Assessment of nervous system in medical surgical.pptx

Medical surgical nursing

1. NERVOUS SYSTEM The neurologic system is a highly complex system that plays a major role in regulating many body functions.

2. Assessment of patients Assessment of subtle and elusive changes in the complex nervous system can be challenging but as a nurse, it is important that the basic concepts and skills required are acquired Assessment of the nervous system is based on: -history taking -clinical examination -radiographic examination -special investigations

3. History Taking Corroboration of the history by others: Memory loss, aphasia, loss of insight, intoxication, and other factors may impair the patient's capacity to communicate normally with the examiner. It is helpful to obtain additional information from family, friends, or other observers to corroborate or expand the patient's description. Ask the patient about their chief complaint. Common complaints include headaches , motor disturbances (e.g. weakness , paresis, and paralysis), seizures, sensory deviations and an altered level of consciousness

4. History Taking Encourage detailed description of the current condition by asking such questions as: Can you describe your headache? When did you start feeling dizzy? What were you doing when the numbness started? Have you ever had seizures or tremors? Have you ever had weakness or paralysis in your arms or legs? Do you have trouble urinating, walking, speaking, understanding others , reading or writing? How is your memory and ability to concentrate?

5. History Taking Each complaint should be pursued as far as possible to identify the location of the lesion, the likely underlying pathophysiology and potential etiologies .

6. History Taking Temporal course of the illness: It is important to determine the precise time of appearance and rate of progression of the symptoms experienced by the patient Rapid onset of a neurologic complaint, occurring within seconds or minutes usually indicates a vascular event, a seizure or migraine A more gradual onset and less well localized symptoms point to the possibility of a transient ischemic attack

7. History Taking Temporal course of the illness: A gradual evolution of symptoms over hours or days suggests a toxic, metabolic, infectious, or inflammatory process. Progressing symptoms associated with the systemic manifestations of fever, stiff neck, and altered level of consciousness imply an infectious process . Slowly progressive symptoms without remissions are characteristic of neurodegenerative disorders, chronic infections, neoplasms and gradual intoxications.

8. History Taking Patients' descriptions of the complaint : The same words often mean different things to different patients. " Dizziness" may imply impending syncope, a sense of disequilibrium, or true spinning vertigo. " Numbness" may mean a complete loss of feeling, a positive sensation such as tingling, or paralysis.

9. History Taking Family history: Some neurologic disorders have an underlying genetic component. Often necessary in polygenic disorders such as Multiple Sclerosis, migraine, and many types of epilepsy.

10. History Taking Medical illnesses: Many neurologic diseases occur in the context of systemic disorders. Diabetes mellitus, hypertension, and abnormalities of blood lipids predispose to cerebrovascular disease. A solitary mass lesion in the brain may be an abscess in a patient with valvular heart disease, a primary hemorrhage in a patient with a coagulopathy, a lymphoma or toxoplasmosis in a patient with AIDS, or a metastasis in a patient with underlying cancer.

11. History Taking Drug use and abuse and toxin exposure: Inquire about history of drug use, both prescribed and illicit. Aminoglycosides may exacerbate symptoms of weakness in patients with disorders of neuromuscular transmission e.g. myasthenia gravis, and may cause dizziness secondary to ototoxicity. Vincristine and other antineoplastic drugs can cause peripheral neuropathy. Immunosuppressive agents e.g. cyclosporine can produce encephalopathy

12. Clinical examination knowledge of the basics in neurological examination are effective in screening for neurologic dysfunction and are essential for nurses. Neurologic function is assessed in these five broad areas : Mental status Cranial nerve function Sensory function Motor function Reflexes

13. Mental status During the interview, look for difficulties with communication and determine whether the patient has recall and insight into recent and past events. The mental status examination is underway as soon as you begin observing and talking with the patient. If the history raises any concern for abnormalities of higher cortical function or if cognitive problems are observed during the interview, then detailed testing of the mental status is indicated .

14. Mental status Perform a quick screening examination to assess a patient’s mental status. What is your name? what year is it? Where are we? How old are you? Where were you born? What did you have for breakfast? Who is the president of Kenya? Can you count backward from 15 to 2? Use the mental status examination to check these three parameters: LOC speech cognitive function.

15. Mental status Level of consciousness It is the patient's relative state of awareness of self and their environment, and ranges from fully awake to comatose. Always start with a minimal stimulus, increasing intensity as necessary. Try to rouse them by providing an appropriate stimulus in this order: Auditory Tactile Painful

16. Mental status Level of consciousness When the patient is not fully awake, the examiner should describe the responses to the minimum stimulus necessary to elicit a reaction . Alertness- Speak to the patient in a normal tone of voice. An alert patient opens the eyes, looks at you, and responds fully and appropriately to stimuli (arousal intact). Lethargy- Speak to the patient in a loud voice e.g. call the patient’s name or ask “How are you ?” A lethargic patient appears drowsy but opens the eyes and looks at you , responds to questions, and then falls asleep.

17. Mental status Level of consciousness Obtundation - Shake the patient gently as if awakening a sleeper . An obtunded patient opens the eyes and looks at you, but responds slowly and is somewhat confused. Stupor- Apply a painful stimulus. For example, pinch a tendon, rub the sternum , or roll a pencil across a nail bed . A stuporous patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent . The patient lapses into an unresponsive state when the stimulus ceases . There is minimal awareness of self or the environment. Coma- Apply repeated painful stimuli . A comatose patient remains unarousable with eyes closed.

18. Mental status Level of consciousness The Glasgow Coma Scale offers an objective way to assess the patient’s LOC .

19. GCS Score The highest possible score is 15 points. Motor Response Points Obeys a simple response = 6 Localizes painful stimuli = 5 Normal flexion (withdrawal) = 4 Abnormal flexion (decorticate posturing) = 3 Extensor response ( decerebrate posturing) = 2 No motor response to pain = 1 Verbal Response Points Oriented = 5 Confused conversation = 4 Inappropriate words = 3 Responds with incomprehensible sounds = 2 No verbal response = 1 Eye-Opening Points Spontaneous = 4 In response to sound = 3 In response to pain =2 No response, even to painful stimuli = 1

20. Mental status Speech Listen to how well the patient expresses thoughts. Does he choose the correct words, or does he seem to have problems finding or articulating words ? Language is assessed by observing the content of the patient's verbal and written output, response to spoken commands, and ability to read.

21. Mental status Speech To assess for dysarthria (difficulty forming words), ask the patient to repeat the phrase, “No ifs, ands, or buts.” Assess speech comprehension by determining the patient’s ability to follow instructions and cooperate with your examination

22. Mental status Thought content Disordered thought patterns may indicate delirium or psychosis . Assess thought pattern by evaluating the clarity and cohesiveness of the patient’s ideas. Is his conversation smooth with logical transitions between ideas? Does he have hallucinations (sensory perceptions that lack appropriate stimuli ) or delusions (beliefs not supported by reality)?

23. Mental status Insight on insight Find out whether the patient: has a realistic view of himself is aware of his illness and circumstances . Ask, for example, “What do you think caused your chest pain ?” Expect different patients to have different degrees of insight. For instance, a patient may attribute chest discomfort to indigestion rather than acknowledge that he has had a heart attack.

24. Cranial Nerve Examination Cranial nerve assessment reveals valuable information about the condition of the central nervous system (CNS ), especially the brainstem . As a bare minimum, you should check the fundi, visual fields, pupil size and reactivity, extraocular movements, and facial movements. The cranial nerves (CN) are best examined in numerical order, except for grouping together CN III, IV, and VI because of their similar function .

25. Cranial Nerve Examination CN I (Olfactory) With eyes closed, ask the patient to sniff a mild stimulus such as toothpaste or coffee and identify the odorant . CN II (Optic) Check visual acuity (with eyeglasses or contact lens correction) using a Snellen chart or similar tool .

26. Cranial Nerve Examination CN III, IV, VI (Oculomotor, Trochlear, Abducens ) Check pupil size, pupil shape , direct and consensual response to light, and directions of gaze. When assessing pupil size, look for trends such as a gradual change in the size of one pupil or appearance of unequal pupils. To check extraocular movements, ask the patient to keep his or her head still while tracking the movement of the tip of your finger. Move the target slowly in the horizontal and vertical planes; observe any paresis, nystagmus, or abnormalities of smooth pursuit (saccades, oculomotor ataxia, etc.).

27. Cranial Nerve Examination CN V (Trigeminal) Examine sensation within the three territories of the branches of the trigeminal nerve (ophthalmic, maxillary, and mandibular) on each side of the face. Test two sensory modalities derived from different anatomic pathways (e.g . light touch and temperature) is sufficient for a screening examination. Testing of other modalities, the corneal reflex, and the motor component of CN V (jaw clench—masseter muscle) is indicated when suggested by the history.

28. Cranial Nerve Examination CN VII (Facial) Look for facial asymmetry at rest and with spontaneous movements. Test eyebrow elevation, forehead wrinkling, eye closure, smiling, and cheek puff. Be particular about differences in the lower versus upper facial muscles. CN VIII (Vestibulocochlear) Check the patient's ability to hear a finger rub or whispered voice with each ear.

29. Cranial Nerve Examination CN IX, X (Glossopharyngeal, Vagus ) Their innervation overlaps in the pharynx: The glossopharyngeal nerve is responsible for swallowing , salivating , and taste perception on the posterior one-third of the tongue. The vagus nerve controls swallowing and is responsible for voice quality. Listen to the patient’s vocal quality. Then check the gag reflex by touching the tip of a tongue blade against the posterior pharynx and asking the patient to open wide and say “ah.” Watch for the symmetrical upward movement of the soft palate and uvula and the midline position of the uvula.

30. Cranial Nerve Examination CN XI (Spinal Accessory) Check shoulder shrug (trapezius muscle) and head rotation to each side (sternocleidomastoid) against resistance. CN XII (Hypoglossal) Ask the patient to stick out his tongue. Look for any deviation from the midline, atrophy, or fasciculations . Test tongue strength by asking the patient to push his tongue against his cheek as you apply resistance. Repeat on the opposite side . Observe the tongue for symmetry

31. Sensory function Assess the sensory system to evaluate the ability of the: Sensory receptors to detect stimulus Afferent nerves to carry sensory nerve impulses to the spinal cord Sensory tracts in the spinal cord to carry sensory messages to the brain . The five primary sensory modalities—light touch, pain, temperature, vibration, and joint position—are tested in each limb. Light touch is assessed by stimulating the skin with single, very gentle touches of a wisp of cotton . Pain is tested using a new pin, and temperature is assessed using a metal object (e.g . tuning fork) that has been immersed in cold and warm water.

32. Sensory function Vibration is tested using a 128-Hz tuning fork applied to the distal phalanx of the great toe or index finger just below the nailbed. By placing a finger on the opposite side of the joint being tested, the examiner compares the patient's threshold of vibration perception with his or her own. Position- Grasp the patient’s big toe, holding it by its sides between your thumb and index finger, and then pull it away from the other toes so as to avoid friction . Then, with the patient’s eyes closed, ask for a response of “up” or “down” when moving the toe in a small arc.

33. Motor examination It includes observations of muscle appearance, tone, strength, and reflexes. The gait is evaluated separately at the end of the examination . Appearance Inspect and palpate muscle groups under good light and with the patient in a comfortable and symmetric position. Check for muscle fasciculations , tenderness, and atrophy or hypertrophy. Involuntary movements may be present at rest (e.g . tics, myoclonus), during maintained posture (pill-rolling tremor of Parkinson's disease)

34. Motor examination Tone When a normal muscle with an intact nerve supply is relaxed voluntarily , it maintains a slight residual tension known as muscle tone. This can be assessed best by feeling the muscle’s resistance to passive stretch. Persuade the patient to relax. Take one hand with yours and, while supporting the elbow, flex and extend the patient’s fingers, wrist, and elbow , and put the shoulder through a moderate range of motion .

35. Motor examination Tone To assess muscle tone in the legs, support the patient’s thigh with one hand , grasp the foot with the other, and flex and extend the patient’s knee and ankle on each side. Note the resistance to your movements.

36. Motor examination Strength See musculoskeletal system. Use the following terms: Paralysis = no movement Severe weakness = movement with gravity eliminated Moderate weakness = movement against gravity but not against mild resistance Mild weakness = movement against moderate resistance Full strength

37. Motor examination Reflexes Muscle Stretch Reflexes Those typically assessed include the biceps ( C5 , C6), brachioradialis (C5, C6 ), and triceps ( C7 , C8) reflexes in the upper limbs and the patellar or quadriceps ( L3 , L4) and Achilles ( S1 , S2) reflexes in the lower limbs . Reflexes are graded according to the following scale: = absent ; 1 = present but diminished; 2 = normoactive; 3 = exaggerated; 4 = clonus(rhythmic oscillations between flexion and extension)

38. Motor examination Reflexes Cutaneous Reflexes Superficial abdominal reflexes are elicited by gently stroking each side of the abdomen , above (T8, T9, T10) and below (T10, T11, T12) the umbilicus with a sharp object (e.g . a key , the wooden end of a cotton-tipped swab ). Note the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus .

39. Motor examination Reflexes Cutaneous Reflexes To test the plantar reflex , use an applicator stick , tongue blade, reflex hammer handle, or key and slowly stroke the lateral side of the patient’s sole from the heel to the great toe. The normal response in an adult is plantar ( downward) flexion of the toes . Upward movement of the great toe and fanning of the other toes—called Babinski reflex —is abnormal

40. Diagnostic Tests Angiography Angiographic studies of the brain include CT angiography and traditional digital subtraction angiography (DSA). During CT angiography, the technician injects a radiopaque contrast medium into a vessel. This procedure highlights cerebral vessels , making it easier to: Detect stenosis or occlusion associated with thrombus or spasm Identify aneurysms and arteriovenous malformations ( AVMs) Locate vessel displacement associated with tumors , abscesses , cerebral edema, hematomas, or herniation Assess collateral circulation

41. Diagnostic Tests CT spine scanning CT scanning of the spine is used to assess such disorders as herniated disk , spinal cord tumors, spinal stenosis, fractures, subluxations , and distraction injuries . CT brain scanning CT scanning of the brain is used to detect brain contusions, calcifications , cerebral atrophy, hydrocephalus, inflammation, space occupying lesions (tumors, hematomas, and abscesses), vascular anomalies (AVM, aneurysms, infarctions, and blood clots), foreign bodies , and bony displacement

42. Diagnostic Tests Magnetic resonance imaging MRI generates detailed pictures of soft tissue structures . MRI can reveal structural abnormalities associated with such conditions as transient ischemic attack (TIA), tumors, multiple sclerosis , cerebral edema, and hydrocephalus .

43. Diagnostic Tests Spinal radiographs Anteroposterior and lateral spinal X-rays can be ordered when spinal disease is suspected or when injury to the cervical , thoracic , lumbar, or sacral vertebral segments exists . Spinal X-rays are used to detect spinal fracture; displacement and subluxation; and destructive lesions, such as primary and metastatic bone tumors

44. Diagnostic Tests Lumbar puncture A procedure where a sterile needle is inserted into the subarachnoid space of the spinal canal, usually between the third and fourth lumbar vertebrae . Lumbar puncture is used to: Detect blood and bacteria in cerebrospinal fluid (CSF) Obtain CSF specimens for laboratory analysis Measure intraspinal pressure Relieve increased ICP by removing CSF.