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Neuro assessment - Lecture notes 5
Nursing Care- Complex Health Problems II (11-63-375)
University of Windsor
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COMPLEX II: FINAL: Neuro assessment - - - - Symptoms r/t neurologic problem – chief complaint o Head or spinal trauma, change in LOC, headache, seizures, visual changes, impaired speech o Change in thought process/behavior o Change in motor fxn/gait o Dizziness o Change in sensory fxn o Memory change o Swallowing difficulties o Difficulties in ADLs Two big ones: change in consciousness and headaches Transient ischemic attack (TIA) brief ischemia that usually characterized by temporary blurring of vision, slurring of speech, numbness, paralysis or syncope often predictive of a serious stroke!!! General appearance o Attire – appropriate for age/environment o Grooming o General behavior o Posture o Gait o Obvious physical defects Someone may be cognitively affected if they have a small brain bleed (look at attire, ask family members if they have been acting “different” Physical Condition: if someone has had a stroke may be paralyzed on one side, numbness tingling, drooping in face Hx of present illness o Provocation – makes it better or worse o Quality o Region or radiation o Severity o Timing Did they fall? How long have they been having headaches? Do the headaches occur in the morning, mid-day or at night? Does light affect them? (photosensitivity) REMEMBER: muscle rigidity and photosensitivity= meningitis’s Past medical hx o Congenital disorders, childhood disease, epilepsy, neuromuscular disease, spinal cord injury, Alzheimer’s, cancer, cardiovascular, diabetes, pulmonary embolus, impairment in vision, impairment in hearing Delirium= acute, dementia = chronic *You can have delirium on top of dementia* - Fam hx o Epilepsy, diabetes mellitus, cardiac disease, hypertension, cerebrovascular disease, cancer, neurologic disorders, psychiatric disorders Medication hx o Prescribed drugs, non-prescribed drugs, pt.’s understanding of drug actions, side effects. Drugs frequently used for neurologic problems, drugs that may cause neurologic problems Patient need to be specifically asked about supplements and natural drugs (vitamins, st john worts, herbs) they can cause severe adverse reactions for example: st john worts and antidepressants, INR sky high when on st johns worts and anticoagulation’s, drugs that interfere with Sertonin - Degree of stimulus necessary to elicit a response o Verbal stimuli – this one requires the least amount of stimulus o Tactile stimuli – before you touch the pt. always check to see if they respond to voice first o Painful stimuli Peripheral – nail bed, pinch inner aspect arm/thigh Central – trap pinch, sternal rub, periorbital rub An example for this: if you walk in the room and you say good morning and the patient turns and looks at you that means they are more responsive then a patient who only looks in your direction when you touch them. - Vital signs o Cushing’s triad – last sign of increased ICP and impending herniation Increased systolic BP (widening pulse pressure) Bradycardia (late sign of increased intracranial pressure) Irregular resp pattern (e., cheyne-stokes) Herniation – swelling of the brain which causes the brain to expand into the foramen magna (pushing down on spinal cord) o BP Hypotension – hemorrhage: bc the cranium is a non-expandable vault, ICP/cranial hemorrhage cannot result in hypotension. Increased pressure causes any bleeding to be cut off Hypertension – systolic hypertension may be seen as a component of cushing’s triad Pulse pressure – normal 30-40, increased pulse pressure is also part of cushing’s triad - o LOC is the most sensitive indicator of a change in neurologic status o Describe the behavior – more useful than assigning a label ex: mr smith does not response to voice but he did response to me when I touched his shoulder. RAS is what keeps us aware of our surroundings and keeps us awake Arousal is a response Coma is either from something affecting our RAS or our cerebral hemispheres IMPORTANT: at shift change do hand off in the room and do initial assessment together to get a baseline Glasgow Coma scale o Standardized observation of responsiveness in neurologic pt’s o Best response is recorded o Note if certain responses cannot be evaluated o Parameters Minimum score: 3 (complete lack of responsiveness) Max score: 15 ( fully awake and alert) Coma: < or equal to 8 Clinically significant is a change of 2 points or more NO ONE CAN SCORE A 0 Its significant if a pt. changes good or bad if change occurs, we need to do another full assessment and let the HCP know especially if their score has gone down! For ex: if a pt scores a 10 and then the next day you do the assessment and they score an 8 and the pt. has a head injury you need to notify the HCP and the pt needs a head CT they could be herniating Best response is 15 and lowest score is a 3 Generally, a score of 8 or less on the GCS is considered a coma (rickeards said we might see in the textbook 7 but we are going to go by 8) On final exam we will be given the scale and we need to know how to rate the scenario and give the pt a score (if something is untestable bc they are paralyzed or something it will say in the scenario) Pupillary response - PERRLA - Small, reactive - Large (5-6mm), fixed - Midposition (4-5 mm), fixed - Pinpoint, non-reactive - Unilateral dilated pupil – can happen with drug overdose Speech and language - Note punctuation, rhythm, stream of talk, sentence structure. - If pt cannot use or understand verbal communication, determine if they can understand and use gestures or written message Inappropriate meaning, they don’t make sense (nurse points to a chair and asks what it is pt. responds potato) Incomprehensible meaning, mumbling not making words for ex a pt that had a stroke Speech disorders - Dysphonia o Difficulty producing sounds; a voice disorder - Dysarthria o Difficulty w/ articulation d/t impaired movement of muscles - Dysprosody o Lack of inflection while talking - Dysphasia o Difficulty understanding or expressing verbal language - Aphasia o Receptive (sensory) aphasia: lesion in Wernicke’s area of temporal area so the pt would have difficulty understanding o Expressive (motor) aphasia: lesion in the Broca’s area in frontal area pt has a water bottle calling it a brush troubling expressing words o Global aphasia: which is both - Know dysarthria vs dysphasia. Muscular issue vs brain issue Motor response - Obeys commands (mr smith can you squeeze my fingers they grip and then DO THEY LET GO is it a reflux or is it a cognitive loop (for ex a baby grabs everything they aren’t following commands) if someone lets go, they followed the command) - If someone is paralyzed, they will have no motor response this would be considered untestable Withdraw from pain: For exam she said know if they give you a picture if its abnormal flexion or extension, top picture is abnormal flexion, bottom is abnormal extension Clinical indications of neurologic trauma - Scalp tears or swelling - Head and face o Battle’s sign – bruising over mastoid process (ear, if we see this we can suspect a basilar skull fracture (posterior/middle)) o Raccoon eyes – bilateral peri-orbital ecchymosis (ecchymosis/bruising under the eyes, we can suspect a front/anterior fossa fracture/damage) *picture below is of battle sign* - Nose o Rhinorrhea – CSF leakage from nose/mixed with blood from the trauma Ears o Otorrhea – CSF leakage from ears Halo test for CSF leakage. Halo effect from glucose, normal nasal secretions does not have glucose. If you suspect they are leaking CSF do not call the doctor and say you see a halo effect you need to confirm it by a sample or litmus stick test or dip stick to test for glucose. Meningeal irritation Meninges protect/cover the brain, there is three layers (dura mater, arachnoid and pia mater) when there is inflammation in the brain for ex meningitis the meninges become irritated there is certain clinical manifestations that we will see. - Nuchal rigidity – stiff neck (pull neck forward pt would complain of pain) Kernig’s sign – back/neck pain when leg is elevated Brudzinski’s sign – knee flexion when head is elevated (DON’T GET THIS CONFUSED WITH BABINSKI) For both of these tests the pt. must be lying flat. For meningeal irritation we would also see photophobia (sensitive to light). Brain death - Seeks to confirm three cardinal findings o Coma or unresponsiveness o Absence of brainstem reflexes o apnea - must first exclude other causes of findings (e. metabolic, drug overdose, etc.) - 1. No cerebro-motor response to pain - 2. Pupils mid-size or totally dilated; no response to light - 3. Eye movement o doll’s eyes – no eye movement in response to head movement; o cold caloric – no eye movement - 4. Absent corneal reflex - 5. Apnea test confirmatory testing (ancillary tests) - 1. EEG (30 minutes) looking for brain activity/seizure activity - 2. 4 vessel angiography – absence of blood flow (this is very invasive injecting dye) - 3. Cerebral blood flow (perfusion scan) – absence of blood flow - 4. Transcranial ultrasound
Neuro assessment - Lecture notes 5
Course: Nursing Care- Complex Health Problems II (11-63-375)
University: University of Windsor
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