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Ch. 65 assessment of neuro function

Terms in this set (48)

Health history → observe overall appearance, mental status, posture, movement and affect
o Details about the onset, character, severity, location, duration and frequency of symptoms and signs
o Associated complaints
o Precipitating, aggravating, relieving factors
o Progression, remission, exacerbation
o Presence or absence of similar symptoms among family members
Neurologic disease may be stable or progressive
characterized by symptom-free periods as well as fluctuations in symptoms
Common symptoms- main be subtle or intense, fluctuating or permanent, inconvenient or devastating
- Pain
- Seizures
- dizziness and vertigo
- visual disturbances
- Muscle weakness
- Abnormal sensation
Pain
multidimensional and completely subjective
• Acute or chronic
• Acute lasts for a relatively short period of time and remits as the patho resolves
• Chronic extends for long periods of time and may represent a broader patho
• Acute pain may be associated with brain hemorrhage, spinal disc disease or trigeminal neuralgia
• Chronic or persistent pain can occur with many degenerative and chronic neuro conditions (multiple sclerosis)
SEIZURES
reflect the area of the brain affected
• A seizure may be the first obvious sign of a brain lesion
DIZZINESS & VERTIGO
- difficult to assess because of the vague and varied terms patients use to describe it
• An abnormal sensation of imbalance or movement
• Can have a variety of causes → viral syndromes, hot weather, roller coasters, middle ear infection
• Vertigo - an illusion of movement, usually rotation
• Usually a manifestation of vestibular dysfunction
• Can be so severe it results in spatial disorientation, lightheadedness, loss of equilibrium (staggering), N/V
MUSCLE WEAKNESS
common manifestation of neuro disease
• Can cause a wide range of disability
• Can be sudden and permanent - stroke
• Progressive - amyotrophic lateral sclerosis
• Any muscle group can be affected
ABNORMAL SENSATION
neuro manifestation of both CNS and PNS
• Small or large areas of body
• Frequently associated with weakness or pain and potentially disabling
• Lack of sensation places person at risk for falls and injury
Assessing consciousness & cognition - comparison over time
o Avoid use of terms "inappropriate" or "demented" - mean different things and are not useful
o Mental status - appearance, behavior, dress, grooming, hygiene
o Orientation to time, place, person
o Intellectual function
Assessing consciousness & cognition - comparison over time Cont.
o Thought content - spontaneous, natural, clear, relevant, coherent; fixed ideas, illusions, or preoccupation
• Preoccupation with death or morbid events, hallucinations, paranoid ideations require further evaluation
o Emotional status - affect, mood, verbal/nonverbal communication
o Language ability - understand and communicate appropriately both spoken and written
o Impact of lifestyle
o Level of consciousness - wakefulness and ability to respond to environment
Examining the cranial nerves
assessed when level of consciousness is decreased, brain stem pathology, or presence of PNS disease
o Right and left compared throughout exam
Examining the motor system
o Motor ability
o Muscle strength
o Balance and coordination
Examining the sensory system
subjective and requires cooperation of the patient
o Tactile sensation
o Superficial pain
o Temperature
o Vibration
o Position sense (proprioception)
o Simultaneous sensation
o Decreased or absent sensations
Examining the reflexes
o Deep tendon reflexes
o Biceps reflex
o Triceps reflex
o Brachioradialis reflex
o Patellar reflex
o Achilles reflex
o Superficial reflexes
Examining the reflexes cont.
o Pathologic reflexes → Babinski reflex
• Indicative of CNS disease affecting the corticospinal tract
• In a person with intact CNS, if the lateral aspect of the sole of the foot is stroked → toes contract and draw together
• Person who has CNS disease of motor system → toes fan out and draw back
Gerontologic considerations
o Diminished strength and agility are a normal part of aging, but localized weakness can only be attributed to disease
o Nursing implications
• Consequences of any neuro deficit and its impact on overall function such as ADLs, use of assistive devices, and individual coping should be assessed and considered in planning care
• Fall risk must be evaluated
• Fall prevention measures instituted in both hospital and home
Gerontologic considerations cont.
Nursing implications continued:
• Visual materials → adequate lighting without glare, contrasting colors and large print
• Low-pitched, clear voice - shouting makes it harder to understand
• Signer, interpreter, or translator may be needed
• Teaching at an unrushed pace and using reinforcement
• Material should be short, concise and concrete
• Vocabulary matched to learner's ability and clearly defined
• Adequate time to receive and respond to stimuli, learn, and react
Diseases and conditions influenced by genetics:
• Alzheimer's
• Amyotrophic lateral sclerosis (ALS)
• Duchenne muscular dystrophy
• Epilepsy
• Friedrich ataxia
Diseases and conditions influenced by genetics cont.
• Huntington disease
• Myotonic dystrophy
• Neurofibromatosis type I
• Parkinson's disease
• Spina bifida
• Tourette syndrome
Genetics: Family history assessment
• Other similarly affected relatives
• Age of onset
• Childhood - duchenne muscular dystrophy
• Adulthood - Huntington, Alzheimer's, ALS
• Presence of related conditions such as mental retardation and/or learning disabilities (neurofibromatosis type I)
Genetics: Patient assessment
• Presence of other physical features suggestive of an underlying genetic condition
• Neurofibromatosis type I - café-au-lait spots
• Congenital abnormalities (cardiac, ocular)
Management specific to genetics:
• Inquire whether DNA mutation or other genetic testing has been performed on affected family members
• If indicated, refer for further genetic counseling and evaluation so that family members can discuss inheritance, risk to other family members, availability of genetic testing, and gene-based interventions
• Offer appropriate genetic information and resources
• Assess understanding of genetic info
Management specific to genetics cont.
• Provide support to families with newly diagnosed genetic-related neuro disorders
• Participate in management and coordination of care of patients with genetic conditions and individuals predisposed to develop or pass on a genetic condition
CT Scanning Nursing Interventions
o Prep & patient monitoring
o Patient should lie quietly throughout
o Relaxation techniques
o Ongoing monitoring if sedation is used for agitation, restless, or confusion
o Iodine/shellfish allergies if using contrast
o Renal function evaluated before and after if using contrast agent
o Suitable IV line for contrast injection
o Period of fasting prior - usually 4 hours
MRI Nursing Interventions
o All metal objects and credit cards must be removed → can cause major burns and may fly like projectiles toward the magnet
• Medication patches with foil backing (nicotine patch)
• Metallic wires
• Aneurysm clips
• Pacemakers
• Orthopedic hardware
• Heart valves
• Intrauterine devices
• No oxygen tanks, IV poles, ventilators, or stethoscopes may be brought in
MRI Nursing Interventions cont.
o Must lie flat
o May need relaxation, sedation if claustrophobic
o May talk during
PET Nursing Interventions
o Teaching inhalation techniques and sensations that may occur (dizziness, lightheadedness, headache)
• Pt either inhales a radioactive gas or is injected with it that emits positively charged particles
o Relaxation techniques to reduce anxiety
Single Photon Emission Computed Tomography (SPECT) Nursing Interventions
o Premenopausal women - practice effective contraception before and several days after
o Breastfeeding - stop for the time period recommended by nuclear medicine department
o Monitoring during and after for allergic reactions to the agent used
Cerebral Angiography Nursing Interventions
o BUN and creatinine must be checked prior to ensure kidneys can excrete contrast agent (Creatinine 0.6-1.2)
o Pt. should be well hydrated & clear liquids usually permitted up to the time of test
o Void immediately before test
o Appropriate peripheral pulses marked with pen
o Remain immobile during angiogram
o Expect a brief feeling of warmth in the face, behind the eyes, or in the jaw, teeth, tongue and lips, and a metallic taste when contrast agent is injected
o Groin is shaved and prepared - local anesthetic administered
Cerebral Angiography Nursing Interventions cont.
o Neuro assessment during and immediately after to observe for embolism or arterial dissection
• New onset of alterations in level of consciousness
• Weakness on one side of body
• Motor/sensory deficits
• Speech disturbances
Cerebral Angiography Nursing Interventions cont.
o Nursing care after cerebral angiography
• Observation of injection site for bleeding or hematoma
• Peripheral pulses monitored frequently
• Involved extremity monitored
Myelography Nursing Interventions
o Changes in position may be made during
o After myelography
• Lies in bed with HOB elevated 30-45 degrees for three hours
• Drinking liberal amounts of fluid
• BP, pulse, respiratory rate, temperature monitored as well as ability to void
Myelography Nursing Interventions cont.
o Untoward signs
• Headache
• Fever
• Stiff neck
• Photophobia
• Seizures
• Signs of chemical or bacterial meningitis
Transcranial Doppler & Non-invasive Carotid Flow Nursing Interventions
o Non-invasive test
o Handheld transducer placed over neck and orbits of the eyes
o Water-soluble jelly used on transducer
o Can be performed at bedside
Electroencephalography (EEG) Nursing Interventions
o May be deprived of sleep night before to increase chances of recording seizure activity
o Anti-seizure meds, tranquilizers, stimulants and depressants held 24-48hrs before-alter EEG patterns or mask abnorm waves
o Coffee, tea, chocolate, cokes omitted in the meal before test
o Standard EEG - Takes about 45-60 minutes
o Sleep EEG - requires 12 hours
Electroencephalography (EEG) Nursing Interventions cont.
o Not cause electric shock and is not a form of treatment
o Sedation is avoided
o Check physician's order regarding administering anti-seizure medication prior
o Routine EEGs use water-soluble lubricant for electrode contact - can be wiped off by shampooing
o Sleep EEGs involve use of collodion glue for electrode contact - requires acetone for removal
Electromyography (EMG) Nursing Interventions
o May experience sensation similar to that of an IM injection as needle is inserted into muscle
o Muscles examined may ache for a short time after
o Was a question on this don't remember it right now
Nerve Conduction Studies
surface or needle electrodes place on the skin over the nerve to stimulate the nerve fibers
Evoked Potential Studies Nursing Interventions
o Remain perfectly still throughout the recoding to prevent artifacts (signals not generated by brain) that interfere with recording and interpretation
Assisting with a Lumbar Procedure
• A needle is inserted into the subarachnoid space through the third and fourth or fourth and fifth lumbar interface to withdraw spinal fluid
Assisting with a Lumbar Procedure Pre-procedure
o Obtain written consent
o Explain procedures and sensations likely to be felt (sensation of cold as site is cleansed and needle prick of anesthetic injection)
o Answer questions. Reassure that needle will not enter spinal cord or cause paralysis
o Void before
Assisting with a Lumbar Procedure Procedure
o Positioned on one side of bed with back toward physician
o Thighs and legs flexed as much as possible to increase space between spinal vertebrae for easier entry
o Small pillow placed under head to maintain horizontal position
o Avoid sudden movement - can produce bloody tap
o Relax and breathe normally - hyperventilation may lower elevated pressure
o Nurse describes step by step
Assisting with a lumbar puncture: Procedure
o Physician cleanses site and drapes
o Injects local anesthetic to numb site and then inserts reading
o Pressure reading may be obtained
o Specimen of CSF removed and collected in three tubes labeled in order of collection. Needle withdrawn
o Small dressing applied to puncture site
o Tubes of CSF sent to lab immediately
Assisting with a lumbar puncture: Post-lumbar puncture headache
o May be avoided if a small gauge needle used and pt remains prone after
o When more than 20 ml of CSF removed, patient positioned supine for several hours
o Keeping flat overnight may reduce risk of headache
o Usually managed by bed rest, analgesic agents and hydration
Assisting with a lumbar puncture: Post-lumbar puncture headache
o If HA persists, may use epidural blood patch technique
• Blood withdrawn from AC vein and injected into epidural space at site of the puncture
• Blood acts a gelatinous plug to seal the hole in the dura, preventing further loss of CSF
Complications of lumbar puncture:
rare but serious
o Herniation of intracranial contents
o Spinal epidural abscess or hematoma
o Meningitis
Teaching Patients Self-Care-->lumbar puncture
• Family members often provide post-procedure care
• Clear verbal and written instructions given about precautions after, complications to watch for, and steps if complications occur
Teaching Patients Self-Care-->lumbar puncture cont.
• Transportation, post-procedure care and appropriate monitoring must be ensured - elderly patients or those who have neuro deficits
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