Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 33: Patient Assessment: Nervous System

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Objectives Gather baseline data in an organized fashion Correlate and look for trends in data Analyze and develop nursing diagnoses Determine how deficit affects activities of daily living

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Equipment Needed Reflex hammer (deep tendon reflexes) Ophthalmoscope and/or flashlight (pupil checks) Tuning fork (hearing evaluation) Monofilament (sensation) Otoscope (hearing evaluation) Blood pressure cuff (identify hypertension)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Understanding Age-Related Changes With age, all of the following may be diminished: –Taste and smell –Hearing and visual acuity –Muscle mass –Sensitivity to touch and pain –Deep tendon reflexes In addition, you may see: –Tremors of head and tongue –Slow and uncertain gait

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Comprehensive History Chief problem Past medical history

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chief Problem: OPQRST Method O = Onset P = Precipitating factors Q = quality; describe your symptoms in your own words R = Radiation S = Severity; on a 1-to- 10 scale T = Timing; how long does it last; does it occur at any particular time of day?

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Past Medical History: Head to Toe Neurological: TIA, stroke, seizures, headache, change in LOR, speech pattern, pain Cardiovascular: CAD, MI, HTN, PVD, syncope, rhythm disturbances (atrial fibrillation) Respiratory: COPD, shortness of breath, recent infections Musculoskeletal: Guillain-Barré, myasthenia gravis, ability to carry out ADLs Others –Medications: antiseizure meds, antihypertensives, anticoagulants, antiplatelets –Surgeries –Social behaviors: ETOH, drugs, cigarette smoking

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical Assessment Level of responsiveness (LOR) Motor strength Vital signs Cranial nerve assessment Deep tendon reflexes (DTRs)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Level of Responsiveness A good, thorough inspection will give you the most information. Gross bedside mental status checks –AVPU (gross check for Awake, Verbal stimulus, Pain, and Unresponsive –A+O x3 (“Who you are, Where you are, What time is it?”) –Glasgow Coma Scale

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Glasgow Coma Scale Done according to responses: –Best eye –Best motor –Best verbal

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The nurse is assessing a stroke patient using the Glasgow Coma Scale (GCS). The patient opens his eyes spontaneously and obeys commands but does not know who he is, where he is, or what time it is. His GCS total score would be: A. 8 B. 13 C. 14 D. 15

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. 14 Rationale: His eye response is a 4. His motor response is a 6. His verbal response is a 4. This is a total of 14 on the GCS scale.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Motor Responses Strength with and without resistance More primitive responses: –Localizing –Withdrawing –Decorticate rigidity –Decerebrate rigidity (See Figure 33-1.)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Motor and Cerebellar Functions Cogwheeling Ataxia Romberg tests Finger-to-nose test Heel-to-shin test

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Vital Signs Temperature: of note are very high temps unresponsive to antipyretics Pulse: increased ICP can cause tachycardias, but bradycardias are late signs of impending herniation down the brain stem Respirations: can be early signs –Snoring/stridor = airway obstruction (partial) –Cheyne Stokes = cerebellar dysfunction Blood pressure: patient is usually hypertensive due to autoregulation mechanisms. Hypotension after herniation

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following might be an early indication of increased ICP? A. Respiratory changes B. Widening of the pulse pressure C. Extremely high temperature D. Bradycardia

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Respiratory changes Rationale: The brain is quick to respond to changes in carbon dioxide, so respiratory changes would occur first. All of the others are late signs and might indicate herniation of the brain down the tentorium and then brain stem.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins The 12 Cranial Nerves Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Acoustic Glossopharyngeal Vagus Spinal accessory Hypoglossal

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins More Detailed View: Oculomotor (CN III) Controls pupil size and reaction to light Trend pupil size in millimeters by using a chart/pupil stick Direct response Consensual response Accommodation Charting: PERRLA

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathological Pupils Large –Fear –Fits (seizures) –Fast living: drug abuse Small –Drugs –Drops –Dead (almost) The “blown” pupil (ipsilateral dilation)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A “blown” pupil is one that is bilaterally large but responsive. A. True B. False

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. False Rationale: A “blown” pupil is one that is fixed and dilated on the same side as the problem. This is caused by a decreased blood supply from pressure exerted from the lesion causing the increased ICP. The opposite pupil is reactive initially but then also becomes fixed and dilated as pressure is unrelieved.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Eye Tests for Brain Stem Functioning Doll’s eyes (oculocephalic pupils) Caloric ice test (oculovestibular pupils)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins More Detailed View: Acoustic (CN VIII) Whisper test Rinne Weber Otoscopic examination

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Percussion: Deep Tendon Reflexes and Primitive and Abnormal Reflexes Biceps Triceps Brachioradialis Patellar Achilles Documentation with stick man Babinski’s reflex Brudzinski's sign Kernig’s sign

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Documentation Mental status: Well-groomed. Slightly slumped posture. Gazed at floor throughout interview. Responds to questions. A+O x3. Recent and remote memory intact. Cranial nerves: Vision 20/30 in both eyes with glasses. PERRLA at 4 mm. EOMs intact; clenches jaw, frowns, and smiles without difficulty. Able to shrug shoulders. Tongue is midline. Cerebellar: Finger-to-nose, heel-to-shin alternating movements coordinated but slow. Romberg negative in bed. Cannot do others due to bed rest status. DTRs: Bilaterally symmetrical. Negative Babinski. Other: Vital signs stable; and BP 120/78.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurodiagnostic Studies Cerebral x-rays Computed tomography (CT scan) Magnetic resonance imaging (MRI) Cerebral angiography Other studies

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Brain Tests Cerebral and spinal x-ray –Must be done to rule out spinal cord injury in all brain AND spinal cord problems –MUST maintain cervical spine precautions –Will show air in the brain CT scan –With or without contrast medium –Superior to MRI for bony disturbances (See Figure 33-10)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A patient is scheduled for a CT with contrast for a previously stable brain tumor. Which of the following lab values should be brought to the physician’s attention? A. Serum potassium 3.5–5.0 mEq/L B. Serum sodium 145 mEq/L C. Creatinine 3 D. BUN 30

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Creatinine 3 Rationale: A creatinine of 3 tells the nurse the kidney won’t be able to excrete the contrast without help. All the other lab values are normal and wouldn’t affect this test.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurodiagnostic Tests MRI –Very fine cross-sections of tissues –Strong magnetic waves are used, so any metallic substances contraindicate procedure –Nurse screens for presence of pacemakers, metallic heart valves, orthopedic pins, and fragments from traumatic injury Cerebral angiography: inject dye to see vascular system Other tests: PET, DSSA, EEG, LP