Neurological Assessment - NUR 105 - PDF

NEUROLOGICAL ASSESSMENT NUR 105 Bon Secours Southside College of Health Sciences Objectives Utilizing a body systems approach, the student will: a. Apply anatomy, physiology, biology, chemistry, psychology, developmental psychology, and sociology concepts to the assessment...

NEUROLOGICAL ASSESSMENT NUR 105 Bon Secours Southside College of Health Sciences Objectives Utilizing a body systems approach, the student will: a. Apply anatomy, physiology, biology, chemistry, psychology, developmental psychology, and sociology concepts to the assessment of the neurological system of the adult b. Apply health history and physical examination principles for holistic assessment of the neurological system of the adult c. Conduct and document (EMR) a health history and physical examination of the adult while applying the principles of caring, therapeutic communication, interprofessional communication, and professionalism d. Utilize concepts of genetics and genomics when assessing the neurological system of the adult Objectives e. Interpret common laboratory and diagnostic findings for the neurological system of the adult f. Based on national guidelines (Healthy People 2030, AHRQ Clinical Prevention Guidelines, and other appropriate national standards), recommend the appropriate health promotion and clinical prevention strategies for the adult g. Assess self and patient scenarios utilizing the clinical reasoning model for the neurological system of the adult h. Demonstrate professionalism in the clinical simulation laboratory by: honoring confidentiality of scenarios and other’s health histories; respecting other’s self-determination and human dignity; and exhibiting integrity by abiding by laboratory guidelines, equipment use, and dress code i. Describe expected and unexpected findings in each body system to include ethnic, cultural, and age variations The Nervous System  Central Nervous System  Brain and spinal cord  Peripheral Nervous System  Cranial and spinal nerves  Autonomic Nervous System  Sympathetic  Parasympathetic A & P Review- Protective Structures  Skull protects brain.  Foramen magnum is large oval opening at base of skull in occipital bone. Spinal cord extends through from medulla oblongata.  Meninges, three layers between skull and brain Dura mater, outer double layer Arachnoid, middle meningeal layer Pia mater, inner meningeal layer Between arachnoid and pia mater is subarachnoid space where cerebrospinal fluid (CSF) circulates.  ________ is colorless, odorless fluid containing:  Glucose, electrolytes, oxygen, water, carbon dioxide, and leukocytes A & P Review- Brain  Brain consists of cerebrum, diencephalon, cerebellum, and brainstem.  Carotid arteries supply most of blood to brain, and branch off into posterior cerebral, middle cerebral, and anterior cerebral Internal Structure of the Brain Occipital CEREBRUM Largest part of brain consisting of two hemispheres, each divided into four lobes:  Frontal  Parietal  Temporal  Occipital Frontal Lobe Contains primary motor cortex and functions related to voluntary motor activity.  Broca’s area --left frontal lobe involved in formulation of words.  Frontal lobe also controls intellectual function, awareness of self, personality, and autonomic responses related to emotion. Parietal lobe  Contains primary somesthetic (sensory) cortex that receives sensory input such as position, touch, shape, and texture of objects. Temporal lobe  Contains primary auditory cortex. Wernicke’s area located in left temporal lobe, responsible for comprehension of spoken and written language Also interprets auditory, visual, and somatic sensory inputs that are stored in thought and memory Occipital lobe  Contains primary visual cortex which receives and interprets visual information.  Diencephalon Made up of thalamus, hypothalamus, epithalamus, and subthalamus. Hypothalamus is important to maintaining homeostasis Functions include: regulation of body temperature hunger, and thirst formation of autonomic nervous system responses storage and secretion of hormones from pituitary gland Basal ganglia Function is balancing production of two neurotransmitters — acetylcholine and dopamine — that create smooth, coordinated voluntary movement Brainstem  Made up of midbrain, pons, and medulla oblongata. Ten of twelve cranial nerves (CNs) originate from brainstem.  Midbrain functions to relay stimuli concerning muscle movement to other brain structures Contains part of motor tract pathways that control reflex motor movements in response to visual and auditory stimuli  Pons relays impulses to brain centers and lower spinal nerves. Brainstem con’t  Medulla oblongata contains reflex centers for controlling involuntary functions such as breathing, sneezing, swallowing, coughing, vomiting, and vasoconstriction.  Motor and sensory tracts from frontal and parietal lobes cross from one side to other in medulla; lesions on right side create abnormal movement and sensation on left side, and vice versa. Cerebellum  Separated from cerebral cortex by tentorium cerebelli.  Functions of cerebellum include coordinating movement, equilibrium, muscle tone, and proprioception.  Each cerebellar hemisphere controls movement for same (ipsilateral) side of body. Spinal Cord  Posterior (dorsal) column carries sensations of touch, deep pressure, vibration, position of joints, stereognosis, and two-point discrimination.  Lateral spinothalamic tract carries fibers for sensations of light touch, pressure, temperature, and pain. Spinal Cord  31 pairs of spinal nerves emerge from spinal cord Cranial Nerves  12 pairs of cranial nerves  Five pairs have only motor fibers.  Three pairs have only sensory fibers.  Four pairs have both motor and sensory fibers. Reflex Arcs  Tested by observing muscle movement in response  to sensory stimuli. Deep tendon reflexes are responses to stimulation of tendon that stretches neuromuscular spindles of muscle group. Striking a deep tendon stimulates a sensory neuron that travels to spinal cord where it stimulates an interneuron, which stimulates a motor neuron to create movement.  Superficial reflexes tested similarly.  Each reflex corresponds to a specific spinal segment. The Autonomic Nervous System Sympathetic Nervous Parasympathetic Nervous System System  Fight or Flight  Dominates during calm, non- stressful times A & P Review- ANS Sympathetic Parasympathetic  Sympathetic nervous system  Parasympathetic nervous (SNS) arises from system (PNS) arises from thoracolumbar segments of craniosacral segments of the spinal cord and is activated spinal cord and controls during stress (the “fight-or- vegetative functions (“breed flight” response). and feed”).  SNS actions include:  PNS actions associated with  Increasing blood pressure and conserving energy such as: heart rate  Decreasing heart rate and force  Vasoconstriction of peripheral of myocardial contraction blood vessels  Decreasing blood pressure and  Inhibiting gastrointestinal respiration peristalsis  Stimulating gastrointestinal  Dilating bronchi peristalsis Neurotransmitters  Communicate messages from one neuron to another or from a neuron to a specific target tissue  Excite or inhibit the target cell’s activity  Usually MULTIPLE neurotransmitters at work in the neural synapse Examples- dopamine, serotonin, GABA, Epinephrine, and many others Functional Organization of the Brain  Localization of function  Multiple systems can overlap  Can be assessed by various techniques (e.g., physiology, imaging, neurological exam, neuropsychologica l exam, post Brain lateralization – the two halves of the human brain are not exactly alike Functional specializations – some functions have neural mechanisms are localized primarily in one hemisphere Lateralization  Left Brain  Right Brain  Logical  Random Sequential Intuitive Rational Holistic Analytical Synthesizing Objective Subjective Looks at parts Looks at wholes Damage to Broca’s Area vs. Wernicke’s Area Broca's Aphasia Wernicke's Aphasia  Prevents a person from  Loss of the ability to understand producing speech language  Person can understand  Person can speak clearly, but the language words that are put together make no sense. This way of speaking has  Words are not properly been called "word salad" because formed it appears that the words are all  Speech is slow and slurred mixed up like the vegetables in a salad. The Neurological Exam Components of the Neurological Exam Health History – Focused Neuro  Health History  Prenatal or birth events  Exposures (toxins, drugs)  Illnesses (Epstein-Barr, Bell’s Palsy, Rocky Mountain Spotted Fever, Lyme disease, encephalitis, etc.)  Injuries (concussion, closed head, etc.) Health History – Focused Neuro  Health History  Clinical manifestations or symptoms Abnormal sensation Dizziness Visualor sensory disturbances Tremors or other motor tics Pain Weakness Seizures Health History – Focused Neuro  Family History  Diseases Amyotrophic Lateral Sclerosis Myasthenia Gravis Parkinson’s Migraine Multiple Sclerosis Neurofibromatosis Seizure disorders Guillain-Barré Tumors Syndrome Alzheimer’s disease Tourette syndrome Muscular Dystrophy  American Academy of Neurology  Mental Status  Level of alertness, appropriate responses  Orientation  Cranial Nerves  Motor System  Strength  Gait  Coordination  Sensory System  Light touch,  Pain/temperature  Proprioception  Reflexes  DTRs-biceps, patellar, Achilles  Plantar Mental Status  Orientation  If orientation is a concern during history, determine if oriented to time, place, person. Date and time is first orientation to disappear. Only a problem if remains disoriented after being reoriented Place is second orientation to disappear. Person is last orientation to disappear.  Orientations returns in opposite order in which is lost.  Appearance, general behavior, mood  Thought content, memory, recall  Intellectual/functional ability Level of Consciousness (LOC)  Altered level of consciousness  Nurse can determine if client alert and oriented by way questions are answered during interview.  Change in level of consciousness (LOC) is earliest and most sensitive indicator of alterations in cerebral function. Awareness is higher level function controlled by reticular activating system. Wakefulness is controlled by brainstem. When client’s awareness cannot be assessed because unconscious, arousal is assessed. LOC (Arousal)  Alertness  Lethargy  Obtunded  Stupor  Coma LOC  Glasgow Coma Scale: assess LOC using 15- point scale.  Assess for best response to eye opening, motor response, and verbal response.  Determine stimulation/pain required to elicit response. Only time acceptable to inflict pain on client  Glasgow Coma Scale Glasgow Coma Scale 1 2 3 4 5 6 Opens eyes Opens Opens Does not open in response eyes in eyes Eyes N/A N/A eyes to painful response spontan stimuli to voice eously Oriented Confuse Incomprehe Utters , Verb Makes no d, nsible inappropria converse N/A al sounds disorien sounds te words s ted normally Extension to Abnormal Flexion painful flexion to / Localizes Obeys Moto Makes no stimuli ( painful Withdra painful comman r movements decerebrate stimuli ( wal to stimuli ds response) decorticate painful response stimuli ) Abnormal Posturing Cranial Nerves (12) Abnormalities of Cranial Nerves  I- anosmia  VII- asymmetrical facial movements,  II- defect in vision loss of taste (central or  VIII- decrease or loss peripheral) of hearing  IX & X- uvula deviates  III, IV, VI- pupil to one side, no gag, abnormalities, hoarse or brassy EOM abnormalities voice, dysphagia  V- absent touch &  XI- absent movement of sternomastoid or pain, no blink, trapezius muscles weakness of  XII- tongue deviates masseter or to one side , slow rate Motor System Motor System  Includes brain and spinal cord motor pathways  Includes all major muscle groups distal and proximal  Muscle tone, strength, symmetry  Unusual movements, fasciculations, tics, Gait and Posture Gait  Walking or ambulating requires coordination of multiple voluntary and involuntary functions  Strength, coordination, symmetry, balance, stance, speed, stride length, arm Coordination and the Cerebellum Cerebellum- Cerebellum responsible for voluntary movement and motor coordination Tests for balance: Tests for coordination: Romberg test (client  Tests for coordination of standing)—feet upper extremity together, arms at Rapid pronation/supination side, eyes on thighs open/closed Alternately touch nose with Pronator drift index fingers (eyes closed) Eyes closed, stand on Touch each finger to thumb one foot in rapid sequence Tandem walking Move index finger between Hop on one foot, then nose and examiner finger other  Tests for coordination of Knee bends Walk on toes and lower extremity Heel to shin of opposite leg then on heels Sensory System (Peripheral Nerves)  Assess for sensation. Areas routinely assessed are the hands, lower arms, abdomen, lower legs, and feet Flex muscles, then resist against opposite force Dermatome map to identify spinal nerve providing sensation Light touch with cotton tipped swab Vibration using tuning fork on bony prominence; feel vibration and when it stops Kinesthetic sensation (proprioception) by moving finger/toe up/down https://www.youtube.com/watch?v=xhygnHkC-9Y Stereognosis Two-point discrimination Reflexes Babinski Also called Plantar reflex  stroke bottom of foot heal to toe; note big toe movement- EXPECTED FINDING- plantar flexion  if toes fan upward- UNEXPECTED FINDING- indicates CNS dysfunction, present before 2 years of age Deep Tendon Reflexes  Reflex–involuntary action in response to impulse sent to CNS  Often first sign of dysfunction  Deep tendon reflexes – muscle stretch reflexes respond to stretching tendons  Rated as normal, hypo-reflexic, hyper-reflexic  Scored as:  0  1+  2+  3+  4+  Meningeal Signs  Neck Mobility  Brudzinski’s Sign  Kernig’s Sign Diagnostic Evaluation  CT Scan  Cerebral Angiography  Myelography  Positron Emission  https://www.youtube.com/watc Tomography h?v=RFWgnmRivGg  Magnetic Resonance  Noninvasive Carotid Flow Imaging Studies  Lumbar Puncture  Transcranial Doppler  https://www.youtube.c  EEG om/watch?v=LZqiu6P  https://www.youtube.com/watc h?v=tZcKT4l_JZk KrZU Enjoy her accent  EMG & Nerve Conduction Studies  https://www.youtube.com/watc h?v=SJTR8A1x8jA Sample documentation  Mental Status: alert, relaxed, and cooperative. Thought processes coherent. Client oriented to person, place, and time. Cranial Nerves: I- deferred; CN II-XII- intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar- RAMs, F to N, H to S, intact. Gait steady with normal base. Romberg- maintains balance with eyes closed. No pronator drift. Sensory: light touch, position, and vibration intact.  Pediatric Considerations  Timing and mastery of developmental milestones can reveal much information  Loss of abilities after achievement of milestones is a red flag  Failure of reflexes to extinguish (disappear) can also be a red flag Geriatric Considerations  Factors to consider  General health and nutritional status  History of head injury, trauma, or neurological disease  Smoking history  Substance use/abuse  Educational level  Social support Geriatric Considerations  Decrease in taste  Loss of vibration & smell sense at the  Decrease in ankle level muscle bulk  Decrease position  Senile tremors sense  Dyskinesias  DTRs less brisk  More deliberate movements  Longer recall Geriatric Considerations  Some decline in memory and cognition is expected  Sensory processing may diminish with aging  Rapid or dramatic declines, or significant personality changes are red flags  Tests for balance and gait are often assessed for older adults to identify those at risk for falls. Health Promotion- CVA  Older adulthood; risk double each decade after 55  Male sex (slightly higher risk)  AA  HTN  Smoking  Chronic ETOH intake (>2 drinks/day)  Hx of CV disease  Sleep apnea  DM  Drug abuse  High estrogen levels  Overweight  Sedentary lifestyle  Family hx of CVA Terminology  Clonus involuntary, rhythmic muscle contractions.  Agnosia Inability to recognize by sight (visual agnosia), touch (tactile agnosia), or hearing (auditory agnosia.)  Akinesia complete or partial loss of voluntary muscle movement  Apraxia inability to carry out learned sequential movements or commands  Dysarthria defective speech; inability to articulate words; impairment of tongue or other muscles needed for speech  Dysphasia (not to be confused with dysphagia) impaired or difficult speech  Dysphonia difficulty with quality of voice; hoarseness  Awareness of body posture, movement and changes in equilibrium Proprioception  Aphasia absence or impairment of ability to communicate through speech, writing, or signs  Expressive(Broca’s or motor)- inability to express language even though person knows what he wants to say. Frontal lobe usually affected  Receptive(Wernicke’s or sensory)-inability to comprehend written or spoken words. Temporal lobe in auditory-receptive; parieto-occipital in visual receptive Considerations for the hospitalized patient  Patient who is unconscious:  Assess CN responses where applicable (pupillary response), any stimulus responses, last resort-painful stimuli assess risk for DVT  Describing levels of consciousness:  Glascow coma  Adjectives (lethargy, obtunded, stuporous, semicomitose and comatose) References Jarvis, C. (2020). Physical examination & health assessment (8th ed.). Saunders Elsevier. Pagana, K.D. & Pagana, T.J. (2022). Mosby’s manual of diagnostic and laboratory tests (7 th ed.). Mosby. Wilson, S.F. & Giddens, J.F. (2022). Health assessment for nursing practice (7th ed.). Mosby.