NEUROLOGIC EXAMINATION

HEALTH HISTORY History of Present Illness Important aspect of neurologic assessment Initial Interview Provides an excellent opportunity to systematically explore the patients current condition and related events while 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 test b. Personal hygiene and grooming c. Evaluate speech and ability to communicate
1. 2. 3. 4. Pace of speech: rapid, slow, halting Clarity: slurred or distinct Tone: high-pitched, rough Vocabulary: appropriate choice of words

*** Facial features may suggest specific syndromes in children

PHYSICAL ASSESSMENT

Mental Status a. General appearance and behavior b. Level of consciousness

1. Oriented to person, place and time 2. Appropriate response to verbal and tactile stimuli 3. Memory, problem solving abilities.

c. Mood d. Thought content & intellectual capacity

PHYSICAL ASSESSMENT

Assess Pupillary Status and Eye movement a. Size of pupils should be equal b. 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 eye

a. Note nystagmus b. Ability of eyes to move together c. Resting position of iris should be at mid-position of the eye socket

d. PERRLA

Clinical Manifestation
The 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

PAIN SEIZURES DIZZINESS a nd VERTIGO VISUAL DISTURBANCES WEAKNESS ABNORMALSENSATION

Clinical Manifestations
PAIN
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 Manifestations
SEIZURES - 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 Manifestations
DIZZINESS 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 Manifestations
VISUAL DISTURBANCES
Visual 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 - Both numbness and weakness can significantly affect balance and coordination
g

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
f

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 patients 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 backwards b. Serial 7s (Subtract 7 from 100, then 7 from that, and so forth) Interpret proverbs Ability to recognize similarities Situational analysis

Thought Content
During the interview, it is important to assess the patients thought content. Are the patients thought

f

Spontaneous Natural Clear Relevant Coherent

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

Emotional Status
Is the patients 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 its called

Screening for visual and tactile agnosia provides insight into the patients cortical interpretation ability
Placing a familiar object (key) in the patients 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 CRANIAL NERVES

CRANIAL NERVES
On Old Olympus 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 S M M M/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 - Olfactory

Normal: 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 nonpathological: 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 chart Use an object to occlude one eye Evaluate the vision one eye at a time

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

Testing eye movements

Testing pupil accommodation

Abnormal: Normal: Able to read without CN II deficits

difficulty Visual acuity intact 20/20, both eyes Hippus phenomenon: Brisk constriction of pupils in reaction to light, followed by dilation and constriction - may be normal or sign of early CN III compression.

- can occur with stroke or brain tumor.

Changes in pupillary reactions

- can signal CN III deficits.

Increased ICP causes changes in pupillary reaction

As pressure increases, response becomes more sluggish until pupils finally become fixed and

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.

CN V - Trigeminal Nerve
b. 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, dont establish a pattern)

Testing CN V sensory function

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
Testing corneal reflex

Cont. CN V

Abnormal:

Normal: Full range of motion (ROM) in jaw and 15 strength.

Patient perceives light touch and superficial pain bilaterally

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.

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 CN VII motor function

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

Testing taste sensation

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 Bells palsy or stroke. Impaired taste/loss of taste: - Damage to facial nerve, chemotherapy or radiation therapy to head and neck.

Cranial Nerve VIII - Acoustic Nerve

a. Perform Weber and Rinne tests for hearing b. Perform watch-tick test by holding watch close to patients ear.
Watch tick test

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.

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.
Testing CN IX and X motor function

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 X
Normal:
Swallow and cough reflex intact. Speech clear.

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.

Elevation and constriction of Diminished/absent gag reflex: pharyngeal Nerve damage musculature and - Risk for aspiration tongue retraction indicate positive gag Impaired taste on posterior reflex 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 XI
Normal: 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.

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.
Testing CN XII motor function

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 patients 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 Council Method 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 Coordiantion

a. 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 coordination Dysdiadochokinesia - 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 test
With 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. Abnormal: Dysmetria - clumsy movement with overshooting the mark - occurs with cerebellar disorder Past-pointing - constant deviation to one side

Normal: Movement is smooth and accurate

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 Coordination

The cerebellum is responsible for balance and coordination. Rombergs 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:

Abnormal:

Negative Romberg Sways, falls, widens base of feet to avoid falling test 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 walk Widens base to maintain balance Staggering, reeling, loss of balance An 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

REFLEXES
Documenting Reflex Findings Use these grading scales to rate the strength of each reflex in a deep tendon and superficial reflex assessment.
Deep tendon reflex grades 0 absent + present but diminished + + normal + + + increased but not necessarily pathologic + + + + hyperactive or clonic (involuntary contraction and relaxation of skeletal muscle) Superficial reflex grades 0 absent + present

 Documentation of reflex finding

ASSESSING REFLEXES
Biceps 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 REFLEXES
b. Triceps Reflex - flex pts arm to 90 angle and positioned in front of the chest Abduct patients 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 REFLEXES
d. Ankle Reflex - Achilles reflex - foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon Normal: Plantar flexion of foot.

ASSESSING REFLEXES
e. 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 patients 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 males 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 patients 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 patients 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 patients 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 Examination
VIBRATION 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.

Stereognosis With patients eyes closed, place a familiar object, such as a coin or a button, in patients hand, and ask patient to identify it. Test both hands using different objects.
Normal:

Abnormal:

Abnormal findings suggest a Stereognosis intact bilaterally. lesion or other disorder involving sensory cortex or a disorder affecting posterior column.

Sensory Extinction Simultaneously touch both sides of patients body at same point. Ask patient to point to where she or he was touched. Normal: Abnormal:
Extinction intact. Identification of stimulus on only one side suggests lesion or other disorder involving sensory cortical region in opposite hemisphere.

Assessing Level of Consciousness

Level of Consciousness (LOC) arousal; awareness of self or environment

d

Alert fully awake; appropriate responses to external and

internal stimuli; oriented to person, place and time

s

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 stimulus
f

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)

ASSESSING LEVEL OF CONSCIOUSNESS a. Test orientation to time, place, and person

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 Findings Abnormalities 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 body Paraplegia 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 Findings Abnormalities in Muscle Movement

Fasciculations Rapid, continuous twitching of resting muscle

Abnormal Findings Abnormalities in Muscle Movement

Tic Repetitive twitching of a muscle group

Abnormal Findings Abnormalities in Muscle Movement

Myoclonus Rapid, sudden jerk at a fairly regular intervals

Abnormal Findings Abnormalities in Muscle Movement

Tremor Involuntary contraction of opposing muscle groups Rest tremor Intention tremor

Abnormal Findings Abnormalities in Muscle Movement

Chorea Sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face

Abnormal Findings Abnormalities in Muscle Movement

Athetosis

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

Neurologic Exam: Meningeal signs

Brudzinskis sign
- neck stiffness - involuntary flexion of hips and knees when flexing neck is positive sign for meningeal irritation

Neurologic Exam: Meningeal signs Positive Kernigs 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 (Alzheimers 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 tumors 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 45 and remain in bed for 3hrs Encourage increased fluid intake Monitor VS

Myelography

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: 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 ANGIOGRAM

Nursing Intervention: CEREBRAL ANGIOGRAPHY

NURSING CARE PRE-TEST 1.) Check allergy to iodine 2.) Keep NPO after midnight or offer clear liquid breakfast only 3.) Explain that the client may have warm, flushed feeling and salty taste in mouth during procedure 4.) Take baseline vital signs and neuro check 5.) Administer sedation if ordered NURSING CARE POST-TEST 1.) Maintain pressure dressing over site if femoral or brachial artery used; apply ice as ordered 2.) Maintain bed rest until next morning as ordered 3.) Monitor vital signs, neuro checks frequently; report any changes immediately 4.) Check site frequently for bleeding or hematoma; if carotid artery used; assess for swelling of neck, difficulty swallowing or breathing 5.) 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 Carotid ultrasonography Oculoplethysmography Opthalmodensinometry

permits evaluation of arterial blood flow and detection of atrial stenosis, occlusion and plaques

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 resultsanticonvulsants, 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 examination Spinal tap - a needle is inserted into the subarachnoid
space through the 3rd and 4th or 4th and 5th lumbar interface to withdraw spinal fluid PURPOSES 1. Measures CSF pressure
h

(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 blood 4. 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 Guidelines

NURSING CARE PRE-TEST 1.) Have client empty bladder 2.) 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-TEST 1.) Ensure labeling of CSF specimens in proper sequence 2.) Keep client flat for 12-24 hours as ordered 3.) Force fluids 4.) Check puncture site for bleeding, leakage of CSF 5.) Assess sensation and movement in lower extremities 6.) Monitor vital signs 7.) Administer analgesics for headache as ordered

Queckenstendts 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. Bates 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

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