Download Neuro Med-Surg

Neuro Med-Surg-outline
NEUROLOGICAL ASSESSMENT
NEURO PHYSICAL EXAMINATION
• History
– Appearance
– Assess speech, affect, and motor function
• Personal and Family History
– Ethnic and cultural background
– ADL’s
• Current Health Problems and Social History
Seizures, Tremors, Weakness, Headache, Difficulty swallowing
PHYSICAL ASSESSMENT
• Follows logical sequence – start from the head down
• Higher levels of neurologic function to lower levels – name? where are you?
• Constant comparison of findings
Five Areas of Neurologic Assessment:
1. Mental status and speech
1st - Level of Consciousness and Orientation
• A change in a persons LOC is the first indication of decline in neurological function.
• Ask questions that require more than a yes or no answer.
• Alert – awake and responsive, oriented
• Lethargic – sleepy but arousable, delayed response
• Stuporous – arousable with difficulty, use sternal rub to arouse (vigorous stimulation to arouse)
• Comatose – not arousable
• A change in a persons LOC is the first indication of decline in neurological function.
Confusion/Memory Problems:
• LOC - We do this by asking questions of orientation
• Appearance and behavior – are they appropriate
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How does pt. behave
• How is the pts grooming – oral care? Facial hair?
• Ask family if it is normal or if it’s a change
• Speech – can the string words together
• How well can pt express himself – can he string together words to make a sentence, does it make
sense, can he carry a intelligent conversation
• Is speech fluent/fragmented – is the pace correct, the volume = low if confused
• Assess for dysarthria = can’t get words out clearly, need to articulate
• Assess for comprehension – do they squeeze your hand, do they follow commands
• Cognitive function – do they think in an orderly manner
• Thought content – how they think, is thinking in tack, evaluate their cohearance, are they seeing thing
that don’t exist, dillusions (believes in things that aren’t true)
• Abstract thinking – thinking outside the box.
• Judgment – ask what they might do if room is on fire. How do they handle their money.
• Emotional status – if their confused, they may have depression. (treat their depression, cognitive
problems go away) How do they feel about the future. Hopeful, etc
• Constructional ability
• Affects patients ability to perform simple tasks and use various objects
ask what’s this? And.. What do you use it for?
• (Can use Mini Mental status exam) – Look up in BOOK!
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Use if your pt can’t communicate
If it’s an emergency
If pt consciousness is in and out – use the
Very reliable tool and used by everyone to assess neuro function, when you use it start with the least
noxious stimuli (least in your face stuff) to the more noxious stimuli.
• Addresses 3 areas of neuro functioning
• Done every 4 hours
• Overview of level of responsiveness
• Evaluate neuro status of head injury patient
• Evaluates motor, verbal, & eye-opening
• Each response awarded a number
• Sum gives indication of severity of coma & prediction of possible outcome
Three Areas of Memory Loss:
• Assess memory loss
• Recent memory loss
• Long-term or Remote Memory – B-day, schools attended, city of birth, mother’s maiden name.
• Recall or Recent Memory – accuracey of medical history, health care provider, type of car you drive, how did
you get here?
• Immediate or New Memory – give 2 or 3 words to remember, distract them then have them repeat back
words,
2. Cranial nerve function
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12 pairs of cranial nerves
S: SENSORY 3 are entirely sensory – I, II, VIII
M: MOTOR5 are entirely motor – III, IV, VI, XI, & XII
B: MIXED4 are mixed – V, VII, IX, & X
Emerge from the lower surface of the brain
Most innervate the head, neck, & special sense structure
S M BOTH
12 pairs
Help to remember nerves
I. Some
I. Olfactory
I. Obtuse
II. Say
II. Optic
II. Octopus
III. Marry
III. Oculomotor
III. Tried
IV. Money
IV. Trochlear
IV. To
V. But
V. Trigeminal
V. Abduct
VI. My
VI. Abducens
VI. A
VII. Brother
VII. Facial
VII. Female
VIII. Says
VIII. Acoustic
VIII. Artist
IX. Bad
IX. Glossopharyngeal
IX. Grabbing
X. Business
X. Vagus
X. Vigorously
XI. Marries
XI. Spinal Accessory
XI. Spinning
XII. Money
XII. Hypoglossal
XII. Her
Cranial nerve
Olfactory (I)
Function
Smell
Symptom / sign of damage
I.
Anosmia
Damage to sinuses affect smells – Assess smell by: close
one nostril but different scents (coffee, vanilla) see if they can
name what under their nose.
Optic (II)
Vision
Blindness
I. Assess – opthalmascope to check the optic nerve, light goes
through the pupil to the retina, eye chart, test visual fields,
Oculomotor (III)
Eye movement
(elevation, adduction)
Eye deviates down & out. Loss of pupillary/accommodation reflexes
Trochlear (IV)
Eye movement.
(depression of adducted
eye)
Diplopia, lateral deviation of eye
Trigeminal (V)
Facial sensation.
Mastication.
Facial anesthesia. Loss of pain sensation. Insignificant.
Weakness/loss of mastication.
Pain is excrucitiating, hurts so bad you don’t want to eat.
Abducent (VI)
Eye movement
(Abduction)
Medial eye deviation
Facial (VII)
Facial expression. Taste.
Salivation & lacrimation.
Paralysis of facial nerve muscles (+ hyperacuisis). Loss of taste
(anterior 2/3rds of tongue). Dry mouth, loss of lacrimation.
VII.
Belle’s Palsy – paralysis of facial nerve muscle
Vestibulocochlear
(VIII)
Balance. Hearing.
Vertigo, dysequilibrium, nystagmus. Hearing.
Glossopharyngeal
(IX)
Taste.
Loss of taste (posterior 1/3 of tongue). Loss of gag reflex.
Vagus (X)
Swallowing & talking.
Cardiac, GI tract,
respiration. Taste.
Dysphagia & hoarseness of voice. Loss of cough reflex
(larynx/pharynx), loss of taste (hard palate)
X.
Valsalvo manuever stimulates the vagal nerve
Spinal Accessory
(XI)
Pharynx/larynx muscles.
Neck & shoulder
movement.
Head turning/shoulder shrugging weakness.
Hypoglossal (XII)
Tongue movement.
Atrophy of tongue muscles, deviation on protrusion, fasciculaations
XII. Check by asking, stick your tongue out and wiggle it
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• Cranial nerve continued
Bell’s Palsy:
• Facial paralysis r/t inflammation of the 7th cranial nerve palsey
• Results in weakness or paralysis of facial muscles
• Cause unknown but thought to be r/t vascular ischemia, viral disease, autoimmune disease or combination of
all
• Rapid onset
• Goes away by itself
• May come from tooth infection, ear infection, virus,
• S/S: distortion of the face from paralysis, increased lacrimation, painful sensations in the face, behind the ear, and
the eye,
possible speech difficulties and inability to eat on affected side
• Management: maintain muscle tone, ensure spontaneous recovery within 3-5 weeks, steroids (to get rid of
inflammation), pain
meds, heat (promotes blood flow), electrical stimulation(help prevent atrophy) and surgery (surgical
decompression,
especially if it’s a tumor causing it)
• If nerve stays pinched, it scars
• Pt. teaching and self-care: eye care, facial exercises and avoidance of cold
Trigeminal Neuralgia:
• Disease of 5th cranial nerve
• Spasms with stab-like pain radiating down nerve pathway
• Caused by degeneration of nerve or increased pressure
• Cause is unknown, causes spasms or proxcisoms
• 400 x more common in pt with MS.
• Treated with antiseizure medications (Dilantin) (tegratol) (Baclofin – antispasm)
• Severe cases treated with surgery
• VERY PAINFUL
• Nursing management: preventing pain, identifying triggering events
• Cut down on electrical spasms, nironton, liraca (gaba),
• Watch for signs of anxiety, depression, because pain is so bad people want to kill or hurt themselves.
SPINAL NERVE
• 31 pairs of spinal nerves
• 8 cervical
Cervical and thoraxic
The nerves exit above the numbered vertebra in the thoraxic all the way below that vertebra
• 12 thoracic
• 5 lumbar
• 5 sacral
• 1 coccygeal
3. Sensory function
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Pain –
Light touch – same thing but use something softer, Q-tip, sharp or dull?
Vibration Position – have pt close eye, move big toe or finger and ask pt if it is pointing up or down. It test
cerebellum function. Have to have an intact cerebellum to have it.
Discrimination – assess the cerebral cortex (outerlayer)
stereognosis= with out looking at the object and identifying what it is. Test cerebral cortex.
Pain - Make sure sensation is same on both sides, have pt. close eyes, Sharp or dull?
Diabetics – feet hurt, but they can feel light touch.
4. Motor function
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Muscle tone = a state of slight contraction usually present in muscles that contribute to posture and
coordination, normal healthy state of your muscles.
• Muscle strength
• Cerebellar function
Muscle Tone:
• Represents muscular resistance to passive stretching
• ROM arm
• ROM leg
• Slight resistance is normal
• Let leg fall - If leg falls and is turned outward it is a problem
Muscle Strength:
• Observe gait (should be heel to toe and straight) and motor activities
• Move muscle groups against resistance
• Graded on a 5 pt. scale
Five Point Scale For Strength:
• 0: no contraction
• 1: minimal contractile power (see it flicker but they can’t move it.
• 2: can move but not overcome the force of gravity
• 3: sufficient strength to overcome the force of gravity
• 4: fair
• 5: indicates full power of contraction
• Flexion and extension against resistance
• Normal between 3-5
Cerebellar function:
• Site of Balance & coordination
• Gait
• Romberg’s test – pt stand up with eyes open feet and together and hands to side, and close eyes (same as
alcohol test) positive if they can’t do it.
• Finger to nose test – should be accurate and smooth
• Rapid alternating movement tests – fingers to thumb. (Parkinson’s pt can’t do it) Pronate and supanate
quickly
• Should be able to sit and stand with out help, should be able to turnaround.
5. Reflexes
• Need reflex hammer
• Achilles reflex may be absent in elderly
• Graded on 0 to 4+ scale –
Deep Tendon Reflex Scale:
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0: absent
• +1: diminished impulses
• +2: normal impulses
• +3: increased impulses
• +4: hyperactive impulses (clonus)= hyperactive reflexes
DTR – Plantar / Babinski Reflex
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Positive babinski = abnormal,
Upper motor neuron lesion – motor cortex
S/s = loss of vol. control, increased muscle tone, muscle spasticity, hyperactive and abnormal
relflexes.
• R/t – stoke, bleed or injury to spinal cord
• Lower motor neuron lesion
• Occurs when motor nerves are severed between a muscle and a spinal cord, usually caused by
trauma, infection, compression of nerve roots by herniated discs.
• s/s = loss of leg control, decreased muscle tone, flacid muscle control (no movement), muscle
atrophy, ablsent or decreased reflexes
DTR – Brachioradialis Reflex
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C5 and C6
• Need to be relaxed, hit in marked spots
• Lower arm should flex and palm will supinate (turn upwards)
DTR – Biceps Reflex
• Have to be relaxed , hit
• Repeat and compare to other arm
• C5 and C6 nerve root
• cervical stenosis or herniated cervical disc – absent reflex or weak reflex
DTR – Triceps Reflex
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C6 and C7.
Tap tricep tendon, should flick and contract, and may be elbow extension.
DTR – Knee Jerk
• L3-4 intervation
• Strike quadraceps tendon directly
• Reflex contraction of quadraceps muscle
DTR – Ankle Reflex
• Syatic nerve – S1
• Should see planter flexion
• Gendrassik DTR – Clonus
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A sudden brief jerking contraction of a muscle or muscle group
Most often seen in seizures, Tonic, clonic
DIAGNOSTIC ASSESSMENT
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Neuro – diagnositc field
Neurologist - will dx the problem, if surgical they will send to a surgeon
Cat Scans (CT) – least invasive, least expensive
Magnetic Resonance Imaging (MRI) – more invasive, more expensive , can’t have one if you weigh more
than 300 lbs.
• Magnetic Resonance Angiography (MRA)- looking at vascularture, at blood vessels
• Electroencephalography (EEG) • Evoked Potential Studies (EPS) • Electromyography (EMG) – applying elect. Stimulation to nerves, invasive
• Nerve Conduction Studies (NCV) non invasive
• Myelography • Lumbar Puncture/Cerebral Spinal Fluid (LP/CSF) – spinal tap
COMPUTED TOMOGRAPHY
• Narrow beams of x-ray in layers
• Performed with and/ without contrast
• Must lie perfectly still
• No talking
• Must not move face
• Motion may cause distortion
• Show all kinds of tissue,
• Stomach problems
• Use any where
• Brains – shows all structures just not in great detail
• Quick, accurate, easy
• Add contrast - usually looking for some kind of tumor
• No contrast – bleeds, etc.
CT SCAN
• Distinguishes bone, soft tissue, and fluids
• Identification of:
– Tumors
– Infarctions (clot causing tissue death)
– Hemorrhage
– Hydrocephalus
– Bone Malformations
MAGNETIC RESONANCE IMAGING (MRI)
• Uses powerful magnetic field to obtain images of different areas of body
• Magnetized photons within body align like small magnets in this magnetic field
• After bombardment with radiofrequency pulses, protons emit signals
• Signals convert to images
• Don’t wear anything that has metal, good for detecting damages to brain and spinal cord
• 5 steps above a Cat Scan.
• Potential for identifying cerebral abnormality earlier & more clearly
• Provides info about chemical changes within cells
• Remove all metallic objects & credit cards
• Lie on flat platform that is moved into narrow tube containing magnet (be able to lay flat for an hour with
out moving)
• Scanning process is painless, but hear thumping of magnetic coils as field is being pulses
MAGNETIC RESONANCE ANGIOGRAPHY (MRA)
• Uses magnetic fields and 3-dimensional images to look at your vessels
• Valuable tool for investigating vascular disease, aneurysms, & arteriovenous malformations
• Demonstrates patency & adequacy of cerebral circulation
ELECTROPHYSIOLOGIC TESTS
ELEECTROECEPHALOGRPHY– EEG
• Record of electrical activity in brain
• Provides physiologic assessment of cerebral activity
• Useful for diagnosing seizures (sudden impulses of electrical activity), screening for coma or organic
brain syndrome (some forms of dementia) , brain death = no electrical activity. Calm, quite,
• Indicator of brain death
• Electrodes arranged on scalp to record electrical activity (printed out on graph)
• For baseline – lie quietly with eyes closed
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May be asked to hyperventilate for 3-4 minutes & then look at bright flashing light
Sleep deprivation is used to record activity.
EEG PREP.
– May be sleep deprived on night before to ↑chances of recording seizure activity
– Tranquilizers & stimulants should be withheld 24-48 hours before test
– Coffee, tea, chocolate, & cola drinks omitted in meal before test (they are stimulants)
– Meal is not omitted because altered blood glucose level can change brain wave patterns. Feed the
brain.
– Remove all metal
– Procedure takes 45 – 60 minutes
– Assure patient test does not cause electric shock
EVOKED POTENTIAL STUDIES
• Evaluate changes & responses in brain waves recorded from scalp electrodes after introduction of
external stimulus
– Visual evoked responses – flash things in front of you. Pictures or shapes, etc.
– Auditory evoked responses – headphones, hearing test sounds.
– Somatosensory evoked responses • No specific prep except reassurance & encouragement of relaxation
• Tests finds delays form pathway to brain
• MS, polyneuropathy, Gillian Burray – speed of nerve impulse slow down.
• Metabolic problems change your brain wave activity.
ELECTROMYELOGRAPHY
• Measures electrical potential of muscles & nerves leading to them by introducing needle electrodes into
them
• Invasive
• Useful in determining presence of neuromuscular disorders & myopathies
• Helps to distinguish weakness due to neuropathy (disease of the nerve)from weakness due to other
causes
• No special patient prep
• From where you shocked to where its being measured
• Diabetics – can have neuropathy
NERVE CONDUCTION STUDIES
• Stimulating peripheral nerves at several points along its course & recording muscle action potential or
sensory action potential
• Non-invasive (technician can do it)
• Surface or needle electrodes placed on skin over nerve to stimulate nerve
• Useful in study of peripheral nerve neuropathies
MYELOGRAPHY
• Radiograph of spinal subarachnoid space taken after contrast medium is injected into spinal
subarachnoid space through spinal puncture (spinal tap)
• Enables visualization of vertebral column, intervertebral disks, spinal nerve roots, and blood vessels
• Use to see if spinal cord is compromised
MYELOGRAPHY POST-OP
• If using Isovue, patient lies in bed with HOB ↑15° to 30° to reduce upward dispersion
– May be ambulatory or remain in bed as prescribed by physician
• If using oil based medium, patient lies in recumbent (with head down) position for usually 12 to 24 hours
to reduce CSF leakage
– Usually permitted to turn from side to side
– Biggest precaution to look for is seizures
LUMBAR PUNCTURE AND CEREBROSPINAL FLUID
• Insert needle into lumbar subarachnoid space (usually 3rd & 4th) to withdraw CSF
CSF
• Clear, colorless, specific gravity – 1.007 (Meningitis – will cause it to look cloudy)
• Disease produces changes in composition
• Lab tests:
– Cell count
– Culture
– Glucose (csf is made up mostly of sugar)
– Protein
– Immunoglobulins
• Specimen should be sent immediately to laboratory (take it down yourself)
• CSF in healthy state should have minimal WBCs & no RBCs
• Purpose:
– to obtain spinal fluid for exam
– to measure & relieve spinal fluid pressure
– to determine presence or absence of blood
– to detect spinal subarachnoid block
– to administer antibiotics intrathecally (straight into spinal cord itself) in certain cases of infection
– Requires patient to be relaxed
– Strict aseptic technique is mandatory by all personnel
– Contraindicated in clients with ICP (increased crainial pressure) – brain herniation can occur if done
with ICP.
– Contraindicated in clients with skin infections at or near puncture site
• Nursing Interventions
– Reassure patient that needle inserted into spine will not result in paralysis
– Needs to empty bladder & bowel before procedure
– Placed on side with back toward doctor – lateral with neck, hips, knees flexed
– Maintain spine in horizontal position (like a mad cat flexed)
POST-LP CARE
• Bedrest in flat (HOB flat) position for 4 – 8 hours
• Encourage fluids(esp. caffeinated fluids) to facilitate CSF production
• Administer analgesics as ordered if headache occurs
• Monitor neurologic signs if LP done to reduce ICP
• Watch for signs of chemical or bacterial meningitis
– Fever, stiff neck, photophobia
POST- LP HEADACHE
• Ranges from mild to severe
• Lasts a few hours to several days
• More severe when sit or stand
• Caused by leakage of CSF at puncture site that continues to escape into tissues by way of needle tract
from spinal canal
• Depletes CSF in cranium producing tension & stretching when assume upright position
• Has sugar and will look thick , with halo sign.
• Usually managed by bedrest, analgesics, & hydration
• Occasionally needs epidural blood patch
– Doctor withdraws ~ 10 cc patient’s blood
– Injects blood to cover (create patch) hole in spinal canal