An

indication of how patient is functioning as a whole and how the patient is adapting to the environment 1.General appearance 2.State of consciousness

Arousal component Content component

3.Mood and effect-changes in the nervous system 4.Thought content 5.Intellectual capacity

I. Comprehensive History Taking Demographic Data Current health Past health history Medication history Growth and development Family health history Psychosocial history

II.V/S III. Mental Status Assessment LOC Orientation Memory Mood/affect Intellectual performance Judgment/Insight Language/communication

IV. Motor System Assessment muscle strength, tone, coordination, gait and station movement V. Sensory Function - superficial sensation, touch/pain, temperature, proprioception, discrimination VI. Reflex Activity VII. Cranial Nerve Testing

 Unilateral

neglect (lack of caring of the other side of the body); strokes involving middle cerebral artery. Poor hygiene and grooming: dementing disorders Abnormal gait and posture: transient ischemicattacks(TIAs) , strokes, and Parkinsons disease Emotional swings, personality changes: strokes

 Aphasia-defective

or absent language function: TIAs, strokes involving anterior/posterior artery; general term for impairment of language Dysphonia- change in tone of voice Dysarthria- (different in speaking); is indistinctness of words in word articulation resulting from interference with the peripheral speech mechanisms (e.g. muscles of the tongue, palate, pharynx, or lips) Decreased level of consciousness Confusion, Coma

Cranial I (Olfactory): Anosmia lesions of frontal lobes impaired blood flow to middle cerebralartery.

Cranial II (Optic) blindness in eye: strokes of internal carotid artery, TIAs Homonymous hemianopia - impaired vision or blindness in one side of both eyes; blockage of posterior cerebral artery. Impaired vision: strokes of anterior cerebral artery; brain tumors

Note: Visual acuity - mediated by the cones of the retina Field of vision or peripheral vision portion of space in which objects are visible during the fixation of vision in one direction. The receptors for peripheral fields are the rod neurons of the retina

Cranial nerve III, IV, VI (Oculomotor, Trochlear, Abducens)-motor nerves that arise from the brainstem Nystagmus - involuntary eye movement; strokes of anterior, inferior, superior, cerebellar arteries Constricted pupils: may signify impaired blood flow to vertebrobasilar arteries. Ptosis (eyelid falldown); dropping of the upper eyelid over the globestrokes of posterior inferior cerebellar artery; myasthenia gravis, palsy of CN III

 Oculomotor

nerve superior rectus, inferior rectus, medial rectus, inferior oblique Trochlear nerve superior oblique Abducens lateral rectus

 Cranial

nerve V (Trigeminal)largest cranial nerve with motor and sensory components: changes in facial sensations; impaired blood flow to carotid artery Decreased sensation of face and cornea on same side of body; strokes of posterior inferior cerebralartery Lip and mouth numbness Loss of facial sensation: contraction of masseter and temporal muscles, lesions CN V Severe facial pain: trigeminal neuralgia (tic douloureux

Cranial VII (Facial nerve)mixed nerve concerned with facial movement and sensation of taste Loss of ability to taste Decreased movement of facial muscles Inability to close eyes, flat nasolabial fold, paralysis of lower face, inability to wrinkle the forehead Eyelid weakness; paralysis of lower face; paralysis of upper motor neuron Pain, paralysis, sagging of facial muscles: affected side in Bells palsy

 Cranial

VIII (Acoustic)composed of a cochlear division related to hearing and a vestibular division related to equilibrium Decreased hearing or deafness: strokes of vertebrobasilar arteries or tumors of CN VIII

 Cranial

IX (Glossopharyngeal) and cranial X (Vagus)chief function of cranial nerve IX is sensory to the pharynx and taste to the posterior third of tongue; cranial nerve X is the chief motor nerve to the soft palatal, pharyngeal and laryngeal muscles
1.Dysphagia (difficulty swallowing) 2.Unilateral loss of gag reflex

 Cranial

XI (Spinal accessory)motor nerve that supplies the sternocleidomastoid muscle and upper part of trapezius muscles
1.Muscle weakness 2.Contralateral hemiparesis: strokes affecting middle cerebral artery and internal artery

 Cranial

XII (Hypoglossal)

1.Atrophy, fasciculations (twitches): LMN disease 2.Tongue deviation toward involved side of the body

 Muscle

atrophy: LMNs disease Tremors (groups, large of muscle fibers)Parkinsons disease (tremors at rest), multiple sclerosis (tremors observed in activity) Fasciculations (single muscle fiber): disease or trauma to LMN, side effects of medications, fever, sodium deficiency, anemia

 Flaccidity

(decreased muscle tone): disease or trauma to LMN and early stroke Spasticity (increased muscle tone): disease of corticospinal motor tract Muscle rigidity: disease of EP motor tract Cogwheel rigidity (muscular movement with small regular jerky movement; Parkinsons disease

 Muscle

weakness-in arms, legs, hands: TIAs Hemiplegia-paralysis of half of body vertically Flaccid paralysis: strokes of anterior spinal artery, multiple sclerosis or myasthenia gravis Total loss of motor function: below level of injury Spasticity of muscle: incomplete cord injuries

 Ataxia

(lack of coordination and clumsiness of movement, staggering, wide-based and unbalanced gait) Steppage gait (client drags or lifts foot high, then slaps foot onto floor; inability to walk on heels; disease of LMN Sensory ataxia (client walks on heels before bringing down toes and feet are held wide apart; gait worsens with eyes closed)

 Parkinsonian

gait (stooped over position while walking with shuffling gait with arms held close to the side) Rombergs test (Positive)-With feet approximated,the patient stands with eyes open and then closed;if closing the eyes increases the unsteadiness, aloss of proprioceptive control is indicated

 Hyperactive:

reflexes Decreased reflexes Clonus of foot (Hyperactive, rhythmic dorsiflexionand plantar flexion of foot) Superficial reflexes (such as abdominal) andcremasteric reflex Positive Babinski reflex (dorsiflexion of big toe)

 pain,

resistance, flexion of hips and knees when head is flexed to chest with the client supine

 Positive

Kernigs sign-excessive pain when examiner attempts to straighten knees with client supine and knees and hips flexed

 also

called decorticate response, decorticate rigidity, flexor posturing, or, colloquially, mummy baby arms flexed, or bent inward on the chest, the hands are clenched into fists, and the legs extended and feet turned inward A person displaying decorticate posturing in response to pain gets a score of three in the motor section of the Glasgow Coma Scale. indicates damage to areas including the cerebral hemispheres, the internal capsule, and the thalamus, midbrain

 also

called decerebrate response, decerebrate rigidity, or extensor posturing the head is arched back, the arms are extended by the sides, and the legs are extended; hallmark of decerebrate posturing is extended elbows A person displaying decerebrate posturing in response to pain gets a score of two in the motor section of the Glasgow Coma Scale (for adults) and the Pediatric Glasgow Coma Scale (for infants). indicative of more severe damage; damage below the red nucleus

 Requires:
1.

2.

Arousal: alertness; dependent upon reticular activating system (RAS); system of neurons in thalamus and upper brain stem Cognition: complex process, involving all mental activities; controlled by cerebral hemispheres

Processes that affect LOC: a) Increased ICP b) Stroke, hematoma, intracranial hemorrhage. c) Tumors d) Infectionse e) Demyelinating disorders

 Hypoglycemia
F/E

imbalance Accumulated waste products from liver or renal failure Drugs affecting CNS: alcohol, analgesics, anesthetic Seizure activity: exhausts energy metabolites

The single most valuable indicator of neurological function is the individual's level of consciousness.You can legally describe the patient's condition in the nursing notes by saying, "appears to be" alert or lethargic or so forth. Alert. The patient is awake and verbally and motorally responsive . Lethargic. The patient is sleepy or drowsy and will awaken and respond appropriately to command . Stupor. The patient becomes unconscious spontaneously and is very hard to awaken . Semi coma. The patient is not awake but will respond purposefully to deep pain . Coma. The patient is completely unresponsive .

 Increased

stimulation required to elicit respo More difficult to arouse; client agitated and confused when awakened Orientation changes: loses orientation to time first, then place, then person. Continuous stimulation required to maintain wakefulness. Client has no response, even to painful stimulation stimulation.

Loss of normal reflex functioning:

Dolls

eye movement: eye movement in opposite direction of head rotation (normal function of brainstem) Oculocephalic reflex: eye move upward with passive flexion of neck; downward with passive neck extension (normal function) Oculovestibular response (cold caloric testing): instillation of cold water in ear canal cause nystagmus (lateral tonic deviation of eyes) toward stimulus (normal function)

ASSESS GRADE OF BEST MOTOR RESPONSE (Max score 6) 6 Carrying out request ('obeying command') 5 Localizing response to pain. 4 Withdrawal to pain - pulls limb away from painful stimulus. 3 Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs 2 Extensor posturing to pain - stimulus causes limb extension 1 No response to pain.

ASSESS GRADE OF BEST VERBAL RESPONSE (Max score 5) 5 Oriented - patient knows who & where they are, and why, and the year, season & month. 4 Confused conversation - patient responds in conversational manner, with some disorientation and confusion. 3 Inappropriate speech - random or exclamatory speech, no conversational exchange. 2 Incomprehensible speech - no words uttered, only moaning. 1 No verbal response.

EYE OPENING (Max score 4) 4 Spontaneous eye opening. 3 Eye opening in response to speech - that is, any speech or shout. 2 Eye opening in response to pain. 1 No eye opening. TOTAL SCORE ...... / 15 RECORD YOUR FINDINGS You may record your findings on a specific CNS chart.

a)
b) c) d) e)

Client follows verbal commands Pushes away purposely from noxious stimuli Movements are more generalized and less purposeful(withdrawal, grimacing) Reflexive motor response. Flaccid with little or no motor response

 Permanent

condition of complete unawareness of self and environment, death of cerebral hemispheres with continued function of brainstem and cerebellum
does not respond meaningfully to environment but has sleep-wake cycles and retains ability to chew, swallow and cough

Client

 Eyes

may wander but cannot track objects

Minimally

conscious state: client aware of environment, can follow simple commands, indicates yes/no responses; make meaningful movements (blink, smile)

Often

results from severe head injury or global anoxia

 Client

is alert and fully aware of environment; intact cognitive abilities but unable to communicate through speech or movement because of blocked efferent pathways from brain Motor paralysis but cranial nerves may be intact allowing client to communicate through eye movement and blinking Occurs with hemorrhage or infarction of pons, disorders of lower motor neurons or muscles

 Cessation

and irreversibility of all brain

functions General criteria:

a) b) c) d) e)

Absent motor and reflex movements Apnea Fixed and dilated pupils No ocular responses to head turning and caloric stimulation Flat EEG

 Ineffective

airway clearance: limit suctioning to <10-15 seconds, hyperoxygenate Risk for aspiration Risk for impaired skin integrity: preventive measures, continual inspection Impaired physical mobility: maintain functionality of joints, physical therapy Risk for Imbalanced Nutrition: Less thanbody requirements Anxiety (of family)

 Increased

blood volume, increased brain volume, increased CSF volume Normal pressure: 5-15 mmHg, with pressure transducer with head elevated 30;60-180 cmH20,water manometer with client lateral recumbent

 Sustained
a) b) c) d) e) f)

increases associated with:

g)

Cerebral edema Head trauma Tumors Abscesses Stroke Inflammation Hemorrhage

 Hypercapnea,

hypoxemia Cerebral vasodilating agents Valsalva maneuver; coughing or sneezing Body positioning (prone, neck flexion, extreme hip flexion)

 Isometric

muscle contraction Emotional upset; noxious stimuli Arousal from sleep Clustering of activities Pain and agitation

Cranial insult Tissue edema Increased ICP

Compression of blood vessels

Decreased cerebral blood flow

Decreased oxygen with brain cell death

Edema around necrotic tissue

Increased ICP with brainstem and respiratory center compression

Carbon dioxide accumulation Vasodilation Increased ICP

DEATH
Pathophysiology:
pressure results to lack of oxygen and blood supply

 Decreasing

level of sensorium most sensitive, reliable and earliest indicator: due to cerebral hypoxia, interference with RAS function Increasing BP, decreasing pulse Pupillary changes (a reflection of tissue shifts Cushings triad-increasing systolic pressure, widening pulse pressure and bradycardia (final compensatory mechanism to maintain CSF)

 Papilledema

due to the compression of

optic disc Respiratory changes dependent on site of pressure Motor changes-dependent on site of pressure; usually starts contralaterally; then hemiplegia, decortication or decerebation depending on pressure on brain stem
Late

signs: coma, apnea, unilateral pupil changes

 Osmotic

diuretics increases osmolarity of blood and draw fluid from edematous brain and tissue into vascular bed Loop diuretics such as furosemide Antipyretics or hypothermia blanket: used to control increases in cerebral metabolic rate Anticonvulsants to manage seizure activity

 Histamine

H2 receptors to decrease risk of stress ulcers Barbiturates: may be given as continuous infusion to induce coma and decrease metabolic demands of injured brain Vasoactive medicine may be given to maintain blood pressure to cerebral perfusion

 include

removal of brain tumors burr holes insertion of drainage catheter or shunt to drain excessive CSF

 Continuous

intracranial pressure monitor is used for continual assessment of ICP and to monitor effects of medical therapy and nursing interventions Risk of infection exists with invasive procedure

 Ineffective

tissue perfusion Risk for infection: open head wounds and intracranial monitor device requires meticulous aseptic technique Anxiety (family)