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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DRUGS USED IN CARDIAC AND NEURO EMERGENCY TRAY...

Sl. No.	Name of drugs	No. of ampoules/ vials	Sl. No	Name of drugs	No. of ampoules/ vials
1	Inj: Adrenalin	5	13	Inj:Calcium gluconate	5
2	Inj:Adenosine	5	14	Inj:Heparin	1
3	Inj:Amiodarone	5	15	Inj:Lasix	5
4	Inj:Aminophyllin	3	16	Inj:Eptoin	10
5	Inj:Atropine	5	17	Inj:Diazepam	3
6	Inj:Avil	3	18	Inj: Lorazepam	3
7	Inj:Deriphyllin	5	19	Inj: Xylocard 2% (50ml )	2
8	Inj:Dexona	5	20	Inj:Midazolam	3
9	Inj:Efcorlin	5	21	25%Dextrose	5
10	Inj:Pantoprazole	5	22	Water for injection	10
11	Inj:Ranitidine	5	23	Tab:Sorbitrate	10 (no)
12	Inj:Sodabicarb	5

 Drugs in emergency tray 

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SAFETY TIPS FOR WOMENS........

.

1) What should a woman do if she finds herself alone in the company of a strange male as she prepares to enter a lift in a high-rise apartment late at night?
Experts Say: Enter the lift. If you need to reach the 13th floor, press all the buttons up to your destination. No one will dare attack you in a lift that stops on every floor.


2) What to do if a stranger tries to attack you when you are alone in your house, run into the kitchen.
Experts Say: You alone know where the chili powder and turmeric are kept.And where the knives and plates are. All these can be turned into deadly weapons. If nothing else, start throwing plates and utensils all over.

Let them break. Scream. Remember that noise is the greatest enemy of a molester. He does not want to be caught.

3} Taking an Auto or Taxi at Night.
Experts Say: Before getting into an auto at night, note down its registration number. Then use the mobile to call your family or friend and pass on the details to them in the language the driver understands .Even if no one answers your call, pretend you are in a conversation. The driver now knows someone has his details and he will be in serious trouble if anything goes wrong. He is now bound to take you home safe and sound. A potential attacker is now your de facto protector!

4}What if the driver turns into a street he is not supposed to - and you feel you are entering a danger zone?

Experts Say: Use the handle of your purse or your stole (dupatta) to wrap around his neck and pull him back. Within seconds, he will feel choked and helpless. In case you don’t have a purse or stole just pull him back by his collar. The top button of his shirt would then do the same trick.

5} If you are stalked at night.

Expert Say: enter a shop or a house and explain your predicament. If it is night and shops are not open, go inside an ATM box. ATM centers always have security guards. They are also monitored by close circuit television.
Fearing identification, no one will dare attack you.

After all, being mentally alert is the greatest weapon you can ever have.

Please spread it to all those women u care & spread awareness as dis is d least we can do for a social & moral cause and for the safety of women.

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PROCEDURES IN INTERVENTIONAL RADIOLOGY LAD(DSA LAB)

.Procedures in Interventional Radiology ( DSA) Lab

Invasive procedures are done in the Digital Subtraction Angiography (DSA) Lab situated at first floor of Block II.  The invasive procedures done in this lab are either vascular procedures or nonvascular procedures.

Vascular procedures

Angiography: 4 vessel angiogram and peripheral angiogram.

Balloon angioplasty: Percutaneous transluminal angioplasty (PTA).

Blood vessel stenting: Often performed with angioplasty. A small wire mesh tube called a stent is placed in the newly opened artery to help it remain open.

Catheter delivered chemotherapy for cancer: Deliver a high dose of cancer killing drugs directly to the tumor depriving the tumor of its blood supply by emboli zing the arteries feeding the tumor, especially in case of liver tumors.

Endovascular embolization: Occlusion of one or more vessels or vascular malformation.

Thrombolysis: is the break up of blood clot that restricts normal blood flow.

Non vascular procedures

Vertebroplasty strengthens vertebral body by injecting bone cement (for vertebral haemangioma, osteoporosis, and malignant tumors). Abscess drainage, bile drainage for obstructed liver bile ducts, Radio Frequency Ablation (RFA) in which a small needle is guided in to the tumor . Radio frequency energy is transmitted into the targeted tissue from the tip of the needle, where it produces heat and kills tumor. 

Carotid angiography (4-vessel angiography)

Both the carotid and vertebral arteries are studied by injecting radio opaque contrast material through specially designed catheters. The usual approach is through right femoral artery (FA). The catheter is navigated from FA through iliac artery, abdominal aorta, arch of aota and then selectively into the cerebral vessels. The contrast material is injected and DSA technology is used whereby the bony and muscular structures are masked and only the arterial tree is visualized.

Indications

1.   To diagnose vascular abnormalities like arteriovenous malformation (AVM), aneurysm and arteriovenous (AV) fistula.

2.   To detect any obstruction in the blood flow.

3.   To assess tumor vascularity.

4.   To detect patency and cross circulation of cerebral blood vessels when the opposite side is occluded or ligated.

Post procedural care

Once the procedure is over the catheter is taken out and manual compression over the artery is applied for 10-15 minutes. When the bleeding stops, distal pulse is confirmed and pressure bandage is applied. After verifying the hemodynamic status, proper documentation is done and patient is shifted to the ICU/ward along with relatives.

Nursing evaluation

Check vital signs, level of consciousness and ensure proper hydration. Observe the site for any bleeding or hematoma, color of the extremity and distal pulses. Observe for allergic reaction, head ache etc. Immobilise the extremity for 4-6 hours.

Spinal angiography

Spinal angiogram is an X-ray study of the blood vessels supplying to the spine.  It is usually performed to detect abnormality of the vessels or to treat a vascular tumour or a vascular malformation.  The angiogram is a minimally invasive procedure.

Contra indications

·         Allergy to radiopaque dye

·         Pregnancy

·         Patients on anticoagulants

·         Recent embolic or thrombotic occurrences

·         Severe liver, thyroid, or kidney disease

Procedure

A catheter is placed and is verified by fluoroscopy. Femoral artery is most commonly used. Contrast medium is injected and series of X-rays are taken for visualization of arterial and venous circulation. After the test, catheter is removed and pressure is applied to the site and pressure dressing is applied when the bleeding stops.

Complications

·        Anaphylactic reaction

·        Seizures

·        Cerebrovascular accidents

·        Visual disturbances

·        Pulmonary embolism

·         Hemorrhage from puncture site

Angioplasty: It is done for stenotic lesions in the concerned vasculature. Once the lesion is made clear by the diagnostic study, the stenotic lesion is crossed with a guide wire over which the balloon catheter is introduced and dilated under fluoroscopic guidance.  Check angiogram is done to evaluate the effectiveness.

Embolization: It is the introduction of an artificial embolizing material through specially designed catheters to block the feeding vessel of arterio venous malformation, arterio venous fistula or aneurysms which are at high risk of rupture when approached surgically. Uterine artery embolization is also done to control the bleeding risk in
post partum hemorrhage or bleeding due to fibroid in the uterus. For various causes of gastrointestinal and pulmonary bleeding also, embolization is useful.

Once the catheter is in situ, embolizing material is injected and check angiogram is done repeatedly till the desired effect is achieved. All major cases are done usually under G.A. Strict aseptic precautions is observed to prevent infection.

CONCLUSION

Interventional Radiology is a speciality in which image guided procedures are used to diagnose and treat multitude of diseases. Today many conditions that once required surgery can be treated nonsurgically by these techniques. Nursing care is pivotal in case of such patients.

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AVM (arteriovenus malformation)...neuro surgery

AVM is a congenital disorder characterised by a complex,tangled web of arteries and veins.

it is caused by abnormal development of veins.

it may occur in brain ,brain stem and spinal cord.

common symptoms are bleeding,seizure,headache,paralysis,loss of speech,memory,vision etc.

ABOUT ELEPHANTS.......(state animal of kerala)

Elephants come under the order PROBOSCIDEA.there are two genera...African 

elephant(LOXODONATA AFRICANA) and asian elephant (ELEPHAS MAXIMUS)
Adult male elephant (bull) grows 2.5-3m height and female (cow) around 2.5m
bull weighs 3.5-5 tonnes and cows 2.5-3.5 tonnes
the ear is an important organ in removing the heat of the body of elephant

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IMAGING SCIENCES AND INTERVENTIONAL RADIOLOGY

.care of patients undergoing procedures in
              imaging sciences and interventional radiology

INTRODUCTION

The imaging sciences and interventional radiology (ISIR) has gained an extremely important place in the medical field. The ISIR is handling a large number of diagnostic procedures such as  X- ray, Computed tomography scan (CT) scan, CT angiography, magnetic resonance imaging (MRI), MR angiography, functional MRI, ultrasonography, doppler study, carotid angiography, aortogram, peripheral angiogram and spinal angiogram and interventional procedures like angioplasty stenting and embolisation etc.

Imaging tools

CT SCAN

·         CT scan – Brain, Chest, Abdomen, Pelvis, Joints, Vertebrae

·         CT Angiography – Brain, Chest, Abdomen, Pelvis, Extremity

·         CT guided biopsy and fine needle aspiration cytology (FNAC) of different organs under LA/GA

·         CT guided Laser Ablation of lesions

·         Post Vertebroplasty Scanning

·         Injection of Sclerotic Agents under CT Guidance

·         CT scan for navigation and planning the surgery CT scan contrast study is done with thin slices and data collected in a CD, which is fed in the operation planning system in Neurosurgery navigation protocol, which aids the surgeon to perform the surgery with minimal invasive techniques.

·         CT scan for stereotactic Biopsies, Pallidotomy and DBS implantation

·         Cardiac CT will be installed in the near future.

Magnetic resonance imaging (MRI scan)

MRI Brain, Chest, Abdomen, Pelvis, Peripheral Angio 3D, and Cardiac MRI are available. For children and non-cooperative adults, MRI is done under general anesthesia. Also patient who has claustrophobia, movement disorders, or memory impairment sedation is used under the care of anesthetist. MRI under GA is done on IP basis only. For MR Angiography and contrast-enhanced studies, patients’ renal function test (RFT) is done. Patient is given hospital attire. In MRI room MR combatable articles only is allowed. The patients with pacemaker or non-combatable heart valve prosthesis are not taken in. Oxygen cylinders, metallic patient trolley, wheel chairs are not allowed in the MRI room.

All ornaments, dentures, cochlear implants are to be removed before entering the MRI room. Food and fluids are allowed except for GA and sedation. Psychological preparation helps to avoid fear and anxiety. The sound of the machine creates a fear in some patients. The staff attending the patients also must be aware of these features.MR contrast media reactions are very rare but we must be ready with all emergency drugs and equipment all through out.MRI under GA is done weekly twice.

Ultrasound and Doppler scan

Ultrasound abdomen, pelvis, ultrasound guided biopsy, aspiration. Doppler scan is done for neck vessels, peripheral and  renal vessels.Patients are given prior appointment for the study. Fasting is essential in case of abdomen and renal studies. For pelvis scan food and fluid is allowed and full bladder is essential.

Common emergencies

Contrast media reactions

A great variety of reactions may occur after the rapid injection of intravascular contrast. This may be a minor or major reaction. Accurate and detailed history, proper explanation, instituting test dose, titrate the amount of contrast used, proper hydration and frequent monitoring should be practised.

Minor reactions

It may be nausea, headache, pruritus or vomiting. It is of short duration and usually self-limiting. Only reassurance is needed. Patient should be informed in each instance by a simple description of the kind of sensation that he will experience and the duration of sensation. If there is vomiting or nausea, slow the rate of injection and re-assure the patient that no serious reaction is going to happen. If it is severe, Inj.chlorpromazine is given. If angioneurotic edema or utricaria occurs, give hydrocortisone. For hypotension, start fluids, oxygen and vasopressor drugs such as dopamine. If bronchospasm occurs, broncho dilators like aminophylline and hydrocortisone is given. Pain at injection site, thrombophlebitis, salivation, weakness, chills and fever, hiccups, swelling of the salivary gland and extravasation needs to be managed accordingly.

Major reactions

In case of any major anaphylatic reaction, immediately administer oxygen and start intravenous fluids. Monitor pulse and blood pressure carefully because development of hypo tension and shock may produce venous collapse. The clinician should be called to handle any major reaction, the specific approach depends on the nature of reaction.

Equipment and drugs for emergency

Emergency drugs and equipments must be available throughout and easily accessible as time is a crucial factor in emergency management. 

Accessories for artificial ventilation and endotracheal intubation, provision for oxygen administration and suctioning, IV cannula, IV fluids, infusion and transfusion sets etc should be readily available.

Special role of a nurse in ISIR

The nurse informs the technologist or radiologist of any unusual patient needs and performs specialized nursing duties, such as administering intravenous sedation or analgesia during special procedures and closely monitoring patients with cardiac monitoring and pulse oximeters. Radiology nurses devote a lot of time to quality improvement and infection control programs. Collecting  data, keeping records and reporting results are also the responsibility of nurse. Because radiology nursing is relatively new, the nurse may be called upon to help write patient care policies, design flow sheets and patient instruction sheets and develop protocols. Radiology nurses utilize skills gained from other nursing specialties and incorporate them in the radiology setting.

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