ASSESSMENT OF PATIENT WITH NEUROLOGICALILLNESS

NURSING ASSESSMENT OF PATIENTS WITH NEUROLOGICAL ILLNESS

Equipments and procedures in neurological assessment

Cotton applicators; needle/pin; test tubes containing hot and cold water; reflex hammer; vials containing coffee, clove, sugar and salt solution; tongue blade; penlight; tuning fork; thermometer; BP apparatus, and ophthalmoscope comprise the equipments. Identify the patient and explain the procedure to the patient. Ensure patient's privacy.

Components of neurological assessment

·         Mental status (cerebral function)

·         Cranial nerve function

·         Cerebellar function

·         Motor function

·         Sensory function

·         Deep tendon reflex

·         Vital signs

Mental status examination

·         State of consciousness (alert, somnolent, stuperous, confused, coma)

·         Memory (short term, long term, intermediate)

·         Cognition (calculation, current events)

·         Affect (mood)

·         Ideational content (hallucination)

·         

While recording the history ask the patient for identifying information (how to spell his name, where he lives) and ask what the date is. Alert patients will be able to give all these information.

·         Patients ability to remember is evaluated as the history is taken – ask past medical history (long term memory), ‘What did you eat for breakfast’? (intermediate memory)

·         Cognition and ideational content evaluated throughout the history.

·         Affect or mood is evaluated by observing patients’ verbal and non verbal behavior in response to questions asked.

State of consciousness

Unconsciousness is a condition in which there is depression of cerebral function ranging from stupor to coma. It is assessed by Glasgow coma scale, a scale developed to standardize observation for the objective and accurate assessment of level of consciousness. It was developed at the University of Glasgow in Scotland in 1974. The scale is divided into 3 subscales: Best eye opening;best verbal response and best motor response..The information collected is plotted on a graph to provide a visual record of deterioration, improvement or stability. The numerical values are added which will range from 3 to 15. A score of 15 indicates a fully alert oriented person and 3-7 means patient is in coma stage.

 

Action	Response	Score
Best eye opening	Spontaneously To Speech To pain None	4 3 2 1
Best verbal response	Oriented Confused Inappropriate words Incomprehensive sounds No verbal response	5 4 3 2 1
Best motor response	Obeys commands Localizes pain Flexion to pain Abnormal flexion Extension None-Flaccid	6 5 4 3 2 1

                                              Glasgow Coma Scale

Assessment of pupillary signs

Pupillary signs provide vital information about CNS function. While assessing pupils three points to be noted: size, shape and reaction to light.Normally pupils are equal in size measuring 2-6 mm in diameter with an average diameter of 3.5mm. It can also be said as pin pointed, small, mid position, and dilated.Normally both pupils are round in shape Abnormal shapes are noted.Reaction to lightis assessed.Direct light reaction:when light is shown directly into the eyes, pupils immediately constricts, with drawl of light produces immediate dilatation.Consensual light reaction: introducing light into one pupil causes similar constriction in the opposite eye and withdrawal causes simultaneous dilatation.Descriptive terms are brisk, weak, sluggish and absent.In APD (afferent pupillary defect) instead of constricting, pupil dilates on flashing light.

Cranial nerve function

The assessment of cranial nerve function is an integral part of neurological examination and is usually carried out by the doctor. These functions and related abnormalities are given in table

Cranial nerves	Function
I. Olfactory Nerve	Sense of smell
II. Optic Nerve	Vision - visual activity Visual field
III. Oculomotor Nerve IV. Trochlerar nerve VI. Abducent Nerve	Motor function Eye movements Pupillary reaction
V. Trigeminal Nerve	Motor function control muscles of mastication, sensation of face Reflex – corneal reflex, jaw reflex
VII. Facial Nerve	Controls facial expression Taste anterior 2/3rd tongue
VIII. Acoustic Nerve or Vestibulocochlear Nerve	Cochlear – hearing Vestibular – controls equilibrium
IX. Glossopharyngeal Nerve	Controls taste posterior 1/3 tongue sensation of pharynx
X. Vagus Nerve	Sensation of pharynx-ability to swallow, movement of vocal cords
XI. Spinal accessory Nerve	Movement of head and shoulder
XII.Hypoglossal Nerve	Protruding of tongue

                                 Cranial Nerve Function

Cerebellar function

Observe posture and gait.Ask patient to walk forward (then backward) in a straight line. Test muscle co-ordination in the lower extremity- Having the patient run his right heal down his left shin and vice versa.To test co-ordination of upper extremity,ask him to close his eyes and touch his nose from the out stretched position first with his right hand then with the left hand in rapid succession.

Motor function

Important points to be assessed are muscle size, using a measuring tape;muscle tone;muscle strength;presence of involuntary movements,posture and gait

Muscle tone

Spasticity: increased resistance to passive movement in UMN disease-affect only one group of muscle; Flaccidity: decreased muscle tone,the muscle being soft, weak and flabby as in LMN diseases.Rigidity:more constant state of resistance in extra pyramidal lesion and affect whole limb;Cogwheel rigidity:Intermittent resistance as in Parkinson’s disease.

Muscle strength:assessed in grade

·         Grade 0 : when there is complete paralysis

·         Grade 1 : when there is flickering movement

·         Grade 2 : able to move only if supported

·         Grade 3 : weak but able to move against gravity

·         Grade 4 : normal range of motion, but not against high resistance

·         Grade 5 : Normal power

Sensory functions

Tested while patient’s eyes are closed and compare both sides of the body. 

·         Touch                         - light touch with cotton

·         Pain                            - tested by pin prick

·         Heat and cold           - with test tube containing hot and cold water

·         Vibration                    - with tuning fork

·         Position sensation

Vital signs

The centers for vital signs are located within the brain stem.Note rate, character and pattern of patient's response. Record temperatures at specific intervals. Damage to hypothalamus will be reflected in grossly abnormal temperature. Record blood pressure and pulse at specific intervals.

Assessment of patient with increased intracranial pressure

1.   Changes in level of responsiveness according to Glasgow  oma scale (GCS)

2.   Changes in vital signs

3.   Pupillary changes

Nurses role in caring for patients undergoing diagnostic procedures in neurology

There are various diagnostic procedures, which are indispensable for correct diagnosis of patient. Patient's emotions and feelings should be considered before each procedure.  In general, an informed written consent must be obtained from patient or relative after detailed explanation about the procedure, benefits and its risks, before each procedure. Check level of consciousness, vital signs, and pupillary signs. Check motor power of extremities. Shave and prepare area, if needed. Keep the patient NPO for six hrs prior to procedure (if specified). Administer analgesics and sedatives as per order. Keep emergency tray and tracheostomy tray ready, if distress occurs.

The common diagnostic procedures are:-

1.    Lumbar pncture

2.    Electroencephalography (EEG)

3.    Electromyography (EMG)

4.    Nerve cnduction study (NCS)

5.    Computerised tomography (CT Scan)

6.    Magnetic resonance imaging (MRI)

7.    Cerebral angiography

8.    Brainstem auditory evoked potentials (BAEP)

9.    Somato sensory evoked potentials (SSEP)

10. Visual evoked potential (VEP)

11. Muscle biopsy

12. Nerve Biopsy

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