cns assess.pptx glasgow coma scale, cranial nerves

neurological assessment

1. SEMINAR ON NEUROLOGICAL EXAMINATION

2. GENERAL OBJECTIVE: At the end of the seminar, students will be able to gain depth of knowledge to perform neurological examination. SPECIFIC OBJECTIVES: At the end of the seminar students will be able to- Review anatomy and physiology of nervous system. Describe the method of obtaining of health history. Discuss the mental status examination. Know about assessment of cranial nerves and the motor functions. Explain the assessment of sensory function. To demonstrate the techniques to examine reflexes. To discuss about the diagnostic evaluation.

3. ANATOMY AND PHYSIOLOGY The neurologic system is divided into the central nervous system (CNS), the peripheral nervous system (PNS), and the autonomic nervous system (ANS). Through complex and coordinated interactions, these three parts integrate all physical, intellectual, and emotional activities. Understanding how each part works is essential to conducting an accurate neurologic assessment. Central nervous system The CNS includes the brain and spinal cord. These two structures collect and interpret voluntary and involuntary motor and sensory stimuli. This illustration shows a cross section of the brain and spinal cord, which together make up the central nervous system (CNS). The brain joins the spinal cord at the base of the skull and ends near the second lumbar vertebrae. Note the H-shaped mass of gray matter in the spinal cord. Autonomic nervous system The ANS contains motor neurons that regulate the activities of the visceral organs and affect the smooth and cardiac muscles and the glands. It consists of two subsystems sympathetic nervous system, which controls fight-or-flight reactions. Parasympathetic nervous system, which maintains baseline body functions, such as breathing, heart rate, digestion, and metabolism.

4. THE NEUROLOGICAL EXAMINATION OBTAINING A HEALTH HISTORY Demographic Data Personal profile or brief description of client Current health : Chief Complaint Obtain a detailed description of the events that have led the client to seek care. Avoid suggesting manifestations to the client, and use open-ended questions. Allow clients to describe the problem in their own words and try not to interrupt Clinical Manifestations

5. Past history: Because many chronic diseases can affect the neurologic system. Ask the patient about his past health. Inquire about major illness, recurrent minor illnesses, accidents or injuries, surgical procedures, and allergies. Family history Dietary Habits Social History Allergies Ask the client about food and drug allergies, especially to antibiotics, shellfish, and IV contrast dye. Medications .

6. PHYSICAL EXAMINATION The physical examination intended to detect abnormalities in neurologic functioning. A suggested sequence for the physical examination is as follows: Vital signs Mental status Assessment of head, neck and back Cranial nerve function Sensory function Motor function Reflexes Autonomic nervous system

7. Vi tal s ig n s Assess vital signs first because neurologic disorders can cause life-threatening changes. Clients who have cervical spinal cord injuries exhibit a classic triad of hypotension, bradycardia, and hypothermia related to the loss of sympathetic nervous system function. Changes in vital signs can accompany the late stages of increased intracranial pressure (ICP) in an attempt to preserve brain tissue. Cushing's response consists of elevated systolic blood pressure, widened pulse pressure, and bradycardia. Respiratory rate and rhythm can be altered by increased ICP on the brain stem.

8. Assessing mental status Level of consciousness Orientation Memory Mood and affect Intellectual performance Judgment and insight Appearance and behavior Level of consciousness Alert :- Follows commands and responds completely and appropriately to stimuli Stuporous :- requires vigorous stimulation for a response Lethargic :- is drowsy; has delayed responses to verbal stimuli; may drift off to sleep during examination

9. Orientation Time- what year is this? Place and event where are you? Person-what is your name? Memory Long term memory:- by asking birth date, historical date, past health history Short term memory:- what brings you here today? What you ate for breakfast? Mood and affect Facial expression may reveal emotions such as anxiety, distrust, and depression. Is the client's affect appropriate to the situation? Intellectual performance Intellectual performance consists of the fund of knowledge and calculation ability. Ask the client to identify commonly known people, places, or current events.

10. Judgement and insight Judgment and insight include reasoning, abstract thinking, problem solving, and the client's perception of the situation. Assess reasoning, abstract thinking, and problem solving for indications of major problems with thought content. Listen to how the client answers questions. Can the client concentrate and remain focused, or is the client easily distracted? Appearance and behaviour Note how the patient behaves, dresses, and grooms himself. Are his appearance and behavior inappropriate? Is his personal hygiene poor? If so, discuss your findings with the family to deter mine whether this is a change. Even subtle changes in a patient's behavior can signal a new onset of a chronic disease or a more acute change that involves the frontal lobe. Speech Next, listen to how well the patient can express himself. Is his speech fluent or fragmented? Note the pace, volume, clarity, and spontaneity of his speech. To assess for dysarthria (difficulty forming words), ask him to repeat the phrase "No ifs, ands,

11. ASSESSMENT OF HEAD NECK AND BACK Inspection Inspect the head for size, shape, contour and symmetry. Note any ecchymosis (bruising) around the eyes or behind the ears (battle's sign), drainage of blood, CSF or both from the ears and eyes. Palpation Palpate skull for nodule or masses and to supplement inspection findings. Skull normally feels smooth and firm. Palpation of neck muscle identify masses or tender areas. Ask client to flex the neck with chin touching the chest and look for nuchal rigidity which is manifestation of meningeal irritation. Palpate spine alignment, note any deviation from normal curvature. Percussion Gentle percussion over the spinous process may produce pain or tenderness which are abnormal findings. Auscultation Auscultation of major neck and other vessels may reveal bruits or other sounds suggesting an abnormality. Use of bell of stethoscope to auscultate the carotid arteries.

12. Assessing sensory function Sensory system evaluation involves checking five areas of sensation: Pain Light touch Vibration Position Discrimination. Pain: - To test the patient for pain sensation, have him close his eyes, then touch all the major dermatomes, first with the sharp end of a safety pin and then with the dull end. Proceed in this order: fingers, shoulders, toes, thighs, and trunk. Ask him to identify when he feels the sharp stimulus. If the patient has major deficits, start in the area with the least sensation, and move toward the area with the most sensation to help you determine the level of deficit. Responses to Painful Stimuli

13. Assessing motor function Muscle size Inspect for symmetry, hypertrophy and atrophy. Muscle tone Muscle tone represents muscular resistance to passive stretching. To test arm muscle tone, move the patient’s shoulder through passive ROM exercises. You must feel slight resistance. Then let the arm drop to the patient's side. It should fall easily. To test leg muscle tone, guide the hip through passive ROM exercises; then let the leg fall to the bed. The leg should not fall into an externally rotated position; this is an abnormal position. Muscle strength

14. CEREBELLUM Cerebellar testing looks at the patient's gait , coordination, general balance, rapid alternative movements, truncal balance and movements. Gait : With cerebellar dysfunction, the patients will have a wide-based, unsteady gait. Deviation to one side may indicate a cerebellar lesion on that side. Ask the patient to walk heel to toe, and observe, his balance. Then perform Romberg's test

15. Co-ordination Test extremity coordination by asking the patient to touch his nose and then touch your outstretched finger as you move it. Have him do this faster and faster. His movements should be accurate and smooth.

16. ASSESSING REFLEXES Evaluating reflexes involves testing deep tendon and superficial reflexes and observing for primitive reflexes. Deep tendon reflexes The key to testing deep tendon reflexes is to make sure the patient is relaxed and the joint is flexed appropriately. First, distract the patient by asking him to focus on a point across the room. Always test deep tendon reflexes by moving from head to toe and comparing side to side. S U P E R F I C I AL R E F LE X E S DEEP TENDON REFLEXES

17. Achille’s reflex

18. AUTONOMIC NERVOUS SYSTEM The autonomic nervous system cannot be examined directly. The autonomic nervous system innervates many body organs through sympathetic and parasympathetic pathways; thus its function is evaluated by a full body systems assessment. Clinical manifestations of autonomic nervous system disorders occur in many body systems. The following are examples of activity under autonomic nervous system influence: Increased or decreased heart rate Peripheral vasoconstriction or vasodilation Bronchoconstriction or Broncho dilatation Increased or decreased peristalsis Constriction or dilatation of pupil. Review medications of the client is taking. Many medications have side effects involving the parasympathetic or sympathetic nervous system.

19. Diagnostic Testing Non-Invasive test of structure Skull and Spinal X-Ray Studies Skull x-ray studies reveal the size and shape of the skull bones, suture separation in infants, fractures or bony defects she size and shape of the skull bres , dislocation, compressions, curvature, erosion, narrowed spinal cord canal, congenital malformations. Computed Tomography Computed tomography (CT) uses a computer to recon-struct a cross-sectional image The primary purpose of CT scanning is to detect inmorterial bleeding, space-occupying lesions, cerebral edema, and shifts of brain structure. Magnetic Resonance Imaging Magnetic resonance imaging (MRI) combines radiofrequency (RF) waves and magnetic fields to provide more anatomically detailed pictures than are available with CT MRI is the scan of choice for congenital brain malformations and spinal cord lesions. Electroencephalogram An electroencephalogram (EEG) is a measurement of the electrical activity of the superficial layers of the cerebral cortex. The electrical potentials from neuron activity within the brain are recorded in the form of wave patterns. The EEG may be used In the operating room to monitor cerebral activity during surgery on the blood vessels in the head or neck. Absence of waves on the recording ("flat lines") may be one of the criteria for defining brain death.

20. Evoked Potential Studies Evoked potential (EP) studies measure evoked potentials or the brain's electrical response to various stimuli. EP studies can be used to assess blind- ness, deafness, and brain stem injury. Evoked potential studies are carried out in the same fashion as EEG stud- ies . Neuropsychological Testing Neuropsychological testing involves a series of tests to evaluate cortical function by localizing the area and the extent of impairment and determining the rate of progression or recovery eg. Wechsler Adult Intelligence Scale. Magnetic Resonance Spectroscopy Noninvasive MRI method of studying the distribution of chemicals or molecules in the body. Functional Magnetic Resonance Imaging Similar to MRI, functional magnetic resonance imaging (MRI) uses a strong magnet and radiofrequency waves to produce an image. Positron Emission Tomography Positron emission tomography (PET) enables visualization of physiologic function in body areas. It is used on visualisations, indepilepsy and to chart the progress of Alzheimer's disease, diagnosis of stroke, bread injury, schizophrenia, and bipolar disorder. Noninvasive Tests for Vascular Abnormalities The noninvasive tests described here are useful in assessing cerebrovascular disorders. *Doppler Ultrasonography *Doppler Scanning

21. Invasive Tests Lumbar Puncture : In a lumbar puncture (LP), also known as a spinal tap, a needle is inserted into the subarachnoid space in the lumbar region of the spine below the level of the spinal cord. CSF can be withdrawn or substances can be injected into this space. Myelography : A myelogram is an x-ray study in which contrast material is injected into the subarachnoid space to examine the spinal canal. Cerebral angiography : A cerebral angiogram consist of injection of contrast material into an artery to visualize intracranial circulation. Digital venous angiography Computerized digital video subtraction system allows visualization of vascular structure. A central venous line is necessary to inject the contrast medium. Muscle of nerve biopsy: Obtaining specimen by open incision or needle biopsy.

22. Summary : Assessment of neurologic system includes: Review of anatomy and physiology of nervous system Obtaining heath history and Mental status examination Assessment of head, neck and back Assessing cranial nerve function , sensory function and motor function Assessment of reflexes Autonomic nervous system Diagnostic testing for neurological disorders.

23. Conclusion: A thorough physical examination including history with focus on neurological examination helps the nurse in nursing assessment and formulation of diagnosis. An accurate and timely neurological examination performed by a nurse can pick up the changes in patients, which often prove crucial in areas like emergency department and critical care units. Practicing the examination and examining the practice makes one confident and skilled in the neurological examination.

24. Research studies: 1) Abstract Background: In the era of the fourth industrial revolution, there is a requirement of innovative strategies to enhance nursing students’ learning transfer. Virtual Reality Simulation Problem- Based Learning (VRS-PBL) has been validated to be an advantageous strategy that can improve knowledge, clinical performance, and self-efficacy. We aimed to identify the effectiveness of VRS-PBL for improving nursing students’ neurologic examination. Results: Compared with the control group, the academic self-efficacy (t = −2.80, P = .007) and neurological examination performance (t = −11.62, P < .001) of the nursing students increased significantly in the experimental group. On the other hand, there was no significant difference between the two groups of the transfer motivation (t = −1.76, P = .082). Conclusion: The nursing students integrated the knowledge and skills learned through VRS-PBL, and improved the effectiveness and efficiency of their learning. VRS-PBL that reflects various clinical situations can be used as a foundation for establishing effective teaching strategies to improve nursing competency from novice to expert nurses. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC10612552/?report=abstract

25. Bibliography : ●Joyce M. Black, Jane Hokanson Hawks, Textbook of Medical Surgical Nursing Clinical Management for Positive Outcomes, First South Asia Edition, Volume II, ELSEVIER Publication, Page No.- 1773-1797 Brunner and Suddharth, Textbook of Medical Surgical Nursing. 13th Edition, Volume II. Wolter Kluwer Publication, Page No.- 1909-1917 Lippincott, Textbook of Assessment 4th Edition, Wolter Kluwer Publication Page No- 104-131 Lippincott, Textbook of Manual of Medical Surgical Nursing, Wolter Kluwer Publication K Sembulingam , Textbook of Essentials of Medical Physiology, 6th Edition, Jaypee brother publication, Page No.844-856 https://images.app.goo.gl/FPmv1jsw4FAnPksdA https://www.canstockphoto.com/human-brain-anatomy-diagram-48996036.htm https://images.app.goo.gl/FPmv1jsw4FAnPksdA https://images.app.goo.gl/oi46inQpSqFyFNzm8 https://images.app.goo.gl/DwsL3NrX26RYsUWd6 https:/ /www . osmosis.org/answers/dysmetria https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201860/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8463407/ https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC10612552/?report=abstract