to one side
Balance and Coordination• Coordination in the lower extremities is
tested by having the patient run heel down the anterior surface of the tibia of the other leg. Each leg is tested
• Ataxia is incoordination of voluntary muscle groups in action
• Tremors are rhythmic, involuntary movements=>The presence of these movements suggests
cerebellar disease
• When abnormality is observed, a thorough examination is indicated
Balance and CoordinationThe cerebellum is responsible for balance and coordination.
Romberg’s Test - screening test for balance- the pt stands with feet together
and arms at the side, first with eyes open and eyes closed for 20 to 30 secs
- slight sway is normal but loss of balance is abnormal and
considered (+) Romberg rest
Normal: Negative Romberg
test
Abnormal:Sways, falls, widens base of feet to avoid falling
Positive Romberg sign -Loss of balance that occurs when closing the eyes.
-Occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication)
-Loss of proprioception, and loss of vestibular function
Perform Tandem Walking- ask the person to walk a straight line in a heel-to-toe fashion.
- This decreases the base of support and will accentuate any
problem with coordination.
Normal:
Person can walk straight
& stay balanced
Abnormal:Crooked line walkWidens base to maintain balanceStaggering, reeling, loss of balanceAn ataxia that did not appear now.
Inability to tandem walk is sensitive for an upper motor neuron lesion, such as multiple sclerosis.
Hopping in place, alternating knee bends (some individuals cannot hop owing to aging or obesity)
Examining the Reflexes• Motor reflex are involuntary contraction of
muscles or muscle groups in response to abrupt stretching near the site of muscle insertion
• Technique: A reflex hammer is used to elicit a deep tendon reflex.
• The tendon is struck briskly, and the response is compared with the opposite side of the body (right and left)
• The response should be equal
Examining the Reflexes
GRADING the REFLEXES
• The absence of reflex is significant, although ankle jerks (achilles reflex) may be absent on older people.
• Some uses the terms: – PRESENT – ABSENT– DIMINISHED
REFLEXESDocumenting Reflex Findings
• Use these grading scales to rate the strength of each reflex in a deep tendon and superficial reflex assessment.
Deep tendon reflex grades0 absent+ present but diminished+ + normal+ + + increased but not necessarily pathologic+ + + + hyperactive or clonic (involuntary contractionand relaxation of skeletal muscle)
Deep tendon reflex grades0 absent+ present but diminished+ + normal+ + + increased but not necessarily pathologic+ + + + hyperactive or clonic (involuntary contractionand relaxation of skeletal muscle)
Superficial reflex grades0 absent+ present
Superficial reflex grades0 absent+ present
• Documentation of reflex finding
ASSESSING REFLEXESBiceps Reflex
- is elicited by striking the biceps tendon of the flexed elbow.- the examiner supports the forearm with one arm while placing the thumb against the tendon and striking the thumb with the reflex hammer.
Normal:■ Flexion at the elbow and
contraction of the biceps
ASSESSING REFLEXESb. Triceps Reflex- flex pt’s arm to 90° angle and
positioned in front of the chest
■ Abduct patient’s arm and flex it at the elbow.■ Support the arm with your non-dominant hand.■ Identify triceps tendon by
palpating 2.5 to 5cm (1-2 in) above the elbow
Normal:■ Contraction of triceps with
extension at elbow
ASSESSING REFLEXES
c. Patellar Reflex■ Have patient sit with legs dangling.■ Strike tendon directly below patella.
Normal:■ Contraction of quadriceps with extension of knee.
ASSESSING REFLEXESd. Ankle Reflex
- Achilles reflex- foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon
Normal:■ Plantar flexion of foot.
ASSESSING REFLEXESe. Test for Clonus• When reflexes are very hyperactive, a
phenomenon called clonus may be elicited• If a foot is abruptly dorsiflexed, it may
continue to “beat” two to three times before it settles into a position of rest
• The presence of clonus always indicates the presence of CNS disease and requires further evaluation
Normal:■ No contraction
F. Superficial Reflexes
Abdominal Reflex■ Stroke patient’s abdomen diagonally from upper and lower quadrants toward umbilicus.■ Contraction of rectus abdominis. Umbilicus moves toward stimulus.
Perianal Reflex■ Gently stroke skin around anus with gloved finger.Normal:■ Anus puckers.
Cremasteric Reflex■ Gently stroke inner aspect of a male’s thigh.Normal:■ Testes rise.
Bulbocavernosus Reflex■ Gently apply pressure over bulbocavernous muscle on dorsal side of penis.Normal:■ Bulbocavernosus muscle contracts.
ASSESSING REFLEXES
BABINSKI REFLEX■ Stroke sole of patient’s foot in an arc
from lateral heel to medial ball. • Fanning of toes when stroked laterally• Normal in newborn (found until 16 – 24 mos)
• Indicates CNS disease of motor system
Normal:■ Flexion of all toes.
SENSORY EXAMINATION• Highly subjective & requires cooperation of the pt• The examiner should be familiar with dermatomes • Most sensory deficits results from peripheral
neuropathy and follow anatomic dermatomes
Assessment involves:• Tactile sensation• Superficial pain• Vibration• Position sense
** during assessment, pt eyes are kept closed
SENSORY EXAMINATION Tactile Sensation or Light Touch
- Brush a light stimulus such as a cotton wisp over patient’s skin in several locations, including torso and extremities.
Normal: Identifies areas
stimulated by light touch.
Abnormal:Hypesthesia: diminished capacity for physical sensation (esp. skin)
■ Hyperesthesia: Increased sensitivity
■ Paresthesia: Numbness & tingling
■ Anesthesia: Loss of sensation.
PAIN and TEMPERATURE- Stimulate skin lightly with sharp and dull ends of
toothpick/ paper clip- Apply stimuli randomly and ask patient to identify
whether sensation is sharp or dull.
- Touch patient’s skin with test tubes filled with hot or cold water.
- Apply stimuli randomly, and ask patient to identify whether sensation is hot or cold.
Sensory ExaminationVIBRATION and PROPRIOCEPTION- Place a vibrating tuning fork over a finger
joint, and then over a toe joint.- Ask patient to tell you when vibration is felt
and when it stops.- If patient is unable to detect vibration, test
proximal areas as well.
Sensory Examination
Normal: Vibratory
sensation intact bilaterally in upper and lower extremities.
Abnormal: Diminished/absent
vibration sense:
- Peripheral nerve damage caused by alcoholism, diabetes, or damage to posterior column of spinal cord.
StereognosisWith patient’s eyes closed, place a familiar object, such as a coin or a button, in patient’s hand, and ask patient to identify it.■ Test both hands using different objects.
Normal: Stereognosis
intact bilaterally.
Abnormal:■ Abnormal findings suggest a lesion or other disorder involving sensory cortex or a disorder affecting posteriorcolumn.
Sensory Extinction■ Simultaneously touch both sides of patient’s
body at same point.■ Ask patient to point to where she or he was
touched.
Normal: Extinction intact.
Abnormal:Identification of stimulus on only one side suggests lesion or other disorder involving sensory cortical region in opposite hemisphere.
AssessingLevel of Consciousness
Level of Consciousness (LOC) – arousal; awareness of self or environmentd
Alert – fully awake; appropriate responses to external and internal stimuli; oriented to person, place and times
Lethargic – somnolent, drowsy, listless, indifferent to surroundings, very sleepy, can be aroused from sleep but when stimulation ceases, falls back to sleep; may be oriented or confused d
Stuporous – unconscious most of the time but makes spontaneous movements and response is evoked only by a strong, continuous, noxious stimuli; loud noises or sounds, bright light, pressure to sternum, response is usually a purposeful attempt to remove the stimulusf
Comatose – absence of voluntary response to stimuli including painful stimuli; no response, no eye opening – score of 7 or less on GCS
Glasgow Coma Scale- A standardized objective assessment that
defines the LOC by giving it a numeric value.
- Most often after brain surgery
- Document as E_V_M_; for example, E4V5M6.
•The three numbers are added; the total score reflects the brain functional level.
•A fully awake person = 15
•Coma = 7 or less
•The GCS assesses the functional state of the brain as a
whole, not of any particular site in the brain. (Juarez and Lyon,1995)
Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)
a. Test orientation to time, place, and person
ASSESSING LEVEL OF CONSCIOUSNESS
Normal: Awake, alert, and
oriented to time, place, and person (AAO x 3)
Responds to external stimuli
Abnormal: Disorientation may be
physical in origin Disorientation can also
be psychiatric in origin (schizophrenia)
Lathargic or somnolent Obtunded Stupor Coma
Abnormal FindingsAbnormalities in Muscle Movement
Paralysis• Loss or impairment of the ability to move a body part,
usually as a result of damage to its nerve supply. • Loss of sensation over a region of the body.
Hemiplegia paralysis of one side of the bodyParaplegia paralysis of both lower limbs due to spinal disease or injury Quadriplegia paralysis of all four limbs or of the entire body below the neck Paresis partial motor paralysis
Abnormal FindingsAbnormalities in Muscle Movement
FasciculationsRapid, continuous twitching of resting
muscle
Abnormal FindingsAbnormalities in Muscle Movement
TicRepetitive twitching of a muscle group
Abnormal FindingsAbnormalities in Muscle Movement
MyoclonusRapid, sudden jerk at a fairly regular
intervals
Abnormal FindingsAbnormalities in Muscle Movement
TremorInvoluntary contraction of opposing muscle
groups• Rest tremor• Intention tremor
Abnormal FindingsAbnormalities in Muscle Movement
ChoreaSudden, rapid, jerky,
purposeless movement involving limbs, trunk, or face
Abnormal FindingsAbnormalities in Muscle Movement
Athetosis
Slow, twisting, writhing, continuous movement, resembling a snake or worm
Neurologic Exam: Meningeal signsBrudzinski’s sign - neck stiffness- involuntary flexion of hips and knees when flexing neck is positive sign for
meningeal irritation
Neurologic Exam: Meningeal signsPositive Kernig’s sign-excessive pain in the lower back when examiner attempts to straighten knees with client supine and knees and hips flexed
Neurologic Exam: Meningeal
Decorticate posturing (up)
Decorticate posturing (down)
DIAGNOSTIC EVALUATION
Computed Tomography Scan• Makes use of narrow x-ray beam to scan body part
in successive layers• Images provide cross-sectional views of the brain
displayed on an oscilloscope or TV monitor and is photographed and stored digitally
• Non-invasive and painless and has high degree in detecting brain lesions
Nursing Intervention:• Teach patient about the need to lie quietly
throughout the entire procedure• Assess for iodine/shellfish allergy• Monitor for side effect of IV or inhalation contrast
agents: flushing, nausea, vomiting
CT SCAN
Positron Emission Tomography (PET)- Computer based nuclear imaging that produces
images of actual organ functioning.- Radioactive gas or substance is inhaled or
injected that emits positively charged particles.- It permits measurement of blood flow, tissue
composition, brain metabolism thus evaluates brain function.
- Useful in showing metabolic changes in the brain (Alzheimer’s disease), locating lesions (tumor, epiliptogenic lesions), identifying blood flow and oxygen metabolism in stroke pt and new therapies for brain tumor.
Positron Emission Tomography (PET)• Key nursing interventions include patient
preparation, which involves explaining the test and teaching the patient about inhalation techniques and the sensations (dizziness, light-headedness, headache) may occur.
• IV injection of radioactive substance produces similar side effects.
• Relaxation exercises may reduce anxiety during the test.
PET Scan
Single Photon Emission Computed Tomography (SPECT)
• 3D imaging technique that uses radionuclides and instruments to detect single photons.
• Perfusion study that captures cerebral blood flow at time of injection of radionuclide.
• SPECT is useful in detecting extent & location of perfused areas of the brain, allowing detection, localization and sizing of stroke, detecting tumor progression and evaluation of perfusion before and after neurosurgical procedures.
Single Photon Emission Computed Tomography (SPECT)
Nursing Intervention• Preparation and monitoring• Observe for allegeric reaction. • Pregnancy and breastfeeding are
contraindications.
Magnetic Resonance Imaging (MRI)
• Uses a powerful magnetic field to obtain images of different areas of the body
• Can identify cerebral abnormality earlier and more clearly than any other diagnostic tests
• Useful in monitoring tumor’s response to treatment, Dx of MS
Nursing Intervention: MRI
• Relaxation techniques• Advise pt that she can speak with the staff by
means of a microphone inside the scanner• ALL metal objects and magnetic cards are
removed (aneurysm clips, ortho-hardware, pacemakers, artificial heart valves, IUD)
• Medication patches removed (cause burns)• Sedation for claustrophobic pt• Scanning process is painless, but the patient
hears loud thumping of magnetic coils as magnetic field is being pulsed.
Myelography Myelogram is an Xray of spinal subarachnoid space
taken with contrast agent (through Lumbar Tap) Shows distortion of spinal cord or spinal dural sac
caused by tumors, cysts, herniated vertebral disks
Nursing Intervention• Meal before procedure is omited• After myelography, patient to lie in bed with head
elevated up to 45º and remain in bed for 3hrs• Encourage increased fluid intake• Monitor VS
MyelographyMyelography
CEREBRAL ANGIOGRAPHY
• X-ray study of the cerebral circulation with contrast agent injected to selected artery.
• Performed by threading a catheter through the femoral artery in the groin and up to the desired vessel.
Uses:Uses: Vascular disease, aneurysms, AVM
Digital Subtraction Angiography- X-ray images of areas in question are taken before and
after injection of contrast agent (peripheral vein) and then compared
CEREBRAL ANGIOGRAMCEREBRAL ANGIOGRAM
Nursing Intervention: CEREBRAL ANGIOGRAPHYNURSING CARE PRE-TEST1.) Check allergy to iodine2.) Keep NPO after midnight or offer clear liquid breakfast only3.) Explain that the client may have warm, flushed feeling and salty taste in
mouth during procedure4.) Take baseline vital signs and neuro check 5.) Administer sedation if ordered
NURSING CARE POST-TEST1.) Maintain pressure dressing over site if femoral or brachial artery used;
apply ice as ordered2.) Maintain bed rest until next morning as ordered3.) Monitor vital signs, neuro checks frequently; report any changes
immediately4.) Check site frequently for bleeding or hematoma; if carotid artery used;
assess for swelling of neck, difficulty swallowing or breathing5.) Check pulse, color, and temperature of extremity distal to site used.6.) Keep extremity extended and avoid flexion
Non-invasive Carotid Flow Studies
• Uses ultrasound and doppler measurements of arterial blood flow to evaluate carotid and deep orbital circulation.
• The graph produced indicates blood velocity.( velocity = stenosis or partial obstruction)
Carotid doppler permits evaluation ofCarotid ultrasonography arterial blood flow andOculoplethysmography detection of atrial Opthalmodensinometry stenosis, occlusion
andplaques
Transcranial Doppler
• Uses the same noninvasive techniques as Carotid flow studies except it records blood flow velocities of intracranial vessels
• Flow velocity is measured through thin area of temporal and occipital bones of the skull.
• A hand-held doppler probe emits a pulsed beam; the signal is reflected by a moving RBC within the blood vessel
• Helpful in assessing vasospasm, altered cerebral
blood flow in occlusive vascular dse or stroke
Electroencephalography (EEG)• Represents a record of electrical
activity generated by the brain through electrodes applied on the scalp
• Used to diagnose seizure disorders, coma
• Tumors, brain abscess, blood clots may cause abnormal patterns in electrical activity
• Used in making a determination of BRAIN DEATH
Electroencephalography (EEG)
Nursing Intervention Withhold medications that may interfere with the results-
anticonvulsants, sedatives and stimulants Wash hair thoroughly before procedure Instruct adult client to sleep no more than 5 hrs the night
before. Coffee, tea, chocolate and cola drinks are omitted Meal itself is not omitted because an altered glucose level
alters brain wave patterns It takes 45min-1hour; 12 hours for sleep EEG
Standard EEG - water-soluble lubricant Sleep EEG - collodion glue for electrode contact (acetone
for removal)
Diagnostic Evaluation
Electromyography (EMG)- obtained by inserting needle electrode into the skeletal muscle to measure changes in the electrical potential of the muscles and the nerves leading to them. Determine presence of neuromuscular disorders & myopathies.
Nerve Conduction Studies-A peripheral nerve is stimulated at several points along its course and recording the muscle action potential or sensory action potential.Useful in studying peripheral neuropathies.
Lumbar Puncture and CSF examinationSpinal tap - a needle is inserted into the subarachnoid
space through the 3rd and 4th or 4th and 5th lumbar interface to withdraw spinal fluid
h
PURPOSES1. Measures CSF pressure
(normal opening pressure 60-150mmH2O)2. Obtain specimens for lab analysis, cytology, C&S
(protein - normally not present, sugar - normally present)3. Check color of CSF (normally clear) and check for
blood4. Inject air, dye, or drugs into the spinal canal
- CSF pressure in lateral recumbent position is 70-200mm H20
Lumbar Puncture and CSF examination
CONTRAINDICATION • INCREASED ICP• COAGULOPATHY & DECREASED PLATELETS• SPINAL DEFORMITIES ( SCOLIOSIS, KYPHOSIS)
Lumbar Puncture GuidelinesNURSING CARE PRE-TEST1.) Have client empty bladder2.) Position client in a lateral recumbent position with head
and neck flexed onto the chest and knees pulled up.3.) Explain the need to remain still during the procedure
NURSING CARE POST-TEST1.) Ensure labeling of CSF specimens in proper sequence2.) Keep client flat for 12-24 hours as ordered3.) Force fluids4.) Check puncture site for bleeding, leakage of CSF5.) Assess sensation and movement in lower extremities6.) Monitor vital signs7.) Administer analgesics for headache as ordered
Queckenstendt’s Test• lumbar manometric test• performed by compressing jugular veins during Spinal
tap• in pressure caused by compression is noted; then
released and read every 10secs interval.
• a slow rise and fall in pressure indicated a partial block due to lesion compressing the spinal subarachnoid path.
• no pressure change => complete block is indicated.
Contraindicated : if intracranial lesion is suspected.
CSF Analysis• CSF should be clear and colorless
• Pink, blood-tinged, or glossy bloody CSF indicates cerebral contusion, laceration or subarachnoid hemorrhage
• Specimens are obtained for: cell count, culture and glucose and protein testing
Post Lumbar Headache• Mild to severe, may occur few hours to several
days after the procedure.
• It is throbbing bifrontal or occipital headache, dull or deep in character
• Cause: leak at puncture site, fluid continues to escape into the tissues by way of the needle track from the spinal canal
• May be avoided if small-gauged needle is used and if pt remains prone
after the procedure.
sources• Dillon, Patricia. Nursing Health Assessment. 2nd
Ed. F.A. Davis. 2007
• Jarvis, Carolyn. Physical Examination and Health Assessment. 3rd ed. New York: W.B. Saunder Company.2000
• Bickley. Lyn and Hoekenan, Robert. Bate’s Guide to Physical Examination and History Taking. 7th ed. New York: Lippincott Williams and Wilkins. 1999
• Estes, Mary Ellen Zator. Health Assessment & Physical Examination. 3rd ed. Delmar Learning. 2006
THANK YOU!!!