NEUROLOGIC EXAMINATION

HEALTH HISTORY

• History of Present IllnessImportant aspect of neurologic

assessment• Initial Interview Provides an excellent opportunity to

systematically explore the patient’s current condition and related eventswhile observing the: Overall appearance Mental status Posture Movement Affect

HEALTH HISTORY

Depending on the patients condition, the nurse may rely on:

YES or NO answer Review of Medical Records Input from Family

HEALTH HISTORY INCLUDES:• Onset, character, severity, location duration

and frequency of signs and symptoms.• Complaints• Precipitating, aggravating and relieving

factors• Progression, remission and exacerbation• Presence or absence of similar signs and

symptoms among family members• History of genetic disease

HEALTH HISTORY

Review of medical history including the system-by-system evaluation is part of the nursing history.

The nurse should be aware of history of trauma or falls that may have involved the head or spinal injury.

Questions about the use of alcohol, medications and illicit drugs are also relevant.

PHYSICAL ASSESSMENT

General Observation of the client:a. Posture, gait, coordination: perform

Romberg testb. Personal hygiene and groomingc. Evaluate speech and ability to

communicate1. Pace of speech: rapid, slow, halting2. Clarity: slurred or distinct3. Tone: high-pitched, rough4. Vocabulary: appropriate choice of words

*** Facial features may suggest specific syndromes in children

PHYSICAL ASSESSMENTMental Status

a. General appearance and behavior

b. Level of consciousness1. Oriented to person, place and time2. Appropriate response to verbal and tactile

stimuli3. Memory, problem solving abilities.

c. Moodd. Thought content & intellectual

capacity

PHYSICAL ASSESSMENT

Assess Pupillary Status and Eye movementa. Size of pupils should be equalb. Reaction of pupils

a. Accommodation: pupillary constriction to accommodate near vision

b. Direct light reflex: constriction of pupil when light is shone directly into the eye

c. Consensual reflex: constriction of the pupil in the opposite eye when the direct light reflex is tested.

c. Evaluate ability to move eyea. Note nystagmusb. Ability of eyes to move togetherc. Resting position of iris should be at mid-position

of the eye socketd. PERRLA

Clinical ManifestationThe clinical manifestation of neurologic disease are as varied as the disease processes themselves. Symptoms may be:• Varied or intense• Fluctuating or permanent• Inconvenient or devastating

PAINSEIZURESDIZZINESS a nd VERTIGOVISUAL DISTURBANCESWEAKNESSABNORMALSENSATION

Clinical ManifestationsPAIN• unpleasant sensory perception & emotional• experience associated with actual or

potential tissue damage- Subjective- Acute > lasts shorter & remits as pathology resolves

> trigeminal neuralgia, spinal disk disease - Chronic or persistent > Lasts longer than 6 months > degenerative and chronic neurologic cond.

Clinical ManifestationsSEIZURES- Are the result of abnormal paroxysmal

discharges in the cerebral cortex, which manifests as alteration in sensation, perception, movement or consciousness

- May be long or short - The type of seizure activity is a direct

result of the brain affected.- May be a first obvious sign of brain

lesion

Clinical ManifestationsDIZZINESS AND VERTIGO- Dizziness is an abnormal sensation of

imbalance or movement. - Variety of causes: viral syndrome, hot

weather, roller coaster rides, middle ear infections

- About 50% of patients with dizziness have vertigo (illusion of movement usually rotation).

- Vertigo is a manifestation of vestibular dysfunction

Clinical ManifestationsVISUAL DISTURBANCESVisual defects that cause people to seek

health care can range from decreased visual acuity associated with aging to sudden blindness caused by glaucoma

Normal vision depends on :- functioning visual pathways thought the retina and optic chiasm - radiations into the visual cortex in the occipital lobes

Clinical Manifestations

WEAKNESS- common manifestation of neurologic

disease (muscle weakness)- Coexists with other symptoms and can

affect variety of muscles causing disability

- Can be sudden or permanent or progressive

Clinical Manifestations

ABNORMAL SENSATION- Numbness, loss of sensation or

abnormal sensation is a neurologic manifestation of both cerebral and peripheral nervous system disease

h

- Usually associated with pain or weakness and is potentially disabling

g

- Both numbness and weakness can significantly affect balance and coordination

PHYSICAL EXAMINATION• The brain and the spinal cord cannot be

examined directly as other body systems• Neurologic examination is an indirect

evaluation that assesses the function of specific body part controlled

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5 COMPONTENTS OF NEURO ASSESSMENT

(1) Cerebral function(2) Cranial Nerves(3) Motor system(4) Sensory System(5) Reflexes

Assessing Cerebral Function

Cerebral abnormalities may cause:

- disturbance in mental status

- Intellectual function

- Thought content

- Pattern of emotional behavior

- Alteration in perception, motor and language ability

- Lifestyle change/s

Assessing Cerebral Function

• Should be specific and non-judgemental• Avoid using the terms

“inappropriate” or “demented”

• Specific records on observations regarding orientation, level of consciouness, emotional state or thought content

Assessing the Mental Status

• Observe patient’s appearance & behavior

• Note dress, grooming & personal hygiene

• Posture, gesture, movements, facial expression & motor activity

• Assess manner of speech & level of consciousness

• Assess orientation to time, place & person

Intellectual Function

A person with an average IQ can:a. Recite 5 digits backwardsb. Serial 7’s (Subtract 7 from 100,

then 7 from that, and so forth)• Interpret proverbs• Ability to recognize similarities• Situational analysis

Thought ContentDuring the interview, it is important toassess the patient’s thought content.• Are the patient’s thought…

Spontaneous Natural Clear Relevant Coherentf

• Unusual thoughts like… hallucinations, preoccupation with death and morbid events, paranoid ideation requires further evaluation

Emotional Status

• Is the patient’s affect natural or even?• Does his or her mood fluctuate

normally?• Are verbal communications consistent

with nonverbal cues?

Perception

The examiner may consider more specific areas of higher cortical function

• Agnosia - inability to recognize objects seen through the special senses– a patient may see a pencil but knows not what to do with

it or what it’s called

• Screening for visual and tactile agnosia provides insight into the patient’s cortical interpretation ability– Placing a familiar object (key) in the patient’s hand, have him

identify it with eyes closed

Language Ability• A person with normal neurologic function

can understand and communicate in spoken and written language.

• Aphasia is a deficiency in language function Type of Aphasia Brain area involved

Auditory-receptive Temporal Lobe

Visual-receptive Parietal-occipital lobe

Expressive speaking Inferior posterior frontal areas

Expressive writing Posterior frontal area

Motor Ability

• Ask the patient to perform a skilled act (throw a ball, move a chair)

• Performance requires

=> the ability to understand the activity desired and normal motor strength

• Failure signals cerebral dysfunction

ASSESSING THE ASSESSING THE CRANIAL NERVESCRANIAL NERVES

CRANIAL NERVESCRANIAL NERVESOn OldOlympus Towering Tops A Finn And German Viewed Some Hops

Olfactory (I)Optic (II)Occulamotor (III) Trochlear (IV)Trigemenal (V)Abducens (VI)Facial (VII)Acoustic (VIII)Glossopharyngeal (IX)Vagus (X)Spinal Accessory (XI)Hypoglossal (XII)

M SM MM/S M M/S S M/S M/S M M

Cranial Nerve I - Olfactory Nerve Before testing nerve function, ensure

patency of each nostril by occluding in turn and asking patient to sniff

Once patency is established, ask patient to close eyes

Occlude one nostril and hold aromatic substance (coffee) beneath nose

Ask patient to identify substance Repeat with other nostril

Cranial Nerve I - OlfactoryNormal:

■ Patient is able to identify substance.

(Bear in mind that some substances may be unfamiliar, especially to children)

Abnormal:■ Anosmia - loss of sense

of smell. • May be inherited and non-

pathological: chronic rhinitis, sinusitis, heavy smoking, zinc deficiency, or cocaine use.

• It may also indicate cranial nerve damage from facial fractures or head injuries, disorders of base of frontal lobe such as a tumor, or artherosclerotic changes.

Cranial Nerve II - Optic Nerve

Use the snellen chart to check/test:- distant vision- color

Client should be 20 feet distant from the chartUse an object to occlude one eyeEvaluate the vision one eye at a time

Testing eye movements

Testing pupil accommodation

Cranial Nerves III, IV and VI

=> Test for ocular rotations,

conjugate movements, nystagmus** Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis

- using direct & consensual pupillary reaction to light

Normal:■ Able to read without

difficulty■ Visual acuity intact

20/20, both eyesHippus phenomenon:

Brisk constriction of pupils in reaction to light, followed by dilation and constriction

- may be normal or sign of early CN III compression.

Abnormal:

■ CN II deficits - can occur with stroke or brain tumor.

■ Changes in pupillary reactions - can signal CN III deficits.

■ Increased ICP causes changes in pupillary reactionAs pressure increases, response becomes more sluggish until pupils finally become fixed and dilated.

CN V - Trigeminal Nerve

a. Testing motor function: - Ask patient to move jaw from side to side against resistance and then clench jaw as you palpate contraction of temporal and masseter muscles, or to bite down on a tongue blade.

Testing CN V – sensory function

CN V - Trigeminal Nerveb. Testing sensory function:

- Ask patient to close eyes- Touch the face with the wisp of cotton- Instruct to tell you when he or she feels sensation on the face. - Repeat the test using sharp and dull stimuli (toothpick or tongue blade)

- Instruct to say “Sharp” or “Dull”(Be random, don’t establish a pattern)

Testing corneal reflex

Cranial Nerve V - Trigeminal Nerve

c. Testing corneal reflex: - Gently touch cornea with cotton wisp. o Touching cornea can cause

abrasions.oAlternative approach is to: > puff air across cornea with a needless

syringe, or > gently touch eyelash

and look for blink reflex

Cont. CN V

Normal: Full range of motion

(ROM) in jaw and 15 strength.

Patient perceives light touch and superficial pain bilaterally

Abnormal: Weak or absent contraction

unilaterally: - Lesion of nerve, cervical spine,

or brainstem

Inability to perceive light touch and superficial pain

- may indicate peripheral nerve damage.

■ Trigeminal Neuralgia:- Neuralgic pain of CN V caused

by the pressure of degeneration of a nerve

■ Corneal reflex test used in patients with decreased LOC

- to evaluate integrity of brainstem.

Testing CN VII – motor function

Cranial Nerve VII - Facial Nerve

a. Testing motor function: - Ask patient to perform these movements: smile, frown, raise eyebrows, show upper teeth, show lower teeth, puff out cheeks, purse lips, close eyes tightly while nurse tries to open them.

- Observe face for flaccid paralysis

Testing taste sensation

Cranial Nerve VII - Facial Nerve

b. Testing sensory function:

• - Test taste on anterior two-thirds of tongue for sweet, sour, salty.

F

Sweet: Tip of the tongue

Sour: Sides of back half of tongue

Salty: Anterior sides and tip of tongue

Bitter: Back of tongue

CN VII - Facial Nerve

Normal:• Facial nerve intact• Able to make faces.

• Taste sensation on anterior tongue intact.

• (Taste decreased in older adults.)

Abnormal:Asymmetrical or impaired

movement: - Nerve damage, such as

that caused by Bell’s palsy or stroke.

Impaired taste/loss of taste:

- Damage to facial nerve, chemotherapy or radiation therapy to head and neck.

Watch tick test

Cranial Nerve VIII - Acoustic Nerve

a. Perform Weber and Rinne tests for hearingb. Perform watch-tick test by holding watch close

to patient’s ear.

c. Perform Romberg test for balance- Nurse at the back or side of the pt.- Instruct client to stand straight, feet together, hands at the side and eyes closed.

(Evaluates the balancing function of the CN VIII)

Cranial Nerve VIII - Acoustic Nerve

Normal: Hearing intact. Negative

Romberg test.

Abnormal: Hearing loss,

nystagmus, balance disturbance, dizziness/vertigo: - Acoustic nerve damage.

■ Nystagmus: - CN VIII, brainstem, or cerebellum problem or phenytoin (Dilantin) toxicity.

Testing CN IX and X – motor function

Cranial Nerves IX and X Glossopharyngeal & Vagus Nerves

a. Observe ability to cough, swallow, and talk.

b. Test motor function: - Ask patient to open mouth and say “ah”

while you depress the tongue with a tongue blade. - Observe soft palate and uvula.

- Soft palate and uvula should rise medially.

CN IX and X

c. Test sensory function of CN IX and motor function of CN X by stimulating gag reflex.

Tell patient that you are going to touch interior throat

Then lightly touch tip of tongue blade to posterior pharyngeal wall.

Observe the pharyngeal movement.

Ask the client to drink a small amount of water*Note the ease & difficulty of swallowing*Note quality of the voice or hoarseness

when speaking

CN IX and XNormal: Swallow and cough

reflex intact.

Speech clear.

Elevation and constriction of pharyngeal musculature and tongue retraction indicate positive gag reflex

Abnormal: Unilateral movement:

Contralateral nerve damage.- Damage to CNs IX and X also

impairs swallowing.

■ Changes in voice quality (e.g., hoarseness): CN X damage.

■ Diminished/absent gag reflex: Nerve damage

- Risk for aspiration

■ Impaired taste on posterior portion of tongue: Problem with CN IX

CN XI - Spinal Accessory Nerve

a. Test motor function of shoulder and neck muscles:

=> Ask patient to shrug shoulders upward against your resistance. (Trapieze muscle)

=> Then ask her or him to turn head from side to side against your resistance. (Strenoclaidomastoid muscle)

**Observe for symmetry of contraction and muscle strength.

Cranial Nerve XINormal: Movement

symmetrical, with patient moving against resistance without pain.

■ Full ROM of neck with +5/5 strength.

Abnormal: Asymmetrical Diminished Absent movement Pain unilateral or bilateral

weakness: Peripheral nerve CN XI damage.

Testing CN XII – motor function

CN XII - Hypoglossal Nerve

a. Have patient say “d, l, n, t” or a phrase containing these letters. - The ability to say these letters requires use of the tongue.

b. Ask the patient to protrude the tongue. Observe any deviation from midline, tumors, lesions, or atrophy.

c. Now ask the patient to move the tongue from side to side.

Normal: Can protrude

tongue medially.

No atrophy, tumors, or lesions.

Abnormal:Asymmetrical/diminished/absent movement/deviation from midline/protruded tongue: - Peripheral nerve CN XII damage.

■ Tongue paralysis results in dysarthria.

Examining the Motor System• Assessing the patient’s ability to flex or

extend the extremities against resistance tests muscle strength.

g

• The evaluation of muscle strength compares the sides of the body with each other

• This way, subtle differences in muscle strength can easily be detected and described.

f

MUSCLE STRENGTH• Muscle tone (tension present in a

muscle at rest) is evaluated by palpation

• Abnormalities in tone include:– Spasticity (increased muscle tone)– Rigidity (resistance to passive strength) – Flaccidity

British Medical CouncilMethod of Scoring

Balance and Coordination• Cerebellar influence on the motor system is

reflected in balance and coordination.

• Coordination of the hands and extremities is tested by:– Rapid, alternating movements

– POINT TO POINT TESTING

Balance and Coordiantiona. Rapid Alternating Movements (RAM)

Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the knees with the backs of the hands.Then ask to do this faster.

Normal: done with equal turning

and quick rhythmic pace

Abnormal:Lack of coordinationDysdiadochokinesia- Slow, clumsy, and sloppy response - occurs with cerebellar disease

The patient is asked to pronate and supinate the hands as rapid as possible

b. Finger-to-Finger testWith the persons eyes open, ask that he or she use index finger to touch your finger, then his or her own nose.After a few times move your finger to a different spot.

Normal: Movement is smooth

and accurate

Abnormal:Dysmetria

- clumsy movement with overshooting the mark

- occurs with cerebellar disorderPast-pointing

- constant deviation to one side

Balance and Coordination• Coordination in the lower extremities is

tested by having the patient run heel down the anterior surface of the tibia of the other leg. Each leg is tested

• Ataxia is incoordination of voluntary muscle groups in action

• Tremors are rhythmic, involuntary movements=>The presence of these movements suggests

cerebellar disease

• When abnormality is observed, a thorough examination is indicated

Balance and CoordinationThe cerebellum is responsible for balance and coordination.

Romberg’s Test - screening test for balance- the pt stands with feet together

and arms at the side, first with eyes open and eyes closed for 20 to 30 secs

- slight sway is normal but loss of balance is abnormal and

considered (+) Romberg rest

Normal: Negative Romberg

test

Abnormal:Sways, falls, widens base of feet to avoid falling

Positive Romberg sign -Loss of balance that occurs when closing the eyes.

-Occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication)

-Loss of proprioception, and loss of vestibular function

Perform Tandem Walking- ask the person to walk a straight line in a heel-to-toe fashion.

- This decreases the base of support and will accentuate any

problem with coordination.

Normal:

Person can walk straight

& stay balanced

Abnormal:Crooked line walkWidens base to maintain balanceStaggering, reeling, loss of balanceAn ataxia that did not appear now.

Inability to tandem walk is sensitive for an upper motor neuron lesion, such as multiple sclerosis.

Hopping in place, alternating knee bends (some individuals cannot hop owing to aging or obesity)

Examining the Reflexes• Motor reflex are involuntary contraction of

muscles or muscle groups in response to abrupt stretching near the site of muscle insertion

• Technique: A reflex hammer is used to elicit a deep tendon reflex.

• The tendon is struck briskly, and the response is compared with the opposite side of the body (right and left)

• The response should be equal

Examining the Reflexes

GRADING the REFLEXES

• The absence of reflex is significant, although ankle jerks (achilles reflex) may be absent on older people.

• Some uses the terms: – PRESENT – ABSENT– DIMINISHED

REFLEXESDocumenting Reflex Findings

• Use these grading scales to rate the strength of each reflex in a deep tendon and superficial reflex assessment.

Deep tendon reflex grades0 absent+ present but diminished+ + normal+ + + increased but not necessarily pathologic+ + + + hyperactive or clonic (involuntary contractionand relaxation of skeletal muscle)

Deep tendon reflex grades0 absent+ present but diminished+ + normal+ + + increased but not necessarily pathologic+ + + + hyperactive or clonic (involuntary contractionand relaxation of skeletal muscle)

Superficial reflex grades0 absent+ present

Superficial reflex grades0 absent+ present

• Documentation of reflex finding

ASSESSING REFLEXESBiceps Reflex

- is elicited by striking the biceps tendon of the flexed elbow.- the examiner supports the forearm with one arm while placing the thumb against the tendon and striking the thumb with the reflex hammer.

Normal:■ Flexion at the elbow and

contraction of the biceps

ASSESSING REFLEXESb. Triceps Reflex- flex pt’s arm to 90° angle and

positioned in front of the chest

■ Abduct patient’s arm and flex it at the elbow.■ Support the arm with your non-dominant hand.■ Identify triceps tendon by

palpating 2.5 to 5cm (1-2 in) above the elbow

Normal:■ Contraction of triceps with

extension at elbow

ASSESSING REFLEXES

c. Patellar Reflex■ Have patient sit with legs dangling.■ Strike tendon directly below patella.

Normal:■ Contraction of quadriceps with extension of knee.

ASSESSING REFLEXESd. Ankle Reflex

- Achilles reflex- foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon

Normal:■ Plantar flexion of foot.

ASSESSING REFLEXESe. Test for Clonus• When reflexes are very hyperactive, a

phenomenon called clonus may be elicited• If a foot is abruptly dorsiflexed, it may

continue to “beat” two to three times before it settles into a position of rest

• The presence of clonus always indicates the presence of CNS disease and requires further evaluation

Normal:■ No contraction

F. Superficial Reflexes

Abdominal Reflex■ Stroke patient’s abdomen diagonally from upper and lower quadrants toward umbilicus.■ Contraction of rectus abdominis. Umbilicus moves toward stimulus.

Perianal Reflex■ Gently stroke skin around anus with gloved finger.Normal:■ Anus puckers.

Cremasteric Reflex■ Gently stroke inner aspect of a male’s thigh.Normal:■ Testes rise.

Bulbocavernosus Reflex■ Gently apply pressure over bulbocavernous muscle on dorsal side of penis.Normal:■ Bulbocavernosus muscle contracts.

ASSESSING REFLEXES

BABINSKI REFLEX■ Stroke sole of patient’s foot in an arc

from lateral heel to medial ball. • Fanning of toes when stroked laterally• Normal in newborn (found until 16 – 24 mos)

• Indicates CNS disease of motor system

Normal:■ Flexion of all toes.

SENSORY EXAMINATION• Highly subjective & requires cooperation of the pt• The examiner should be familiar with dermatomes • Most sensory deficits results from peripheral

neuropathy and follow anatomic dermatomes

Assessment involves:• Tactile sensation• Superficial pain• Vibration• Position sense

** during assessment, pt eyes are kept closed

SENSORY EXAMINATION Tactile Sensation or Light Touch

- Brush a light stimulus such as a cotton wisp over patient’s skin in several locations, including torso and extremities.

Normal: Identifies areas

stimulated by light touch.

Abnormal:Hypesthesia: diminished capacity for physical sensation (esp. skin)

■ Hyperesthesia: Increased sensitivity

■ Paresthesia: Numbness & tingling

■ Anesthesia: Loss of sensation.

PAIN and TEMPERATURE- Stimulate skin lightly with sharp and dull ends of

toothpick/ paper clip- Apply stimuli randomly and ask patient to identify

whether sensation is sharp or dull.

- Touch patient’s skin with test tubes filled with hot or cold water.

- Apply stimuli randomly, and ask patient to identify whether sensation is hot or cold.

Sensory ExaminationVIBRATION and PROPRIOCEPTION- Place a vibrating tuning fork over a finger

joint, and then over a toe joint.- Ask patient to tell you when vibration is felt

and when it stops.- If patient is unable to detect vibration, test

proximal areas as well.

Sensory Examination

Normal: Vibratory

sensation intact bilaterally in upper and lower extremities.

Abnormal: Diminished/absent

vibration sense:

- Peripheral nerve damage caused by alcoholism, diabetes, or damage to posterior column of spinal cord.

StereognosisWith patient’s eyes closed, place a familiar object, such as a coin or a button, in patient’s hand, and ask patient to identify it.■ Test both hands using different objects.

Normal: Stereognosis

intact bilaterally.

Abnormal:■ Abnormal findings suggest a lesion or other disorder involving sensory cortex or a disorder affecting posteriorcolumn.

Sensory Extinction■ Simultaneously touch both sides of patient’s

body at same point.■ Ask patient to point to where she or he was

touched.

Normal: Extinction intact.

Abnormal:Identification of stimulus on only one side suggests lesion or other disorder involving sensory cortical region in opposite hemisphere.

AssessingLevel of Consciousness

Level of Consciousness (LOC) – arousal; awareness of self or environmentd

Alert – fully awake; appropriate responses to external and internal stimuli; oriented to person, place and times

Lethargic – somnolent, drowsy, listless, indifferent to surroundings, very sleepy, can be aroused from sleep but when stimulation ceases, falls back to sleep; may be oriented or confused d

Stuporous – unconscious most of the time but makes spontaneous movements and response is evoked only by a strong, continuous, noxious stimuli; loud noises or sounds, bright light, pressure to sternum, response is usually a purposeful attempt to remove the stimulusf

Comatose – absence of voluntary response to stimuli including painful stimuli; no response, no eye opening – score of 7 or less on GCS

Glasgow Coma Scale- A standardized objective assessment that

defines the LOC by giving it a numeric value.

- Most often after brain surgery

- Document as E_V_M_; for example, E4V5M6.

•The three numbers are added; the total score reflects the brain functional level.

•A fully awake person = 15

•Coma = 7 or less

•The GCS assesses the functional state of the brain as a

whole, not of any particular site in the brain. (Juarez and Lyon,1995)

Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)

a. Test orientation to time, place, and person

ASSESSING LEVEL OF CONSCIOUSNESS

Normal: Awake, alert, and

oriented to time, place, and person (AAO x 3)

Responds to external stimuli

Abnormal: Disorientation may be

physical in origin Disorientation can also

be psychiatric in origin (schizophrenia)

Lathargic or somnolent Obtunded Stupor Coma

Abnormal FindingsAbnormalities in Muscle Movement

Paralysis• Loss or impairment of the ability to move a body part,

usually as a result of damage to its nerve supply. • Loss of sensation over a region of the body.

Hemiplegia paralysis of one side of the bodyParaplegia paralysis of both lower limbs due to spinal disease or injury Quadriplegia paralysis of all four limbs or of the entire body below the neck Paresis partial motor paralysis

Abnormal FindingsAbnormalities in Muscle Movement

FasciculationsRapid, continuous twitching of resting

muscle

Abnormal FindingsAbnormalities in Muscle Movement

TicRepetitive twitching of a muscle group

Abnormal FindingsAbnormalities in Muscle Movement

MyoclonusRapid, sudden jerk at a fairly regular

intervals

Abnormal FindingsAbnormalities in Muscle Movement

TremorInvoluntary contraction of opposing muscle

groups• Rest tremor• Intention tremor

Abnormal FindingsAbnormalities in Muscle Movement

ChoreaSudden, rapid, jerky,

purposeless movement involving limbs, trunk, or face

Abnormal FindingsAbnormalities in Muscle Movement

Athetosis

Slow, twisting, writhing, continuous movement, resembling a snake or worm

Neurologic Exam: Meningeal signsBrudzinski’s sign - neck stiffness- involuntary flexion of hips and knees when flexing neck is positive sign for

meningeal irritation

Neurologic Exam: Meningeal signsPositive Kernig’s sign-excessive pain in the lower back when examiner attempts to straighten knees with client supine and knees and hips flexed

Neurologic Exam: Meningeal

Decorticate posturing (up)

Decorticate posturing (down)

DIAGNOSTIC EVALUATION

Computed Tomography Scan• Makes use of narrow x-ray beam to scan body part

in successive layers• Images provide cross-sectional views of the brain

displayed on an oscilloscope or TV monitor and is photographed and stored digitally

• Non-invasive and painless and has high degree in detecting brain lesions

Nursing Intervention:• Teach patient about the need to lie quietly

throughout the entire procedure• Assess for iodine/shellfish allergy• Monitor for side effect of IV or inhalation contrast

agents: flushing, nausea, vomiting

CT SCAN

Positron Emission Tomography (PET)- Computer based nuclear imaging that produces

images of actual organ functioning.- Radioactive gas or substance is inhaled or

injected that emits positively charged particles.- It permits measurement of blood flow, tissue

composition, brain metabolism thus evaluates brain function.

- Useful in showing metabolic changes in the brain (Alzheimer’s disease), locating lesions (tumor, epiliptogenic lesions), identifying blood flow and oxygen metabolism in stroke pt and new therapies for brain tumor.

Positron Emission Tomography (PET)• Key nursing interventions include patient

preparation, which involves explaining the test and teaching the patient about inhalation techniques and the sensations (dizziness, light-headedness, headache) may occur.

• IV injection of radioactive substance produces similar side effects.

• Relaxation exercises may reduce anxiety during the test.

PET Scan

Single Photon Emission Computed Tomography (SPECT)

• 3D imaging technique that uses radionuclides and instruments to detect single photons.

• Perfusion study that captures cerebral blood flow at time of injection of radionuclide.

• SPECT is useful in detecting extent & location of perfused areas of the brain, allowing detection, localization and sizing of stroke, detecting tumor progression and evaluation of perfusion before and after neurosurgical procedures.

Single Photon Emission Computed Tomography (SPECT)

Nursing Intervention• Preparation and monitoring• Observe for allegeric reaction. • Pregnancy and breastfeeding are

contraindications.

Magnetic Resonance Imaging (MRI)

• Uses a powerful magnetic field to obtain images of different areas of the body

• Can identify cerebral abnormality earlier and more clearly than any other diagnostic tests

• Useful in monitoring tumor’s response to treatment, Dx of MS

Nursing Intervention: MRI

• Relaxation techniques• Advise pt that she can speak with the staff by

means of a microphone inside the scanner• ALL metal objects and magnetic cards are

removed (aneurysm clips, ortho-hardware, pacemakers, artificial heart valves, IUD)

• Medication patches removed (cause burns)• Sedation for claustrophobic pt• Scanning process is painless, but the patient

hears loud thumping of magnetic coils as magnetic field is being pulsed.

Myelography Myelogram is an Xray of spinal subarachnoid space

taken with contrast agent (through Lumbar Tap) Shows distortion of spinal cord or spinal dural sac

caused by tumors, cysts, herniated vertebral disks

Nursing Intervention• Meal before procedure is omited• After myelography, patient to lie in bed with head

elevated up to 45º and remain in bed for 3hrs• Encourage increased fluid intake• Monitor VS

MyelographyMyelography

CEREBRAL ANGIOGRAPHY

• X-ray study of the cerebral circulation with contrast agent injected to selected artery.

• Performed by threading a catheter through the femoral artery in the groin and up to the desired vessel.

Uses:Uses: Vascular disease, aneurysms, AVM

Digital Subtraction Angiography- X-ray images of areas in question are taken before and

after injection of contrast agent (peripheral vein) and then compared

CEREBRAL ANGIOGRAMCEREBRAL ANGIOGRAM

Nursing Intervention: CEREBRAL ANGIOGRAPHYNURSING CARE PRE-TEST1.) Check allergy to iodine2.) Keep NPO after midnight or offer clear liquid breakfast only3.) Explain that the client may have warm, flushed feeling and salty taste in

mouth during procedure4.) Take baseline vital signs and neuro check 5.) Administer sedation if ordered

NURSING CARE POST-TEST1.) Maintain pressure dressing over site if femoral or brachial artery used;

apply ice as ordered2.) Maintain bed rest until next morning as ordered3.) Monitor vital signs, neuro checks frequently; report any changes

immediately4.) Check site frequently for bleeding or hematoma; if carotid artery used;

assess for swelling of neck, difficulty swallowing or breathing5.) Check pulse, color, and temperature of extremity distal to site used.6.) Keep extremity extended and avoid flexion

Non-invasive Carotid Flow Studies

• Uses ultrasound and doppler measurements of arterial blood flow to evaluate carotid and deep orbital circulation.

• The graph produced indicates blood velocity.( velocity = stenosis or partial obstruction)

Carotid doppler permits evaluation ofCarotid ultrasonography arterial blood flow andOculoplethysmography detection of atrial Opthalmodensinometry stenosis, occlusion

andplaques

Transcranial Doppler

• Uses the same noninvasive techniques as Carotid flow studies except it records blood flow velocities of intracranial vessels

• Flow velocity is measured through thin area of temporal and occipital bones of the skull.

• A hand-held doppler probe emits a pulsed beam; the signal is reflected by a moving RBC within the blood vessel

• Helpful in assessing vasospasm, altered cerebral

blood flow in occlusive vascular dse or stroke

Electroencephalography (EEG)• Represents a record of electrical

activity generated by the brain through electrodes applied on the scalp

• Used to diagnose seizure disorders, coma

• Tumors, brain abscess, blood clots may cause abnormal patterns in electrical activity

• Used in making a determination of BRAIN DEATH

Electroencephalography (EEG)

Nursing Intervention Withhold medications that may interfere with the results-

anticonvulsants, sedatives and stimulants Wash hair thoroughly before procedure Instruct adult client to sleep no more than 5 hrs the night

before. Coffee, tea, chocolate and cola drinks are omitted Meal itself is not omitted because an altered glucose level

alters brain wave patterns It takes 45min-1hour; 12 hours for sleep EEG

Standard EEG - water-soluble lubricant Sleep EEG - collodion glue for electrode contact (acetone

for removal)

Diagnostic Evaluation

Electromyography (EMG)- obtained by inserting needle electrode into the skeletal muscle to measure changes in the electrical potential of the muscles and the nerves leading to them. Determine presence of neuromuscular disorders & myopathies.

Nerve Conduction Studies-A peripheral nerve is stimulated at several points along its course and recording the muscle action potential or sensory action potential.Useful in studying peripheral neuropathies.

Lumbar Puncture and CSF examinationSpinal tap - a needle is inserted into the subarachnoid

space through the 3rd and 4th or 4th and 5th lumbar interface to withdraw spinal fluid

h

PURPOSES1. Measures CSF pressure

(normal opening pressure 60-150mmH2O)2. Obtain specimens for lab analysis, cytology, C&S

(protein - normally not present, sugar - normally present)3. Check color of CSF (normally clear) and check for

blood4. Inject air, dye, or drugs into the spinal canal

- CSF pressure in lateral recumbent position is 70-200mm H20

Lumbar Puncture and CSF examination

CONTRAINDICATION • INCREASED ICP• COAGULOPATHY & DECREASED PLATELETS• SPINAL DEFORMITIES ( SCOLIOSIS, KYPHOSIS)

Lumbar Puncture GuidelinesNURSING CARE PRE-TEST1.) Have client empty bladder2.) Position client in a lateral recumbent position with head

and neck flexed onto the chest and knees pulled up.3.) Explain the need to remain still during the procedure

NURSING CARE POST-TEST1.) Ensure labeling of CSF specimens in proper sequence2.) Keep client flat for 12-24 hours as ordered3.) Force fluids4.) Check puncture site for bleeding, leakage of CSF5.) Assess sensation and movement in lower extremities6.) Monitor vital signs7.) Administer analgesics for headache as ordered

Queckenstendt’s Test• lumbar manometric test• performed by compressing jugular veins during Spinal

tap• in pressure caused by compression is noted; then

released and read every 10secs interval.

• a slow rise and fall in pressure indicated a partial block due to lesion compressing the spinal subarachnoid path.

• no pressure change => complete block is indicated.

Contraindicated : if intracranial lesion is suspected.

CSF Analysis• CSF should be clear and colorless

• Pink, blood-tinged, or glossy bloody CSF indicates cerebral contusion, laceration or subarachnoid hemorrhage

• Specimens are obtained for: cell count, culture and glucose and protein testing

Post Lumbar Headache• Mild to severe, may occur few hours to several

days after the procedure.

• It is throbbing bifrontal or occipital headache, dull or deep in character

• Cause: leak at puncture site, fluid continues to escape into the tissues by way of the needle track from the spinal canal

• May be avoided if small-gauged needle is used and if pt remains prone

after the procedure.

sources• Dillon, Patricia. Nursing Health Assessment. 2nd

Ed. F.A. Davis. 2007

• Jarvis, Carolyn. Physical Examination and Health Assessment. 3rd ed. New York: W.B. Saunder Company.2000

• Bickley. Lyn and Hoekenan, Robert. Bate’s Guide to Physical Examination and History Taking. 7th ed. New York: Lippincott Williams and Wilkins. 1999

• Estes, Mary Ellen Zator. Health Assessment & Physical Examination. 3rd ed. Delmar Learning. 2006

THANK YOU!!!