Neurological assessment (3) (1).ppsx

Assessment of Neurological functions Prepared By Samah El Garhy Masry Assist. Prof. Medical Surgical Nursing  Assessment of Neurologic function Out lines: Structures and functions of the central and peripheral nervous systems. The functioning o...

Assessment of Neurological functions Prepared By Samah El Garhy Masry Assist. Prof. Medical Surgical Nursing  Assessment of Neurologic function Out lines: Structures and functions of the central and peripheral nervous systems. The functioning of the sympathetic and parasympathetic nervous system. Protective structure Cerebral Circulation Functions of nervous system The neurologic examination Diagnostic tests of nervous system Nervous System Changes old age Introduction The nervous system directs the complex processes of the body's internal environment and also provides a link to the external world. This allows us to respond to changes both from internal sources as well as form external Introduction The nervous system is broken down into two major parts: the central nervous system, which includes the brain and spinal cord, and the peripheral nervous system, which includes all nerves, which carry impulses to and from the brain and spinal cord.  Overview of Anatomy Central Nervous System –Brain –Spinal cord Peripheral Nervous System –12 pairs of cranial nerves –Spinal and peripheral nerves  Four Regions of Brain 1. Diencephalon: regulates consciousness 2. Brainstem: connects the upper part of the brain with the spinal cord, consist of (pons, medulla, midbrain) 3. Cerebellum: gait and coordination 4. Cerebrum: thinking and higher functions Central Nervous System  Brain components 1.Brain stem Medulla Oblongata The medulla oblongata is located just above the spinal cord. This part of the brain is responsible for several vital autonomic centers including: The respiratory center, which regulates breathing. The cardiac center that regulates the rate and force of the heartbeat. The vasomotor center, which regulates the contraction of smooth muscle in the blood vessel, thus controlling blood pressure. The medulla also controls other reflex actions including vomiting, sneezing, coughing and swallowing. Midbrain The midbrain extends from the pons to the diencephalons. The midbrain acts as a relay center for certain head and eye reflexes in response to visual stimuli. The midbrain is also a major relay center for auditory information 2. The Diencephalon The diencephalon is made up of four main components: the thalamus, the subthalamus, the hypothalamus, and the epithalamus. Thalamus The thalamus is responsible for "sorting out" sensory impulses and directing them to a particular area of the brain. Nearly all sensory impulses travel through the thalamus. Hypothalamus The hypothalamus is the great controller of body regulation and plays an important role in the connection between mind and body, where it serves as the primary link between the nervous and endocrine systems. The hypothalamus produces hormones that regulate the secretion of specific hormones from the pituitary. The hypothalamus also maintains water balance, appetite, sexual behavior, and some emotions, including fear, pleasure and pain. 3. Cerebellum The functions of the cerebellum include the coordination of voluntary muscles, the maintenance of balance when standing, walking and sitting, and the maintenance of muscle tone ensuring that the body can adapt to changes in position quickly. 4. Cerebrum The cerebrum is composed of two hemispheres (right and left hemispheres) The cerebral hemispheres are divided into pairs of frontal, parietal, temporal and occipital lobes. Frontal –personality, behavior, emotions, intellectual function Parietal -primary Centre for sensation Occipital–Primary visual receptor Centre Temporal–Primary auditory reception Centre Meninges They are fibrous connective tissue that covers the brain and the spinal cord to provide protection, support, and nourishment. Because the brain and spinal cord are vital organs they are protected by three meningeal layers.  Central Nervous System Spinal Cord The spinal cord and brain stem from a continuous structure extending from the cerebral hemispheres and serving as a connecting link between the brain and the periphery. Approximately 45 cm long and about the thickness of a finger  Central Nervous System Spinal Cord The vertebral column surrounds and protects the spinal cord and consists of 7 cervical, 12 thoracic, 5 lumbers as well as 5 sacral, and 1 coccygeal. The spinal cord is an H shaped with nerve cell bodies (gray matter) surrounded by ascending and descending tracts (white matter).  Central Nervous System Cerebrospinal Fluid The cerebrospinal fluid is a clear liquid that circulates in and around the brain and spinal cord. Its function is to cushion the brain and spinal cord, carry nutrients to the cells and remove waste products from these tissues.  The peripheral Central Nervous System The peripheral nervous system includes the cranial nerves, the spinal nerves, and autonomic nervous system Cranial nerves There are 12 pairs of cranial nerves that emerge from the lower surface of the brain and pass through the foramina in the skull. Three are entirely sensory (I,II,VIII), five are motor (III,IV,VI, XI, and XII), and four are mixed (V, VII,IX, and X) as they have both sensory and motor functions. The cranial nerves are numbered in the order in which they are arise from the brain.  Cranial Nerves There are 12 pairs that emerge from the lower surface of the brain and pass through the foramina in the skull Cranial nerve I: olfactory Cranial nerve II: optic Sensory Cranial nerve VIII: acoustic Cranial nerve III: oculomotor Cranial nerve IV: trochlear Cranial nerve VI: abducens Trochlear nerve innervates a single muscle: the Motor superior oblique Cranial nerve XI: spinal accessory muscle of the eye. Abducens Cranial nerve nerveinnervates the musculus retractor bulbi, XII: hypoglossal  Cont., Cranial nerve V: Trigeminal Cranial nerve VII: Facial Mixed Cranial nerve IX: glosspharyngeal S.& M. Cranial nerve X: Vagus The cranial nerves are numbered in the order in which they arise from the brain E.G. Cranial nerve I, II attach in the cerebral hemispheres whereas cranial nerve IX,X,XI,XII attach at the medulla Most cranial nerves innervate the head , neck and special sense structures. Spinal nerves The spinal cord has 31 pairs of spinal nerves; each segment has 1 for each side of the body. 8 cervical, 12 thoracic, 5 lumbers, 5 sacral, and 1 coccygeal. Spinal nerves attach to the spinal cord; the spinal cord; each nerve has an anterior (ventral) root containing motor fibers and a posterior (dorsal) root containing sensory fibers Most peripheral nerves contain both sensory (afferent) and motor (efferent) fibers Spinal cord contains both gray and white matter  Autonomic Nervous System  The autonomic nervous system controls specific body processes, such as blood circulation, digestion, breathing, urination, heartbeat, etc.  The autonomic nervous system is named so because it works autonomously, i.e., without a person’s  Autonomic Nervous System  There are two major divisions; the sympathetic and parasympathetic systems, which generally act in opposition to each other.  The autonomic nervous system is regulated by centers in the spinal cord, brain stem, and  The sympathetic Nervous System  It is the part of the autonomic nervous system located near the thoracic and lumbar regions in the spinal cord. Its primary function is to stimulate the body’s fight-or-flight response. It does this by regulating the heart rate, rate of respiration, pupillary response and more.  It prepares the body to handle stressful situations.  Under stress condition from either physical or  The parasympathetic Nervous System  It is located in between the spinal cord and the medulla. It primarily stimulates the body’s “rest and digest” and “feed and breed” responses.  The parasympathetic nervous system functions as the dominant controller for most visceral effectors. During quiet, non stressful conditions.  Protective structure The skull:- The brain is contained in the rigid skull which protects it from injury. Its major bones are the frontal, temporal, parietal, and the occipital bones. The meanings Cerebrospinal fluid  Functions of nervous system: It receives stimuli from internal and external environmental through afferent sensory pathways. The peripheral nervous system communicates information between distant parts of the body and the central nervous system.  Functions of nervous system: It computes and processes the information received to determine appropriate responses to the situation. It transmits the information over efferent or motor pathways for body action.  Assessment General Signs & Symptoms Health History Physical Examination Diagnostic measures and laboratory investigation  Major Considerations in Determining The Extent of Neurologic Exam Client`s chief complaints Client`s physical condition : level of consciousness Ability for ambulation to test: Movements Coordination of extremities Client`s willingness to participate & cooperate  Assessment General Signs / Symptoms Headache or pain Numbness or tingling Head injury Difficulty swallowing Dizziness/vertigo Difficulty speaking Seizures Significant past history Tremors Environmental/ Weakness occupational hazard Incoordination  Past Medical & Surgical History Medications / allergies Habits / Lifestyle Changes (alcohol/ drug abuse) Familial History of neurological disorders Physical Examination Considerations Assessing mental status and speech Level of Consciousness : Assessment Tools Glasgow Coma Scale (GCS)  Assessing mental status and speech A quick check of mental status To quickly screen a patient for disordered thought processes, ask the questions below. An incorrect answer to any question may indicate the need for a complete Level of Consciousness : Assessment Tools: Glasgow Coma Scale (GCS) Three Categories: Eye opening Best motor response Best verbal response Scoring Highest or best possible score 15 13-14 mild neurological deficits 9-12 moderate neurological deficits A score of < 8 indicates coma and severe neurological neurological deficits  Mental Status Mental status assessment reflects client`s general cerebral function It includes : Intellectual function “ cognitive” Emotional function “affective” Major areas of mental status assessment are: Language Orientation Memory Attention span calculation Language Aphasia is any loss of power to express them self by speech due to a disease or injury in cerebral cortex It can be categorized as: Sensory or receptive Motor or expressive  Sensory or receptive aphasia It is the loss of ability to comprehend either written or spoken words Types of sensory aphasia: Auditory “ acoustic” …. Patients losing the ability to understand the symbolic content associated with sounds Visual …. Patients losing the ability to understand printed or written  Motor or expressive aphasia It involves loss of power to express them self by: Writing Making signs Speaking Client`s have losing the ability to combine speech sounds into words  Orientation The aspect of the assessment determine : Client ability to recognize other person.. person Awareness of when and where.. time and place Who are they Self  Memory The nurse assessing recall of information : Previously within seconds… immediate recall Events or information early in the day… recent memory Knowledge recalled from months, or years… long term memory Brain Exercises  Attention Span and calculation It determines the ability to focus on….. Mental Task That is expected to be performed by a person of... Normal Intelligence  Motor Movements & Strength Evaluate each extremity and compare with opposite side; record each extremity separately. Deep Tendon Reflexes (DTR) Tap appropriate tendon with percussion or reflex hummer Achilles, quadriceps, brachioradialis, biceps and triceps  Cranial Nerves The nurse must be aware of each cranial nerve functions to detect the abnormalities Reflexes: A reflex is an automatic response of the body stimuli It involuntary The quality of reflex response varies among people and age The more age , the less response of reflex will be differ It is assessed using a percussion hammer It can be measured by scale starts from 0 - 14  Reflexes Biceps  Brachioradialis  Achilles o Triceps o Patellar  Plantar “ babinski” Reflexes are graded from 0 to 4+ –4+: Very brisk, hyperactive, with clonus –3+: Brisker than average; possible by not necessarily indicative of disease –2+: Average; normal –1+: Somewhat diminished; low normal –0: No response -Hyperactive reflex indicate CNS disease -Absent or diminished of reflex indicate loss of sensation, relevant spinal segment damage, or PN damage  Sensory Function It includes: Touch * Pain Temperature * Position Tactile judgment In case of any complain of: Numbness Peculiar sensation *Examiner should check flexor Paralysis & extensor surfaces of the limbs * Mapping out clearly any  Abnormal sensation Anesthesia… loss of sensation Hyperesthesia…increase sensation than normal Example: increased sound sensitivity is called: "auditory hyperesthesia Hypoesthesia… decrease sensation than normal Paresthesia… abnormal sensation as in burn,  Who has to be checked toward sensation periodically? Examples of Risk Groups: Diabetics…. Arteriosclerotic heart disease…. Rationale … Low sensation may ended by severe tissue damage What we should do? Initial foot screening then annual assessment Evaluate their feet and shoes at least four times yearly why?... Prevention and early detection of foot problems.  Tactile Discrimination One & two point discrimination. Sterognosis is the ability to recognize object by touching them Extinction is the failure to perceive touch on one side of the body when other two areas are touched symmetrically  Diagnostic and laboratory investigation Plain X-ray a- Skull plain x-ray Skull plain X- ray reveals: Fracture of the skull or bony defects. Size & shape of the skull bone. Presence of foreign bodies e.g. tumors. Preparation Hair pins, dentures, must be removed from the patient.  Diagnostic and laboratory investigation Plain X-ray b- Spinal X-ray:- Spinal X- ray reveals: Spinal fracture lesion. Comparison. Dislocation. Narrowed spinal cord.  Diagnostic and laboratory investigation Nursing role Patient with neurological disorder should be assessed for level of conscious & treatment with the patient according to his condition. If the patient has a suspected spinal fracture; the neck is immobilized prior to moving the patient to make the X- ray. Metal items should be removed from the body parts.  Diagnostic and laboratory investigation 2- Computed Tomography scanning (CT). Useful to diagnosing disorder of multiply body system as regard the brain, head injury, Cerebrovascular disorder, hydrocephalus, Identification spacing occupying lesions, metastasis tumors and brain abscess.  Diagnostic and laboratory investigation Magnetic Resonance Imaging (MRI) Non invasive scanning to visualize internal organs & structures by use of magnetic forces rather then radiation.  Diagnostic and laboratory investigation Electroencephalogram (EEG) Records the electrical activity of the brain through a series of electrodes on the scalp. Used to diagnose and evaluate seizures disorders, identify tumors, brain abscesses or infections and to confirm of brain death.  Diagnostic and laboratory investigation Lumbar puncture Lumbar puncture is insertion of a needle into lumbar subarachnoid space to withdrawal cerebro-spinal fluid (CSF) for diagnostic & therapeutic purposes.  Nervous System Changes in Old Age We are born with all the brain neurons--about 100 billion nerve cells that we will ever have. This network performs communication within the brain and to the rest of the body. After age 25, everyone loses nerve cells both in the brain and spinal cord. Gradually over time, this results in a reduced the ability of nerve transmission, changing response time and coordination. In addition to, diminished all senses of smell, taste, sight, touch and hearing over time.  Nervous System Changes in Old Age The brain also shrinks in size, which does not significantly affect functioning except in the most extreme cases. These changes may also affect sleeping patterns somewhat by decreasing the length of total sleep time, and causing depression in more than 25.0% of elderly people.