1. ASSESSMENT OF NEUROLOGICAL FUNCTION MICHELLE GARDNER RN, MSN

2. 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

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

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

5. NEURON

6. NEUROTRANSMITTERS

7. Central Nervous System
The Brain
cerebrum
brain stem
cerebellum

8. Protective Structures

9. Spinal Cord

10. Peripheral Nervous System
Include
Cranial nerves
Spinal nerves
Autonomic nervous system

11. CRANIAL NERVES

12. Dermatome Distribution

13. 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

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

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

16. 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

17. CT scan

18. 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

19. Magnetic Resonance Imaging

20. 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

21. Electroencephalography -EEG

22. 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.

23. Cerebral Angiography

24. 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

25. Electromyography

26. 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.

27. Lumbar Puncture

28. 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

29. 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

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

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

32. 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

33. Decorticate Posturing Decerebrate Posturing

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

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

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

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

38. 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

39. 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

40. 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

41. 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.

42. 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

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

44. 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.

45. 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)

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

47. 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

48. Brain with intracranial shifts

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

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

51. 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

52. 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)

53. 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)

54. 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

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

56. 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

57. ICP Monitoring

58. ICP Monitoring

59. 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

60. 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