Neurological Assessment & Diagnostic Studies

NET 2420 Neuro Lecture Handout S. Compton RN, MSN

Nursing History
Current Health History
Headaches, memory and concentration, visual disturbances, hearing, balance, dizzy spells, speech, muscle strength, abnormal sensations

Past Health History

Head injury, spinal cord injury, surgery, seizures

Family History
Neurological diseases, headaches, HTN, stroke, DM

Social History and Habits

Diet, vitamin deficiencies, ability to read or concentrate, exposure to toxins or chemicals, alcohol or drug use, sexual difficulties, sleep problems

Medication History-neuro as well as all others

Complete Neurological Assessment 5 Components

Cerebral Function Cranial Nerve Function: I-XII Cerebellar and Motor Function Sensory System Reflexes

Neuro Check
Level of consciousness (LOC) Pupil response and size Verbal responsiveness Extremity strength and movement Vital signs Establishing BASELINE and regularly reevaluating key indictors reveals trends and detects changes warning signs of problems

Cerebral Function
Level of consciousness: Level of arousal: Subcortical RAS Alert lethargic unresponsive Auditory tactile painful stimuli to elicit response Level of orientation: Cortex activity Person, place, time Speech Quality: Clear, slurred Verbal responses appropriate or nonsensical Ability to understand and follow commands Awareness of and difficulties with communication

Cerebral Function:
Verbal Responsiveness and Speech
Dysarthria: difficulty with mechanics of speech Aphasia: TEMPORAL-receptive Inability to understand or process speech Wernickes Auditory: spoken word Visual: written word FRONTAL-expressive Inability to form or use language Brocas Area Spoken OR written or BOTH GLOBAL: both receptive and expressive

Mini-Mental State
Widely used tool Assesses only cognitive abilities
LOC, abstract reasoning, arithmetic calculations, writing ability, memory and judgment

Objective score based on results

Cranial Nerves (CNs)

Smeltzer & Bare Table 60-5 p 1837
CN I- Olfactory CN II- Ophthalmic CN IIIOcculomotor* CN IV- Trochlear* CN V- Trigeminal CN VI- Abducens* CN VII- Facial CN VIIIVestibulocochlear CN IXGlossopharyngeal CN X- Vagus CN XI- Spinal Accessory CN XII- Hypoglossal

Cranial Nerve I
Olfactory nerve (sensory)
Vulnerable to damage in frontal head, basilar, and facial injuries Performed one nostril at a time Able to correctly identify smells

Cranial Nerve II
Optic nerve (sensory)
Visual acuity, visual fields, ophthalmic exam of retinal structures Area and extent of visual field loss depends on location of problem

Visual Field Defects

Cranial Nerve III

Oculomotor nerve (motor) Elevation of eyelid Muscles of eye (with IV and VI) Assess pupil size, shape, response to light and accommodation parasympathetic inervation Assesses midbrain Normal response: PERRLA-> pupils equal round reactive to light and accommodation
How do you test for accommodation? If PERRL, usually no need to test

CN III, CN IV, CN VI
Oculomotor, trochlear, abducens nerves (motor) Assess EOMs Assesses midbrain and pons

CN V: Trigeminal Nerve (sensory and motor)

Sensory: three branches: Opthalmic, Maxillary, Mandibular Motor: Muscles of mastication Palpate temporal and masseter muscles Open mouth symmetry Corneal reflex ? Contact wearers

CN VII: Facial Nerve (sensory and motor)

Sensory: taste to anterior 2/3 of tongue Motor: Facial expression and secretion of saliva Wrinkle forehead, raise and lower eyebrows, smile and show teeth, puff cheeks, close eyes Observe for symmetry UMN problems vs. facial nerve paralysis

CN VIII: Acoustic Nerve (sensory)

Vestibulocochlear nerve: Hearing (cochlear) and balance (vestibular) Testing: Tuning Fork: Weber and Rinne tests Weber: tuning fork to center of forehead: NORMAL: hear equally in both ears RINNE: tuning fork to mastoid process then auditory canal NORMAL: hear air conduction 2X as long as bone (Rinne positive)

CN IX and CN X
Glossopharyngeal and Vagus Sensory and motor Assess together Taste posterior 1/3 of tongue Swallowing, gag reflex Movement of pharynx (ahhhhh) Assesses medulla

CN XI: Spinal Accessory Nerve

Motor Shrug shoulders trapezius Turn head sternocleidomastoid

CN XII: Hypoglossal Nerve

Motor Tongue movements, strength Speech sounds: d, l, n, t

Motor Assessment
Assess muscle strength, tone, size
Observe for decreased fine motor movements Finger grasp, arm strength Compare side to side

Can indicate UMN problems:

Degenerative cerebral disease, trauma or ischemia

Can indicate LMN disease:

Problems within spinal cord: cord compression or injury

Cerebellar Function
Balance:
Tandem, heel-toe walking Romberg test (feet together, eyes closed)

Coordination:
Rapid alternating movements Finger to nose to finger test Heel down shin

Cerebellar Function: Abnormal Findings

Ataxia: incoordination of voluntary muscle action Dysdiadochokinesia: inability to do rapid alternating movement Dysmetria: past pointing Positive Rombergs sign
Pt sways badly or loses balance positive Romberg sign If cerebellar, pt sways with eyes open or closed If proprioceptive ( posterior columns) patient OK with eyes open

Gait Disturbances
A. Spastic Hemiparesis B. Spastic Paresis (Scissors Gait) C. Foot Drop D. Sensory Ataxia (+ Rombergs eyes closed) E. Cerebellar Ataxia (+ Rombergs eyes open or closed) F. Parkinsonian

Deep Tendon Reflexes Assessing Spinal Cord Level

Biceps C5C6 Brachioradialis C5C6 Triceps C7C8 Abdominal T8T9T10 Patellar (knee-jerk) L2L3L4 Achilles S1S2

Grading Reflexes
Grade 0-4+
0 reflex absent 2+ normal 4+ CLONUS UMN disease

Compare side to side Many variations Patient must be relaxed

Superficial Reflexes
Graded as PRESENT or ABSENT Corneal Reflex (CN V)
Present Brisk blink Loss in stroke, coma, CONTACT WEARERS EYE PROTECTION

Gag Reflex (CN X)

Present Elevation of uvula bilaterally Loss in stroke ASPIRATION PRECAUTIONS

Plantar Reflex: Babinski Response

Stroke lateral aspect of sole of foot NORMAL response plantar FLEXION BABINSKI response pathological in adult POSITIVE BABINSKI: Dorsiflexion of great toe with fanning of other toes Indicates upper motor neuron disease

Grasp Reflex: Significance

COMA: Stimulation of palm of hand
POSITIVE: Pt will grasp firmly Will not let go to command Indicates frontal lobe damage, thalamic degeneration, cerebral atrophy

Sensory Function
Assessing dorsal columns or parietal lobe Light touch, position sense, vibration Stereognosis: able to identify object placed in hand Graphesthesia Extinction: touch one or both sides of body Two point discrimination Spinothalamic tracts and parietal lobe Pain and temperature Sharp or dull

Gerontologic Considerations
Smeltzer & Bare p 1841 Structural changes Decreased conduction Muscle atrophy Diminished reflexes Sensory alterations Mental status changes BUT.CANNOT ATTRIBUTE NEUROLOGIC CHANGES TO AGE WITHOUT THOROUGH ASSESSMENT!!!!

Anatomical Planes

Skull and Spinal X-rays

C-spine films routinely ordered in multiple trauma to rule out cervical fracture X-rays used to evaluate skull, spinal abnormalities, pituitary tumor Frequently ordered to evaluate low back pain

Computerized Tomography
Cross sectional images brain and spine using radiation and computer More specific views of bone and tissue than X-rays Useful in detecting tumors, hemorrhages, hematomas, ventricular enlargement May be used with IV contrast enhancement

CT: Patient Preparation

Pt must be as motionless as possible Confused combative client/ pediatric considerations If contrast used: ?? allergies to shellfish NPO for 4 hours prior to test IV started in radiology (if not already in place) Should remove wigs, hairpins, clips and jewelry interfere with image seen Test should take 30-60 minutes Post-test: resume diet and encourage fluids if IV contrast used

PET Scan
Images of actual organ functioning Inhaled or injected radioactive substance Shows metabolic changes
Alzheimers Brain tumors O2 uptake after stroke

MRI: Nursing Considerations

Use of electromagnet and radio waves Check patient history!! PATIENTS WHO CANNOT HAVE MRI: Pacemakers Metal implants, plates, screws, or clips (old aneurysm surgeries!) IUDs, metal heart valves SAFETY: IV pumps, portable oxygen tanks cannot be in scan area Patient Preparations and teaching: No metals: jewelry, credit cards, eyemakeup Process takes 45 minutes to 1 hour pt. must lie still MRI machine makes loud beating noise Closed MRI: tight space: problems with claustophobia? May need Valium pre-test/ some cannot tolerate

Cerebral Angiography
Injection of contrast medium into cerebral circulation Useful in detecting cause of stroke, headaches, seizures Femoral access most commonly used vessel Risk: stroke

Cerebral Angiography:
Procedure & Patient Preparation
Injection of contrast medium into cerebral circulation
Useful in detecting cause of stroke, headaches, seizures

NPO solids 6-10 hours Clear liquids/ water encouraged 24 hours prior Assess PT/ PTT Stop anticoagulants prior to test (usually) Contrast dye precautions/ informed consent Patient AWAKE; slight sedation Femoral puncture mark peripheral pulses Burning or flushing with contrast injection expected Procedure will take 1-2 hours http://www.heartcenteronline.com/myheartdr/common/ artprn_rev.cfm?filename=&ARTID=560

MR Angiography (MRA)
Utilization of MR technology to view vasculature Same restrictions as MRI May use contrast material (gadolinium) but is not iodine based

Myelogram
Injection of contrast medium into subarachnoid space x-ray visualization Useful for visualizing obstructions within spinal canal
Dye bathes nerve roots any compressin of nerve roots visualized Helpful in diagnoses of herniated discs and spinal cord tumor

Patient Preparation
Inpatient procedure/ 23 HR Consent form NPO 4-8 hours prior Probably mild sedation given; IV started Lumbar puncture in radiology CSF aspirated Either water based (Amipaque) or oil based (Pantopaque) dye used Hold phenothiazines (Phenergan), TCAs, SSRIs 48 hours Lower seizure threshhold X-ray table tilted CT performed at end

Post-procedure Care
Amipaque: not aspirated absorbed by body
HOB 30-60 degrees for 24 hours

Pantopaque: aspirated at end of visualization

Patient flat for 24 hours (rarely used)

Quiet activity, little stimulation Push fluids, monitor I and O, BUN, Creatinine BP, RR, pulse temperature monitored May experience nausea, headache should diminish no Phenergan or Compazine! No neck stiffness or confusion should occur

EEG
Amplifies and records electrical activity in brain Uses:
Detecting areas of abnormal or absent brain activity Brain tumors, hematomas, seizure activity Determination of brain death in comatose patient

EEG Preparation Use of Evoked Potentials

Preparation:
Avoidance of caffeine prior to exam No gels, sprays in hair Must be quiet and still as possible

Evoked Potentials:
Auditory, sensory, visual: record brain activity in response to stimuli Diagnostic for various disorders

Electromyography (EMG) and Nerve Conduction Velocities (NCV)

EMG: Needle electrodes inserted into skeletal muscles patient relaxes and contracts various muscles and action potential recorded NCV: Nerve stimulated with electrical impulse Useful in studying patients with cervical or lumbar disc disease, myasthenia gravis, muscular dystrophy (LMN diseases) Patient should be taught to expect some mild discomfort

Lumbar Puncture
Insertion of needle into subarachnoid space between L2 and S1 Withdrawal of small amount CSF for diagnostic evaluation Measurement of CSF pressure Should not be performed if evidence of greatly increased CSF pressure (papilledema)

Lumbar Puncture
Patient preparation:
No diet or fluid restrictions Empty bowel and bladder before Careful instructions regarding cooperation during test Signed consent required

Positioning Chart 60-4 p 1847

Lumbar Puncture
CSF in three labeled tubes Protein and glucose Culture Blood cell counts Post-procedure care: Prone with pillow under abdomen for 1 hr Flat in bed 6-24 hours (30 degrees) Increased fluid intake Observe site for swelling, leakage Observe for post spinal headache

Post-Lumbar Puncture Headache

Most common complication CSF leaks from needle track depleted Increases when patient upright AVOID: use small gauge needle/ keep prone after Treatment: bedrest, analgesics, hydration Persistent: Blood patch

CSF Fluid Analysis

Pressure: Normal: 70-180 mmH2O (5-15mmHg) Increased: SAH, brain tumor, viral meningitis Appearance: clear and colorless Bloody: SAH or traumatic tap (will clear) Cloudy: infection Orange or yellow: RBC breakdown, elevated protein

CSF Fluid Analysis

Cell Count: 0-5 monos and no RBCs
Elevated monos infection, abcess, tumor, infarction, chronic illness (MS) RBCs SAH or traumatic tap

Protein: 15-45 mg/dl

Lower than plasma because of BBB Elevated: infection, tumor, MS, degenerative brain disease

Glucose: 50-75 mg/dl

Elevated: DM or diabetic coma Decreased: acute bacterial meningitis, tumor