Assesment of neurological system

Assessment of neurologic

function in nursing

ObjectivesOn the completion of this lecture student

will be able toi. Describe the structure and function of

central and peripheral nervous systemii. Enumerates the functioning of sympathetic

and Parasympathetic nervous systemiii.Discuss the significance of physical

assessment and examination in detecting the dyfunctioning of nervous system

iv.Discuss the various diagnostic procedures used to discuss the disfunctioning of nervous system

INTRODUCTION

• The function of nervous system is to control All motor ,cognitive ,autonomic and behavioral activities happening in the human body, disorders of nervous system can occur during any point of life and a nurse must be skilled in the assessment and functioning of the neurologic system

Anatomy of the nervous system

Neurons are the structural and functional unit of the nervous system consisting of axon ,dendrite and cell body

Anatomy of the nervous system

Neurotransmitters:

They transmit message from one neuron to the other neuron

Most of the neurological disorders are due to the imbalance in the transmission of neurotransmitters

Eg:low serotonin level in epilepsy, decrease of dopamine in Parkinson's disease.

Major neurotransmittersNEUROTRANSMITTER SOURCE ACTION

Acetylcholine (major transmitter of theparasympathetic system)

Many areas of the brain; autonomic nervousSystem

Usually excitatory; parasympathetic effects

Serotonin Brain stem, hypothalamus, the spinal cord

Restraining, helps control mood sleep, Inhibiting pain pathways

Dopamine Substantia nigra and basal ganglia

Usually restrains, affects behavior (attention, emotions) and fine movement

Norepinephrine (major transmitter of thesympathetic system)

Brain stem, hypothalamus, sympathetic nervoussystem

Usually excitatory; affects mood and overallactivity

Gamma-aminobutyric acid (GABA)

Spinal cord, cerebellum,,some cortical areas

Excitatory amino acid

Enkephalin, endorphin Nerve terminals in the spine, brain, pituitarygland

Excitatory; pleasurable sensation, inhibitspain transmission

Central Nervous system: anatomy of the Brain

2% of total body weight

1400gm in an average adult.

The brain is divided in to 3 major areas

Forebrain: Cerebrum, thalamus and hypothalamus

Midbrain:tectum and tegmentum

Hindbrain:Cerebellum,Pons and medulla

Anatomy of the brain: Forebrain

1.CEREBRUM consists of two hemisphere that are incompletely

separated by fissureBoth hemispheres divided in to

Frontal Lobe: largest lobe of the brain specialized in concentration, thought

formation and judgment Parietal lobe: analyses sensory

information and gives orientationTemporal lobe: contains the auditory

receptive areasOccipital: posterior lobe responsible for

visual interpretation

Anatomy of the brain: forebrain

2.Thalamus- a large mass of gray matter deeply situated in the forebrain. primarily as a relay station for all sensation exceptsmell. All memory, sensation, and pain impulses through this section of the brain 3. Hypothalamus: It controls homeostasis, emotion, thirst, hunger, circadian rhythms, autonomic nervous system and pituitary gland

Anatomy of the brain: forebrain

4. Amygdala:located in the temporal lobe; involved in memory, emotion, and fear. 5. Hippocampus-. important for learning and memory , for converting short term memory to more permanent memory, and for recalling spatial relationships

Anatomy of the brain: Midbrain

Midbrain/ Mesencephalon- the rostral part of the brain stem, which includes the tectum and tegmentum. It is involved in functions such as vision, hearing, eyemovement, and body movement.

Anatomy of the brain: Hindbrain

1.Cerebellum: The cerebellumhas both excitatory and inhibitory actions and is largely responsible for coordination of movement. It also controls finemovement, balance, position sense (awareness of where each part of the body is) and integration of sensory input.

Anatomy of the brain: Hindbrain

2. Pons :It is a bridge between thetwo halves of the cerebellum, and between the medulla and the cerebrum. It contains motor and sensory pathways. Portionsof the pons also control the heart, respiration, and blood pressure3. Medulla Oblongata- this structure between the pons and spinal cord. It is responsible for maintaining vital body functions, such as breathing and heart rate

Anatomy of the brain: Structures protecting the brain

brain is protected from outside by rigid skull by 8 cranial bones.

Meninges :connective tissue which covers the brain and spinal cord made up of

Duramater: tough, thick and inelastic outermost layer

Arachanoid mater: delicate middle membrane ,white in color with choroid plexus which produce cerebrospinal fluid

Piamater:thin innermost layer which hugs the brain closely

Cerebrospinal fluid

CSF, a clear and colorless fluid with a specific gravity of 1.007

It is produced from the ventricles and is circulated through ventricular system (right and left lateral, and the third and fourth) to brain and spinal cord

The composition of CSF is similar to that of plasma

Normally CSF contains few white blood cells but no red blood cells

Cerebrospinal fluid

• Circulation of CSF:

Cerebral circulation The cerebral circulation receives 15% of the

cardiac output, or 750 mL per minute. The brain does not store nutrients and requires

the high blood flow. The brain’s blood pathway is unique because it

flows against gravity Irreversible tissue damage will occur if blood

flow is occluded even for short span of time as the brain lacks additional collateral blood flow

Internal carotid artery and vertebral artery branches provide blood supply to the brain

blood brain barrier makes many substances In the blood stream inaccessible to the central Nervous system.

Spinal Cord • The spinal cord and medulla form a

continuous structure about45 cm (18 in) long and about the thickness of a finger

• Contrary to the brain spinal cord consists of gray matter inside and white matter outside and is protected by meninges

• The spinal cord is an H-shaped structure• Lower portion of the H is anterior horn and

upper portion is called posterior horns both serving reflex activity.

• The thoracic region of the spinal cord has a projection at the crossbar of H and is called the Lateral Horn

• The bones of the vertebral column made up of 33 bones

CRANIAL NERVES

There are 12 pairs of cranial nervesCRANIAL NERVE TYPE FUNCTION

I (olfactory)II (optic)III (oculomotor)

IV (trochlear)V (trigeminal)VI (abducens)VII (facial)

VIII (acoustic)

IX (glossopharyngeal)

X (vagus)

XI (spinal accessory)

XII (hypoglossal)

SensorySensoryMotor

MotorMixedMotorMixed

Sensory

Mixed

Mixed

Motor

Motor

Sense of smell Visual acuity Muscles that move the eye and lid, lens

accommodation Muscles that move the eye Facial sensation, corneal reflex,

mastication Muscles that move the eye Facial expression ,salivation and tearing,

taste, sensation in the ear Hearing and equilibrium Taste, sensation in pharynx and tongue

and pharyngeal muscles Muscles of pharynx, larynx, and soft

palate; sensation in external ear, parasympathetic innervations of thoracic and abdominal organs

Sternocleidomastoid and trapezius muscles

Movement of the tongue

12 pairs of cranial nerve (3 sensory,5 motor and 4 mixed)

Spinal nerves

• The spinal nerves are of 31 pairs8 cervical12 thoracic5 lumbar5 sacral1 coccygeal.

Each spinal cord contains a dorsal root and a ventral root

The dorsal roots are sensory and transmit sensory impulses from specific areas of the body to dorsal ganglia of the spinal cord.

The ventral roots are motor and transmit impulses from the

spinal cord to the body.

Autonomic/involuntary nervous system

Regulates the activities of internal organs and plays a role in the maintenance of internal homeostasis

PARASYMPATHETIC NERVOUS SYSTEM

(controls visceral function)Mainly functions in quiet and

stressful conditionsThe neurotransmitter is

acetylcholine’Response is cholinergic

Located in craniosacral division

SYMPATHETIC NERVOUS SYSTEM

(fight and flight response)Activates under stress condition

The neurotransmitter is norepinephrine or adrenalineThe response is adrenergic

Located in thoracolumbar division

Somatic/voluntary nervous system

Responsible for carrying motor and sensory information to and from the nervous system & all voluntary muscle movements

Consists of

i.sensory neurons: carries information from nerves to the central nervous system

ii.Motor neurons: carries information from central nervous system to the nerves

Neurological Examination

• Health history : Details about the onset, character,

severity, location, duration, and frequency of symptoms and signs; precipitating, aggravating, and relieving factors; progression, remission, and exacerbation; any family history of genetic diseases

history of trauma or falls that may have involved the head or spinal cord.

Use of alcohol, medications

Neurological Examination

• Clinical Manifestation: Asses for major symptoms which may

point a neurological disturbance such as pain, seizures, weakness, abnormal sensation, parasthesias,visual disturbance, vertigo and imbalance

• Physical examination: Detailed and thorough physical

examination is needed to evaluate the functioning of the nervous system.

Neurological Examination• Assessing cerebral function: It includes Mental status: appearance, posture, manner of

speech, level of consciousness, orientation. Intelligent quotient Thought process Emotional status PERCEPTION: assess for agnosia which Is the

inability to interpret object which is seen through special senses. (visual, auditory and tactile)

Assessment of motor ability Language ability• A deficiency in language function is called aphasia.

Neurological Examination: Assessment of Cranial Nerves

I. Olfactory nerve: Assessment

of the olfactory nerve is done by

asked the person to smell

something very familiar with the

eyes closed.

II.Optic Nerve: Examination is

done by using the Snellen chart


III,IV &VI Occulomotor, trochlear and Abduscens Nerve:

Ocular rotation, conjugate

movement, nystagmus ,

testing of puppillary

reflexes and checking for

ptosis is done to assess

the functioning of these nerves


• V.Trigeminal Nerve: the nerve has two divisions:

a. Sensory: Touch one side of the patients face slightly

with a cotton ball and ask the patient to identify if both sides of the face was touched or not

Touch the sides of face gently with a safety pin and ask the patient to verbalize the difference in the sensation of pain .Touch the patients face sometimes with the sharp point of the pin and at other times with the dull guard. Ask the patient to describe the sensation.

Testing for the corneal reflex and the pain sensation


V.Trigeminal Nerve: Motor divisions• Observe the skin over the temporal masseter

muscles. Concavity or asymmetry suggests atrophy. The tip of the mandible should be in the midline.

• Ask the patient to clench his or her jaws. Palpate the masseter and temporal muscles for asymmetry of volume and for tone.

• Observe for deviation of the tip of the mandible as the jaws are opened.

• Ask the patient to move the jaw from side to side against the resistance of your palm. The paralyzed side will not move laterally.

• For the stretch reflex, demonstrate to the patient what you are going to do. Have the jaws half open and relaxed. Then place your index finger on the tip of the mandible and tap your finger gently but briskly with a reflex hammer.


VII:Facial Nerve: The examiner should

observe for the symmetry of the face when the patient performs movement like smiling, frowning, whistling elevating eyebrows, closing of the eyelid as the examiner tries to open it

Observing for flaccid face Ability to determine sugar

and salt.


• VIII Acoustic Nerve (Vestibulocochlear)• For Hearing:

Whisper test: Ask the patient to repeat the numbers which the examiner whispers by standing behind the patient and masking the other ear. Note for any asymmetry in the hearing.

• To differentiate conductive and sensorineural hearing loss:

Rinnes test: Place a tuning fork next to the mastoid process and then behind the ear. Then ask the patient in which position sound is heard louder

NORMAL RESPONSE: Sound should be heard louder in second

Weber’s test: Place the tuning fork in the centre of forehead and ask in which ear sound is heard louder.

NORMAL RESPONSE: The sound is heard equally in both the ears.


• IX, X: Glossopharyngeal, Vagus

• Assess voice: Hoarse /Nasal

• Examine palate for uvular displacement .

• Observe for the symmetrical rise of uvula and soft palate when patient says "Ah"

• Elicit Gag reflex • Stimulate back of throat each side.• Normal to gag each time.


. XI: Accessory• Examine for any atrophy or asymmetry of

trapezius muscle from behind while patient shrugs shoulders against resistance

• Note for asymmetry of sternocledomastoid muscle as the patient turn head against resistance

XII: Hypoglossal• Ask the patient to protrude tongue to note

any unilateral deviation or tremors.• Test the strength of the tongue by having

the patient move the tongue side to side against a tongue depressor

Testing for reflexesTechnique: A Reflex hammer is used to elicit the reflex .Testing of the reflexes should give symmetrically equivalent result.

Observations: Absence of reflexes is important. Deep tendon reflexes are graded on a scale from 0 to 4+ 0-no response 1+-diminished reflex 2+-normal response 3+-brisk /hyperactive response 4+-clonus/repetitive response

Major deep tendon reflexes checked: Biceps reflex Triceps reflex Brachiordialis reflex Patellar reflex Ankle reflex/achilles reflex

Testing for superficial reflexes

Reflex Method Response Interpretation

Corneal reflex

Gag reflex

Plantar Reflex

Babinski reflex

Touch the sclera of each eye on the outer corner with clean wisp of a cotton

Touch the posterior potion of the pharynx with a cotton tipped applicator Stroking the lateral side of the tongue with a tongue blade

Stroke the lateral aspect of the sole of the foot

Blink response is expected

Equal elevation of uvula and gag response is expected.Flexion of the toe is expected

Toes get contracted and draws together

•May be absent in case of CVA or coma

•Absent in CVA ,paralysis

•Serious central nervous system dysfunction

•Toes fan out in adults with nervous system disorders

Common diagnostic test

Computed tomography It is noninvasive and painless and has a high degree of sensitivity for detecting lesions. makes use of a narrow x-ray beam to scan different areas of the body .

Positron emission tomography PET is a computer-based nuclear imaging technique that produces images of actual organ Functioning and produces a series of two-dimensional views at various levels

Nursing Interventions Teach the patient to lie quietly throughout the procedure.Sedation can be used for agitated patientsIodine or shell fish allergy should be reported in case of CT with contrastAn intravenous line and a period of fasting (usually 4 hours) are required prior to the study.

Nursing Interventions Teach the patient to lie quietly throughout the procedure.Sedation can be used for agitated patientsIodine or shell fish allergy should be reported in case of CT with contrastAn intravenous line and a period of fasting (usually 4 hours) are required prior to the study.

Nursing interventions• Explaining the test and the sensations (e.g., dizziness, lightheadedness, and headache) that may occur. •Relaxation exercises may reduce anxiety during the test.

Single photon emissionComputed tomographySPECT is a three-dimensional imaging technique that uses radio nuclides and instruments to detect single photons. It is a perfusion study thatcaptures a moment of cerebral blood flow at the time of injection of a radionuclide and helps to see the contrast between normal and abnormal tissue

Magnetic resonance imagingMRI uses a strong magnetic field to obtain the I mages of the bodyDoes not involve ionizing radiationWill detect cerebral abnormalities earlier than other testTest takes up an hour to complete

Nursing interventions patient preparation & monitoringTeaching about what to expectbefore the testthe woman who is breastfeeding is instructed to stopMonitor for allergic reactions during and after the procedure

Nursing InterventionsExplain about the procedure and what to expectAll metallic objects should be removedClear history to know the presence of any metallic objects in the bodyNo metallic patient care equipment should be brought near the MRI roomprocedure is painless loud sound is expected during the procedure

Cerebral angiographyIt is an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery. It is a valuable tool to investigate vascular disease, aneurysms, and arteriovenous malformations

MyelographyIt is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. It outlines the spinal subarachnoid space and shows any abnormality of the spinal cordLess sensitive as compared to CT and MRI

Nursing Interventions•The patient should be well hydrated. •The locations of the appropriate peripheral pulses are marked•The patient is instructed to remain immobile during the process and is told to expect a brief feeling of warmth a metallic taste when the contrast agent is injected..•Observe for signs and symptoms of complications•The color and temperature of the involved extremity are assessed to detect possible embolism.

Nursing Interventions:Inform about to what to expect during the procedure and position change required during the samePreparation for lumbar punctureAfter the procedure patient should be in fowlers positionThe patient is encouraged to drink waterObserve for signs of complication

Electroencephalogram (EEG) It represents a record of the electrical activity generated in the brain obtained through electrodes applied on the scalp. The EEG is a useful test for diagnosing and evaluating seizuredisorders, coma, or organic brain syndrome., Tumors, brain abscesses, blood clots, and infection and also used in determination of brain deaththe standard EEG takes 45 to 60 minutes, 12 hours for a sleep EEG

ELECTROMYOGRAPHYAn electromyogram (EMG) is obtained by introducing needle electrodes into the skeletal muscles to measure changes in theelectrical potential of the muscles and the nerves leading to them.The electrical potentials are shown on an oscilloscope and amplified by a loudspeaker so that both the sound and appearance of the waves can be analyzed and compared simultaneously.An EMG is useful in determining the presence of a neuromuscular disorder and myopathies.

Nursing Interventions•Anti seizure agents, tranquilizers, stimulants,•and depressants should be withheld 24 to 48 hours before an EEG • Coffee, tea, chocolate, and cola drinks are omitted•in the meal before the test because of their stimulating effect.•The meal is not omitted• An EEG requires patient cooperation and ability to lie quietly during the test.

Nursing InterventionsThe procedure is explained and the patient is warned to expect asensation similar to that of an intramuscular injection as the needleis inserted into the muscle. The muscles examined may achefor a short time after the procedure.

Lumbar puncture and examination

It is a procedure by which CSF is withdrawn by inserting a needle in to the subarachanoid

space

Indication• To obtain CSF for examination• To measure or reduce the pressure of CSF• To detect subarachanoid block• To administer medcine intrathecally

Preprocedure• Obtain a written consent• Explain the procedure to the patient and

tell what to expect• Reassure the patient and provide support• Instruct the patient to void before the

procedure• Assist the patient to lateral recumbent

position with maximum flexion of the thighs

Procedure: (performed by physician) .The nurse assists the patient to maintain the position

to avoid sudden movement, which can produce a trauma

The patient is encouraged to relax and is instructed to breathe normally

Describe the procedure step by step as it proceeds The physician cleanses the puncture site with an

antiseptic solution and drapes the site. Local anesthetic is injected to numb the puncture site A spinal needle is inserted into the subarachnoid

space through the third and fourth or fourth and fifth lumbar interspace.

A specimen of CSF is removed and usually collected in three test tubes, labeled in order of collection

A small dressing is applied to the puncture site. The tubes of CSF are sent to the laboratory

immediately.

• PostprocedureInstruct the patient to lie prone for 2 to

3 hours to separate the alignment of the Dural and arachnoid needle punctures in the meninges, to reduce leakage of CSF.

• A post puncture head ache is common after the procedure which is usually relieved by positioning ,rest ,analgesic agents and hydration

Cerebrospinal Fluid Analysis

• The CSF should be clear and colorless. • Pink, blood-tinged, or grossly bloody CSF may

indicate a cerebral contusion, laceration, or subarachnoid hemorrhage.

References

• Suzanne c Smeltzer,Brinda BareBrunner & Suddarth’s Textbook of Medical-Surgical Nursing 10th edition,lippincott williams and wilkins,pn 1820-1850

• Lewis Heitkamper,drisken,Medical and surgical Nursing,aseessment and management of clinical Problems, Mosby publications.Pn 1441-1452

• Ignativicus and workman medical surgical Nursing.Ptient centered collabritive care,pn-1183-1215

Assesment of neurological system

Health & Medicine

Transcript of Assesment of neurological system