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Assessment of Neurologic Function

Assessment of Neurologic Function . Function of the Nervous System. Controls all motor, sensory, autonomic, cognitive, and behavioral activities. Structures of the Neurologic System. Central Nervous System Brain and spinal cord Peripheral nervous system Includes cranial and spinal nerves

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Assessment of Neurologic Function

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  1. Assessment of Neurologic Function

  2. Function of the Nervous System • Controls all motor, sensory, autonomic, cognitive, and behavioral activities.

  3. Structures of the Neurologic System • Central Nervous System • Brain and spinal cord • Peripheral nervous system • Includes cranial and spinal nerves • Autonomic and somatic systems • Basic functional unit—neuron

  4. Neuron

  5. Neurotransmitters • Communicate messages from one neuron to another or to a specific target tissue. • Neurotransmitters can potentiate, terminate, or modulate a specific action or can excite or inhibit a target cell. • Many neurologic disorders are due to imbalance in neurotransmitters.

  6. Brain

  7. Medial View of the Brain

  8. Bones and Sutures of the Skull

  9. Meninges and Related Structures

  10. Arterial Blood Supply of the Brain

  11. Cross Section of the Spinal Cord Showing the Major Spinal Tracts

  12. Cranial Nerves

  13. Dermatome Distribution

  14. Autonomic Nervous System • Functions to regulates activities of internal organs and to maintain and restore internal homeostasis • Sympathetic NS • “Fight or flight” responses • Main neurotransmitter is norepinephrine • Parasympathetic NS • Controls mostly visceral functions • Regulated by centers in the spinal cord, brainstem, and hypothalamus

  15. Anatomy of the Autonomic Nervous System

  16. Neurologic Assessment: Health History • Pain • Seizures • Dizziness (abnormal sensation of imbalance or movement) and vertigo (illusion of movement, usually rotation) • Visual disturbances • Weakness • Abnormal sensations

  17. Neurologic Assessment • Cerebral function; mental status, intellectual function thought content, emotional status, perception, motor ability, and language ability • Note the impact of any neurologic impairment on lifestyle and patient abilities and limitations • Cranial nerves • Motor system; posture, gait, muscle tone and strength, coordination and balance, Romberg test • Sensory system; tactile sensation, superficial pain, vibration and position sense • Reflexes; DTRs, abdominal, and plantar (Babinski)

  18. Techniques Eliciting Major Reflexes

  19. Figure Used to Record Muscle Strength

  20. Gerontological Considerations • Important to distinguish normal aging changes from abnormal changes • Determine previous mental status for comparison. Assess mental status carefully to distinguish delirium from dementia. • Normal changes may include: • Losses in strength and agility; changes in gait, posture and balance; slowed reaction times and decreased reflexes; visual and hearing alterations; deceased sense of taste and smell; dulling of tactile sensations; changes in the perception of pain; and decreased thermoregulatory ability

  21. Diagnostic Tests • Computed tomography(CT) • Positron emission tomography (PET) • Single photon emission computed tomography (SPECT) • Magnetic resonance imaging (MRI) • Cerebral angiography • Myelography • Noninvasive carotid flow studies • Transcranial doppler • Electroencephalography (EEG) • Electromyography (EMG) • Nerve conduction studies, evoked potential studies • Lumbar puncture, Queckenstedt’s test, and analysis of cerebrospinal fluid

  22. Magnetic Resonance Imaging

  23. Management of Patients With Neurologic Dysfunction

  24. Altered Level of Consciousness (LOC) • Level of responsiveness and consciousness is the most important indicator of the patient's condition • LOC is a continuum from normal alertness and full cognition (consciousness) to coma • Altered LOC is not the disorder but the result of a pathology • Coma: unconsciousness, unarousable unresponsiveness • Akinetic mutism: unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes • Persistent vegetative state: devoid of cognitive function but has sleep-wake cycles • Locked-in syndrome: inability to move or respond except for eye movements due to a lesion affecting the pons

  25. Nursing Process: The Care of the Patient with Altered Level of Consciousness—Assessment • Assess verbal response and orientation • Alertness • Motor responses • Respiratory status • Eye signs • Reflexes • Postures • Glasgow Coma Scale

  26. Decorticate Posturing Decerebrate Posturing

  27. Nursing Process: The Care of the Patient with Altered Level of Consciousness— Diagnoses • Ineffective airway clearance • Risk of injury • Deficient fluid volume • Impaired oral mucosa • Risk for impaired skin integrity and impaired tissue integrity (cornea) • Ineffective thermoregulation • Impaired urinary elimination and bowel incontinence • Disturbed sensory perception • Interrupted family processes

  28. Collaborative Problems/Potential Complications • Respiratory distress or failure • Pneumonia • Aspiration • Pressure ulcer • Deep vein thrombosis (DVT) • Contractures

  29. Nursing Process: The Care of the Patient with Altered Level of Consciousness— Planning • Goals may include: • Maintenance of clear airway • Protection from injury • Attainment of fluid volume balance • Maintenance of skin integrity • Absence of corneal irritation • Effective thermoregulation • Accurate perception of environmental stimuli • Maintenance of intact family or support system • Absence of complications

  30. Interventions • A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care. Protection also includes maintaining the patient’s dignity and privacy. • Maintaining an airway • Frequent monitoring of respiratory status including auscultation of lung sounds • Positioning to promote accumulation of secretions and prevent obstruction of upper airway—HOB elevated 30°, lateral or semiprone position • Suctioning, oral hygiene, and CPT

  31. Maintaining Tissue Integrity • Assess skin frequently, especially areas with high potential for breakdown • Frequent turning; use turning schedule • Careful positioning in correct body alignment • 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 • Measures to protect eyes; use eye patches cautiously as the cornea may contact patch • Frequent, scrupulous oral care

  32. Interventions • Maintaining fluid status • Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O. • Administer IVs, tube feedings, and fluids via feeding tube as required—monitor ordered rate of IV fluids carefully. • Maintaining body temperature • Adjust environment and cover patient appropriately. • If temperature is elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow fan to blow over patient to increase cooling. • Monitor temperature frequently and use measures to prevent shivering.

  33. Promoting Bowel and Bladder Function • Assess for urinary retention and urinary incontinence • May require indwelling or intermittent catherization • Bladder-training program • Assess for abdominal distention, potential constipation, and bowel incontinence • Monitor bowel movements • Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated • Diarrhea may result from infection, medications, or hyperosmolar fluids

  34. Sensory Stimulation and Communication • Talk to and touch patient and encourage family to talk to and touch the 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 • Programs for sensory stimulation • Allow family to ventilate and provide support • Reinforce and provide and consistent information to family • Referral to support groups and services for family

  35. Increased Intracranial Pressure • The cranium contain:1400g brain tissue,75ml CSFand 75ml Blood ( these value always in state of equilibrium) • Monro-Kellie hypothesis: because of limited space in the skull, an increase in any one of components of the skull—brain tissue, blood, and CSF—will cause a change in the volume of the others • Compensation to maintain a normal ICP of 10–20 mm Hg is normally accomplished by shifting or displacing CSF • With disease or injury ICP may increase • Increased ICP decreases cerebral perfusion and causes ischemia, cell death, and (further) edema • Brain tissues may shift through the dura and result in herniation • Autoregulation: refers to the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow • CO2 plays a role; decreased CO2 results in vasoconstriction, increased CO2 results in vasodilatation

  36. Brain with Intracranial Shifts

  37. ICP and CPP • CCP (cerebral perfusion pressure) is closely linked to ICP • CCP = MAP (mean arterial pressure) – ICP • Normal CCP is 70–100 • A CCP of less than 50 results in permanent neurolgic damage

  38. Manifestations of Increased ICP: Early • Changes in LOC • Any change incondition • Restlessness, confusion, increasing drowsiness, increased respiratory effort, purposeless movements • Pupillary changes and impaired ocular movements • Weakness in one extremity or one side • Headache—constant, increasing in intensity or aggravated by movement or straining

  39. Manifestations of Increased ICP: Late • Respiratory and vasomotor changes • VS: Increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate; pulse may fluctuate rapidly from tachycardia to bradycardia; temperature increase • Cushing’s triad: bradycardia, hypertension, bradypnea • Projectile vomiting • Further deterioration of LOC; stupor to coma • Hemiplegia, decortication, decerebration, or flaccidity • Respiratory pattern alterations including Cheyne-Stokes breathing and arrest • Loss of brainstem reflexes—pupil, gag, corneal, and swallowing

  40. Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Assessment • Frequent and ongoing neurologic assessment • Evaluate neurologic status as completely as possible • Glasgow Coma Scale • Pupil checks • Assessment of selected cranial nerves • Frequent vital signs • Assessment of intracranial pressure

  41. ICP Monitoring

  42. Location of the foramen of Monro for calibration of ICP monitoring system

  43. Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Diagnoses • Ineffective airway clearance • Ineffective breathing pattern • Ineffective cerebral perfusion • Deficient fluid volume related to fluid restriction • Risk for infection related to ICP monitoring

  44. Collaborative Problems/Potential Complications • Brainstem herniation • Diabetes insipidus • SIADH • Infection

  45. Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Planning • Major goals may include: • Maintenance of patent airway • Normalization of respirations • Adequate cerebral tissue perfusion • Respirations • Fluid balance • Absence of infection • Absence of complications

  46. Interventions • Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway • Position with head in neutral position and elevation of HOB 0–60° to promote venous drainage • Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP • Maintain a calm, quiet atmosphere and protect patient from stress • Monitor fluid status carefully; every hour I&O during acute phase • Use strict aseptic technique for management of ICP monitoring system

  47. Preoperative Care: Medical Management • Preoperative diagnostic procedures may include CT scan, MRI, angiography, or transcranial Doppler flow studies • Medications are usually given to reduce risk of seizures • Corticosteroids, fluid restriction, hyperosmotic agent (mannitol), and diuretics may be used to reduce cerebral edema • Antibiotics may be administered to reduce potential infection • Diazepam may be used to alleviate anxiety

  48. Preoperative Care: Nursing Management • Obtain baseline neurologic assessment • Assess patient and family understanding of and preparation for surgery. • Provide information, reassurance, and support

  49. Postoperative Care • Postoperative care is aimed at detecting and reducing cerebral edema, relieving pain, preventing seizures, monitoring ICP, and neurologic status. • The patient may be intubated and have arterial and central venous lines.

  50. Seizures • Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons • Classification of seizures • Partial seizures: begin in one part of the brain • Simple partial: consciousness remains intact • Complex partial: impairment of consciousness • Generalized seizures: involve the whole brain

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