00183 (2).ppt
- 1. NEUROLOGICAL NURSING DIAGNOSTIC EXAMS BY: FRIA SORIANO-DEMAISIP, R.N., M.A.N.
- 2. Lumbar Puncture • introduction of hollow needle with stylet into the lumbar subarachnoid space of the spinal canal between L1/L5 and of withdrawal of CSF fluid for diagnostic and therapeutic purposes.
- 3. Purpose: • Measures CSF pressure (normal opening pressure 60-150mm H20) • Obtain specimen for laboratory analysis • Check color of CSF (normally clear) and check for blood • Inject air, dye, or drugs into the spinal canal.
- 8. Nursing Care • Pretest – Have client empty bladder – Position client in lateral recumbent position with head and neck, flexed on the chest and knees pulled up. – Explain the need to remain still during the procedure.
- 9. • Post test – Ensure labelling of CSF specimens in proper sequence – Keep client flat for 12-24hours as ordered – Forced fluids – Check puncture site for bleeding, leakage of CSF – Assess sensation and movement in lower extremities – Monitor vital signs – Administer analgesics for headache as ordered.
- 10. Cisternal Puncture introduction of short hollow needle stylet in the median line below the occipital bone into the cisterna magnum
- 11. Purpose – remove CSF when impossible to obtain at lumbar puncture level. Potential complication: Respiratory distress
- 12. Nursing Care • Same as for lumbar puncture • Observe for cyanosis, dyspnea and apnea
- 13. X-ray of the Skull • – films examined for signs of fracture, erosion of the bone including size of sella turcica. Reveals configuration, destiny, vascular markings.
- 15. CEREBRAL ANGIOGRAPHY injection of radiopaque substance into the cerebral circulation (carotid or vertebral arteries in the neck to visualize by means of x-rays of the blood vessels of the head and neck).
- 16. Purpose – localization of tumors, abscesses, aneurysms, hematomas, and occlusions. Potential Complications: Anaphylactic reaction to dye, local haemorrhage, vasospasm, adverse intracranial pressure.
- 18. Nursing Care • Pre Test – Check allergies for iodine – Take baseline assessment – Measure neck circumference – NPO after midnight or clear liquid – Explain the warm flushed feeling and salty taste in mouth may be felt during the procedure.
- 19. Post Test • Have emergency equipment available. • Monitor neurological status and vital signs for shock, LOC, hemiparesis, hemiplegia and aphasia. • Administer ice collar/cap intermittently to relive swelling and discomfort. • Maintain pressure dressing • Maintain bed rest until next morning as ordered.
- 20. Pneumoencephalograph • introduction of air or oxygen into the subarachnoid space by lumbar or cisternal puncture to outline the ventricular system and intracranial subarachnoid space for x- ray study. Demonstrates intracranial subarachnoid space and ventricular system. Localize intracranial lesion.
- 21. Ventriculography • introduction of air or O2 directly into the lateral ventricles by ventricular puncture thru an opening made in the frontal, parietal or occipital regions for special x- ray study of the brain.
- 22. • Purpose: - to visualize ventricles, localized tumors. • Potential Complications – Headache – Nausea and vomiting – Meningitis – Increased intracranial pressure • Nursing Care • Post Test – Monitor Vital signs – Check neurological status – Elevate head of bed (15-20 degrees)
- 23. BRAIN SCANNING (RADIONUCLIEDE IMAGING STUDIES) • – intravenous injection of radioactive compound and the application of a scintillation scanner in the patient’s brain – there’s an increase uptake or radioactive materials at the site of pathology.
- 24. • Purpose: use to detect intracranial masses, vascular lesions, infarct and hemorhage. • Nursing Care – Check for allergy – Keep NPO 4-6 hours before exam
- 25. ENCEPHALOGRAM recording of echoes (sounds) derived from deep structure within the skull by transmission
- 28. MAGNETIC RESONANCE IMAGING (MRI) • visualization of the distribution of hydrogen molecules in the body in 3 dimensions
- 30. • Noninvasive procedure that identifies tumors and vascular abnormalities and provide a more detailed picture. • Remove all metals from the body • Pacemakers, implanted defibrillator, metal implants and vascular clips are contraindicated for the procedure.
- 31. • Pulse oximeters are not allowed because it can burn during testing • Assess for claustrophobia • Client may resume normal activities after the procedure.
- 33. Computed Tomography Scan • Brain scan that may or may not require a contrast dye. • Used to detect space-occupying lesions, bleeding, edema, hydrocephalus and atrophy. • Assess for allergies to iodine, dyes, or shellfish.
- 34. • Instruct the need to lie still and flat during the entire procedure. • Assess for claustrophobia. • Inform of possible mechanical noises • There may be a hot, flushed sensation and metallic taste in the mouth when dye is injected. • Provide fluids after the procedure for diuresis
- 37. Myelogram Injection of air or dye in the subarachnoid space to detect abnormalities of the spinal cord and vertebrae. Obtain informed consent. Hydrate patient 12 hours prior to the test Assess for allergies to iodine Pre-medicate for sedation
- 38. Water based dye (most often used): elevate the head of bed 15 to 30 degrees for 6 to 8 hours. Oil based dye: keep the head lower 6 to 8 hours. If air is used: keep the head lower that the trunk for 48 hours.
- 42. LEVEL OF CONSCIOUSNESS • – ask questions about his present, past, illness and not the general level of consciousness most sensitive indicator of changes in the neurologic status. • Orientation to time, place and person • Speech, clear , garbled, ramping • Ability to follow commands
- 43. • Levels – Hyperactivity – Conscious – Lethargy, drowsiness or obtunded – Stupor – Coma
- 45. Objective evaluation of level of consciousness, motor and verbal response A standard system for assessing the degree of neurologic assessment in critically ill patients. Score – 15 (patient is awake and oriented) 7 or below (coma) Lowest score 3 – deep coma
- 47. Abnormal Posturing • Decerebrate – extension and adduction of arms, hyperextension of legs • Decorticate – flexion adduction internal rotation of arms, extension of leg (damage to corticospinal tracts, cerebral hemispheres)
- 49. Mood – may have diagnostic significance • schizophrenia
- 51. Manic depressive
- 54. • Memory – maybe revealed by volume of detail that he can provide in relating the health history. • Cortex – attempt to conceal memory details by: – Circumlocation – talking around an issue without really answering the question. – Confabulation – relating imaginary experiences rather than admitting ability to remember past events.
- 55. Complex Function – Higher function should be evaluated – To ascertain the level of patient’s cerebral functioning • Ability to reason abstractly tested by asking patient to explain proverb, ability to perform mathematical calculations
- 56. • Speech –Note quality of articulation, manner of syllabication, aptness of his word choice, strength of his voice, comprehension of questions. –Impaired articulation results of infarction of the dominant cerebral hemispheres, cerebellar dysfunction, lesion of the brain stem, dysfunction of 5,7, 9 or 10th or 12th cranial nerve. • Reading • Writing
- 57. VITAL SIGNS – respiratory patterns help localize possible lesion
- 58. – Cheyne-stoke respiration » Regular rhythmic, alternating between hyperventilation and apnea » Maybe caused by structural cerebral dysfunction of metabolic problems such as diabetic coma.
- 59. – Central neurogenic hyperventilation » Sustained rapid, regular respiration (rate of 25/min) with normal blood oxygen levels » Usually due to brainstem dysfunction – Apneustic breathing » Prolonged inspiratory phase, followed by a 2-3 second pause. » Usually indicates dysfunction of respiratory center in pons. – Ataxic breathing – breathing pattern completely irregular indicates damage to respiratory center of the medulla – Biots respiration » Irregular breathing » Deep and shallow breathing randomly
- 61. PUPILS (PERRLA) – pupils equal, round, reactive to light and accommodation
- 63. HIPPUS – a rapid constriction and dilation of pupils is the first indication of increasing intracranial pressure.
- 64. • Affected pupil is usually on the same side (ipsilateral) as the brain lesion, whereas the motor and sensory deficits are usually on the opposite side (contralateral) • Observe size, shape and equality of pupils • Reaction to light papillary constriction • Corneal reflex – blink reflex in response to light stroking of cornea • Oculocephalic reflex (doll’s eyes) – present in unconscious patient with intact brainstem
- 66. MOTOR FUNCTION • Muscle size – Inspect major muscle groups bilaterally for symmetry – Inspect the trunk and intercostals and abdominal muscles.
- 67. Muscle strength Five Point Scale – Muscle Strength 5/5 Normal full strength muscle is able to move through full range of motion against the effects of gravity and applied resistance.
- 68. 4/5 Muscle is able to move actively through full range of motion against the effect of gravity with weakness to applied resistance. 3/5 Muscle is able to move actively against the effect of gravity alone
- 69. 2/5 Muscle is able to move with support against the gravity 1/5 Muscle contraction is palpable and visible trace or flicker movement occurs. 0/5 Muscle contraction or movement is undetectable.
- 70. • Muscle tone – assessed while moving each extremity through passive range of motion. – Increased muscle tone – muscle are restless to movement, rigid or spastic – Decreased muscle tone – muscles are soft, flabby or flaccid
- 71. • Muscle coordination – testing rapid alternating movements. Point to point maneuvers and maintenance of truncal balance and head position • Gait and Station – assess by having client stand still. Walk and walk in tandem.
- 72. • Pain – Response seen when painful stimuli are applied, tested by a pin which the patient is pricked over various parts of skin surface – Localization – the client pushes the stimuli away – Flexion – client pulls away from the stimuli – Decorticate posturing (abnormal extension) – indicates damage to the cerebellum – No response – no visible movement to painful stimuli
- 73. • Touch – tested by a cotton wisps on as applicator or by a camel’s hair brush or even by examiners which is brought gingerly and lightly down the skin • Heat and Cold – Patient with eyes closed is asked to identify hot and cold over various parts of the body – Tested by means of test tubes containing hot water and cracked ice.
- 74. REFLEXES • Normal Reflexes – Pupillary reflex – Corneal reflex • Tested by a means of a curved hair attached to a stick enabling the examiner to touch to cornea without stimulating the hair being seen • Result: quick wink reflex.
- 77. –Biceps reflex •Examined by placing the elbow of the arm to be examined in the hand of the examiner. The examiner. The examiners thumb being placed over the biceps tendon and struck briskly with a reflex hammer •Result : Flexion of arms
- 80. Brachial reflex Elicited by the lower third of the radius with the forearm midway between pronation and supination Result: flexion of the forearm on the arm and flexion of the finger and hand
- 81. – Triceps • Taken by holding the arm of the patient supported by the elbow with the arm partly extended, the triceps tendon being tapped by the reflex hammer. • Result: An extension movement of the arm • In supine position: The arm is drawn across the chest, the forearm slightly flexed and the triceps tendon is tapped.
- 83. – Patellar reflex • Taken by tapping the patellar tendon with the leg partly extended • If it is taken in bed, placing a rolled pillow under the knee facilities taking the reflex.
- 86. – Achilles reflex – maybe taken with patient lying on his face, the knees flexed , the feet held in slightly dorsiflexed by the examiners hand and Achilles tendon struck in order to produce plantar flexion.
- 88. –Plantar reflex • Sole of the feet is stimulated with a blunt object carried along its outer and inner sides • Result: Flexion of the toes
- 89. – Abdominal reflex • Running an object along the upper and lower abdominal quadrants on either side. • Result: Movement of the abdominal musculature and a pull of umbilicus toward stimulated side • Medium tension of abdominal muscle – most favourable
- 90. Cremasteric reflex – examined by stimulating the inner side of the thigh.
- 91. Anal reflex – stimulating the perineal skin, results to contraction of the rectal sphincter.
- 92. Gag reflex – gentle stimulation with a tongue blade at the back of the throat and pharynx producing gagging.
- 94. Abnormal Reflexes – indicative of meningeal irritation – Babinski reflex – tested by gently scrapping the sole of the foot with a blunt point: produces dorsiflexion of the great toe and fanning of the other toes – Brudzinski’s sign – flexing the head results pain and involuntary flexion at hip and knee joints – Kernig’s sign – passive extension of the leg with the thigh flexed is restricted and considerably causes pain
- 98. CEREBRAL DYSFUNCTION • APHASIA – loss of language ability • Types: • Expressive or motor – inability to send messages due to damaged Broca’s center – Complete – patient will be unable to formulate any spoken language – Incomplete – words uttered or terms of profanity and vulgarity
- 99. • Receptive aphasia – Inability to comprehend messages received from others and can relate either to written or spoken language – Lesion in posterior or temporal portion of dominant hemisphere • Global aphasia – Loss of all speech function – Destruction of both motor and sensory speech areas in the dominant hemisphere – Seen in occlusion of left carotid or middle cerebral artery, massive cerebral haemorrhage or blood transfusion
- 100. • AGNOSIA – inability to recognize objects due to parietal lobe lesion • Visual agnosia – unable to identify and understand the function of familiar objects he can see. • Tactile agnosia – Due to parietal lobe lesion – Unable to identify and comprehend the use of an object he can touch and manipulate – Test for agnosia: consists of pointing to or placing in the patient’s hand such as object as coin, button, key, safety pin and asking him to name the item and explain what is its use for.
- 101. • APRAXIA – loss of previously acquired ability to perform such simple skilled acts tying one’s shoelace, buttoning a coat, opening and closing a safety pin and fastening a belt buckle.
- 102. CEREBELLAR SYSTEM • ARMS – Finger – nose test • Patient is asked to place the index finger of each hand on the nose • This test may be varied by asking the patient several times quickly to touch the nose in rapid succession.
- 103. • Finger-finger test – Patient is asked to place the index of his hand on the examiner’s index finger – Repeated several times in rapid succession.
- 105. • Pronation – supination test –With the arms extended in front of him, the patient is asked to pronate and supinate rapidly, using the elbow as fulcrum. Under normal circumstances, the movement are of equal amplitude, smooth and even there’s no tendency on the part of the arms to drift outward or inward during the movement –Beat and rhythm are well maintained
- 108. • Patting test – patient requested to pat rapidly with each hand the examiner’s hand or his own leg. Under normal condition this is performed smoothly with even amplitude and a smooth rhythm.
- 109. • LEGS • Heel Test – with the patient in supine position the heel of one foot is placed on the opposite knee. This is done smoothly without tremor and with accuracy. • Heel-toe test – the patient is asked in supine position the heel to toe along a straight line. This can be done normally without faltering or lose balance.
- 112. • TRUNK • Gait • Good method of determining trunk coordination • Patient should be given plenty of room and asked to walk briskly with the eyes open and closed and to turn quickly. • May be asked to walk around a chair, to sit and rise quickly from a chair.
- 113. • Station: tested by asking the patient to stand with the leg close together, first with eyes open then closed. • Tandem Romberg – asked to stand with one feet directly in front of the other.
- 121. EVALUATION OF BRAIN STEM FUNCTIONING • Spontaneous motion of eyes • Oculocephalic reflex (Doll’s Eye) – Doll’s Phenomenon • Eyes deviate conjugately in the direction opposite to head turning. • Tested by briskly turning the head from side to side while holding the eyes open.
- 122. – Normal response if present – normal for eyes to deviate conjugately in the direction opposite to the head turning. – Abnormal response if absent – abnormal movement of the eyes in the same direction as the head is turned.
- 123. • Occulovestibular test – Ice H20 test – done by slowly injecting ice water into the external auditory canal until eye deviation or nystagmus occurs. – Implications – slow conjugate deviation of eyes towards irrigated ear where they remain 30-120 seconds is considered a response of a comatose person with intact brain stem. – Abnormal movement such as jerky movements indicates brain stem lesion .
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