ASSESSMENT OF NEUROLOGICAL FUNCTION MICHELLE GARDNER RN, MSN

OBJECTIVES Review the structures and functions of the central and peripheral nervous systems Describe the significance of physical assessment to the diagnosis of neurologic dysfunction. Describe diagnostic tests used for assessment of suspected neurologic disorders and related nursing implications Describe the needs of patients with various neurologic dysfunctions

NEUROLOGIC OVERVIEW Central nervous system (CNS) - brain and spinal cord Peripheral nervous system - cranial/spinal nerves - autonomic nervous system Basic functional unit neuron

Function of the Nervous System Control all motor, sensory, autonomic, cognitive, and behavioral activities

NEURON

NEUROTRANSMITTERS

Central Nervous System The Brain cerebrum brain stem cerebellum

Protective Structures

Spinal Cord

Peripheral Nervous System Include Cranial nerves Spinal nerves Autonomic nervous system

CRANIAL NERVES

Dermatome Distribution

Autonomic Nervous System (ANS) Functions to regulate activities of internal organs and to maintain and restore internal homeostasis. Sympathetic NS - “fight or flight responses Parasympathetic NS - controls most visceral functions - serves to conserve and restore the energy stores in the body

Neurological Assessment Health history History of the present illness-DETAILS Review the medical records Input from witness/family member

Neurological Assessment Common symptoms Pain Seizures Dizziness/vertigo Visual disturbances Muscle weakness Abnormal sensations

Diagnostic Evaluation CT scan (Computer Tomography) MRI (Magnetic Resonance Imaging) PET (Positron Emission Tomography) Cerebral angiography Electroencephalography (EEG) Electromyography (EMG) Lumbar puncture – analysis of CSF

CT scan

CT Scan Computer – assisted x-ray of multiple cross sections of the brain to detect problems hemorrhage, brain atrophy, infection, tumor and other abnormalities. Contrast media may be used Assess for contraindications to contrast media shell fish/iodine/dye allergy Explain appearance of scanner Instruct client to remain still during the procedure. Evaluate renal function

Magnetic Resonance Imaging

Magnetic Resonance Imaging (MRI) Imaging of brain, spinal cord  by means of magnetic energy. Used to detect strokes, tumors, seizures, trauma Not an invasive procedure Has greater contrast in images of soft tissue structures than CT scan. Contrast media may be used to enhance images. Screen client for metal parts

Electroencephalography -EEG

Electroencephalography -EEG Electrical activity of the brain is recorded by scalp electrodes to evaluate seizure disorders, cerebral diseases, brain death. Procedure is noninvasive and without danger of electrical shock. Medication may be withheld Resume medication and wash electrode paste out of hair after the test.

Cerebral Angiography

Cerebral Angiography X-ray visualization of intracranial/extracranial blood vessels viewed to detect vascular lesions and tumors of the brain. Contrast medium is used/explain procedure. Assess client for stroke risk before procedure Monitor neurological signs and VS Report any neurological changes

Electromyography

Electromyography EMG Electrical activity associated with nerve and skeletal muscle is recorded by insertion of needle electrodes to detect muscle and peripheral nerve disease. Inform client that pain and discomfort may be associated with procedure  insertion of needles.

Lumbar Puncture

Lumber Puncture Cerebrospinal fluid analysis CSF is aspirated by needle insertion in L3-4 or L4-5 interspace to assess many CNS diseases Client assumes and maintains lateral recumbent position Ensure strict aseptic technique Post procedure- headache CONTRAINDICATED with patients with ICP

Consciousness Person is aware of self and the environment and is able to respond appropriately to stimuli Full consciousness requires both alertness and full cognition

Altered LOC - Altered LOC is not a disorder but the result of a pathology Full consciousness Confusion Disorientation Obtundation Coma

Pathophysiology A-E-I-O-U = Alcohol, Epilepsy, Insulin, Opium, Uremia TIPSS = Tumor, Injury, Psychiatric, Stroke, Sepsis

LOC – Assessment Assess verbal response and orientation Alertness Motor responses Respiratory status Eye signs Reflexes Posturing Glasgow Coma Scale Client is at risk for alterations in every body system

Decorticate Posturing Decerebrate Posturing

Interdisciplinary Care Must begin immediately Focus identify the underlying cause preserve function prevent deterioration

Diagnostic Procedures CT scan/MRI EEG Cerebral angiography Laboratory tests - blood glucose - electrolytes - ABG - liver function test - toxicology screening

Potential Complications Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Deep vein thrombosis (DVT) Contractures

Ineffective Airway Clearance Assess/monitor Positioning to prevent obstruction of upper airway—HOB elevated 30° Suctioning, and CPT Monitor ABG analysis

Impaired Physical Mobility Frequent turning; use turning schedule Passive ROM Use of splints, foam boots, trochanter rolls, and specialty beds as needed Clean eyes with cotton balls moistened with saline Use artificial tears as prescribed

Risk for Imbalanced Nutrition - Assess swallowing/gag reflex Monitor and report manifestations of aspiration Provide interventions to prevent aspiration Monitor nutritional status Assess the need for alternative methods of nutritional support - collaboration dietitian

Communication/Family Support Encourage the family to talk to and touch patient Maintain normal day/night pattern of activity Orient the patient frequently Note: When arousing from coma, a patient may experience a period of agitation; minimize stimulation at this time Allow family to ventilate and provide support to them Reinforce and provide consistent information to family Referral to support groups and services for family

Increased Intracranial Pressure Skull is like a closed box  (3) essential volume components - brain tissue (80%) - blood (12%) - cerebrospinal fluid (8%) These components equal a state of equilibrium and produce ICP. ICP measured in the lateral ventricles  normal pressure 10-15mmHg. 15mmHg being the upper limit.

Increased Intracranial Pressure Monroe-Kellie hypothesis A state of equilibrium exist: if the volume of any of the three components increases, the volume of the others must decrease to maintain normal pressures within the cranial cavity . Brain tissue has limited space to expand, compensation is accomplished by - displacing/shifting CSF, - increasing the absorption/diminishing the producing CSF - decrease cerebral blood volume

Increased Intracranial Pressure Sustained elevated pressure within the cranial cavity Caused by – head trauma, tumors stroke hemorrhage infection *cerebral edema

Increased Intracranial Pressure Compensatory mechanism that compensate for increased ICP  autoregulation and decreased production/flow of CSF . Autoregulation – the brain’s ability to change the diameter of the blood vessels to maintain a constant cerebral blood flow.

Increased Intracranial Pressure ICP is increased by: Endotracheal or oral tracheal suctioning Coughing Blowing nose forcefully Head of bed less than 30 degrees Increased intra-abdominal pressure(restrictive clothing, Valsalva)

Increased Intracranial Pressure Clinical Manifestations Early sign – change in LOC Motor responses Vision & pupils Vital signs Other

Clinical Manifestations - late Cushing’s triad: bradycardia, severe hypertension, bradypnea projectile vomiting further deterioration of LOC stupor to coma decortication, decerebration respiratory abnormalities Cheyne-Stokes breathing Headache

Brain with intracranial shifts

Increased Intracranial Pressure Diagnostic studies CT scan/MRI Serum Osmolality ABG’s

Increased Intracranial Pressure Complications Brain stem herniation Diabetes inisipidus Syndrome of inappropriate antidiuretic hormone (SIADH)

Complications Brain Stem Herniation Displacement of brain tissue from its normal compartment  presses down on the brain stem. results in cessation of blood flow to the brain  irreversible brain anoxia and brain death Lethal complications of IICP

Complications Diabetes Insipidus decreased secretion of antidiuretic hormone (ADH) S/S  excessive urine output, decrease urine osmolality treatment  administer fluids, replace electrolytes, vasopressin therapy – desmopressin (DDAVP)

Complications Syndrome of inappropriate antidiuretic hormone (SIADH) increased secretion of ADH S/S – volume overload, diminished urine output, serum sodium concentration decreased treatment – fluid restriction (< 800mL/day – with no free water)

Increased Intracranial Pressure Medical Management Goal  to relieve the increased ICP, decrease cerebral edema, lower the volume of CSF or decrease cerebral blood volume Medication ICP monitoring

Medication Osmotic Diuretics Mannitol (Osmitrol) Loop diuretics Furosemide (Lasix) Other Neuromuscular blocking agents Antipyretics Antihypertensive Antiulcer

ICP Monitoring Continuously assess ICP, the effects of medical therapy and nursing interventions Identify increased pressure early on before cerebral damage occurs. ICP monitoring can be done with the use of: - intraventricular catheter - subarachnoid screw/bolt - epidural probe Insertion and care of any ICP monitoring device requires surgical aseptic technique – to reduce the risk of infection

ICP Monitoring

ICP Monitoring

Nursing Diagnosis/Interventions Assessment History of events leading up to the present illness Pertinent medical history Neurologic examination - evaluation of mental status - cranial nerve function - monitoring of vital signs - reflexes - sensory/motor function

Ineffective Tissue Perfusion - Cerebral Assess for and report manifestations of IICP Monitor if patient on ventilator Monitor ABG’s Teach patient at risk - interventions to avoid Monitor bladder distention and bowel constipation Plan/schedule nursing care Provide quiet environment Maintain fluid restriction