NEUROLOGIC FUNCTION ASSESSMENT BSN IV INTEGRITY

Goals and Objectives: 1. Know and understand the terminology commonly used to describe neurologic signs and symptoms. 2. Recognize symptoms which suggest neurologic dysfunction. 3. Develop a plan for monitoring the neurologic status of patients with headache, epilepsy, Parkinsons disease and cerebrovascular disease as it relates to drug therapy.

PATTERN VITAL SIGNS

DEFINITION Changes in vital signs are not consistent early warning signals. Vitals are more useful in detecting progression to late symptoms. Both respiratory and cardiac centres are located in the brainstem. Therefore, compression of the brainstem will cause changes in vital signs. This is usually a late sign and impending herniation/death will occur if the problem is not resolved. The respiratory centres in the brainstem control rate, rhythm, inspiration/expiration. The cardiac centres also play a part in cardiac acceleration/inhibition e.g. controlling heart rate and rhythm as well as hemodynamic stability/instability.

ASSESMENT Respiratory The role of the Nurse is to: 1. Ensure patent airway is maintained 2. Assess rate, rhythm, and characteristics of inspiration/expiration 3. Assess gas exchange, tissue perfusion, airway clearance, and risk for aspiration 4. Assess for causes of respiratory disturbances or secondary conditions that can cause respiratory complications 5. Assess for actual respiratory complication/insufficiency and intervene appropriately Pulse 1. Assess rate, rhythm, and quality of pulse 2. Assess tissue perfusion, cardiac output, activity intolerance 3. Assess for causes of cardiac instability and intervene appropriately Do not forget to compare findings to previous assessment. What can cause changes in pulse from a neurological standpoint? Tachycardia 1. If a patient has tachycardia related to neurological impairment it can mean that they are reaching a terminal phase in their disease process. 2. In a patient with multiple trauma, hemorrhage must be ruled out (intra-abdominal). Bradycardia 1. Bradycardia is seen in the later stages of increased intracranial pressure. As BP rises to overcome the increased ICP, reflex inhibition causes a slowing of the HR. 2. Bradycardia can also be seen with spinal cord injury and interruption of the descending sympathetic pathways. Cardiac Arrhythmias Cardiac arrhythmias may occur in several neurological conditions. Subarachnoid

hemorrhage patients with blood in the CSF and patients who have undergone posterior fossa surgery tend to have an increased incidence of arrhythmia. Blood Pressure 1. Assess for hypertension, hypotension, and pulse pressure 2. Assess tissue perfusion, cardiac output Do not forget to compare findings to previous assessment. What can cause changes in blood pressure from a neurological standpoint? Hypertension Increases in blood pressure are usually associated with rising ICP. An increased systolic pressure, widening pulse pressure, bradycardia and apnea are advanced stages of increased ICP and are known as Cushing's response. Hypotension 1. Decrease in blood pressure is rarely seen as a result of neurological injury. If it is present it is usually accompanied by tachycardia and is terminal. 2. Hypotension and bradycardia can be seen with cervical spine injuries as a result of neurogenic shock. Temperature The hypothalamus is the regulatory centre for temperature. Regulation of heat is monitored by blood temperature and is controlled through impulses to sweat glands, dilation of peripheral vessels and shivering of skeletal muscles. ASSESS FOR: a. attention span-test the ability to repeat a series of five or six digits backward and forward b. orientation-ask the patient to state his or her name, the date including the month, year, and time of day, and the name of the health facility or clinic c. memory-immediate, recent, and remote immediate: state 3 objects, ask the patient to repeat them back to you in 5 minutes recent: ask the patient world event questions remote: ask the patient his or her age, date of birth, questions about their first job, where he or she grew up d. general knowledge-ask the patient the names of the last 3 presidents, ask about current events e. mood and behavior-observe the patient for anxiousness, depression.

1. MENTAL STATUS

A comprehensive description or statement of a patient's intellectual capacity, emotional state, and general mental health based on examiner's observations and directed interview; includes assessment of mood, behavior, orientation, judgment, memory, problemsolving ability, and contact with reality.

12 CRANIAL NERVES Assessment Techniques (I) Olfactory Nerve-smell, not usually tested a. patient should close both eyes and occlude one nostril b. identify the odor of a common object placed under each nostril c. objects frequently used include coffee, cloves, lemon or soap (avoid ammonia or harsh soaps) (II) Optic Nerve-visual acuity and visual fields a. Visual Acuity 1. Snellen eye chart at 14" 2. counting fingers covering one eye at a time b. Visual Fields 1. patient covers one eye 2. examiner moves fingers of left hand and then right into patient view 3. patient identifies when fingers can be seen 4. repeat with patient covering the opposite eye (III) Oculomotor, (IV) Trochlear, and (VI) Abducens o CN III controls pupillary reactions (pupillary light reflex and accommodation), eyelid elevation, eye movements up, down, and medially o CN IV controls eye movement down and in toward nose o CN VI controls eye movement laterally toward temporal field o (CN III, IV, and VI function together to control eye movement) a. Pupillary reaction (CN III) 1. instruct the patient to fix both eyes on an object 2. shine the beam of a light directly into each pupil 3. note the size, shape, and reaction of the pupils (may see "PERRLA" in chart notations) b. Ocular movement (CN III, IV, and VI) 1. instruct the patient to follow your finger without moving head 2. examiner moves finger up, down, left, right 3. note the presence of nystagmus, limited eye movement (V) Trigeminal Nerve-sensation of face, corneal reflex, muscles of mastication (jaw movement) (has both motor and sensory functions) a. Motor function testing 1. ask the patient to open mouth as wide as possible 2. observer attempts to close mouth by placing one hand under chin and the other on top of head (VII) Facial Nerve-controls facial muscles, supplies taste fibers to the anterior 2/3 of tongue, controls eyelid closure (has both motor and sensory functions) a. Motor function testing 1. have patient wrinkle forehead, smile showing teeth, and wink eyes 2. note any asymmetrical movement or facial drooping (VIII) Auditory or Acoustic Nerve-controls hearing and sense of balance a. test using Rinne and Weber tests with tuning fork b. test gross hearing by holding a watch or rubbing fingers together close to ears (IX) Glossopharyngeal Nerve and (X) Vagus Nerve-control cough, gag, swallow, articulation, and phonation o CN IX also controls posterior 1/3 of tongue o CN X also controls autonomic function o (have both motor and sensory functions) a. instruct patient to open mouth and say "ahhh" b. look for elevation of soft palate and uvula in the midline c. assess gag reflex by stimulating back of pharynx with tongue depressor d. note any difficulties in articulation and/or speech (XI) Spinal Accessory Nerve-controls trapezius and sternocleidomastoid muscles, movement of shoulder and head, shoulder shrugging a. Trapezius testing 1. patient raises both shoulders while examiner applies resistance b. Sternocleidomastoid testing 1. patient turns head to left and then to right while examiner applies resistance (XII) Hypoglossal Nerve-controls tongue movement and strength a. patient protrudes tongue b. normally should be midline, note deviation to the right or left

2.

LEVEL OF CONSCIOUSNESS

Consciousness can be defined as a state of general awareness of oneself and the environment. Consciousness is difficult to measure directly but it is estimated by observing how patients respond to certain stimuli.

It is the most sensitive indicator of the changes I neurologic status of the client The center for wakefulness is ascending reticular activating system (ARAS) Assess both wakefulness and content of thought

Level of Consciousness: Level I Conscious, cognitive, coherent ( 3 Cs ) Level II Confused, drowsy, lethargic, odtuned, somnolent Level III Stuporous, respond only to noxious, strong or intense stimuli. Ex. Sternal pressure, trapezius pinch, very loud noise. Level IV Coma Light Coma response only by grimace or withdrawing limb from pain. Deep Coma absence of response to even the most painful stimuli .

GLASGOW COMA SCALE is an objective measure to describe LOC. It based on the clients response in three areas: eye opening, motor response and verbal response. AREAS TO BE TEST 1. EYE OPENING- assess arousal level Spontaneous On request To painful stimuli No opening 2. MOTOR RESPONSE Obeys Command Localize painful stimuli Flexion withdrawal Abnormal Flexion (decorticate) Abnormal Extension (decerebrate) No response

4 -

3 2 1

5 3 2 -

6 4

3. VERBAL RESPONSE Oriented to time, place and person 5 Engages in conversation, confused in content 4 Word spoken but conversation not sustained 3 Sounds are incomprehensible 2 No response 1 *This test is perform every 2 to 4 hours. *Score of 7 and below indicates coma.

4. SENSORY FUNCTION

Defined as the extent to which an individual correctly senses skin stimulation, sounds, proprioception, taste and smell, and visual images.

When assessing sensory function remember that there are three main pathways for sensation and they should be compared bilaterally: 1. pain and temperature sensation 2. position sense (proprioception)

3. light touch Pain can be assessed using a sterile pin. Light touch can be assessed with a cotton wisp. To test proprioception, grasp the patient's index finger from the middle joint and move it side to side and up and down. Have the patient identify the direction of movement. Repeat this using the great toe. Sensory Tests: A number of tests for lesions of the sensory cortex can be done. Examples include: Stereognosis: The ability to recognize an object by feel. Place a common object in the persons hand and ask them to identify the object. Graphesthesis: Draw a number in the palm of the persons hand and ask them to identify the number. Two-Point Discrimination: Simultaneously apply two pin pricks to the skin surface. Continually repeat the test while bringing the two pins closer together, until the individual can no longer identify two separate stimuli. The finger tips are the most sensitive location for recognizing two point differences while the upper arms, thighs and back are the least sensitive. Extinction: Touch the same spot on both sides of the body at the same time (e.g. the left and right forearms. Ask the individual to describe how many spots are being touched. Normally, both sides are felt; with sensory lesions the individual will sense only one. Point Locations: Touch the surface of the skin and remove the stimulus quickly. Ask the individual to touch the spot where the sensation was felt. Sensory lesions can impair accurate identification, even if they retain their sensation of light touch. The ability to perceive sensory stimuli is known as Stereognosis. Inability to perceive sensory stimuli is known as Agnosia. 5. MOTOR FUNCTION/CEREBRAL FUNCTION defined as the ability of the cranial nerves to convey sensory and motor impulses Regulating Mechanism Motor Center ( fontal lobe ) - is responsible for voluntary, purposeful., coordinates movement Apraxia inability to perform fine motor activities Agrapia inability to write Cerebellum responsible for equilibrium, sense of posture and direction. Romberg Test is done to assess sense of equilibrium. Ataxia is uncoordinated movement, characterized by wide-base stance with swaying manner of walking. Extrapiramidal System it maintain balance, posture and regulates locomotion.

General Appearance - presence of involuntary, unpurposeful and uncoordinated movements Muscle Power - weakness ( paresis ), paralysis ( plegia ) Muscle Tone - flaccidity ( hypotonicity ), rigidity ( hypertonocity ) Muscle Volume atrophy is loss of muscle volume, hypertrophy is increase in muscle volume Movement bradykinesia is slow muscle movement not associated with weakness. Akinesia is absence of muscle movement Coordination To test function use the following tests: 1. Finger to finger test: have the patient touch their index finger to your index finger (repeat several times). 2. Finger to nose test: perform with eyes open and then eyes closed. 3. Tandem walking: heel to toe on a straight line 4. Romberg test: stand with feet together and arms at their sides. Have patient close his/her eyes and maintain this position for 10 seconds. If the patient begins to sway, have them open their eyes. If swaying continues, the test is positive or suggestive of cerebellum problems. Station and gait station is posture, gait is manner of walking Assess if there is inability to speak and make gesture ( motor aphasia ). Assess if there is inability to understand sound or language ( auditory aphasia ). Assess if there is Impairement may result to inability to read ( alexia ).

6. REFLEX TESTING

A reflected action or movement; the sum total of any particular automatic response mediated by the nervous system.

The center for reflex act is the spinal cord The cerebral cortex determines the motor response

TYPES OF REFLEXES Superficial Reflex Pupillary Reflex Corneal Reflex Abdominal Reflex Cremasteric Reflex Anal Reflex Babinski Reflex *** Interpretation of Superficial Reflexes = - - absent = x - slightly present = + - present

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2.

Deep Tendon Reflex ( DTRs ) Ankle jerk is produced by tapping the tendon of Achilles; plantar flexion of the foot occurs

Knee jerk ( patellar reflex ) is produced by tapping the quadriceps femoris, just below the patella; it result to leg extension. Reflexes to assess meningeal irritation Kernigs sign the client is placed in supine position. Flex the knee, attempt to extend the leg. Pain is experienced. Brudzinskis sign the client is placed in supine position. Passively flex the neck, spontaneousl flexion of the hips occur. This is more accurate indicators of meningeal irritation than Kernigs sign Oculocephalic Reflex or Dolls Eye Phenomenon This is demonstrated by holding the persons eyelids open and rotating the head from side to side. Positive or normal dolls eye is demonstrated by conjugate movement of eyes towards the opposite side.

3.

4.

5.

Oculovestibular Reflex or Caloric Ice Water Test This is done by irrigating the semi-circular canals of the ear with ice water. It causes conjugate eye movements or nystagmus. This is an accurate method of assessing brainstem functioning.

7. BOWEL AND BLADDER

Excretory function (bowel, bladder, and skin).

Usual bladder pattern (discomfort voiding, difficulty starting stream, frequency, nocturia, incontinence, self care, assistance, other ie., catheter and etc.) Usual bowel pattern (frequency, description, last bowel movement, incontinence, ileostomy, colostomy, aids, self care, assistance). Impairment of Sympathetic Nervous System leads to bowel and bladder retention Impairment of Parasympathetic Nervous System leads to bowel and bladder incontenence

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