NEUROLOGICAL ASSESSMENT

BSC NURSING III YEAR - MEDICAL SURGICAL NURSING - II

1. NEUROLOGICAL ASSESSMENT Mr. Manikandan.T , RN., RM., M.Sc (N)., D.C.A .,( Ph.D ) Assistant Professor, Dept. of Medical Surgical Nursing, VMCON, Puducherry.

2. HISTORY Health history Symptoms – pain,seizure , dizziness, visual disturbances, muscle weakness, abnormal sensation

3. NEUROLOGICAL ASSESSMENT

4. I. CONSCIOUSNESS AND COGNITION 1. MENTAL STATUS observing the patient’s appearance and behavior, noting dress, grooming and personal hygiene. Posture, gestures, movements, and facial expressions often provide important information about the patient. Assessing orientation to time, place, and person Assessment of immediate and remote memory is also important. Immediate – asking the patient to repeat 6 digit forward & backward Recent – what was the breakfast/ dinner Remote – birthday / childhood

5. 2. INTELLECTUAL FUNCTION A person with an average IQ can repeat seven digits without faltering and can recite five digits backward. The examiner might ask the patient to count backward from 100 or to subtract 7 from 100, then 7 from that, and so forth (called serial 7s). The capacity to interpret well-known proverbs tests abstract reasoning, which is a higher intellectual function. for example, does the patient know what is meant by “a stitch in time saves nine”? assess intellectual capacity - for example, how are a mouse and dog or pen and pencil alike? Can the patient make judgments about situations: for example, if the patient arrived home without a house key, what alternatives are there?

6. 3. THOUGHT CONTENT interview -Are the patient’s thoughts spontaneous, natural, clear, relevant, and coherent? Does the patient have any fixed ideas, illusions, or preoccupations? What are his or her insights into these thoughts? Preoccupation with death or morbid events, hallucinations, and paranoid ideation are examples of unusual thoughts or perceptions that require further evaluation.

7. 4. EMOTIONAL STATUS Is the patient’s affect (external manifestation of mood) natural and even, or irritable and angry, anxious, apathetic or flat, or euphoric? Does his or her mood fluctuate normally, or does the patient unpredictably swing from joy to sadness during the interview? Is affect appropriate to words and thought content? Are verbal communications consistent with nonverbal cues?

8. 5. LANGUAGE ABILITY The person with normal neurologic function can understand and communicate in spoken and written language. Does the patient answer questions appropriately? Can he or she read a sentence from a newspaper and explain its meaning? Can the patient write his or her name or copy a simple figure that the examiner has drawn? A deficiency in language function is called aphasia.

9. 6. IMPACT ON LIFESTYLE The patient’s role in society, including family and community roles.

10. 7.LEVEL OF CONSCIOUSNESS Consciousness is the patient’s wakefulness and ability to respond to the environment. Level of consciousness is the most sensitive indicator of neurologic function. To assess level of consciousness, the examiner observes for alertness and ability to follow commands. GCS

11. II. Cranial nerve exam Tongue depressor Flashlight Sugar and salt samples Watch Cotton-tipped swab Snellen chart Ophthalmoscope Samples of familiar odors Tuning fork

12. Cranial Nerve I: OLFACTORY NERVE . The sense of smell is tested by having the patient occlude one nostril and close his or her eyes. The examiner then takes a non irritating substance and places it near the non occluded nostril. patient is asked to identify familiar odors (coffee, tobacco). Each nostril is tested separately Repeat the process for the opposite side using a different scent.

13. Cranial nerve II: OPTIC NERVE. The optic nerve testing includes assessment of both visual acuity and visual fields. Each eye is examined separately while the patient covers the other one. Visual acuity is tested by having the patient read a snellen chart from 20 feet away Have the patient start with one eye covered and read the lines from top to bottom (largest to smallest letters). Record the lowest line that the patient can read with 50% accuracy.

14. CN III : OCOULOMOTOR NERVE Test for eye movement toward the nose inspect for conjugate movements and Evaluate papillary size and test for pupillary reactivity to light inspect ability to open eyelids.

15. CN IV : TROCHLEAR NERVE Trochlear - Test for upward eye movement inspect for conjugate movements and nystagmus

16. CN V: TRIGEMINAL NERVE. Steps: The trigeminal nerve is the largest of the cranial nerves The patient should have his or her eyes closed during the testing procedure. Touch cotton to forehead, cheeks, and jaw. Sensitivity to superficial pain is tested in these same three areas by using the sharp and dull ends of a broken tongue blade. Alternate between the sharp point and the dull end. Patient reports “sharp” or “dull” with each movement. If responses are incorrect, test for temperature sensation. Test tubes of cold and hot water are used alternately. While patient looks up, lightly touch a wisp of cotton against the temporal surface of each cornea. A blink and tearing are normal responses. have patient clench and move the jaw from side to side. Palpate the masseter and temporal muscles, noting strength and equality.

17. CN VI : ABDUCENS NERVE. Abducens - Test for lateral eye movement 3 cranial nerves are usually tested together because they control the function of the extra ocular eye muscles. The functions include eyelid elevation, constriction of the pupils, and movement of the eye through the six cardinal directions.

18. CN VII: FACIAL NERVE. Sensory test The facial nerve is also a mixed cranial nerve with both sensory and motor components. The sensory component includes the sense of taste on the anterior two- thirds of the tongue. The testing of the sensory component is often deferred, unless changes are noted in the health history interview. When tested, have the patient stick out his or her tongue and test each side separately. The taste is sweet and pleasant, but different from the standard sweet taste. Test ability to discriminate between sugar and salt. Motor : Observe for facial tics. Then, ask the patient to perform the following movements: raise his or her eyebrows, close his or her eyelids tightly, puff out his or her cheeks, smile, and frown. Observe for weakness or asymmetry of muscle movement. Abnormal findings of upper motor neuron lesion, lower motor neuron lesion, or a stroke can cause weakness or paralysis of the facial muscles. Have the patient rinse his or her mouth with water between tests.

19. CN VIII : ACOUSTIC NERVE. T he acoustic nerve has two divisions: cochlear and vestibular. The cochlear division is involved in hearing- Do weber and rinnes test The vestibular division is involved in the sense of balance, which includes equilibrium, coordination, and orientation is space. First, examine the patient’s ear canals for obvious blockages or malformation.

20. CN IX: GLOSSOPHARYNGEAL NERVE Assess patient’s ability to swallow and discriminate between sugar and salt on posterior third of the tongue.

21. CN X: VAGUS NERVE. The glosso pharyngeal and vagus nerves are usually tested together. In the pharynx, CN IX is primarily sensory, and CN X is mostly motor. observe the patient as he or she swallows a small amount of water. Ask if he or she frequently chokes on food or has trouble swallowing. Dysphagia (difficulty swallowing ) can often be seen after neurosurgical procedures or CVA (stroke.) Depress a tongue blade on posterior tongue, or stimulate posterior pharynx to elicit gag reflex. Note any hoarseness in voice. Check ability to swallow. Have patient say “ah.” Observe for symmetric rise of uvula and soft palate

22. XI SPINAL ACCESSORY Assess the trapezius & sternocleidomastoid Trapezius – examiner place the hands on patient shoulder, ask the patient TO shrug his /her shoulder. Observe strength Sternocledoid - examiner place hands on one cheek and ask the patient to turn his/her head against hand as the movement is resisted Repeat the test on opposite Abnormality - CVA

23. CN XII: HYPOGLOSSAL NERVE. The hypoglossal nerve is tested by asking the patient to open his or her mouth, stick out his or her tongue, and wiggle it side to side. While patient protrudes the tongue, note any deviation or tremors. Test the strength of the tongue by having patient move the protruded tongue from side to side against a tongue depressor. The tongue should be midline. Observe for asymmetry, atrophy, or fasciculations . Carotid endarterectomy is a common cause of dysfunction of CN XIII.

24. III. Sensory function

25. SENSATION Tactile sensation is assessed by lightly touching a cotton wisp or fingertip to corresponding areas on each side of the body. The sensitivity of proximal parts of the extremities is compared with that of distal parts, and the right and left sides are compared.

26. PAIN AND TEMPERATURE SENSATIONS Determining the patient’s sensitivity to a sharp object can assess superficial pain perception. The patient is asked to differentiate between the sharp and dull ends of a broken wooden cotton swab or tongue blade; using a safety pin is inadvisable because it breaks the integrity of the skin. Both the sharp and dull sides of the object are applied with equal intensity at all times, and the two sides are compared. Use the hot and cold object for skin to determine the hot and clod sensation.

27. VIBRATION AND PROPRIOCEPTION Are transmitted together in the posterior part of the cord. The handle of the vibrating fork is placed against a bony prominence, and the patient is asked if he or she feels a sensation and is instructed to signal the examiner when the sensation ceases. Common locations used to test for vibratory sense include the distal joint of the great toe and the proximal thumb joint. If the patient does not perceive the vibrations at the distal bony prominences, the examiner progresses upward with the tuning fork until the patient perceives the vibrations. As with all measurements of sensation, a side-to-side comparison is made.

28. POSITION SENSE OR PROPRIOCEPTION May be determined by asking the patient to close both eyes and indicate, as the great toe or index finger is alternately moved up and down, in which direction movement has taken place. Vibration and position sense are often lost together, frequently in circumstances in which all other sensation remains intact.

29. IV. Motor function

30. MOTOR ABILITY A thorough examination of the motor system includes an assessment of muscle size and tone as well as strength, coordination, and balance. The patient is instructed to walk across the room, if possible, while the examiner observes posture and gait. The muscles are inspected, and palpated if necessary, for their size and symmetry. Any evidence of atrophy or involuntary movements (tremors, tics) is noted. Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Resistance to these movements is assessed and documented. Abnormalities in tone include spasticity (increased muscle tone), rigidity (resistance to passive stretch), and flaccidity.

31. MUSCLE STRENGTH Assessing the patient’s ability to flex or extend the extremities against resistance tests muscle strength. The function of an individual muscle or group of muscles is evaluated by placing the muscle at a disadvantage. The quadriceps, for example, is a powerful muscle responsible for straightening the leg. Once the leg is straightened, it is exceedingly difficult for the examiner to flex the knee. If the knee is flexed and the patient is asked to straighten the leg against resistance, weakness can be elicited. The evaluation of muscle strength compares the sides of the body to each other. For example, the right upper extremity is compared to the left upper extremity. Subtle differences in strength may be evaluated by testing for drift. For example, both arms are out in front of the patient with palms up; drift is seen as pronation of the palm, indicating a subtle weakness that may not have been detected on the resistance examination.

32. 5-point scale to rate muscle strength. 5 indicates full power of contraction against gravity and resistance or normal muscle strength; 4 indicates fair but not full strength against gravity and a moderate amount of resistance or slight weakness; 3 indicates just sufficient strength to overcome the force of gravity or moderate weakness; 2 indicates the ability to move but not to overcome the force of gravity or severe weakness; 1 indicates minimal contractile power (weak muscle contraction can be palpated but no movement is noted) or very severe weakness; 0 indicates no movement.

33. COORDINATION Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the patient perform rapid, alternating movements and point-to-point testing. First, the patient is instructed to pat his or her thigh as fast as possible with each hand separately. Then the patient is instructed to alternately pronate and supinate the hand as rapidly as possible. Last, the patient is asked to touch each of the fingers with the thumb in a consecutive motion. Speed, symmetry, and degree of difficulty are noted. Point-to-point testing is accomplished by having the patient touch the examiner’s extended finger and then his or her own nose. This is repeated several times.

34. Coordination in the lower extremities is tested by having the patient run the heel down the anterior surface of the tibia of the other leg. Each leg is tested in turn. Ataxia is defined as incoordination of voluntary muscle action, particularly of the muscle groups used in activities such as walking or reaching for objects. Tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination.

35. BALANCE /ROMBERG TEST Ask the clients stand still with their heels together. Ask the clients to remain still and close their eyes. Result: if the clients loses their balance after standing still with their eye closed. This is positive Romberg.

36. GAIT TESTING To check ability to stand and walk: Ask the patient to walk across the room, turn, and come back towards you. Pay particular attention to, difficult to walk and indicate upper extremities weakness. Difficulty getting up from a chair, Can the patient easily arise from a sitting position. Problems with this activity might suggest proximal muscle weakness, a balance problem, or difficulty initiating movements. Ask the clients to walk on heels is the most sensitive way to test foot dorsiflextion .

37. REFLEX TESTING Biceps reflex Triceps reflex Brachio radialis reflex Patellar reflex Achilles reflex

38. BICEPS REFLEX TESTING: Triceps (C7C8- Radial Nerve): This is most easily done with the client seated. The biceps reflex is elicited by striking the biceps tendon over a slightly flexed elbow The examiner supports the forearm with one arm while placing the thumb against the tendon and striking the thumb with the reflex hammer. The normal response is flexion at the elbow and contraction of the biceps.

39. TRICEPS REFLEX To elicit a triceps reflex, the patient’s arm is flexed at the elbow and positioned in front of the chest. The examiner supports the patient’s arm and identifies the triceps tendon by palpating 2.5 to 5 cm (1 to 2 inches) above the elbow. A direct blow on the tendon normally produces contraction of the triceps muscle and extension of the elbow.

40. BRACHIO RADIALIS With the patient’s forearm resting on the lap or across the abdomen, the brachioradialis reflex is assessed. A gentle strike of the hammer 2.5 to 5 cm (1 to 2 inches) above the wrist results in flexion and supination of the forearm

41. PATELLAR REFLEX TESTING Achilles (s1,s2- Sciatic Nerve): This is most easily done with the clients seated, feet dangling over the edge of the exam table. The patellar reflex is elicited by striking the patellar tendon just below the patella. The patient may be in a sitting or a lying position. If the patient is supine, the examiner supports the legs to facilitate relaxation of the muscles (see Fig. 60-13C). Contractions of the quadriceps and knee extension are normal responses.

42. ACHILLES REFLEX TESTING To elicit an Achilles reflex, the foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon This reflex normally produces plantar flexion. If the examiner cannot elicit the ankle reflex and suspects that the patient cannot relax, the patient is instructed to kneel on a chair or similar elevated, flat surface. This position places the ankles in dorsiflexion and reduces any muscle tension in the gastrocnemius . The Achilles tendons are struck in turn, and plantar flexion is usually demonstrated

43. BABINSKI REFLEX: The clients may either sit or lies supine. Use the handle end of your reflex hammer, which is solid and comes to a point. Start at the lateral aspects of the foot, near the apply gentle, steady pressure with the end of the hammer as you move medial, stroking across this area. A well-known pathologic reflex indicative of central nervous system disease affecting the corticospinal tract

44. SUPERFICIAL REFLEXES The corneal reflex : using a clean wisp of cotton and lightly touching the outer corner of each eye on the sclera. The reflex is present if the action elicits a blink. A stroke or brain injury might result in loss of this reflex, either unilaterally or bilaterally. The gag reflex is elicited by gently touching the back of the pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other. Positive response is an equal elevation of the uvula and “gag” with stimulation. Absent response on one or both sides can be seen following a stroke The plantar reflex is elicited by stroking the sole of the foot with a tongue blade or the handle of a reflex hammer. Stimulation normally causes toe flexion.

45. DIAGNOSTIC PROCEDURES CT SCAN : Computed tomography (CT) scan is a structural imaging study that uses a computer-based X-ray to provide a cross-sectional image of the brain. A computer calculates differences in tissue absorption of the X-ray beams. The CT produces a three dimensional view of structures in the brain and distinguishes between soft tissues and water. I.V. contrast dye may be used to examine the integrity of the blood – brain barrier. CT is primarily used to detect tumors and inflammatory disorders. Spinal CT scan may be used to evaluate lower back pain due to herniated intervertebral disk or other spinal lesions.

46. Magnetic resonance imaging (MRI) Magnetic resonance imaging (MRI) uses computer generated radio waves and a powerful magnetic field to produce detailed images of body structures including tissues, organs, bones, and nerves. Neurological uses include the diagnosis of brain and spinal cord tumors, eye disease, inflammation, infection, and vascular irregularities that may lead to stroke. MRI can also detect and monitor degenerative disorders such as multiple sclerosis and can document brain injury from trauma.

47. Single photon emission computed tomography (SPECT), A nuclear imaging test involving blood flow to tissue, is used to evaluate certain brain functions. The test may be ordered as a follow-up to an MRI to diagnose tumors, infections, degenerative spinal disease, and stress fractures. As with a PET scan, a radioactive isotope, which binds to chemicals that flow to the brain, is injected intravenously into the body, Areas of increased blood flow will collect more of the isotope. As the patient lies on a table, a gamma camera rotates around the head and records where the radioisotope has traveled. That information is converted by computer into cross-sectional slices that are stacked to produce a detailed three-dimensional image of blood flow and activity within the brain. The test is performed at either an imaging center or a hospital.

48. Angiography Angiography is a test used to detect blockages of the arteries or veins. A cerebral angiogram can detect the degree of narrowing or obstruction of artery or blood vessel in the brain, head, or neck. It is used to diagnose stroke and to determine the location and size of a brain tumor, aneurysm, or vascular malformation. This test is usually performed in a hospital outpatient setting and takes up to 3 hours, followed by a 9- to 8- hour resting period. The patient, wearing a hospital or imaging gown, lies on a table that is wheeled into the imaging area. While the patient is awake, a physician anesthetizes a small area of the leg near the groin and then inserts a catheter into a major artery located there.

49. Lumbar puncture Sampling of cerebrospinal fluid (CSF) via lumbar puncture is crucial for accurate diagnosis of meningeal infections and carcinomatosis . CSF analysis is also helpful in evaluating patients with central or peripheral nervous system demyelinating disorder and with intracranial hemorrhage particularly when imaging studies are inconclusive.

50. Purpose To diagnose central nervous system infections, subarachnoid hemorrhages, and many other neurologic pathologies.

51. Equipment Needed Spinal or lumbar puncture tray (specifically the items listed below) Sterile gloves Manometer Three-way stopcock Sterile dressing Antiseptic solution with skin swabs sterile drape 1% Lidocaine 3-cc syringe 20 – and 25 gauge needle 20 – and 22 gauge spinal needle Four plastic test tubes, numbered 1 to 4, with caps.

52. Technique Obtain informed consent from the patient or next of kin. Obtain a CT scan of the head or perform a fundoscopic exam to check for papilledema . It is absolutely necessary to rule out increased intracranial pressure before proceeding. Locate the L3 – L4 space. To do this, find the iliac crests and move your fingers medially from the crests to the spine. Mark the entry site with your thumbnail or a marker. Open and prepare the spinal tray in a sterile manner.

53. Complications Post- spinal puncture headache Brain herniation Bloody tap (may lead to hematoma) meningitis

54. Post-procedure care: Send the four tubes for the following labs: Tube 1, bacteriology: Gram stain, culture and sensitivity, acid-fast bacilli, fungal cultures and stains, cell count (compare with tube 3 to differentiate traumatic tap from subrachnoid hemorrhage). Tube 2, biochemistry: glucose, protein, and electrophoresis (if working up for multiple sclerosis to detect oligoclonal banding). Tube 3, hematology: cell count with differential . Tube 4, special studies if needed: VDRL ( neurosyphilis ), India ilk ( cryptococcus neoformans .)

55. Electroencephalgraphy (EEG) Eletroencephaloghaphy is the recording and measurement of scalp potential in orders to evaluate baseline brain funtioning as well as paroxysmal brain electrical activity suggestive of a seizure disorder. An EEG is performed by securing 20 electrodes to scalp at prodetrmined locations based on an international system theta uses standardized percentage of the head circumferences, the 10-20 . Each elector is labelled using a letter and a number, the letter identifying the skull region (FP= Fronttopolar , F=frontal, P=parietal, T=temporal, O=Occipital, V=vertex) and the number the specific location, with odd numbers representing the left sided electrodes.

56. Nerve Conduction Study (NCS) A Nerve conduction study is the recording the measuring of the compound nerve and muscle action potentials elicited in response to an electrical stimulus. to perform a motor NCS, a surface (activate) electrode is placed over the belly of a distal muscle that is innervated by the nerve is question,

57. Repetitive stimulation study The repetitive stimulation study is a method of measuring electrical conduction properties at the neuromuscular junction. To perform a RSS a surface recording electrode is placed over a muscle belly and the nerve innervating that muscle is electrically stimulated with a superamaximal stimulus at a certain frequency.

58. Electromyography Electromyography is the recording and study of insertional , spontaneous and voluntary electrical activity of muscle. This test allows one to physiologically evaluate the motor unit, including the anterior horn cell, peripheral nerve and muscle.

59. Evoked potentials Evoked potentials are ways of measuring conduction velocities fro sensory pathways in the central nervous system by means of computer averaging techniques. Three types of evoked potentials are routinely performed; visual, brain stem auditory, and somatosensory evoked responses. Pattern reversals visual evoked responses(PVER) Brain stem auditory evoked responses (BAER)