ASESSMENT of Client with Diseases in Nervous System

The Neurologic Examination I. Health History An important aspect of the neurologic assessment is the history of present illness. The initial interview provides an excellent opportunity to systematically explore the patient’s current condition and related events while simultaneously observing overall appearance, mental status, posture, movement and affect. Depending on the patient’s condition, the nurse may rely on yesor-no questions, a review of medical record, or input from the patient’s family. It includes details about the onset, character, severity, location, duration, and frequency of symptoms and sign, associated complaints, and relieving factors; progression and remission and exacerbation; and the presence or absence of similar symptoms among family members. It includes system-by-system evaluation. The history-taking portion of the neurologic assessment is critical and, in many cases of neurologic disease, leads to and accurate diagnosis.

II. Clinical Manifestations The clinical manifestations of neurologic disease are as varied as the disease processes themselves. Symptoms maybe subtle or intense, fluctuating or permanent, inconvenient or devastating. A, Pain Pain is considered an unpleasant sensory perception and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is multidimensional and entirely subjective. It can be chronic or acute. B. Seizures Seizures are the result of abnormal paroxysmal discharges in the cerebral cortex, which then manifest as an alteration in sensation, behaviour, movement, perception, or consciousness. C. Dizziness and Vertigo Dizziness is an abnormal sensation of imbalance or movement. It is fairly common in the elderly and one of the most complaints encountered by health professionals. Vertigo is usually a manifestation of vestibular dysfunction. It can be so severe as to result in spatial disorientation, light-headedness, loss of equilibrium, and nausea and vomiting.

and the appropriate affect is assessed for a given situation. Posture. A. facial expressions.D. is a common manifestation of neurologic disease. or irritable and angry. apathetic or flat. Visual Disturbances Visual defects that cause people to seek health care can range from the decreased visual acuity associated with aging to sudden blindness caused by glaucoma. anxious. Physical Examination The neurologic examination is a systematic process that includes a variety of clinical tests. Abnormal Sensation Numbness. Weakness Weakness. causing a wide-range of disability. and personal hygiene. a. E. The examiner can ask the patient to repeat sets of numbers. a. and assessments designed to evaluate the neurologic status of a complex system. . grooming. to know the patient emotional status. observations.3 Emotional Status Is the patient’s affect natural and even. gestures.1 Mental Status It begins by observing the patient’s appearance and behaviour. or euphoric? Fluctuation of moods are observed. Both numbness and weakness can significantly affect balance and coordination. noting dress.2 Intellectual Function A person with an average IQ can repeat seven digits without faltering and can recite five digits backward. show abstract pictures and ask to explain a written situation and interpret. III. Assessing Cerebral Function a. or loss of sensation is a neurologic manifestation of both central and peripheral nervous system disease. Normal vision depends on functioning visual pathways through the retina and optic chiasm and the radiations into the visual cortex in the occipital lobes. F. abnormal sensation. Weakness frequently co-exists with other symptoms of disease and can affect a variety of muscles. and motor activity often provide important information about the patient. to test the intellectual capacity of a person. movements. specifically muscle weakness.

 In routine examinations this is not usually tested unless the patient complains of loss or changes in a sense of smell. Failure signals cerebral dysfunction. There are a number of rhymes or mnemonics to help you remember the names of the nerves. Others still are connected to glands or organ such as the lungs and heart. To test visual acuity. coffee. Ask the patient to concentrate his gaze on your nose or directly into your eyes. a patient should be able to identify common smells such as cinnamon. The patient covers one eye at a time and reads to smallest line possible. With the eyes closed.  To test visual fields. Some control muscles. Agnosia is the ability to interpret or recognize objects seen through the special senses. Successful performances requires the ability to understand the activity desired and normal strength.4 Perception The examiner may now consider more specific areas of higher cortical function. I. The cranial nerves are numbered using Roman Numerals I-XII. Some transmit information from the sensory organs to the brain. Optic Nerve Its modality is Special Sensory and its function is vision. Each nostril should be patent. stand about 2 feet (60 cm) away from the patient. a.a.6 Language ability Person with normal neurologic function can understand and communicate in spoken and written language. II. a. have the patient read a Snellen Eye Chart from a distance of 20 feet (6 meters). A deficiency in language function is called aphasia. Olfactory Nerve Its modality is Special Sensory and its function is smell. vanilla or cloves. Examining the Cranial Nerves What Are the Cranial Nerves? The Cranial Nerves are made up of 12 pairs of nerves which are located on the ventral surface of the brain. Have the patient occlude on and then the other during testing. Spread your arms so that your hands are about 2 feet apart and lateral to the patient's ears. Wave your fingers as . IV. Different aphasia result from injury to different parts of the brain.5 Motor ability Assessment of cortical motor integration is carried out by asking the patient to perform a skilled act. Examining the function of the cranial nerves will provide you with pertinent information about your patient's nervous system.

IV and VI are tested together. Facial Nerve This nerve has four modalities and functions. The functions include taste on the anterior 2/3 of the tongue and salivary glands. The patient should report the sensation as being symmetrical. control of muscles used in facial expression. A cotton swab can be used to test for dull sensation. VII. VI.you slowly draw your hands in towards the patient's line of gaze. Muscle strength in the temporal and masseter muscles of the face should be felt and should be symmetrical. V. They each control the extraoccular muscles involved in eye movement. The Brachial Motor controls the muscles of mastication (chewing). Ask him to tell you when he first visualizes your wiggling fingers. Oculomotor Nerve Its modality is two-fold. Visceral Motor. and back in towards the nose and up and down. Trigeminal Nerve This nerve has two modalities Brachial Motor and General Sensory. Trochlear Nerve Its modality is Somatic Motor and its function is eye movement. You can use a clean safety pin or suitable sharp object) for testing pain sensation.  To test these nerves. Its function is also two-fold. . The Somatic Motor function is eye movement and the Visceral Motor function is pupil dilation. back in towards the nose and up and down. DO this from all quadrants of the visual field. Cranial Nerves III. The modalities are Brachial Motor. The patient should see both hands simultaneously and from all directions. The General Sensory provides sensory information regarding touch and pain in the face to the brain. Touch the patient's face at the forehead cheek and chin on each side.    To test this nerve first have the patient clench jaw muscles by clenching his teeth. transmission of somatosensory information from the ear to the brain. IV. First move your finger out to the right side then up and down. III. Abducens Nerve Its modality is Somatic Motor and its function is eye movement. Have the patient follow your finger with his eyes without moving his head. General Sensory and Special Sensory. Somatic Motor and Visceral Motor. You can also test for sensation of temperature using test tubes filled with warm water and ice water. have the patient hold his head steady while you move your finger about 1 foot (30 cm) from his nose to watch his eyes move peripherally and up and down. Then outward from the left side and up and down.

It has two branches. To test for taste.  To test these nerves have the patient swallow some sweet or salty water and test for taste sensation as well as ability to swallow. (Stay close to the patient in case he does begin to fall. . Then ask the patient to open wide and say "ah" while you observe the uvula and palate. Its functions include autonomic. Look for symmetry especially in the nasolabial folds. X.  To test this nerve. the Cochlear which transmits sound messages to the brain. Next tell the patient you're going to test his gag reflex. The reflex should be present or symmetrically diminished. tonsils and pharynx. Visceral Motor. heart rate and digestion. frown. Stand about 1 to 2 feet away (30-60 cm) and softly whisper a word with two distinct syllables such as football. have the patient repeat a sentence. Repeat the word slightly louder if necessary and observe for difficulties distinguishing words. baseball. puff out his cheeks.)  Cranial Nerves IX and X are tested together as they both have a function that innervates the pharynx. IX. Observe his facial expression during normal conversation check for any asymmetry. Spinal Accessory Nerve (also known as Accessory Nerve) The modality is Brachial Motor and the function is control of the trapezius and sternocleidomastoid muscles in movement of the head. but should not fall. Special Sensory. These should move symmetrically and without deviation to one side. drop a few drops of sweet or salty water on the front part of the tongue and see how it tastes to your patient. tics. General Sensory and Special Sensory. Vagus Nerve This nerve also has four modalities: Brachial and Visceral Motor as well as Visceral Sensory and Special Sensory. Lightly stimulate the back of the throat on each side with a swab or tongue depressor. Repeat with the other ear and a different word. or doorbell. sensory and motor functions of viscera such as glands. Next ask the patient to smile. some swallowing muscle function. Make sure the patient can't read your lips. Its function includes taste on the posterior 1/3 of the tongue. VIII. He might sway slightly. Acoustic Nerve (also known as Vestibulocochlear or Auditory Nerve) This nerve has one modality. Ask him to close his eyes tightly and you try to open them by pulling upward on the eyebrows and downward on the cheeks just below the eyes checking for strength and symmetry. and transmitting somatosensory information from the tongue.  To Test this nerve have the patient occlude one ear with a finger. Glossopharyngeal Nerve This nerve has four mobilities Brachial Motor. or other facial movements. Equilibrium can be tested using the Romberg test: Have the patient stand erect with his feet close together and his eyes closed. and Vestibular which controls balance or equilibrium. XI.

Repeat to the other side.1 Muscle strength Assessing the patient’s ability to flex or extend the extremities against resistance test muscle strength. Additional cerebellar tests for balance in an ambulatory patient include hopping in place. Coordination in the hands and upper extremities is tested by having the patient perform rapid. Next place one hand on the side of the patient's jaw and the other on the opposite sternocleidomastoid muscle. VI. Rombergs test is a screening test for balance. The function of an individual muscle or group of muscles is evaluated by placing the muscle at a disadvantage. Hypoglossal Nerve The modality is Somatic Motor and the function is control of the muscles of the tongue. The tendon is struck with a reflex . a. Each leg is tested in turn. Examining the Motor System a. Place your hands on the patient’s shoulders from the back. XII. Have the patient push his tongue against the inside of each cheek and you palpate for strength from the outside of his cheek.  This nerve is tested by listening to the patient's articulation as he speaks as well as observing for any atrophy or deviation of the tongue while speaking. Check for symmetry of movement. Coordination in lower extremities is tested by having run the heel down the anterior surface of the tibia of the other leg. Have him shrug his shoulders upward while you exert slight resistance. Have the patient stick his tongue out and move it from side to side. Observe the strength in both muscles. The strength and contraction of the trapezius muscles should be symmetrical. Document your assessment carefully and report all abnormal findings to the physician or other practitioner. and heel-to-toe walking. alternating knee bends. Ataxia is defined as an incoordination of voluntary muscle action. alternating movements and point-to-point testing. V.2 Balance and Coordination Cerebellar influence on the motor system is reflected in balance control and coordination. Have the patient turn his head towards the hand on his jaw while you apply slight resistance. particularly of the muscle groups used in activities. Examining the Reflexes The motor reflexes are involuntary contractions of muscles or muscle groups in response to abrupt stretching near the site of the muscle’s insertion.

and ankle reflexes) and superficial or cutaneous reflexes (abdominal reflexes and plantar or Babinski response). It is largely subjective and requires the cooperation of the patient. brachioradialis. Changes throughout the nervous system that occur with age vary in degree. It is important for clinicians not to attribute abnormality or dysfunction to aging without appropriate investigation. the nervous system undergoes many changes. triceps. Disease in the elderly often makes it difficult to distinguish normal from abnormal changes. Motor Alterations This is an overall reduction of muscle bulk. Common reflexes that may be tested include the deep tendon reflexes (biceps. When reflexes are very hyperactive. vibration and position sense. In the peripheral nervous system. There is an overall slowing of autonomic nervous system responses. Nerve fibers that connect directly to muscles show little decline in function with age. The examiner should be familiar with dermatones that represent the distribution of the peripheral nerves that arise from the spinal cord.hammer or indirectly by striking the examiner’s thumb. It involves tests for tactile sensation. Hypothalamic function is modified such that stage IV sleep is reduced. resulting in a decrease in conduction velocity in some nerves. GERONTOLOGIC CONSIDERATIONS During the normal aging process. Structural Changes A number of alterations occur with increasing age. In older . superficial pain. a phenomenon called clonus may be elicited. VII. Nerve cells in the vestibular system of the inner ear. and rigidity of movement. There is an overall reduction in muscle bulk and the electrical activity within muscles. myelin is lost. and it extremely vulnerable to general systemic illness. and proprioceptive pathways also degenerate. as do simple neurologic functions that involve a number of connections in the spinal cord. Cerebral blood flow and metabolism are reduced. shuffling gait. Temperature regulation becomes less efficient. A loss of neurons occurs in select regions of the brain. cerebellum. Deep tendon reflexes can be decreased or some case absent. such as atrophy shown in hands. which is placed firmly against a tendon of a patient. Brain weight decreases. patellar. Taste buds atrophy and nerve cell fibers in the olfactory bulb degenerate. Pupillary responses are reduced or may not appear at all in the presence of cataracts. Sensory examination Sensory modalities are carried out in different parts of the spinal cord. as does the number of synapses. Changes is motor function often result in a flexed posture.

. There may be difficulty in identifying objects by touch. Sensory Alteration Sensory isolation due to visual and hearing loss can cause confusion. and a constricted visual field. such as abdominal and chest pain. Because the elderly person takes longer to recover visual sensitivity when moving from a light to dark area. as well as extra orientation to new surroundings. may be more serious than the patient’s perception might indicate and thus require careful evaluation.persons. Taste and Smell Alterations The acuity of the taste buds decreases with age. this may cause a decreased appetite and subsequent weight loss. decreased peripheral vision. are critical for the elderly. caution must be used when hot or cold packs are used. and feelings of inadequacy. especially at night when there is little or no light in the room. Simple explanations of routines. Two pain syndromes that are common in the neurological system in older adults are diabetic neuropathies and postherpetic neuropathies. misinterpretation of the environment. A decreased sense of smell due to atrophy of olfactory organs may present a safety hazard. temperature somewhat higher than usual may be desirable. the location of the bathroom. Temperature Regulation and Pain Perception The temperature regulation and pain are related to other manifestation. night-lights and a safe and familiar arrangement of furniture are essential. disorientation. reaction time and movement time are decreased. the person may become confused about body position and location. Reaction to painful stimuli may be decreased with age. strength and agility are diminished. and how to operate the call bell or light are just a few examples of information the elderly patient may need when hospitalized. The elderly patient may feel cold more readily than heat and may require extra covering when in bed. Observation of gait may reveal a wide-based gait with balance difficulties. because elderly people living alone may be unable to detect houseold gas leaks or fires. Smoke and carbon monoxide detectors. Sensory alterations may require modification of the home environment. Extra seasoning often increases food intake as long as it does not cause gastric irritation. along with an altered olfactory sense. and because fewer tactile cues are received from the bottom of the feet. important for all. combined with sensitivity to glare. anxiety. may result in disorientation. Complaints of pain. These factors. Because pain is an important warning signal. Tactile and Visual Alterations Another neurologic alteration in elders is the dulling of tactile sensation due to a decrease in the number of areas of the body to responding to stimuli and in the number and sensitivity of sensory receptors. such as large-print reading materials or sound enhancement for the telephone. Repetitive movements and mild tremors may be noted during an examination and may be of concern to the person. The older patient may suffer frostbite or burn.

which is a chronic and irreversible deterioration of cognitive status. A review of relaxation techniques may be helpful for patients with claustrophobia. Nursing Intervention Preparations for the procedure and for patient monitoring. Areas of judgement. Abnormalities of tissue indicate possible tumor masses. brain infarction. The image provide cross-sectional views of the brain. or dehydration. and ventricles. . With advances in CT scanning. which is an acute change in mental status attributable to a treatable medical problem. Whole body CT-scans allows sections of the spinal cord to be visualized. but monitoring the patient is needed while being sedate. and grooming are assessed. delirium. Drug toxicity should always be suspected as a causative factor when the patient has a change in mental status. Preparation includes teaching the patient about the need to lie quietly throughout the procedure. The CT scan along with MRI has largely replaced myelography as a diagnostic procedure for the diagnosis of herniated lumbar disks. IV monitoring is needed. CT scanning is non-invasive and painless and has a high degree of sensitivity for detecting lesions. Check for allergy on iodine/shellfish allergy. usually with delusions and hallucinations) is seen in elderly patients who have underlying central nervous system damage or are experiencing an acute condition such as infection.Mental Status Mental status is evaluated when obtaining the history. Delirium (mental confusion. intelligence. adverse medication reaction. The brightness of the parts of the brain in the image is proportional to the degree which it absorbs xray. memory. orientation. affect. Injection of water soluble iodinated contrast agent into the subarachnoid space through lumbar puncture improves the visualization if the spinal and intracranial contents on these images. the number of disorders and injuries that can be diagnosed is increasing. In elderly patients. and sedation may be helpful for restless patient. DIAGNOSTIC EVALUATION Computed Tomography Scanning Computed Tomography (CT) Scanning makes use of narrow x-ray beam to scan the body part in successive layers. with distinguishing differences in tissue densities of the skull. subcortical structures. mood. displacement of the ventricles and cortical atrophy. Depression may produce impairment of attention and memory. Lesions in the brain are seen as variations in tissue density differing from the surrounding normal brain tissue. because the contrast agent is iodine based. cortex. speech. must be differentiated from dementia.

The patient either inhales or is injected with a radioactive substance that emits positively charged particles. 80% of glucose in the body is consumed by the brain. tissue composition. localization and sizing of stroke. PET permits measurement of blood flow. and . and the duration is similar to that of a CT scan. evaluating new theraphies for brain tumors. The IV injection of the radioactive substance produce similar side-effects. Dizziness. light-headedness. Nursing Interventions It includes patient preparation. Single Photon Emission Tomography Single photon emission tomography (SPECT) is a three dimensional imaging technique that uses radionuclides and instruments to detect single photons. It is relatively inexpensive. Pregnancy and breastfeeding are contraindications to SPECT. It is a perfusion study that captures a moment of cerebral blood flow at the time of injection of a radionuclide.Positron Emission Tomography PET is a computer-based nuclear imaging technique that produces images of actual organ functioning. identifying blood flow and oxygen metabolism in patient with strokes. and brain metabolism and thus indirectly evaluates brain function. epileptogenic lesions). Nursing Interventions It includes patient preparation and patient monitoring. which involves explaining the test and teaching the patient about inhalation techniques and the sensations (eg. the image is sent to a minicomputer. Relaxation exercises may reduce anxiety during the test. PET measures this activity in specific areas of the brain and can detect changes in glucose use. and headache) that may occur. Premenopausal women are advised to practice contraception before and after the test for several days. greatly increasing the contrast between normal and abnormal tissue. the resultant gamma rays can be detected by a scanning device that produces a series of two-dimensional views at various level of the brain. This information is integrated by a computer and gives a composite picture of the brain at work. thus allowing detection. It is useful in showing metabolic changes in the brain (Alzheimer’s disease). Teaching the client what to expect before the test and allay the anxiety and ensure patient cooperation during the test. locating lesions (brain tumor. Brain is one of the most metabolically active. SPECT is useful in detecting the extent of that perfused areas of the brain. This allows areas behind overlying structures or background to be viewed. Gamma photons are emitted from a radiopharmaceutical agent administered to the patient and are detected by a rotating gamma camera. When these positrons combine with negatively charged electrons (normally found in the body’s cell).

MRI scan can be done with or without a contrast agent and can identify a cerebral abnormality earlier and more clearly than other diagnostic test. artificial heart valves. but the patient hears loud thumping of the magnetic coils as the magnetic field is being pulsed. Magnetic Resonance Imaging Magnetic resonance imaging (MRI) uses a powerful magnetic field to obtain images of different areas of the body. It involves altering hydrogen ions in the body. MRI can provide information about the chemical changes within cells. Patients are monitored during and after the test for allergic reactions to the radiopharmaceutical agent. aneurysms. In line with the use of radiofrequency pulses. It is specifically useful in diagnosis of multiple sclerosis and can describe the activity and exten of disease in the brain and spinal cord. damage to a very expensive equipment may occur. intrauterine devices). Aneurysm clips. MRI is painless. Cerebral Angiography Cerebral angiography is an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery. It is frequently done before craniotomy to assess that patency and adequacy of the cerebral circulation and to determine the site. There should be no any metal objects inside the MRI room. allowing the clinician to monitor a tumor’s response to treatment. and it is most valuable in the diagnosis of non-acute conditions.women under breastfeeding are advised to stop nursing for the time period recommended by the nuclear medicine department. pacemakers. the protons emit signals. size. A patient history is obtained to determine the presence of any metal in the body of the patient (ex. Nursing interventions Patient preparation should include teaching relaxation techniques and informing the patient that he will be able to talk to the staff by means of a microphone located inside the scanner. . and arteriovenus malformations. which are converted to images. The patient is place under a powerful magnetic field that causes the hydrogen nuclei (proton) within the body to align like small magnets in a magnetic field. It is a valuable tool to investigate vascular disease. and nature of the pathologic processes. because the test takes up to an hour to complete. All metal objects and credit cards are removed. orthopaedic hardware. This can cause death and severe injury. The patient may experience claustrophobia during the test. sedation may be prescribed in these circumstances. This can cause burns if not removed. These object could malfunction and be dislodged. MRI does not involve ionizing radiation. because the magnetic field is too strong that it can pull any metal objects near the machine. or heat up during the procedure.

In some instances. tounge. Patients are encouraged to drink liberal amounts of fluid fir rehydration and replacement of CSF and to decrease the incidence of post-lumbar headache. motor or sensory deficits. Myelography A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space and shows any distortion of the spinal cord or spinal dural sac caused by tumors. or other lesions. Alternatively. The patient is instructed to be immobile during the angiogram process and is told to expect a brief feeling of warmth in the face. resulting to neurologic defect. weakness of one side of the body. the patient lie in bed with the head of the bed is elevated 30 to 45 degrees. and an ice bag may be applied intermittently to the puncture site to relieve swelling and discomfort. and lips. seizures and signs of chemical or bacterial meningitis. photophobia. Nursing Interventions Patient should be well hydrated. or in the jaw. . thrombosis or haemorrhage. Untoward signs include headache. teeth. Signs of such an occurrence include in alterations in the level of responsiveness and consciousness. these agents disperse upward through the CSF. and clear liquids are usually permitted up to the time of a regular arteriogram. cysts. Nursing care after cerebral angiography includes observation for signs and symptoms of altered cerebral blood flow. Voiding is done before having an X-ray. and speech disturbances. direct puncture of the carotid or vertebral artery or retrograde injection of a contrast agent into the brachial artery may be performed. Water-based agents have replaced oil-based agents.Most of CA are performed by threading a catheter through the femoral artery in the groin and up to the desired vessel. The patient is advised to remain in bed for 3 hours or as ordered by the physician. and their use has reduced side-effects and complications. Locations of appropriate peripheral pulses are marked with felt-tip pen. Therefore patient must be monitored frequently and immediately report if such signs occur. Vital signs of the patient are monitored as well the capacity to void. herniated vertebral disks. The meal that normally would be eaten before this procedure is omitted. and a metallic taste when the contrast agent is injected. A sedative may help the patient cope with this lengthy test. behind the eyes. stiff neck. fever. After myelography. Injection site is observed for hematoma. patient may experience major or minor arterial blockage due to embolism. Nursing Interventions Patient is informed about what to expect during the procedure and should be aware that changes in position may be made during procedure.

and infection may cause abnormal patterns in electrical activity. This EEG test is useful for diagnosing and evaluating seizure disorders. Nursing Interventions To increase the chances of recording seizure activity. the signal is reflected by the moving red blood cells within the blood vessels. Electrodes are applies to the scalp to record the electrical activity in various regions of the brain. blood clots. It provides a physiologic assessment of cerebral activity. Transcranial Doppler Transcranial Doppler uses the same noninvasive techniques as carotid flow studies except that it recors the blood flow velocities of the intracranial vessels. which carries a higher risk of stroke or death. Tumors. The graph produced indicates blood velocity. . A handheld Doppler probe emits a pulsed beam. carotid ultrasonography. tranquilizers. The amplified activitiy of the neurons between any two of these electrodes is recorded on continuously moving paper. Carotid Doppler. Antiseizure agents. Nursing interventions The patient is informed that this is a noninvasive test. or organic brain syndrome. Electroencephalography An EEG represents a record of the electrical activity generated in the brain. brain abscesses. These vascular studies allow noninvasive imaging of extra and intracranial circulation.Non-invasive Carotid Flow Studies Non-invasive carotid flow studies use ultrasound imagery and Doppler measurements of arterial blood flow to evaluate carotid and deep orbital circulation. it is sometimes recommended that the patient be deprived of sleep on the night before EEG test. The EEG is also used in making a determination of brain death. that a hand-held transducer will be placed over the neck and the orbits of the eyes. altered cerebral flow found in occlusive vascular disease or stroke. and other cerebral pathology. this record is called the encephalogram. Flow velocities of the basal artery can be measured through thin areas of the temporal and occipital bones of the skull. and that some type of water-soluble jelly is used on the transducer. Increased blood velocity can indicate stenosis or partial obstruction. Transcranial Doppler Sonography is a noninvasive technique that is helpful in assessing vasospasm. These tests are often obtained before arteriography. It is obtained through electrodes applied on the scalp or through microelectrodes placed within the brain tissue. coma. and opthalmodynamometry are four common nonivasive vascular techniques that allows arterial blood flow and detection of arterial stenosis. occlusion. and plaques. oculoplethysomography.

Patient preparation is done by explaining what to do during the procedure. to detect subarachnoid block. to determine the presence or absence of blood in the CSF. chocolate. The test may be performed to obtain CSF for examination. Lumbar Puncture and Examination of Cerebrospinal Fluid A lumbar puncture (spinal tap) is carried out by inserting a needle into the lumbar subarachnoid spaced to withdraw CSF. The needle is usually inserted into the subarachnoid space between the third and fourth or fourth or fifth lumbar vertebrae. Coffee. . Sedation is not advisable. and the patient is warned to expect a sensation similar to that of an intramuscular injection as the needle is inserted to the muscle. CSF pressure with the patient in lateral recumbent position is normally 70 to 200 mm H2O. and depressant should be withheld 24 to 48 hours before an EEG. and to administer antibiotics intrathecally in certain cases of infection. and this may increase the pressure reading. An EMG is useful in determining neuromuscular disorders and myopathies. because it can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. A successful lumbar puncture requires that the patient be relaxed. an anxious patient is tense. because it may lower the seizure threshold in patients with a seizure disorder and it alters brain wave activity in all patients. tea. to reduce and measure CSF pressure.stimulants. Nursing Intervention The procedure is explained. the meal is not omitted. However. The electrical potential are shown on an oscilloscope and amplified so that both the sound and appearance of the waves can be analysed and compared simultaneously. and cola drinks are omitted in the meal before the test because of their stimulating effect. It helps distinguish weakness due to neuropathy from weakness resulting from other causes. Electromyography An EMG is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles and the nerves leading to them. Pressures of more than 200mm H2O are considered abnormal. The muscles examined may ache for a short time after the procedure. because an altered blood glucose level can also cause changes in the brain wave patterns. The nurse needs to check the physician prescription regarding the administration of antiseizure medication prior to testing.

specimens are obtained for cell count. Value Normal Range Appearance Clear & colourless White Cells 0 .180 mmH2O Condition Appearance White Cells Raised neutrophils Raised lymphocytes Raised lymphocytes N Red Cells N N N VH Protein H or VH N or H H or VH N or H Glucose VL N or L VL N or L Bacterial Meningitis Cloudy & Turbid Viral Meningitis Tuberculous Meningitis Subarachnoid Haemorrhage N N or slightly cloudy Usually blood stained . This test is not performed if an intracranial lesion is suspected.0.4. or subarachnoid haemorrhage.4 grammes per litre (or less than 1% of the serum protein concentration) 3. II. then the pressure is released and pressure readings are made at 10second time intervals. I. culture. laceration. CSF pressure rises rapidly in response to compression of the jugular veins and returns quickly to normal when the compression is released. the CSF initially is a bloody because of a local trauma but then becomes clearer.2 . blood-tinged. The specimens should be sent to the laboratory immediately because changes will take place and alter the result if the specimens are allowed to stand.A lumbar puncture may be risky in the presence of an intracranial mass lesion because intracranial pressure is decreased by the removal of CSF. Usually. and the brain may herniate downward through the tentorium and the foramen magnum. or grossly bloody CSF may indicate cerebral contusion.4 mmol per litre (or ≥ 60% of a simultaneously derived plasma glucose Glucose concentration) pH 7.3 .5 x 106 per litre (all lymphocytes with no neutrophils) Red Cells 0 . Queckenstedt’s Test A lumbar manometric test (Queckenstedt’s test) may be performed by compressing the jugular veins on each side of the neck during the lumbar puncture. a complete block is indicated. and glucose and protein testing. The increase in pressure caused by the compression is noted. Cerebrospinal Fluid Analysis The CSF should be clear and colorless. Normally.31 Pressure 70 . A slow rise and fall in pressure change. Pink.10 x 106 per litre Protein 0. Sometimes with a difficult lumbar puncture.

It is a throbbing bifrontal or occipital headache. Post Lumbar Puncture Headache A post lumbar puncture headache. and then supine or prone for 6 more hours. BSN III-2 . Occasionally. if the headache persists. may occur a few hours to several days after the procedure. usually at the site of the previous spinal puncture. the epidural blood patch technique may be used. Post lumbar headache can be avoid by using smaller gauge of needle is used. When a large of CSF volume is removed (more than 20ml) the patient is remain prone for 2 hours. dull and deep in character. ABAT. The leakage of CSF allows settling of the brain when the patient assumes an upright position. and if the patient remains prone after the procedure. Blood is withdrawn from the antecubital vein and injected into the epidural space. producing tension and stretching the venous sinuses and pain sensitive structures. The rationale is that the blood acts as a gelatinous plug to seal the hole in the dura. As a result of this leak.Guillan-Barré Syndrome Multiple Sclerosis VL = Very Low L = Low N = Normal H = High VH = Very High N N N Raised lymphocytes N N H (only after 1 N or L week) H N III. The postpuncture headache is usually managed by bed rest.MIKO G. It is promptly absorbed by the lymphatics. and hydration. ranging from mild to severe. It is particularly severe on sitting or standing but lessens or disappears when the patient lies down. preventing further loss of CSF. analgesics. then flat in a side-lying position for 2 to 3 hours. occurring in 15% to 30% of patients. The headache is caused by CSF leakage at the puncture site. Keeping the patient flat overnight may reduce the incidence of headaches. the CSF supply in the cranium is depleted to a point at which it is insufficient to maintain proper mechanical stabilization of the brain. This is the most common complication. The fluid continues to escape into the tissues by way of the needle track from the spinal canal.

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