Nursing 4 Lecture 8 Abnormal Neuro Assessment

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  1. What are the components of a Neuro exam?
    • -Vital Signs
    • -Mental status & LOC
    • -Cranial Nerves
    • -Motor function: easiest way to check is to get up and walk
    • -Sensory function
    • -Reflexes: general nurses do NOT do alot of reflexes

    It is best if nurses do a neuro assessment with an off coming nurse to know what documentation stands so you will be aware of ANY changes

    *Must make sure you inspect the head and neck
  2. Vital Signs:
    • Abnormal Findings:
    • -Alterations in BP
    • -Initially systemic hypertension: increased HR & increased CO
    • ---Widening pulse pressure occurs with increased intracranial hypertension and decompensation of cerebral autoregulation
    • -Stimulation of medulla and vagus nerve results in bradycardia
    • -Sympathetic stimulation: increased HR and potential for tachy dysrhythmias

    • Increased intracranial pressure causes increased BP: swelling of the brain causes increase pressure, as the pressure increases brain perfusion is compromised,
    • causes autonomic response to raise blood pressure to perfuse the brain.

    Low BP in head trauma is usually a terminal event.

    Pulse is decreased as a result of the increased ICP.

    Increased ICP can cause RR to increase, decrease of become irregular. Not as useful as other VS in monitoring head injury because it can be affected by fear, hysteria, chronic illness, chest injuries, spinal cord injuries.
  3. Mental Status:
    -Loss of early memory tends to be an early sign of neurologic problems

    *Young adults are unfamiliar with abstract statements

    • Includes Evaluating:
    • Congitive Processes
    • Memory
    • Speech
    • -Aphasia
    • -Dysphasia
    • -Dysphonia
    • -Dysarthria

    Orientation: person place time

    Ability to learn: three words to remember, repeats them after you immediately and then at different intervals in the interview.

    Mood/Affect: is affect appropriate to the situation, what is the mood, is this their normal demeanor. We tend to explain this away.

    Intellectual performance: ability to indentify commonly known people, objects, places, current events, reversed serials (count backwards in 3’s or 7’s), simple addition or subtraction.

    Judgment/insight reasoning: are the answers logical? do they relate to the question? What would you do if you lost you house keys? Explain a proverb “a rolling stone gathers no moss.”

    Speech and communication: evaluate for flow, choice of words, and completion of sentences, evaluate expression, comprehension of spoken word(ability to follow commands, stick out your tongue) Comprehension or written word (ability to read several sentences and explain them).

    Integrated sensory: cortical function (calculation-simple calculation without writing it down) and visual recognition with expressive speech (ask the client to identify common objects, pen, watch, key. Ask the client to write a sentence. These skills require integration of cortical functioning and visual recognition with expressive speech.
  4. Level of Consciousness:
    LOC is the most sensitive indicator to changes in neuro status

    LOC refers to level of arousal, wakefulness and ability to respond to the environment.

    • Begin with the least invasive stimuli, increase as needed if no response.
    • Types of stimuli: none, verbal, light touch, pain (use central stimuli).
    • Document stimuli used and response: obeys simple commands
    • localizes pain- moves arms across midline away from stimuli
    • withdrawal: movement to move away from stimuli, but does not cross midline;
    • Abnormal posturing- flexion: arm abduction and elbow flexion; extension: arm adduction and elbow extension

    Delirium: A temporary state of mental confusion and fluctuating consciousness resulting from high fever, intoxication, shock, or other causes. It is characterized by anxiety, disorientation, hallucinations, delusions, and incoherent speech.

    Lethargic: the quality or state of being drowsy and dull, listless and unenergetic, or indifferent and lazy; apathetic or sluggish inactivity.

    Obtunded: To make less intense; dull or deaden

    Stuporous: A state of mental numbness, as that resulting from shock; a daze. See Synonyms at lethargy.

    Comatose: a state of prolonged unconsciousness, including a lack of response to stimuli, from which it is impossible to rouse a person
  5. Long Term (Remote) Memory:
    -Ask birth date, schools attended, city of birth
  6. Recall (Recent) Memory:
    -Time of admission, clinic or physicial appointent, mode of transportation
  7. Immediate (New) Memory:
    -Give patient 2 or 3 unrealated words and ask them to repeat them then ask again in about 5 minutes to see if the patient can remember them
  8. Central Nervous System:
    Brain and Spinal Cord
  9. Peripheral Nervous System:
    12 pairs of cranial nerves, 31 pairs of spinal nerves, and the autonomic nervous system

    • Autonomic Nervous System:
    • -Sympathetic and Parasympathetic Nervous System
  10. Cushings Triad:
    • **Must know
    • -Late finding: towards the end

    • Significance= increased pressure on medulla; brain stem herniation
    • -Systemic hypertension
    • -Widening pulse pressure
    • -Bradycardia

    Foramen magnum gets pressure and bluges our the bottom

    Medulla= worst place for a brain injury
  11. Widening Pulse Pressure:
    • -Sign of increased intracranial pressure
    • -Respiratory rate and rhythm can also be altered with increased ICP.

    • -Pulse pressure is the difference between systolic and diastolic blood pressures.
    • -Normally, systolic pressure is about 40 mmHg higher than diastolic pressure.
    • -Widened pulse pressure—a difference of more than 50 mm Hg—commonly occurs as a physiologic response to fever, hot weather, exercise, anxiety, anemia, or pregnancy. However, it can also result from certain neurologic disorders—especially life-threatening increased intracranial pressure (ICP)—or from cardiovascular disorders that cause backflow of blood into the heart with each contraction, such as aortic
    • insufficiency.
    • -Widened pulse pressure can easily be identified by monitoring of arterial blood pressure and is commonly detected during routine sphygmomanometric recordings
  12. Vital Sign Changes: Respirations
    • Will initially increase
    • BUT you see late changes in respiratory
    • Most commonly see changes in rhythm

    Cheyne-Stokes: also known as periodic breathing is an abnormal pattern of breathing characterized by oscillation of ventilation between apnea and tachypnea with a crescendo-decrescendo pattern in the depth of respirations, to compensate for changing serum partial pressures of oxygen and carbon dioxide. *MOST COMMON

    Central Neurogenic Hyperventilation: (CNH) is an abnormal pattern of breathing characterized by deep and rapid breaths at a rate of at least 25 breaths per minute. Increasing irregularity of this respiratory rate generally is a sign that the patient will enter into coma. CNH is unrelated to other forms of hyperventilation, like Kussmaul's respirations. CNH is the human body's response to reduced carbon dioxide levels in the blood. This reduction in carbon dioxide is caused by contraction of cranial arteries from damage caused by lesions in the brain stem. However, the mechanism by which CNH arises as a result from these lesions is still very poorly understood.

    • Apneustic: (a.k.a. apneusis) is an abnormal pattern of breathing characterized by deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release. Accompanying signs and symptoms may include decerebrate posturing; fixed, dilated pupils; coma or profound stupor; quadriparesis; absent corneal reflex; absent doll's eye sign; negative oculocephalic reflex; and obliteration of the gag reflex. cluster breathing, a breathing pattern in which a closely grouped series of respirations is followed by apnea. The activity is associated with a lesion in the lower pontine
    • region of the brainstem.

    • Ataxic Respirations: is an abnormal pattern of breathing characterized by complete irregularity of
    • breathing, with irregular pauses and increasing periods of apnea. As the breathing pattern deteriorates, it merges with agonal respirations.

    Agonal Respirations: is an abnormal pattern of breathing characterized by shallow, slow (3-4 per minute), irregular inspirations followed by irregular pauses. It may also be characterized by gasping, labored breathing, accompanied by strange vocalizations and myoclonus. Possible causes include cerebral ischemia, extreme hypoxia or even anoxia. Agonal breathing is an extremely serious medical sign requiring immediate medical attention, as the condition generally progresses to complete apnea and heralds death.

    Cluster Breathing
  13. Stimulation Techniques:
    **First call there name and a little push

    • Central Stimulation:
    • -Trapezius pinch
    • -Sternal rub

    • Peripheral Stimulation:
    • -Nailed pressure
    • -Pinching inner aspect of arm/leg

    **Men are often more depressed after strokes than women
  14. Head & Neck:
    • Inspect: head for size shape, contour, symmetry, look for bruising around eyes and behind ears.
    • -Racoon eyes=Anterior basilar skull fracture.
    • -Battle sign=middle fossa basilar skull fracture & drainage of blood, CSF or both from the ears. SIGN OF SKULL FRACTURE
    • -Look in ears for clear fluid, feel skull for crepitus

    Palpate: palpate the skull lightly. Skull normally feels smooth and firm. Areas of bogginess or depressions are abnormal findings. Inspect and palpate spine allignment.

    Auscultate for bruits which result from turbulent flow.

  15. Cranial Nerves:
    Cranial Nerve I: Smell

    • Cranial Nerve II: Visual Acuity
    • -Blurred Vision
    • -Diplopia: commonly known as double vision
    • -Papilledema: is optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral but can be unilateral which is extremely rare and can occur over a period of hours to weeks.

    • Cranial Nerve III, IV, VI: All Eye Movements as well as Lids
    • -Nystagmus: means involuntary eye movement.
    • -Ptosis: is an abnormally low position (drooping) of the upper eyelid; usually unilaterally, can be a result of a stroke

    • Cranial Nerve V, VII, IX, X:
    • -Control protective reflexes
    • -Corneal and blinking
    • -Cough, gag, and swallowing

    • Cranial Nerve VII, VIII, XI, XII:
    • -Facial sensation
    • -Acoustic
    • -Shoulder
    • -Tongue
  16. PERRLA:
    • P: pupils
    • E: equal in size
    • R: round and
    • R: regular in shape and react to
    • L: light and
    • A: accomodation


    Aniscoria: unequal pupils
  17. Eye Exam:
    Pupils should be equal in size, shape, equality, and light reflex (consensual)

    >1 mm is an abnormal finding
  18. Dolls Eyes:
    AKA Oculocephalic Reflex

    Contraindications: Possible Cervical Spine Injury


    • Technique:
    • Eyes open
    • Head is rotated briskly from side to side
    • Eyes deviate contralaterally Interpretation
    • If Brainstem intact: Look away from rotation
    • If Brainstem injury: Eyes follow direction of head rotation

    • To test the oculocephalic: or doll's eye, reflex, turn the
    • patient's head briskly from side to side; the eyes should move to the left while the head is turned to the right, and vice versa. If this reflex is absent, there will be no eye movement.

    To test the oculovestibular reflex: also known as the ice caloric or cold caloric reflex, a physician will instill at least 20 ml of ice water into the patient's ear. In patients with an intact brain stem, the eyes will move laterally toward the affected ear. In patients with severe brain stem injury, the gaze will remain at midline.
  19. Motor Function:
    • -Check against resistence
    • -Observe for involuntary tremors or movements

    • -Test strength by having patient move against resistance.
    • -Always compare one side to another.
    • -Grade strength on a scale of 1-5.

    • Motor Strength: 0 to 5 scale
    • -0: No movement or contraction
    • -1: Trace contraction
    • -2: Active movement with gravity eliminated
    • -3: Active movement against gravity
    • -4: Active movement with some resistance
    • -5: Active movement with full resistance= GOOD
  20. Muscle Strength:
    Pronator Drift: have the client hold out the arms like holding a tray with the palms up. Ask the client to close the eyes and maintain the position. A pronator drift issaid to be present if one arm pronates or falls below the other. If adeficit is noticed ask patient or family if this is a long standing finding.Need to listen to the family!

    Rombergs Sign: Arms out to side they will not maintain balance with eyes close; cerebellar fuction; MAINTAIN SAFETY!

    Pronator drift & Rombergs sign are checked in cerebral or brainstem injuries!

    • Gait:
    • -Ataxia: loss of the ability to coordinate muscular movement.
    • -Dystonic: involuntary movements and prolonged muscle contraction, resulting in twisting body motions,
    • tremor, and abnormal posture. These movements may involve the entire body, or only an isolated area. Symptoms may even be "task specific," such as writer's cramp
    • -Steppage
    • -Spastic hemiparesis
  21. Muscle Tone:
    • -Weakness
    • -Flaccid
    • -Spastic: muscle tightens up
    • -Rigid
    • -Hypotonia: tone is not as good as it should be
    • -Hypertonia: extreme muscle tone

    Motor function: observation-involuntary movements, muscle symmetry (left to right and proximal to distal), atrophy, gait.

    Muscle tone: ask the patient to relax, flex and extend the patients fingers, wrist, and elbow, flex and extend patient’s ankle and knee. There is normally a small, continuous resistance to passive movement, observe for decreased (flaccid) or increased (rigid, spastic) tone.
  22. Abnormal Positiong:

    • Decorticate (Flexed):
    • - Arms, wrists, and fingers are flexed with internal rotation and plantar flexin of the legs

    • Decerebrate (Extensor):
    • -Extension of arms and legs, pronation of the arms, plantar flexion and opisthotonos

    • Mixed:
    • -One flexed arm, one extended arm
  23. Motor Dysfunction:
    -Cerebellar lesions affect both sides of the body

    -Problems in the brainstem, thalamus, and cortex effect the opposite side
  24. Sensory Function:
    • *Pain and light touch are most commonl assessed
    • *Best way to start= light touch, next you try a dull object
    • *Pain and temp are transmitted by the same nerve endings to if one is found to be intace it is safe to assume the other is as well

    • Pain:
    • -Hypalgesia: diminished sensitivity to pain.
    • -Analgesia: absence of sensibility to pain.
    • -Hyperalgesia: abnormally increased pain sense.

    • Touch:
    • -Hypoesthesia: impairment of tactile sensitivity; decrease of sensitivity
    • -Anesthesia: total or partial loss of sensation, especially tactile sensibility, induced by disease, injury, acupuncture, or an anesthetic
    • -Hyperesthesia: an abnormal or pathological increase in sensitivity to sensory stimuli, as of the skin to touch or the ear to sound.

    Stereognosis: have patient close eyes, place a familiar object in their hand (coin, paper clip, pencil) and ask them to identify it.

    • Three sections for exam:
    • -Exteroceptive sensations: superficial sensations
    • that originate in the sensory receptors in the skin and mucous membranes; these include include light touch, superficial pain and temperature.
    • -Proprioceptive sensations: deep sensations with sensory receptors in the muscles, joints, tendons, and ligaments; these include testing of motion, postion, and vibration sense.
    • -Cortical sensations: require cerebral integrative and discriminative abilities; these include testing for stereognosis, graphesthesia, two-point discrimination, and extinction.

    • Testing:
    • -Test superficial sensation by having patient supine and exposing arms, legs, abdomen; light touch: use cotton balls, go from distal to proximal; assess superficial pain--ability to differentiate between "dull" and " sharp" in the same fashion; also, check for temperature perception.
    • -Test proprioception by moving thumb and big toe in
    • space and have patient tell you which way it is being moved; check vibration with tuning fork (low pitch).
    • -Test for stereognosis by having patient identify common object (such as a key or paper clip or coin) placed in hand; test for graphesthesia by drawing a number with your finger in the handof the patient and having him name it; test for two point discrimination by touching fingers with two points(ends of cotton tipped applicators) and increasing the distance apart until the patient can discriminate the two points(can also check back of hand); test for extinction by simultaneously touching both sides of the the patient's face with cotton balls and then on one side and asking the patient to state if, when and where one or two points were felt.
  25. Reflexes:
    -Have the patient interlock hands and pull outward helps decrease muscle tension to test reflexes

    Hyperactive: upper motor neuron disease, tetanus, hypocalcemia

    Hypoactive: lower motor neuron disease, disease of neuromuscular junction, muscle disease, DM, hypothyroidism, hypokalemia


    • Deep Tendon Reflexes:
    • -Biceps reflex muscle
    • -Puts own thumb down then hits his thumb for the reflex

    • Ankle Clonus:
    • -Looking for ankle jerk

    • Tonic Neck:
    • -extensions of the arm and sometimes of the leg on the side to which the head is forcibly turned, with flexion of the contralateral limbs; seen normally in the newborn.

    Plantar Grasp

    • Babinski:
    • - dorsiflexion of the big toe on stimulation of the sole, occurring in lesions of the pyramidal tract, although a normal reflex in infants.
    • - positive babinski in someone over 2 years old is abnormal
  26. Nursing Responsibilities: Identify and monitor neurologic changes
    • -Mini mental status
    • -Vital signs
    • -LOC
    • -Motor and sensory function
    • -Reflexes

    Clonus: Sudden brief jerking contraction of a muscle or group of muscles often seen in a seizure

    • *Want a baseline and monitor any changes
    • *Best for outgoing nurse and oncoming nurse to check on the patient together
  27. Nursing Responsibilities: Priorities
    • -LOC
    • -Motor function
    • -Changes in pupillary response
    • -Respiratory fuction: regular and easy
    • -Vital signs: WNL, no widening pulse pressure
  28. Glasgow Coma Scale:
    • Rate 1-5 each category:
    • -Eyes opening
    • -Verbal response
    • -Motor response

    • 15= BEST SCORE
    • 3= WORST SCORE

    13 to 15= not a huge area of concern, until your score starts to drop and worsen
  29. Diagnostic Testing: MRI
    • *Gold Standard
    • Gadolinium: non iodine based contrast

    • An MRI scan can be used as an extremely accurate method of disease detection throughout the body. In the head, trauma to the brain can be seen as bleeding or swelling. Other abnormalities often found include brain
    • aneurysms, stroke, tumors of the brain, as well as tumors or inflammation of the spine. Neurosurgeons use an MRI scan not only in defining brain anatomy but in evaluating the integrity of the spinal cord after trauma. It is also used when considering problems associated with the vertebrae or intervertebral discs of the spine.

    • Patient teaching:
    • -Patients who have any metallic materials within the body must notify their physician prior to the examination or inform the MRI staff. Metallic chips, materials, surgical clips, or foreign material (artificial joints, metallic bone plates, or prosthetic devices, etc.) can significantly distort the images obtained by the MRI scanner. Patients who have heart pacemakers, metal implants, or metal chips or clips in or around the eyeballs cannot be scanned with an MRI because of the risk that the magnet may move the metal in these areas. Similarly, patients with artificial heart valves, metallic ear implants, bullet fragments, and chemotherapy or insulin pumps should not have MRI scanning.

    • During:
    • -patient lies in a closed area inside the magnetic tube. Some patients can experience a claustrophobic sensation during the procedure. Therefore, patients with any history of claustrophobia should relate this to the practitioner who is requesting the test, as well as the radiology staff. A mild sedative can be given prior to the MRI scan to help alleviate this feeling. It is customary that the MRI staff will be nearby during MRI scan. Furthermore, there is usually a means of communication with the staff (such as a buzzer held by the patient) which can be used for contact if the patient cannot tolerate the scan. There are loud, repetitive clicking noises which occur during the test as the scanning proceeds. Occasionally, patients require injections of liquid intravenously to enhance the images which are obtained. The MRI scanning time depends on the exact area of the body studied, but ranges from half an hour to an hour and a half.
  30. Diagnostic Testing: CAT scan
    • CAT scan: A large donut-shaped x-ray machine takes x-ray images at many different angles around the body. These images are processed by a computer to produce
    • cross-sectional pictures of the body. In each of these pictures the body is seen as an x-ray "slice" of the body, which is recorded on a film. This recorded image is called a tomogram. "Computerized Axial Tomography" refers to the recorded tomogram "sections" at different levels of the body.

    Imagine the body as a loaf of bread and you are looking at one end of the loaf. As you remove each slice of bread, you can see the entire surface of that slice from the crust to the center. The body is seen on CT scan slices in a similar fashion from the skin to the central part of the body being examined. When these levels are further "added" together, a three-dimensional picture of an organ or abnormal body structure can be obtained

    In preparation for a CT scan, patients are often asked to avoid food, especially when contrast material is to be used. Contrast material may be injected intravenously, or administered by mouth or by an enema in order to increase the distinction between various organs or areas of the body. Therefore, fluids and food may be restricted for several hours prior to the examination.
  31. Diagnostic Testing: EEG
    • *Used to identify nerve and muscle disorders as well as spinal cord disease
    • *Look at brain patterns; determines brain death and for people with seizure disorders

    EEG: Electroencephalogram, a technique for studying the electrical current within the brain. Electrodes are attached to the scalp. Wires attach these electrodes to a machine which records the electrical impulses. The results are either printed out or displayed on a computer screen. Electroencephalogram is abbreviated EEG

    An electroencephalogram ( EEG) is a test that measures and records the electrical activity of your brain. Special sensors (electrodes) are attached to your head and hooked by wires to a computer. The computer records your brain's electrical activity on the screen or on paper as wavy lines. Certain conditions, such as seizures, can be seen by the changes in the normal pattern of the brain's electrical activity.
  32. Diagnostic Testing: EMG
    *Records electrical active of cerebral hemispheres; can determine origin of seizure activity

    • An electromyogram (EMG) measures the electrical activity of muscles at rest and during contraction. Nerve
    • conduction studies measure how well and how fast the nerves can send electrical signals. Nerves control the muscles in the body by electrical signals (impulses), and these impulses make the muscles react in specific ways. Nerve and muscle disorders cause the muscles to react in abnormal ways.

    • Measuring the electrical activity in muscles and nerves can help find diseases that damage muscle tissue (such as muscular dystrophy) or nerves (such as amyotrophic
    • lateral sclerosis or peripheral neuropathies). EMG and nerve conduction studies are often done together to give more complete information.
  33. Normal Age Related Changes:
    • -Loss of accomodation in eyes (changes in pupil size)
    • -Rigidity of the iris may result in decreased pupil size
    • -Decreased reaction time to light and reflexes
    • -Glasgow coma scale may underestimate extent of injury
    • -Certain common meds may increase ICP in the presence of an injury
    • -May be predisposed to electrolyte imbalances due to meds given to decrease ICP
    • -Head of the bed elevated may not be effective and may actually worsen condition
Card Set:
Nursing 4 Lecture 8 Abnormal Neuro Assessment
2012-02-26 19:14:48

Nursing 4 Lecture 8 Abnormal Neuro Assessment
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