1. Assessment and diagnosis of patients with problems related to the nervous system

2. Nervous system disease can affect
Consciousness
Mentation
Movement
Sensation
Integrated regulation eg breathing, circulation, temperature control, elimination, special senses eg eye, ear, nose, throat

3. 1. Health/Nursing History
ASSESSMENT
1. Health/Nursing History
Put patient at ease, consider reliability of patient
Patient to tell own story
Avoid suggesting S & S
History will help in focusing the neurologic examination
Mode of onset and course of illness:
quality
intensity
distribution
duration
frequency of S & S

4. Past History
Medical & surgical eg infections & laminectomies
Injuries e.g. MVA
Medication
Pre-natal and peri -natal problems? Eg exposure to German measles/complication at birth
Growth or development history  milestones met?

5. Personal/Social History
Family History
Neuro problems may be congenital or hereditary e.g. epilepsy/ hydrocephalus
Personal/Social History
Changes in daily living routines?
Appetite, sleep, exercise
Recreation, occupation
Stressors, sexual practices

6. Review other systems
Neuro dysfunction common in system illness e.g. neuropathy related to diabetes mellitus

7. Conduct review of neurological function (Screening purposes)
2. Health Assessment
Conduct review of neurological function
(Screening purposes)
Mentation Function (cerebral function)
Cerebellar Function (screen co-ordination)
Motor Function (Movement)
Sensory Function (Sensation)
Integrated regulation
Coping aspects

8. Important Points
Symmetry of function and findings on both sides of body is important to note
Always compare one side with the other
Integrate with examination of other systems

9. State of consciousness Memory Cognition Affect (mood)
Examination
Mental status
State of consciousness
Memory
Cognition
Affect (mood)
Ideational content (hallucinations)

10. Appearance
Height, weight, grooming, clothing, posture, gait
Behavior & Psychomotor activity
Movement, nail biting, agitation
Attitude towards interviewer/people
Co-operative, eye contact, guarded
Speech
Rate of production – rapid Quality – stutter

11. Responsiveness to environment
Reduced?
Ability to carry out orders
Protrusion of tongue, put finger on nose
Mood
“I feel" Tone of voice
Emotional expression
Your observation

12. Appropriateness
Laughing but feels sad
Anxiety – patient description
“I’m a nervous wreck
Observation
Tremor, sweating
Productivity
Overabundance, poverty

13. Nature of thoughts
Content
Associative processes
How thoughts are linked, loosening of association
Obsessions
What patient is thinking about
Phobias
Fear for people

14. Delusions
False fixed belief
Perceptual disturbances
Hallucination
Time
Time, date, year
Place
State where

15. Person
Own name, family names
Remote memory
Childhood
Recent past
Last 3 months
Recent
Previous days news, breakfast

16. Immediate retention and recall
3 unrelated items, 6 digits forward and then backward
Information & intelligence
Calculate change, state president, provinces, patient background
Concentration
Abstract thinking

17. Judgment
Hit an elderly person
Insight
Understanding
Dreams
About life
Reliability
Medical records, patient doesn’t contradict himself

18. Test in conjunction with skeletal system Test muscle mass, tone,
Cerebellar Function
To screen coordination of voluntary muscular movement, posture and balance
Motor Function
Test in conjunction with skeletal system
Test muscle mass,
tone,
strength,
abnormalities eg twitching

19. Test sensitivity to the following and compare both sides of the body:
Sensory Function
Test sensitivity to the following and compare both sides of the body:
Touch (Cotton)
Pain (pin-prick)
Vibration (tuning fork)
Position

20. Check: Breathing Circulation Temperature control Elimination
Integrated Regulation
Check:
Breathing
Circulation
Temperature control
Elimination

21. EXAMINATIONS:
Neurological examinations
Cerebral angiogram
CAT scan
MRI scan
Electro-encephalogram
Lumber puncture
Myelogram

22. Cranial Nerves
Observation
Ptosis (III)
Facial Droop or Asymmetry (VII)
Hoarse Voice (X)
Articulation of Words (V, VII, X, XII)
Abnormal Eye Position (III, IV, VI)
Abnormal or Asymmetrical Pupils (II, III)

23. Involuntary Movements Muscle Symmetry
Motor
Observation
Involuntary Movements
Muscle Symmetry
Left to Right
Proximal vs. Distal
Atrophy
Pay particular attention to the hands, shoulders, and thighs.
Gait

24. Muscle Tone
Ask the patient to relax.
Flex and extend the patient's fingers, wrist, and elbow.
Flex and extend patient's ankle and knee.
There is normally a small, continuous resistance to passive movement.
Observe for decreased (flaccid) or increased (rigid/spastic) tone.

25. Muscle Strength
Test strength by having the patient move against your resistance.
Always compare one side to the other.
Grade strength on a scale from 0 to 5 "out of five":

26. 2. Cerebral Angiogram

27. Definition 
Cerebral Angiography is an x-ray procedure used to visualize the blood vessels of the neck, head and brain (cerebral = head, angio = blood vessel, graphy = picture).

28. What is it used for? 
This test may be used for evaluating any disease which effects the blood vessels of the head, neck or brain. Most commonly it is used to look for narrowing of the blood vessels in the neck that can be associated with a risk of stroke, or in looking for weak points in the vessels that might cause hemorrhage.

29. Preparation
shower the evening before or morning of testing to ensure skin is clean (the area will be further cleaned with antiseptic solution at the time of the test).
Some medications need to be withheld before the examination because they may interact with the dye - ask for instructions from the radiology.
NPO / light breakfast
Declare any history of asthma, allergies, diabetes mellitus, or any medications,

30. Are there side effects? 
groin areas will be shaved.
Some discomfort when the freezing is injected to numb the area in the groin, Remainder of the test is usually painless.
Injection of the dye = associated with a warm feeling in the head or a metallic taste in the mouth.
Rarely people note flashes of light in their vision.
Serious side effects can include allergic reaction to the dye, bleeding or haematoma at the catheter insertion site or stroke. Bleeding at the insertion site is avoided by firm compression of the site for 15 minutes, application of a tight pressure bandage for several hours, lying with the hip and leg straight for about 6 hours and staying mostly in bed for about 24 hours.

31. 3. CAT scan

32. Definition
Computed Tomography (CT) is a computer assisted X-ray in which two dimensional pictures are obtained of parts of the body. 

33. What is it used for?
computer is able to produce a two dimensional view or 'slice' of the area scanned, allowing a better view of the individual structures.
used to identify any structural abnormality of the tissue including tumors, swelling, strokes, scarring, bleeding, protrusion of discs in the back etc.

34. Preparation
Preparation depends upon the area being scanned. For CT of the brain and spinal column there is usually no preparation.

35. Are there side effects?
Apart from the needle to inject the dye CT scanning is painless.
no adverse reactions to the scan, but there can be rare allergic reactions to the dye.
Inform docter of history of allergies

36. 4. MRI scan

37. Definition
employs powerful magnetic fields and radio waves to produce detailed images of body structures.

38. What's it used for?
Images from MRI are often superior to those from CT scanning,
particularly for soft tissues, brain, spinal cord, joints and the abdomen,
and in certain conditions such as Multiple sclerosis.

39. Preparation
Do not wear any makeup the day of the scan (some brands contain metal components).

40. Are there side effects?
painless procedure with no side effects.
involves a magnetic field it can not be done on people who have any implanted devices such as a cardiac pacemaker, a cerebral aneurysm clip, a neuro stimulator or an implanted hearing aid.
presence of fragments or shrapnel in the body would have to be excluded for the MRI to be done.
persons subject to claustrophobia  or unable to lie flat for an extended period of time may not be able to tolerate a scan. 

42. 5. Electro-encephalogram
Definition
Electroencephalography measures the electrical activity of the brain derived from leads (electrodes) on the scalp.

43. What is it used for?
primarily in the diagnosis and monitoring of seizures and epilepsy.
It is also useful in other circumstances including sleeping disorders, encephalitis (inflammation of the brain),
some metabolic or chemical disturbances of the brain and
in recognizing large structural abnormalities such as tumors.

44. Preparation
usually no preparation needed and the test itself is painless. 
The electrodes that are placed on the scalp are often glued on with a paste which can be difficult to remove and causes the hair to be messy. A cap or hat to cover the hair is a good idea.
Sometimes the study is done in a 'sleep deprived' or over tired state. This increases the sensitivity of the EEG in picking up seizure activity. In these cases the patient will need to stay up all night without the benefit of any stimulants such as coffee and have the test done first thing in the morning.

45. 6. Lumber puncture

46. Definition
Lumbar puncture (LP) is the insertion of a needle into the sub arachnoid space of the lumbar region for diagnostic or therapeutic purposes.

47. What's it used for?
to obtain a sample of CSF for testing.
identifying infections such as meningitis and encephalitis and in cases where they are suspected must be carried out quickly.
identifying CSF abnormalities in other diseases of the nervous system including multiple sclerosis,

48. Preparation
There is no preparation required. If going home after the test - ensure that the patient has a ride and not drive himself.
The test is usually done with the patient lying on their side, with their knees drawn up and their back arched towards the doctor. This spreads apart the bones between which the needle is passed.
Occasionally it is done in the sitting position or under X-ray guidance.

49. Are there side effects?
There is minor discomfort
Local anesthetic is usually injected before the spinal needle is inserted. 
anxiety - serious side effects are remarkably rare.
most common is headache which occurs in about 40% of people and begins within 48 hours and resolves spontaneously in  less than 5 days. It is typically better with lying flat and worse while standing.

50. 7. Myelogram
What is it?
older test that is still used to examine the spinal canal and spinal cord.
A special dye
myelogram is used only for very special purposes, such as for complicated revision spine surgeries. It is rarely the first test used

51. Why is it done?
unusual indentations or abnormal shapes in the spinal cord.
The myelogram is useful for patients who have metal plates and screws in their spine, which prevents them from having either a CT or MRI scan.

52. What are the limitations?
does not show the soft tissues
shows only the bones and the spinal fluid where the dye has mixed with the fluid.

53. What are the risks?
Myelogram requires a spinal tap - more risks associated with it than most other tests.
meningitis, spinal headache, and allergic reaction to the dye.