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NEUROLOGICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT. Presented by: Kenna Olmsted, RN CCRN Jenny Hopkins, RN CCRN. Neurological System. Most organized, complex and challenging body system Controls motor, sensory and “automatic” functions of the body Assessment should be conducted in a systematic, hierarchical approach

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NEUROLOGICAL ASSESSMENT

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  1. NEUROLOGICAL ASSESSMENT Presented by: Kenna Olmsted, RN CCRN Jenny Hopkins, RN CCRN

  2. Neurological System • Most organized, complex and challenging body system • Controls motor, sensory and “automatic” functions of the body • Assessment should be conducted in a systematic, hierarchical approach • Begin assessment with the highest level of function (cerebral cortex) and then move to simplest (reflexes)

  3. Components of Neurological Assessment • Mental Status- LOC considerations • Cranial Nerve Assessment • Motor System • Muscle size, tone, movement, ROM, strength, posturing • Sensory • Perception to pain, temperature, light touch, vibration, position sense • Reflexes • Gait, balance, coordination, deep tendon reflexes, babinski

  4. Neuro Assessment Compromised By: • Language dysfunction • Memory impairment • Reduced level of consciousness • Cognitive deficits • Age and developmental level • Concomitant trauma • Drugs/alcohol • Comorbidities • Cultural Issues

  5. Level of Consciousness • Change in LOC– 1st clue • Orientation to person, place, time and situation • Memory—recent, remote, immediate recall • Thought processes—add, count backwards, determine patient’s understanding of current situation • Mood/affect • Attention span/concentration

  6. Language/Communication • Assess all forms of communication possible • Verbal, written, facial expression • Left hemisphere-primary language center • Right hemisphere- visual-spatial perception, music, processing of information, recognition of faces

  7. Language/Communication • Speech clear----garbled • Dysphasia—impairment of speech as the result of brain lesion • Aphasia • Many types—see handout • Dysarthria—difficult and defective speech due to impairment of the tongue or other muscles essential to speech. Mental function is intact

  8. Abnormal Breathing Patterns • Cheyne-Stokes • Central Neurogenic Hyperventilation • Apneustic Breathing • Cluster Breathing • Ataxic Breathing

  9. Cranial Nerve Assessment • 12 Cranial Nerves • Sensory, Motor or Both • Physician Assessment at this facility • Corneal Reflex/Blink Reflex • Gag/Swallow Reflex

  10. Motor Examination • Strength • Tone • Symmetry • Coordination • Assess for drift • Test against and without resistance • Posturing

  11. Sensory Examination • Superficial Sensation • (pain, touch, temperature, sharp vs. dull) • Mechanical Sensation • (Vibration, Position Sense) • Tactile Discrimination • (Right vs. Left)

  12. Coordination • Rapid alternating movements • Finger-to-nose • Heel-down-shin • Point-to-point

  13. Cerebellar Assessment • Assess balance and coordination • Pronate-supinate hand • Tap index finger to thumb • Romberg • Assesses balance • Indicative of cerebellar damage on the side to which the patient leans

  14. Deep Tendon Reflexes • Upper Extremities • Biceps-C5 • Brachioradialis- C6 • Triceps- C7 • Lower Extremities • Patellar- L4 • Achilles S1

  15. Pathological Reflexes • Indicative of intracranial pathology • Graded as present or absent • Grasp • Snout • Sucking • Rooting • Babinski

  16. GCS—Glasgow Coma Scale • Point system for • Scores range from 3 to 15 • 13-15 Mild • 9-12 Moderate • 8 or less—intubate--severe • Eye Opening • Best Verbal • Best Motor

  17. CVA • Results from sudden impairment of cerebral circulation in one or more blood vessels supplying the brain • Diminished oxygen supply, causes serious damage or necrosis of the brain tissue. • ½ of those who survive will remain permanently disabled • 3rd most common cause of death

  18. CVA- Major Causes • Thrombosis • Narrowing and ultimate occlusion of a vessel by an atherosclerotic plaque • Often will experience TIA before actual stroke occurs • Embolism • Blockage of a cerebral blood vessel by a clot • A-fib issue • Hemorrhage

  19. CVA—Signs/Symptoms • Depend on the cause, location and extent of the insult • Hemorrhagic—sudden onset comes on without warning • Left affects right; right affects left

  20. CVA Effects • Hemiplegia-paralysis on one side of the body • Aphasia • Neglect—inability to recognize the affected side • Dysphagia • Bladder/bowel issues • Hemianopsia-loss of vision toward the hemiplegic side • Ataxia

  21. TIA • Transient ischemic attack • Warning sign of impending thrombotic CVA • Most distinctive characteristics—neurological impairment that lasts from seconds to hours—symptoms resolve within 24 hours

  22. GOAL with TIA • Preventative Treatment • ASA • Heparin (inpatient) • Warfarin • Ticlid

  23. ICP • Pathophysiology • Cerebral Autoregulation • Uncontrolled ↑ICP can lead to irreversible neurological pathology

  24. Headache Nausea/vomiting Amnesia for events Subtle change in LOC Restlessness Drowsy Changes in speech Loss of judgment Seizures Change in pupillary response Papilledema Dilated- Non reactive pupil Unresponsive to verbal or painful stimuli Abnormal posturing Change in respiration rate/pattern CUSHING’s Response Increase systolic B/P Widening pulse pressure Decreased pulse rate Early vs. Late S/S in ↑ICP

  25. S&S ↑ICP in Infants • Bulging Fontanels • Cranial Suture Separation • Increased Head Circumference • High Pitched Cry

  26. IICP Nursing Care Fundamentals • HOB up 30 degrees • Neck midline • Avoid straining/coughing • Avoid suctioning • Seizure precautions • Hyperventilation—controversial • Osmotic/Loop diuretics • Corticosteriods • Anticonvulsants????? • IV fluids---TKO with appropriate solutions

  27. Warning Signs After a Head Injury(First 24 Hours) • Changes in LOC • Drowsiness • Difficult to arouse • Confusion • Seizures • Bleeding or watery drainage from ears/nose • Slurred Speech • Vomiting • Blurred Vision • Loss of sensation to extremity • Pupils slow to react or unequal

  28. Cerebral Hemorrhage • “Worst headache of my life” • Nausea/Vomitting • Delirium • Focal to generalized seizure • Eye deviation • Pinpoint pupils • Decreased LOC • Coma

  29. Guillain-Barre’ Syndrome • Acute, rapidly progressive, potentially fatal • Associated with segmented demyelination of peripheral nerves • Thought to be a cell-mediated, immunological attack on peripheral nerves because of a virus • Symptoms progress in an ascending pattern—lower extremities up the body

  30. Guillian-Barre’ • Progression hours to days • Numbness/Tingling • Muscle weakness, immobility, or paralysis • Muscle stiffness/pain • Sensory loss • Loss of position sense • Diminished or absent deep tendon reflexes • Death usually result of respiratory failure

  31. Alzheimer’s • Progressive degenerative disorder of the cerebral cortex • Degeneration most marked in the frontal lobe • Poor prognosis • Death usually a complication of immobility, aspiration pneumonia

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