Unit 1: Neurological Assessment Flashcards
Week 1
Nursing Assessment: History
- Chief Complaint
- Regular Healthcare
- Medical HX, Family HX
- Allergies
- Medications
- Social HX
History: Regular Healthcare Includes
- Name of primary care provider
- Hx of routine health screenings (lipid screen, colonoscopy, and mammography)
- Status of vaccines (tetanus, hepatitis, influenza, pneumonia)
- Alterative healthcare (acupuncture, herbal medicines)
History: Medical Hx includes
- Chronic illnesses (diabetes, hypertension, or renal disease)
- Treatment for chronic diseases or current problem
- Past trauma/ injury
- Recent treatments or diagnostic studies
- Past surgical procedure/treatments
- Hx of father, mother, and siblings; if deceased, include cause of death
- Hx of chronic illness (diabetes, obesity, or hypertension)
History: Allergies
- list all medication, food, or environmental allergies
- allergic response
- allergy treatment
History: Medications
- Taken on a regular basis; name, dose, frequency, and time of administration
- Length of time on medication
- Last time the medication was taken
- Knowledge and presence of side effects
- Routine monitoring of the medication by a healthcare provider
- Self-administration of OTC products, vitamins, minerals, and alternative medications
History: Social Hx
- age and gender
- marital status
- religion
- social support networks
- work hx; any environmental risk factors or exposures
- smoking, alcohol use/abuse, or drug (legal and illegal) abuse
History: Current history of chief complaint
- description of current symptoms that brought the patient to the hospital/clinic
- review of time of onset ad presentation of symptoms
- current treatment of symptoms
Nursing Assessment: Physical
- Levels of Consciousness (Glasgow Coma Scale (GCS))
- Cognitive Function
- Cranial Nerves
- Motor Assessment
- Sensory System
- Cerebellar Assessment
- Reflex Assessment
Physical: Level of Consciousness
best indicator of neurological deterioration is a change in LOC
- identifying patient responsiveness and orientation to person, place, and time
- LOC assessed using Glasgow Coma Scale (GCS)
- categories: conscious, confused, lethargic, obtundation, stupor, coma
Conscious
awake w/ appropriate speech and behavior
Confusion
- disorientation
- bewilderment
- difficulty following demands
Lethargic
- sleepiness
- slow and delayed response to stimuli
Obtundation
- somnolence w/ drowsiness between sleep states
- lessened interest in environment
- slowed responses to stimulation
Stupor
- minimal movement w/o stimulus
- requires strong vigorous stimulus and then drifts back to unresponsiveness
Coma
- not arousable
- unresponsive
Physical: Cognitive Function
- Mini-Mental Status Examination (MMSE) is a tool used to assess cognitive function
- MMSE assesses patients orientation, attention, calculations, memory, and language abilities
Mini-Mental Status Examination (MMSE)
tool used to assess cognitive function
-assesses orientation, attention, calculation, memory, and language abilities
-asked to answer questions:
>Correct answer: 1 point; 30 points available
>Score below 20: cognitive impairment
-Orientation: who are you?, what is today?, where are you?
-Attention + Calculation: Count backward by seven, spell a word backwards
-Memory: Immediate: repeat these 3 words…, Recent: what did you have for breakfast?, Remote: where did you attend highschool?
-Language: what is this object in my hand?, repeat this phrase…., perform this 3 step command…
Physical: Cranial Nerve Assessment
can identify neurological impairment d/t disease or trauma in the brain
- CN I (Olfactory)
- CN II (Optic)
- CN III (Oculomotor)
- CN IV (Trochlear)
- CN V (Trigeminal)
- CN VI (Abducens)
- CN VII (Facial)
- CN VIII (Acoustic, Vestibulocochlear)
- CN IX (Glossopharyngeal)
- CN X (Vagus)
- CN XI (Spinal Accessory)
- CN XII (Hypoglossal)
Physical: Motor Assessment
- inspect and assess muscle mass and tone
- assess strength and equality between left and right extremities
- note any abnormalities (atrophy, paresis, plegia, contraction, involuntary movements, spasm, spasticity)
Atrophy
decrease in muscle mass
Paresis
slight or incomplete paralysis
Plegia
complete loss of muscle funcion
Contraction
shortening or tightening of the muscles
Involuntary Movements
uncontrolled movements
Spasm
involuntary muscle contraction
Spasticity
increased muscle tone that creates stiff movement
Motor Assessment: Biceps/Triceps
grabbing wrists and ask pt to “pull me toward you” and “push me away”
Motor Assessment: Quadriceps
ask pt to lift legs against gravity and then resistance
Motor Assessment: Plantar Flexion
“Step on gas” against hand
Motor Assessment: Dorsiflexion
“pull toes to nose”
Pronator Drift
-extend both arms in front of the body
-turn palms upward
-close eyes
>Weak arm: hand pronates and begins to drift downward (positive pronator drift); sign of subtle motor weakness
Motor Strength Scale
5: Strong, full ROM against gravity and full resistance
4: Slight weakness, full ROM against gravity and moderate resistance
3: Moderate weakness, full ROM against gravity but not resistance
2: Severe weakness, full ROM but w/o gravity or resistance
1: Very Severe weakness, muscle contraction only
0: No movement
Physical: Sensory System
assessed to determine if the patient can feel or identify specific sensations such as temperature, vibration, superficial or deep pain, proprioception or position sense, and cortical sensory interpretation
- an advanced practitioner would use a pin, cotton wisp, and tuning fork to determine pain, light touch, and vibration
- start at feet working upwards
- pt should be able to distinguish between dull and sharp
- both sides compared
Proprioception
patients ability to recognize position w/ eyes closed
- examiner holds a digit, toe, or finger on the lateral aspect and moves it up or down
- with eyes closed, pt should be able to tell if the position is up or down
Cortical Sensory Interpretation
function of the parietal lobe
- stereognosis
- graphesthesia
Stereognosis
ability to identify an object by its shape by simply holding the object
-place a common object (key or coin) in patients hand and ask to identify it
Graphesthesia
ability to identify letters or numbers when drawn on skin
- close eyes while examiner draws
- patient should be able to identify it
- neglect of or failure to recognize one side of the body may be noted w/ issues in cortical sensory function
Abnormalities of the Sensory System
- Anesthesia
- Hypoesthesia
- Hyperesthesia
- Parasthesia
Abnormalities of the Sensory System: Anesthesia
absence of sensation
-sensations are blocked
Abnormalities of the Sensory System: Hypoesthesia
decreased sense of touch or sensation
-numbness
Abnormalities of the Sensory System: Hyperesthesia
increased sensitivity to touch
Abnormalities of the Sensory System: Paraesthesia
“pins and needles”
-itching, numbness, tingling
Cerebellar Assessment
evaluating balance, coordination, gait, and posture
-Romberg Test
Romberg Test
assess balance
- stand with feet together, arms at the sides, with eyes open; check that patient can do this w/o swaying
- then asked to close eyes
- if unable to maintain balance = positive Romberg test; may indicate vestibular or proprioceptive problems
- a pt w/ cerebellar damage may not be able to balance w/ eyes opened or closed
Cerebellar Assessment: Assess Coordination
observing:
-basic activities: walking, getting up and down from a chair, or reaching for an object
Cerebellar Assessment: Assess Gait and Posture
- should be able to stand and walk erect, with a steady gait
- assess for length of stride, arm movement, base of gait (how far apart feet are placed) and ability to turn steadily
Reflexes
involuntary and automatic responses to stimuli that provide the body with protection
- helps to adjust to an ever changing and sometimes dangerous environment
- reflex arc: occurs when the sensory neurons carry a stimulus to the motor neurons in the spinal cord
- evaluate major deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles)
- plantar reflex; Babinski sign
The reflex arc
occurs when the sensory (afferent) neurons carry a stimulus to the motor neurons in the spinal cord
-motor (efferent) neurons carry the stimulus from the spinal cord to the muscle (a response)
Reflex: Babinski Sign
practitioner takes the heel of the reflex hammer, or sharp object, and stimulates the outside of the sole of the foot
- positive sign= toes flare upward; upper motor neuron lesions (damage to the corticospinal tract of the spinal cord)
- negative= toes flare downward; normal in adults
Vital Sign Assessment
- HR, BP, Respirations are regulated in the brain and brainstem
- changes in VS may develop as a result of alterations in cerebral perfusion, disease, trauma, or swelling
- VS changes is a late sign of increased ICP or neurological deterioration
Increased ICP
occurs when there is a disturbance in the balance of volumes within the brain
- brain tissue, CSF, and blood
- normal ICP: 0-15 mm Hg
- increased: > 20 mm Hg
- show changes in LOC, vomiting, headaches, and seizures
- Cushing’s Triad: Elevated Systolic BP with widening pulse pressure, bradycardia, and irregular respirations
What is a late sign of increased ICP?
changes in vital signs
Cushing’s Triad for increased ICP
- increased systolic BP w/ widening pulse pressure
- bradycardia
- irregular respirations
How does Increased ICP Occur?
-mass or lesion
-increased volume d/t hemorrhagic event
-increase in CSF d/t blockage or buildup within the CSF drainage system
>the skull is a hard, bony structure w/ no ability to expand
Monro-kellie Hypothesis
the sum of the volumes of the brain (brain tissue, CSF, and blood) is constant
- a change or increase in one should create a compensatory decrease in one or both of the other two
- if the increase in the volume of one of the components exceeds the brains compensatory ability, the intracranial pressure increases = medical emergency
Diagnostic Studies
- Computed Tomography (CT)
- Positron Emission Tomography (PET)
- Magnetic Resonance Imaging (MRI)
- Magnetic Resonance Angiography (MRA)
- Cerebral Angiography
- Computed Tomography Angiography (CTA)
- Electroencephalography (EEG)
- Lumbar Puncture (LP)
- Myelography/ myelogram
- Brain biopsies
Diagnostic Studies: Computed Tomography (CT)
cross-sectional images that are viewed as cuts or slices
- allows views of the brain and spine
- orbits in a quick, noninvasive manner
- used to assess for bleeding, edema, or masses
Diagnostic Studies: Positron Emission Tomography (PET)
- administration of the radioactive glucose tracer fluorodeoxyglucose (FDG)
- detects areas of increased metabolic activity in the body
Diagnostic Studies: Magnetic Resonance Imaging (MRI)
- noninvasive
- uses magnetic fields to obtain images
- provides three-dimensional images
- offers clear visualization and detail of small structures
Diagnostic Studies: Magnetic Resonance Angiography (MRA)
type of MRI that uses radio-wave signal characteristics of flowing blood to get images of the body’s blood vessels
- looks at blood flow in the vessels
- determines the presence of aneurysms, clots, dissections, or vessel stenosis
- performed the same as an MRI
Diagnostic Studies: Cerebral Angiography
- invasive
- intra-arterial (inserted in an artery; femoral)
- radiological procedure
- looks at blood flow in the vessels
- involves administration of radiopaque dye through a catheter
Diagnostic Studies: Computed Tomography Angiography (CTA)
combines the technology of a CT scan (cross-sectional images of the brain) and traditional cerebral angiography (enhanced visualization of cerebral vasculature through the IV injection of contrast dye)
-evaluates cerebral vasculature
Diagnostic Studies: Evoked Potential
- painless
- noninvasive
- measures the speed and size of nerve conduction generated by the nervous system in response to stimuli
- electrodes are attached to the scalp and to different areas on the body depending on type of test being conducted
Diagnostic Studies: Lumbar Puncture
most common procedure done to obtain a sample of cerebrospinal fluid (CSF) for analysis and to measure intracranial pressure
- increased pressure may = CSF obstruction or overproduction
- can be done at beside
- CSF should be clear, and contains glucose and protein
- traces of RBC may be related to the puncture done for the test
- post-procedure: flat bedrest 4-6 hours; hydration
- headache post-procedure = leakage of CSF and may require a blood patch
Diagnostic Studies: Myelography/myelogram
- invasive radiographic procedure
- involves lumbar puncture and injection of contrast medium into the subarachnoid space around the spinal cord
- x-rays are taken that enable visualization of the entire spinal column
- evaluates for lesions, cysts, injury, herniated discs, and masses/tumors
Diagnostic Studies: Biopsy
- invasive
- done to obtain tissue samples for examination
- indicated to r/o or identify infections or abscesses
- used to identify tumor tissue
- types: needle, stereotactic, and open
Positioning for a Lumbar Puncture
- can be done at bedside
- CSF should be clear, and contains glucose and protein
- Traces of RBC may be r/t the puncture done for the test
- post-procedure: Flat bedrest 4-6 hours; hydration
- headache post-procedure = leakage of CSF and may require blood patch
- patient lays on side with shoulders vertical (–) or
- patient sits on the edge of the bed, head down, leaning forward over a bedside table
Age-related Changes
- motor changes, sensory changes, and altered thermoregulation
- changes can be subtle and occur over time
- changes in CNS occur as the brain weight and mass decline w/ a loss of neurons
- gerontological changes: slowed body movements, decreased reaction time, decreased muscle strength and flexibility, decreased smell, decreased temperature, decreased touch, decreasing neurosensory function
- pain sensations can be decreased
- slower cognitive processing
Diagnostic Studies: Electroencephalogram (EEG)
records electrical activity in different regions of the cerebral cortex
- used for seizure activity
- used to identify areas of abnormal wave patterns indicating brain tissue dysfunction
- continuous EEG used to detect seizure activity and status epilepticus
- used as a test to confirm cessation of electrical activity in the brain when brain death is suspected
- neurologist provides official reading of EEG
