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. Neurologic assessment becomes multifaceted and lengthy. Perception-conscious recognition and interpretation (awareness) of the sensory stimuli that serve as a basis for understanding, learning and knowing or for the motivation of a particular action or reaction Coordination-when action or reaction towards a stimulus is occurring in a purposeful, orderly fashion, appropriate response to a stimulus 3 essential components of skull: 1. Brain tissue-78% 2. Blood -12 % 3. CSF-10% Monro-Kellie Hypothesis If volume added to the cranial vault equals the volume displaced from it, the total intracranial volume will not change Normal ICP: 60-150 mmH20 or 0-15 mmHg Cerebral Blood Flow • Amount of blood in milliliters passing through 100g of brain tissue in 1 minute • Global CBF-approximately 50 ml/min • Brain needs constant supply of oxygen and glucose (20% of body’s oxygen, 25% of body’s glucose)
More than 10 minutes of oxygen deprivation-brain death Mean arterial pressure at which autoregulation is effective (70-105 mmHg) -Upper limit is 150 mmHg MAP= 3 Cerebral perfusion pressure needed to ensure blood flow to the brain CPP= MAP-ICP -30 mmHg is incompatible with life Cranium and Cerebral column Cranial meninges Dura mater Arachnoid Pia mater Falx cerebri-divides the left from right hemispheres Subdural-more bleeding NEUROLOGIC ASSESSMENT Comprehensive History Taking 1. Biographical and demographic data- it includes personal profile of the patient, source of history and the clients mental status 2. Current health SBP + 2 (DBP)
a. Chief complaint- obtains a detailed description of the event that have led the client to seek care. Use open ended question. b. Symptom analysis3. Past health history a. Childhood infectious disease and immunizations • Rubella and rubeola • Meningitis • Herpes simplex virus • cytomegalovirus • influenza b. Major illnesses and hospitalizations • Pernicious anemia • Cancer • DM • Infections • Hypertension • Liver and renal disease • F & E imbalances • Acid-Base Imbalances • Head trauma • Seizures and stroke c. Medications• CNS stimulants • Sedatives and hypnotics • Antideppressives • Analgesics • Anti hypertensive and stroke d. Growth and development
Mental Status Examination An indication of how patient is functioning as a whole and how the patient is adapting to the environment 1. General appearance2. Intellectual capacity or performance- consists of fund of knowledge and calculation activity 3. LOC-the most sensitive indicator of changes in the neurologic status -begin by observing spontaneous behavior -visual cue -verbal cues -tactile -Noxious agent- use of central stimulus rather than peripheral (nail bed pressure) because it may elicit a reflex a. sterna pressure b. supraorbital ridge pressure c. sternocleidomastoid muscle pinch 4. Orientation- to time, place and event or situation 5. Memory- retrograde (long-term memory) and anterograde (recent memory or short-term) 6. Mood/affect 7. Judgment/Insight- include reasoning, abstract thinking, problem solving and the clients’ perception of the situation. 8. Language/communication MENTAL STATUS ASSESSMENT WITH ABNORMAL FINDINGS
Unilateral neglect (lack of caring of the other side of the body); strokes involving middle cerebral artery.
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Poor hygiene and grooming: dementing disorders Abnormal gait and posture: transient ischemic attacks(TIAs) , strokes, and Parkinson’s disease Emotional swings, personality changes: strokes Aphasia-defective or absent language function: TIA’s, strokes involving anterior/posterior artery; general term for impairment of language Dysphonia- change in tone of voice Dysarthria- (different in speaking); is indistinctness of words in word articulation resulting from interference with the peripheral speech mechanisms (e.g. muscles of the tongue, palate, pharynx, or lips) [Phipps, 1998, p. 1901] Decreased level of consciousness Confusion, Coma
COGNITIVE FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS • Disorientation to time and place: stroke of right cerebral hemisphere 1. Memory deficits 2. Emotional defense CRANIAL NERVE ASSESSMENTS • Cranial I (Olfactory): Anosmia 1. lesions of frontal lobes 2. impaired blood flow to middle cerebral artery. • Cranial II (Optic) 1. blindness in eye: strokes of internal carotid artery, TIA’s 2. Homonymous hemianopia - impaired vision or blindness in one side of both eyes; blockage of posterior cerebral artery.
3. Impaired vision: strokes of anterior cerebral artery; brain tumors Note: • Visual acuity-mediated by the cones of the retina • Field of vision or peripheral vision-portion of space in which objects are visible during the fixation of vision in one direction. The receptors for peripheral fields are the rod neurons of the retina. (Phipps, 1998, p. 1906) • Cranial nerve III, IV, VI (Oculomotor, Trochlear, Abducens)-motor nerves that arise from the brainstem 1. Nystagmus –- involuntary eye movement; strokes of anterior, inferior, superior, cerebellar arteries 2. Constricted pupils: may signify impaired blood flow to vertebralbasilar arteries. 3. Ptosis (eyelid falldown); dropping of the upper eyelid over the globe—strokes of posterior inferior cerebellar artery; myasthenia gravis, palsy of CN III Cranial nerve V (Trigeminal)—largest cranial nerve with motor and sensory components: changes in facial sensations; impaired blood flow to carotid artery 1. Decreased sensation of face and cornea on same side of body; strokes of posterior inferior cerebral artery 2. Lip and mouth numbness 3. Loss of facial sensation: contraction of masseter and temporal muscles, lesions CN V 4. Severe facial pain: trigeminal neuralgia (tic dorlourex) Cranial VII (Facial nerve)—mixed nerve concerned with facial movement and sensation of taste 1. Loss of ability to taste
2. Decreased movement of facial muscles 3. Inability to close eyes, flat nasolabial fold, paralysis of lower face, inability to wrinkle the forehead 4. Eyelid weakness; paralysis of lower face; paralysis of upper motor neuron 5. Pain, paralysis, sagging of facial muscles: affected side in Bell’s palsy Cranial VIII (Acoustic)—composed of a cochlear division related to hearing and a vestibular division related to equilibrium (Phipps, 1998, p. 1909) • Decreased hearing or deafness: strokes of vertebralbasilar arteries or tumors of CN VIII Cranial IX(Glossopharyngeal) and cranial X (Vagus)—chief function of cranial nerve IX is sensory to the pharynx and taste to the posterior third of tongue; cranial nerve X is the chief motor nerve to the soft palatal, pharyngeal and laryngeal muscles (Phipps, 1998, p. 1909) 1. Dysphagia (difficulty swallowing) 2. Unilateral loss of gag reflex Cranial XI (Spinal accessory)—motor nerve that supplies the sternocleidomastoid muscle and upper part of trapezius muscles 1. Muscle weakness 2. Cortralateral hemiparesis: strokes affecting middle cerebral artery and internal artery Cranial XII (Hypoglossal) 1. Atrophy, fasciculations (twitches): LMN disease 2. Tongue deviation toward involved side of the body SENSORY FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS Altered sensation occurs with variety of neurologic pathology
Altered sense of position: lesions of posterior column of spinal cord Inability to discriminate fine touch: injury to posterior columns MOTOR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS Muscle atrophy: LMNs disease Tremors (groups, large of muscle fibers)-Parkinson’s disease (tremors at rest), multiple sclerosis (tremors observed in activity) Fasciculations (single muscle fiber): disease or trauma to LMN, side effects of medications, fever, sodium deficiency, anemia Flaccidity (decreased muscle tone): disease or trauma to LMN and early stroke Spasticity (increased muscle tone): disease of corticospinal motor tract Muscle rigidity: disease of EP motor tract Cogwheel rigidity (muscular movement with small regular jerky movement; parkinson’s disease Muscle weakness-in arms, legs, hands: TIAs Hemiplegia-paralysis of half of body vertically Flaccid paralysis: strokes of anterior spinal artery, multiple sclerosis or myasthenia gravis Total loss of motor function: below level of injury Spasticity of muscle: incomplete cord injuries CEREBELLAR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS Ataxia (lack of coordination and clumsiness of movement, staggering, wide-based and unbalanced gait)
Steppage gait (client drags or lifts foot high, then slaps foot onto floor; inability to walk on heels; disease of LMN Sensory ataxia (client walks on heels before bringing down toes and feet are held wide apart; gait worsens with eyes closed Parkinsonian gait (stooped over position while walking with shuffling gait with arms held close to the side) Romberg’s test (Positive)- With feet approximated, the patient stands with eyes open and then closed; if closing the eyes increases the unsteadiness, a loss of proprioceptive control is indicated REFLEX Hyperactive: reflexes Decreased reflexes Clonus of foot (Hyperactive, rhythmic dorsiflexion and plantar flexion of foot) Superficial reflexes (such as abdominal) and cremasteric reflex Positive Babinski reflex (dorsiflexion of big toe) (plantiflexion- Normal)
Positive Kernig’s sign-excessive pain when examiner attempts to straighten knees with client supine and knees and hips flexed
Decorticate posturing (up)- decorticate response, mummy baby, flexor posturing- damage to mesencephalic region and the corticospinal tract
Special Neurologic Assessment Brudzinski’s sign (pain, resistance, flexion of hips and knees when head flexed to chest with client supine)
Decerebrate posturing (down)- extensor posturing- the head is arched back, the arms are extended by the sides, and the legs are extended. Decerebrate posturing indicates brain stem damage or rather damage below the level of the red nucleus (eg. mid-collicular lesion) #Altered Level of consciousness 1. Consciousness Requires: 1. Arousal: alertness; dependent upon reticular activating system (RAS); system of neurons in thalamus and upper brain stem
2. Cognition: complex process, involving all mental activities; controlled by cerebral hemispheres Process that affect LOC: a. Increased ICP b. Stroke, hematoma, intracranial hemorrhage c. Tumors d. Infections e. Demyelinating disorders
c. Orientation changes: losses orientation to time first, then place, person d. Continuous stimulation required to maintain wakefulness e. Client has no response, even to painful stimulation Loss of Simultaneous Eye Movement Loss of normal reflex functioning: 1. Doll’s eye movement: eye movement in opposite direction of head rotation (normal function of brain stem) 2. Oculocephalic reflex: eye move upward with passive flexion of neck; downward with passive neck extension (normal function) 3. Oculovestibular response (cold caloric testing): instillation of cold water in ear canal cause nystagmus (lateral tonic deviation of eyes) toward stimulus (normal function)
Systemic Conditions affecting LOC Hypoglycemia F/E imbalance Accumulated waste products from liver or renal failure Drugs affecting CNS: alcohol, analgesics, anesthetics Seizure activity: exhausts energy metabolites Level of Consciousness • Alert • Lethargic-very sleepy • Obtunded Glasgow Coma Scale • Stuporous 1 2 3 4 • Coma Opens eyes E Opens eyes in Does not in response Opens eyes • Death ye response to Client Assessment with Decreased LOC a. Increased stimulation required to elicit response from client b. More difficult to arouse; client agitated and confused when awakened
s open eyes to painful stimuli voice V Incomprehe Utters er Makes no nsible inappropriate ba sounds sounds words l M Makes no Extension to Abnormal
spontaneously Confused, disoriented Flexion /
Oriented, converses normally Localizes
painful flexion to o stimuli painful stimuli Withdrawal to painful t movements (decerebrate (decorticate painful stimuli stimuli or response) response)
c. Movements are more generalized and less purposeful commands
(withdrawal, grimacing) d. Reflexive motor responses e. Flaccid with little or no motor response COMA Use CPOMR to evaluate the lesion C: Conscious P: Pupil O: Ocular movement M: Motor response R: Respiratory pattern Irreversible coma - vegetative state Permanent condition of complete unawareness of self and environment, death of cerebral hemispheres with continued function of brain stem and cerebellum Client does not respond meaningfully to environment but has sleep-wake cycles and retains ability to chew, swallow and cough Eyes may wander but cannot track objects Minimally conscious state: client aware of environment, can follow simple commands, indicates yes/no responses; make meaningful movements (blink, smile) Often results from severe head injury or global anoxia Locked-in syndrome 1. Client is alert and fully aware of environment; intact cognitive abilities but unable to communicate through speech or movement because of blocked efferent pathways from brain
Interpretation Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35". Generally, brain injury is classified as:
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Severe, with GCS ≤ 8 Moderate, GCS 9 - 12 Minor, GCS ≥ 13.
Intubation and severe facial/eye swelling or damage makes it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. 'E1c' where 'c' = closed, or 'V1t' where t = tube. A composite might be 'GCS 5tc'. This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for 'abnormal flexion'. Often the 1 is left out, so the scale reads Ec or Vt. MOTOR FUNCTION ASSESSMENT a. Client follows verbal commands b. Pushes away purposely from noxious stimuli
2. Motor paralysis but cranial nerves may be intact allowing client to communicate through eye movement and blinking 3. Occurs with hemorrhage or infarction of pons, disorders of lower motor neurons or muscles Brain Death 1. Cessation and irreversibility of all brain functions 2. General criteria: a. Absent motor and reflex movements b. Apnea c. Fixed and dilated pupils d. No ocular responses to head turning and caloric stimulation e. Flat EEG ICP Increased blood volume, increased brain volume, increased CSF volume Normal pressure: 5-15 mmHg, with pressure tranducer with head elevated 30˚; 60-180 cmH20, water manometer with client lateral recumbent Manifestations: • Decreasing level of sensorium-most sensitive, reliable and earliest indicator: due to cerebral hypoxia, interference with RAS function • Increasing BP, decreasing pulse • Pupillary changes (a reflection of tissue shifts • Cushing’s triad-increasing systolic pressure, widening pulse pressure and bradycardia (final compensatory mechanism to maintain CSF)
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Papilledema-due to the compression of optic disc Respiratory changes-dependent on site of pressure Motor changes-dependent on site of pressure; usually starts contralaterally; then hemiplegia, decortication or decerebation depending on pressure on brain stem
Late signs: coma, apnea, unilateral pupil changes ICP monitoring • Continuous intracranial pressure monitor is used for continual assessment of ICP and to monitor effects of medical therapy and nursing interventions
STROKE Right brain damage • Paralyzed left side • Spatialperceptual deficits • Tend to deny or minimize problems • Impaired judgment • Impaired time concepts • Short term span Left brain damage • Paralyzed right side • Impaired speech/language • Impaired right and left discrimination • Aware of deficits, depression, anxiety • Impaired comprehension • Slow performance,
cautious SPINAL CORD INJURY A. Early symptoms of spinal shock • Absence of reflexes below level of lesion • Flaccid paralysis below level of injury • Hypotonia results in bowel and bladder distention • Inability to perspire in affected parts • Hypotension B. Later symptoms of spinal cord injury • Reflex hyperexcitability • State of diminished reflex hyperexcitability below site in all instances of cord damage following hyperreflexia • In total cord damage-loss of motor and sensory function is permanent • Sacral region-atonic bladder and bowel with impairment of sphincter control • Lumbar region- spastic bladder and loss of bladder and anal sphincter control • Thoracic-trunk below the diaphragm • Cervical-from neck down, if above C4 respirations and depressed • In partial cord damage, depends on the type of neurons affected (spastic vs. flaccid) MUSCLE FUNCTION AFTER SPINAL CORD INJURY (((log-rolling) Spinal Cord Muscle Muscle Injury Functioning Function remaining Loss Cervical, None All including
above C4 C5 C6-C7
Neck, scapular elevation Neck, some chest movement, some arm movement Neck, arms (full), some chest Neck, arms, chest, turnk
respiration Arm, chest, all below chest Some arm, fingers, some chest movement all below chest Trunk, all below chest Legs
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