Neuro Assessment c nerves handout - AACN

18 Pages·2014·2.72 MB·English

4/1/2014
Disclosure
Neuro Assessment (cid:1) Rachel Malloy, MSN, RN, CNRN, SCRN
Clinical Specialist
Integra Lifesciences
Neurosurgery Division
[email protected]
Purpose Neuro Assessment Findings
Documentation of what is observed
(cid:1) Identify the presence
of nervous system (cid:1) Consistent amongst clinicians
dysfunction
(cid:1) Systematic approach
(cid:1) Detect life threatening
situations (cid:1) Succinct and to the point
(cid:1) Establish a neurological (cid:1) Organized manner
database -Baseline
(cid:1) Identify changes from
baseline
Tools for the assessment Parameters
(cid:1) Penlight (All patients) (cid:1) Mental status
(cid:1) Pupillary assessment
(cid:1) Glasgow Coma Scale (All patients)
(cid:1) Motor function
(cid:1) Pupil Gauge (All patients)
(cid:1) Sensory exam
(cid:1) Paperclip (for stroke and spinal cord (cid:1) Cranial nerve
patients) evaluation
(cid:1) NIH Stroke Scale (Stroke patients) (cid:1) Speech assessment
(cid:1) Cerebellar examination
(cid:1) Dermatome Sheet (Spinal cord
(cid:1) Pathologic reflexes
patients)
(cid:1) Respiratory patterns
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A Phrase you never want to
Subsequent Assessments hear from a doctor…
Determined by diagnosis and
acuity of illness
(cid:1) “How long has
(cid:1) Problem-focused
my patient
(cid:1) Zeroed-in on affect parts of
been like this?”
nervous system
(cid:1) Frequency varies
Questions to ask yourself…
(cid:1) What do I see?
(cid:1) What does it mean?
Your initial assessment is the
(cid:1) How does it relate to the previous
most important assessment!!!
assessment?
(cid:1) How am I going to proceed?
Mental Status Reticular Activating System
(cid:1) Arousal-
state of awakeness
(cid:1) Cognition-
state of awareness
RAS = dimmer switch for the brain
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Level of Consciousness –
Arousal Language
(cid:1) Lethargic
(cid:2) Requires light stimulus to arouse but maintains (cid:1) Dominant hemisphere
(cid:1) Obtunded (cid:2) Usually the left
(cid:2) Requires noxious and continuous stimulus to Broca’s Wernicke’s
remain aroused (cid:1) Aphasia
(cid:1) Stuporous (cid:2) Ranges from
(cid:2) Requires vigorous noxious stimulus to obtain difficulty
arousal and cannot be maintained remembering words
(cid:1) Coma to being completely
(cid:2) No response to the environment unable to speak,
read, or write.
Description ….. better than labeling
Speech Assessment Speech Center
Aphasia
Wernicke’s-
(cid:2) Fluent-receptive (Wernicke’s) (receptive)
speech
(cid:2) Non fluent-expressive (Broca’s) Broca’s-
(motor)
(cid:2) Global-all language functions are speech
impaired
Located on dominant hemisphere
Motor Strength Scale
(cid:1) 0 -Flaccid
Pronator Drift
(cid:1) 1 -Muscle
contraction
The earliest
(cid:1) 2 -Lateral only
sign of weakness
(cid:1) 3 -Raise against
gravity-unable to
sustain
(cid:1) 4 -Sustain against
gravity-not
against resistance
write as a fraction
(cid:1) 5 -Normal
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Motor Exam Noxious Stimuli
May see it written as…
Central Peripheral
(cid:1) Earlobe (cid:1) Nailbed pressure
(cid:1) Trapezius squeeze (cid:1) Pinching
3/5 5/5 (cid:1) Supraorbital
pressure
(cid:1) Suctioning
(cid:1) Sternal rub
2/5
5/5
Stimulus Used
Don’t
(cid:1) Central Noxious
Stimuli
(cid:2) Earlobe
(cid:2) Trapezius squeeze
(shoulder)
(cid:2) Mastoid pressure
(cid:2) Supra-orbital
pressure Sternal rub
(cid:2) Suctioning
Glasgow Coma Scale
(GCS)- 3-15
Peripheral Stimuli
(cid:1) Spinal Reflex
(cid:1) Best Verbal (1 - 5)
(cid:1) Eye Opening (1 - 4)
Arc
Oriented (5)
(cid:2) Nailbed Confused
Opens eyes
pressure [disoriented] (4)
spontaneously (4)
(cid:2) Pinching Opens eyes to verbal (3) Inappropriate [swearing,
yelling] (3)
Opens eyes to pain (2)
Incomprehensible sounds
No eye opening (1)
[moans] (2)
None (1)
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Glasgow Coma Scale
(GCS)- 3-15
(cid:1) Motor (1 - 6)
Follows commands (6)
Localizes to pain [purposeful] (5)
Normal flexion [withdrawal] (4)
Abnormal flexion [decortication]
(3)
Extension [decerebration] (2)
None (1)
Modified from Critical Care Nursing: A Holistic
Approach, Lippincott Williams & Wilkins, 2005
Traumatic Brain Injury
•A: Cerebral hemisphere
lesion with some
involvement in the (cid:1) Mild: GCS 13-15
diencephalon
(cid:1) Moderate: GCS 9-12
•B: A lesion involving a
cerebral hemisphere & the
diencephalon (cid:1) Severe: GCS 3-8
•C: A lesion in the midbrain
or upper pons
•D: Lesions in the lower
pons & below
Modified from Critical Care Nursing: A Holistic Approach, Lippincott Williams & Wilkins, 2005
Pupillary Assessment Pupillary Assessment
(cid:1) Size
(cid:2) 2-6mm normal
(cid:1) Shape
(cid:2) round vs ovoid
(cid:1) Reaction to light
(cid:2) brisk
(cid:2) sluggish
(cid:2) non reactive (absent light reflex)
(cid:2) direct and consensual
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Direct vs Consensual Accommodation
(cid:1) Hold your finger about 10cm from
Consensual the patient's nose.
(cid:1) Ask them to alternate looking into
the distance and at your finger.
(cid:1) Observe the pupillary response in
each eye.
Direct
Distant= dilation
Closeness = constriction
Disconjugate gaze
Eye Deviation
•Conjugate vs disconjugate
•Gaze preference
Also called “vergence”-
involves simultaneous movement of both eyes
in opposite directions.
Amaurosis (Fugax) Pathologic pupils
Bilateral fixed & dilated pupils
Unilateral dilated pupils Pontine pupils
Life Art, www.lifeart.com
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Pontine Stroke Midbrain
Pinpoint pupils
3rd Cranial Nerve Palsy Anisocoria
Horner’s Syndrome Sensory Response
(cid:1) Start assessment at lower
extremities
(cid:2) Pain and temp –spinothalamic
•Ptosis (cid:2) Dull versus sharp
•Miosis (cid:2) Position sense and vibration –dorsal
•Anhidrosis columns
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Cranial Nerves
Cranial Nerves
(cid:1) CN I -Olfactory
(cid:1) CN II -Optic
12 pairs- (cid:1) CN III -Oculomotor
(cid:1) CN IV -Trochlear
(cid:1) CN V -Trigeminal
Motor
(cid:1) CN VI -Abducens
Sensory (cid:1) CN VII -Facial
Both (cid:1) CN VIII –Vestibulocochlear (Acoustic-old term)
(cid:1) CN IX -Glossopharyngeal
(cid:1) CN X -Vagus
(cid:1) CN XI –Spinal Accessory
(cid:1) CN XII -Hypoglossal
Cranial Nerve I-Olfactory Cranial Nerve I-Olfactory
Test sense of
smell...
not routinely
tested in ICU
With TBI,
first to lose-
last to return
Lies beneath
frontal lobes
Cranial Nerve II-Optic
Visual acuity, Visual fields Snellen Chart
–
(pocket card)
Have patient read
from ~6 inches away
II
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Assess for Visual Fields
Hold up fingers….inches
away from patient
X X
X X
Test both eyes
Have patient look straight…test all 4 quadrants
Vision Visual Fields (Intact)
Pathway
CN II deficits Amaurosis (Fugax)
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Bitemporal Hemianopia
Left Right
Homonymous Hemianopia
Bitemporal Hemianopsia
Right Homonymous Hemianopsia Left Homonymous Hemianopsia
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