Transcript ASSESSMENT OF NEUROLOGICAL FUNCTIONMICHELLE GARDNER RN…

ASSESSMENT
OF
NEUROLOGICAL
FUNCTION
MICHELLE 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 Brain
cerebrum
brain stem
cerebellum
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 illnessDETAILS
• 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 Puncture
Cerebrospinal fluid analysis
• CSF is aspirated by needle insertion in L34 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
Pathophysiology
A-E-I-O-U =
• Alcohol, Epilepsy, Insulin, Opium, Uremia
TIPSS =
• Tumor, Injury, Psychiatric, Stroke, Sepsis
LOC – Assessment
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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 immediately
Focus
• 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
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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 1015mmHg. 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 CheyneStokes 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)
Complications
Syndrome 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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