NSB103 Health Assessment PDF

NSB103 Health Assessment Neurological Health Assessment Dr Margie MacAndrew Objectives By the end of this session you will start to:  Apply your understanding of the major functions of the neurological system to conducting an assessment of neurological function  Have an underst...

NSB103 Health Assessment Neurological Health Assessment Dr Margie MacAndrew Objectives By the end of this session you will start to:  Apply your understanding of the major functions of the neurological system to conducting an assessment of neurological function  Have an understanding of the tools used to assess the neurological system and how to interpret these  Have an understanding of how assessment data guides decision making about appropriate care Neurological assessment will be practiced in the labs this week Neurological assessment- A&P Anatomy of the Neurological System 1. Central nervous system (CNS) 3. Cranial Nerves a. brain & cranial nerves b. spinal cord 2. Peripheral nervous system (PNS) a. afferent division – message to brain b. efferent division – message from brain 1) Somatic nervous system (voluntary muscle control) 2) Autonomic nervous system (involuntary) a) sympathetic division (fight and flight) b) parasympathetic division (rest and digest) CNS: The Brain 2 Hemispheres 4 lobes with specific function Frontal Lobe Parietal Lobe Higher executive Integrating sensory functions: emotional information, including regulation, planning, touch, temperature, reasoning, problem pressure and pain. solving. Occipital Lobe Major visual Temporal Lobe processing centre in Processing sensory Limbic System Contains amygdala, the brain – recognition information, of objects and depth hippocampus, important for hearing, thalamus, hypothalamus, perception recognising language, basal ganglia, and and forming cingulate gyrus – memories. memory formation Brain Fun Facts Contributes to 2% of total body weight ~ 1.5kg (Craft et al, 2019) Uses 20% energy and oxygen Contains approx. 86 billion brain cells 5 minutes without oxygen can cause permanent damage A baby's head is big compared with body to accommodate rapidly growing brain Brain not fully formed till you are 25 years old Use most of our brain most of the time – unlimited storage and ability to rewire pathways (Reuber, 2010) – life-long capacity. Neuroplasticity ‘the ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections’ (Cramer et al., 2011, p. 1592) retraining or rewiring a brain that has been damaged to regain function physical activity (Erickson, Gildengers, & Butters, 2013), adult learning (Lövdén et al., 2013) and non-invasive brain stimulation (Di Pino et al., 2014) promote neuroplasticity Key to rehabilitating brain injury  The ageing brain Changes to the brain start around 50 years old ↓ Brain weight, synapses and neurones Main changes in cortex and cerebellum + atrophy mainly in frontal lobe →  Reduced mental flexibility, abstract thinking, recall and visual-spatial ability  Short term memory may decrease slightly  Extended learning and word retrieval (Humayun, Yao, & Surgery, 2019, p. 843) time Changes should not interfere with independent function or notable disability (Calleja, Theobald, & Harvey, 2020) Cognition ‘the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses’ (Oxford Languages, 2020) Judgement Memory & Problem Knowledge & Recall Solving Reasoning Decision Communicatio Making n & Language Memory Long term memory Short term memory Moved from short term memory Hold for short periods More likely to become long Can access quickly term memory if attention Prefrontal cortex given, rehearsal + is meaningful Hippocampus SIGNIFICANT MEMORY PROBLEMS ARE NOT A NORMAL PART OF AGEING  CNS: Cranial nerves How to remember cranial nerves - https://www.youtube.com/watch?v=ZQ1TN6C1Lug Sources of assessment data Subjective: What we are told? Objective: What can we measure? Directly from the patient Primary health assessment – ABCD Family and friend  D = Disability →neurological status Formal/informal carers Full system assessment Other health professionals Vital signs  Age care/acute care nurses  Ambulance officer / Police Pathophysiology  Social worker  Medical officer Imaging e.g. x-rays, CAT scans,  Allied health workers MRI, ultrasound  Medical charts (Crisp et al., 2013) Assessment of the Neurological system Subjective data Objective data Health history including reports of Inspection – Alertness, symmetry, recent/long term: trauma, colour/texture, lesions/tumors/scars  Pain involving head or nerve Mental status – level of related (burning) consciousness, orientation  Altered sensation – numbness, CNS tingling, paresthesia Cranial nerves – symmetry of  Altered function – mobility/gait/ face, smile, poke out tongue, puff weakness/tremors/incoordination, cheeks speech/swallow, memory Motor system – strength, equal  Dizziness, seizures movement arms and legs  Head injury/surgery  Medication/drug use Sensory system - sensation PNS Reflexes Neurological assessment Level of Consciousness (Glasgow Coma Scale) + Motor response (strength right = left) + Pupil response (size, PEARLA) + Vital Signs (T, P, BP, RR) Equipment you will need Assessment of CNS - brain 1. Mental status Level of Consciousness = level of awareness of self & the environment 3 levels of assessment  Eyes Opening  Best Verbal Response  Best Motor Response Glasgow Coma Scale Developed 1974 by Teasdale and Jennett - Glasgow Royal Infirmary + University of Glasgow Identifies brain damage Assessment of Level of Consciousness (LOC) 1. Eyes opening - observe patient’s alertness when you enter the room Observation How to assess GCS score Spontaneous Eyes already open 4 To speech Open after being disturbed or 3 your voice To pain If light touch does not work 2 apply painful stimulation. Note response to pain for part 3 (NOT sternal rub) None 1 Assessment of Level of Consciousness (LOC) 2. Best verbal response Orientation to person, place and time “Can you tell me your name and date of birth” “Do you know what day it is” Assessment of Level of Consciousness (LOC) 3. Best motor response  How well do they follow you command “Can you squeeze my fingers” – compare symmetry of strength Observation How to assess GCS score Obeys commands 6 Localise to pain If no response note response to 5 pain Withdrawal Note: no need to re-test pain 4 response if used already Flexion 3 Extension 2 None 1 Steps for assessing LOC Observe eyes when you enter the room and any changes to stimuli (environmental stimuli) - Alert If eyes remain closed – introduce yourself (verbal stimuli) If no response, lightly touch or squeeze the patients hand or gently shake them If no response to environment or verbal stimuli, apply painful stimuli ❖ Pressure with pen to nail bed Only progress ❖ Firmly pinch trapezius muscle OR if NO response ❖ Apply pressure to supraorbital ridge or the manubrium  Limitations of GCS Paediatrics - Best verbal response modified to AVPU include developmental milestones. May present as A Alert extreme agitation, high pitched cry V Response to voice Not useful as a guide for evaluating pts in P Response to pain longstanding unconscious states – e.g. Persistent U Unresponsive vegetative state Moderate interrater reliability in ED departments  Used clinically for adults and children and relies on surrogate markers of neurological  Quick change – not intended to be used alone (Gill,  Better reliability Reiley & Green, 2004) GCS Scoring GCS Score for Eyes Open (/4) + Score for Best Verbal Response (/5)+ Score for best Motor Response (6) Best GCS = 15 Lowest GCS = 3 Interpreting GCS data Prognosis GCS score Level of Consciousness Possible causes (LOC) 15 Alert, orientated, follows commands 14 Confused Intoxication, organic causes 13-14 Lethargy Organic causes, Medications, ↑ ICP 12-13 Stupor Organic causes, Medications, ↑ ICP 8-10 Permanent vegetative Anoxic brain injury state 6 Locked in syndrome Spinal cord injury 3-6 Coma Anoxia, trauma, space occupying lesion 3 Brain death Anoxia, structural damage Estes et al., 2016. p. 190 Assessing neurological status in a child Neurological status can be impacted by:  Changes to neurological system – trauma, oxygenation  Effect of a disease process – delirium – infection, oxygenation Manifestations:  Listless or uninterested in surroundings, ↓ level of consciousness  Altered muscle and limb tone e.g. decorticate (upper limb flexion, lower limb extension); decerebrate (upper and lower limb extension) → ↑raised intracranial pressure  Jittery, hypotonia, lethargy, seizures  Up to 12-month-old – tense fontanel → ↑raised intracranial pressure  Parents know their child – listen to them! Fraser, Waters, Forster, Brown (2017) Paediatric neurological assessment tools GCS AVPU A Alert Modified for infants and children V Response to voice GCS = 8 = serious low score = P P Response to pain U Unresponsive  Used clinically for adults and children  Quick  Better reliability Fraser, Waters, Forster, Brown (2017) Altered orientation: Need more info Is this a new symptom? Collect more data: Previous history of memory problems? How long? If new disorientation, despite their age, it must be investigated. Head injury in older adult can take 10 days for symptoms to develop Memory loss can be temporary or permanent Test of global cognition – thinking, memory MMSE (cont) Assesses only global cognitive function: helpful as a means to detect cognitive deficits. Further assessment needed to diagnose permanent loss (dementia) or acute change (delirium) Limitations in paediatrics. Disadvantages speech dysfunctions Non-verbal tool available understanding of language – e.g. English.  Delirium v’s Dementia Disorientated to time, person and place Disorientated to time, person and place Functional and behaviour changes Functional and behaviour changes Sudden onset Progresses over time Treatable cause Cause is incurable Possible causes: infection, deoxygenation, Causes: Alzheimer’s disease, vascular pain, hypoglyceamia, constipation, sleep dementia, dementia with Lewy Bodies, deprivation Parkinson’s disease Old and very young patients at risk Old age is a risk factor  Diagnosis of Delirium Consider risk factors – very old and very young, people with dementia Is it a new change in cognition or behaviour Are they having problems attending and are their thoughts disorganised? Is there an acute altered state of consciousness? Is there acute changes in orientation? Assessment of communication between CNS & PNS 2. Motor response Assessing gross motor responses and strength in arms Looking at potential causes and legs preventing motor reflexes & responses moving from Ask person to squeeze your hands & push hands away CNS to PNS: with their feet Brian injury → ↑ICP Look for symmetry Brain ischemia – CVA  Normal power Spinal cord injury  Mild weakness  Severe weakness  Flexion  Extension  No response Neurological Assessment cont. 3. Pupillary response to light Pupils should be round size 2- 6mm Constrict when illuminated (direct response) Other pupil should constrict at the same time (consensual response) Controls light entering the eye PEARRLA Pupil Equal And Round Reacting to Light and accommodation Pupillary response to light Pupils size, shape, reaction to light, accommodation and constriction reactions Determines pupil size – pupil gauge Dim the lights Ask patient to open eyes and gaze on object in the room Using a penlight shine it directly into the pupil – start from the side Can be difficult to see in very dark eyes – dim lights Document size before light and reaction time Abnormal pupil response: Clinical implications Unequal pupils can indicate raised intracranial pressure → ↑ pressure on optic nerve May be due to trauma – ask if new or old symptom Pinpoint pupils can be associated with opioid and elicit drug use Bilateral blown pupils indicative of poor prognosis Doll eye test – a test for brain death CNS assessment - Cranial nerves 12 pairs with motor and/or sensory function Symptoms indicate dysfunction & damage I is the Olfactory nerve - smell II is the Optic nerve - sight III is the Oculomotor nerve – eye lid/pupil response IV is the Trochlear nerve – eye movement V is the Trigeminal nerve – muscles of the face/chew VI is the Abducens nerve – move eye away from nose VII is the Facial nerve - smile VIII is the Vestibulocochlear nerve - balance IX is the Glossopharyngeal nerve - swallow X is the Vagus nerve – movement of major organs XI is the Spinal accessory nerve - neck & shoulders XII is the Hypoglossal nerve - tongue Assessment of cranial nerves Need to know motor and/or sensory response Tests normal function Deficit suggests damage Watch cranial nerve assessment https://www.youtube.com/ watch?v=PG4zrRfocoQ Cranial nerve dysfunction Cranial Nerve III - Ptosis Cranial Nerve VII – Facial palsy Includes Cranial Nerve IX – assessment of Glossopharyngeal sensation: Dysphagia – Pain, impaired swallow & numbness, slurred speech Burning Reflexes Unconscious response to external stimuli Stimulation to joint, muscle or skin 3 categories – muscle stretch/deep tendon reflex, superficial reflexes, pathological reflexes Testing reflexes https://www.youtube.com/watch?v=BNz skBYjt4c Modifications for paediatric patients Neurological system not completely developed at birth By 1 year, neurons become myelinated, and primitive motor reflexes become purposeful responses (most by *3-4 months)  *Rooting reflex  *Sucking reflex  *Palmer grasp reflex  Tonic neck reflex (2mnths)  *Stepping reflex  Planter grasp reflex  *Babinski reflex  *Moro (startle)reflex  Galant reflex  Placing reflex Altered sensory responses due to  Landau reflex ageing  Subjective & Objective Data Compare the data against normal parameters Identify Health Problems Set realistic goals (nurse initiated & collaborative) Interpreting assessment data What do the signs and symptoms mean? Use subjective and objective data: Link to functions of CNS & PNS Link to brain A&P and function Consider history leading to changes & age of person  Potential Health Problems NS Abnormal Clinical Impact on Health status Data/Pathophysiology indication Altered level of GCS < 15 ❖ Compromised safety consciousness Confused → Coma ❖ Self help deficits Intoxication ❖ Impaired hydration & nutrition Head injury ❖ Impaired mobility Organic cause ❖ Anxiety/fear Impaired motor Para/hemiplegia ❖ Impaired mobility responses Uneven arm/leg ❖ Self help deficits Spinal cord injury strength ❖ Anxiety/fear Brain anoxia/injury Unsteady gait Impaired/Altered Uneven sensation ❖ Compromised safety Sensation/reflexes Loss of sensation ❖ Altered rest and sleep Cranial Nerve damage Delayed/absent ❖ Fatigue Spinal cord damage reflexes ❖ Anxiety/fear Brain injury Pain Key points Assessment of the neurological system requires subjective and objective data related to the central and peripheral nervous system. Important to understand the function of each part of the system to identify dysfunction – changes across the lifespan Assessments will include: level of consciousness, orientation, movement and strength, cranial nerves (movement/sensory), reflexes. Consider acute/temporary and permanent causes of change Assessment data will guide identification of problems and direct care planning. References Craft, J., Gordon, C., Huether, S. E., McCance, K. L., & Brashers, V. L. (2019). Understanding pathophysiology-ANZ adaptation: Elsevier Health Sciences. Crisp, J., Taylor, C., Douglas, C., Rebeiro, G. (2013) Potter and Perry’s Fundamentals of Nursing. 4th Ed. Calleja, P., Theobald, K., & Harvey, T. (2020). Estes Health Assessment & Physical Examination (3rd Australian & New Zealand Edition ed.). Sydney: Cengage Learning Australia. Di Pino, G., Pellegrino, G., Assenza, G., Capone, F., Ferreri, F., Formica, D.,... Rothwell, J. C. J. N. R. N. (2014). Modulation of brain plasticity in stroke: a novel model for neurorehabilitation. 10(10), 597-608. Erickson, K. I., Gildengers, A. G., & Butters, M. A. J. D. i. c. n. (2013). Physical activity and brain plasticity in late adulthood. 15(1), 99. Fraser, J., Waters, D., Forster, E., Brown, N. (2017) Paediatric Nursing in Australia: Principles for practice (2 nd Ed). Cambridge University Press, UK. Gill, M., Reiley, D., Green, S. (2004). Interrater Reliability of Glasgow Coma Scale Scores in the Emergency Department. Annals of Emergency Medicine. 43, (2) 215-223, doi:10.1016/mem.2004.421 Jarvis (2008). Physical Examination & Health Assessment (5 th Ed). Elsevier, St Louis Jones, C., (1979). Glascow Coma Scale. American Journal of Nursing. 79 (9) 1551-1557. Lewis, P.A., & Foley, D. (Eds.). (2011). Weber and Kelley's health assessment in nursing (Australasian version) e1. Broadway, NSW: Lippincott Williams andWilkins. Lövdén, M., Wenger, E., Mårtensson, J., Lindenberger, U., Bäckman, L. J. 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