Assessment and Assessment and diagnosis of patients with diagnosis of patients with problems related to the problems related to the

nervous systemnervous system

Nervous system disease can affectNervous system disease can affect

ConsciousnessConsciousness MentationMentation MovementMovement SensationSensation Integrated regulation eg breathing, Integrated regulation eg breathing,

circulation, temperature control, circulation, temperature control, elimination, special senses eg eye, elimination, special senses eg eye, ear, nose, throatear, nose, throat

ASSESSMENTASSESSMENT

1. Health/Nursing History1. Health/Nursing History Put patient at ease, consider reliability of Put patient at ease, consider reliability of

patientpatient Patient to tell own storyPatient to tell own story Avoid suggesting S & SAvoid suggesting S & S History will help in focusing the neurologic History will help in focusing the neurologic

examinationexamination Mode of onset and course of illness:Mode of onset and course of illness:

qualityquality intensityintensity distributiondistribution durationduration frequency of S & Sfrequency of S & S

Past HistoryPast History Medical & surgical eg infections & Medical & surgical eg infections &

laminectomieslaminectomies Injuries e.g. MVAInjuries e.g. MVA MedicationMedication Pre-natal and peri -natal problems? Pre-natal and peri -natal problems?

Eg exposure to German Eg exposure to German measles/complication at birthmeasles/complication at birth

Growth or development history Growth or development history milestones met?milestones met?

Family HistoryFamily History– Neuro problems may be congenital or Neuro problems may be congenital or

hereditary e.g. epilepsy/ hydrocephalushereditary e.g. epilepsy/ hydrocephalus

Personal/Social HistoryPersonal/Social History– Changes in daily living routines?Changes in daily living routines?

Appetite, sleep, exerciseAppetite, sleep, exerciseRecreation, occupationRecreation, occupationStressors, sexual practicesStressors, sexual practices

Review other systemsReview other systems

Neuro dysfunction common in Neuro dysfunction common in system illness e.g. neuropathy system illness e.g. neuropathy related to diabetes mellitusrelated to diabetes mellitus

2. Health Assessment2. Health Assessment

Conduct review of neurological Conduct review of neurological functionfunction

(Screening purposes)(Screening purposes)– Mentation Function (cerebral function)Mentation Function (cerebral function)– Cerebellar Function (screen co-Cerebellar Function (screen co-

ordination)ordination)– Motor Function (Movement)Motor Function (Movement)– Sensory Function (Sensation)Sensory Function (Sensation)– Integrated regulationIntegrated regulation– Coping aspectsCoping aspects

Important PointsImportant Points Symmetry of function and findings on Symmetry of function and findings on

both sides of body is important to both sides of body is important to notenote

Always compare one side with the Always compare one side with the otherother

Integrate with examination of other Integrate with examination of other systemssystems

ExaminationExamination– Mental statusMental status

State of consciousnessState of consciousnessMemoryMemoryCognitionCognitionAffect (mood)Affect (mood)Ideational content Ideational content (hallucinations)(hallucinations)

AppearanceAppearance Height, weight, Height, weight, grooming, clothing, grooming, clothing, posture, gaitposture, gait

Behavior & Behavior & Psychomotor activityPsychomotor activity

Movement, nail biting, Movement, nail biting, agitationagitation

Attitude towards Attitude towards interviewer/peopleinterviewer/people

Co-operative, eye Co-operative, eye contact, guardedcontact, guarded

SpeechSpeech Rate of production – Rate of production – rapid Quality – stutterrapid Quality – stutter

Responsiveness to Responsiveness to environmentenvironment

Reduced?Reduced?

Ability to carry out Ability to carry out ordersorders

Protrusion of tongue, Protrusion of tongue, put finger on noseput finger on nose

MoodMood ““I feel" Tone of voiceI feel" Tone of voice

Emotional expressionEmotional expression Your observationYour observation

AppropriatenessAppropriateness Laughing but feels Laughing but feels sadsad

Anxiety – patient Anxiety – patient descriptiondescription

““I’m a nervous wreckI’m a nervous wreck

ObservationObservation Tremor, sweatingTremor, sweating

ProductivityProductivity Overabundance, Overabundance, povertypoverty

Nature of thoughtsNature of thoughts ContentContent

Associative processesAssociative processes How thoughts are How thoughts are linked, loosening of linked, loosening of associationassociation

ObsessionsObsessions What patient is What patient is thinking aboutthinking about

PhobiasPhobias Fear for peopleFear for people

DelusionsDelusions False fixed beliefFalse fixed belief

Perceptual Perceptual disturbancesdisturbances

HallucinationHallucination

TimeTime Time, date, yearTime, date, year

PlacePlace State whereState where

PersonPerson Own name, family Own name, family namesnames

Remote memoryRemote memory ChildhoodChildhood

Recent pastRecent past Last 3 monthsLast 3 months

RecentRecent Previous days news, Previous days news, breakfastbreakfast

Immediate retention Immediate retention and recalland recall

3 unrelated items, 6 3 unrelated items, 6 digits forward and digits forward and then backwardthen backward

Information & Information & intelligenceintelligence

Calculate change, Calculate change, state president, state president, provinces, patient provinces, patient backgroundbackground

ConcentrationConcentration

Abstract thinkingAbstract thinking

JudgmentJudgment Hit an elderly personHit an elderly person

InsightInsight UnderstandingUnderstanding

DreamsDreams About lifeAbout life

ReliabilityReliability Medical records, Medical records, patient doesn’t patient doesn’t contradict himselfcontradict himself

– Cerebellar FunctionCerebellar Function To screen coordination of voluntary To screen coordination of voluntary

muscular movement, posture and muscular movement, posture and balancebalance

– Motor FunctionMotor Function Test in conjunction with skeletal Test in conjunction with skeletal

systemsystem Test muscle mass,Test muscle mass, tone, tone, strength, strength, abnormalities eg twitchingabnormalities eg twitching

– Sensory FunctionSensory Function Test sensitivity to the following and Test sensitivity to the following and

compare both sides of the body:compare both sides of the body: Touch (Cotton)Touch (Cotton) Pain (pin-prick)Pain (pin-prick) Vibration (tuning fork)Vibration (tuning fork) PositionPosition

– Integrated RegulationIntegrated Regulation Check:Check: BreathingBreathing CirculationCirculation Temperature controlTemperature control EliminationElimination

EXAMINATIONS:EXAMINATIONS:

1.1. Neurological examinationsNeurological examinations

2.2. Cerebral angiogramCerebral angiogram

3.3. CAT scanCAT scan

4.4. MRI scanMRI scan

5.5. Electro-encephalogramElectro-encephalogram

6.6. Lumber punctureLumber puncture

7.7. MyelogramMyelogram

Cranial NervesCranial Nerves

ObservationObservation Ptosis (III) Ptosis (III) Facial Droop or Asymmetry (VII) Facial Droop or Asymmetry (VII) Hoarse Voice (X) Hoarse Voice (X) Articulation of Words (V, VII, X, XII) Articulation of Words (V, VII, X, XII) Abnormal Eye Position (III, IV, VI) Abnormal Eye Position (III, IV, VI) Abnormal or Asymmetrical Pupils (II, III) Abnormal or Asymmetrical Pupils (II, III)

MotorMotor ObservationObservation Involuntary Movements Involuntary Movements Muscle Symmetry Muscle Symmetry

– Left to Right Left to Right – Proximal vs. Distal Proximal vs. Distal

Atrophy Atrophy – Pay particular attention to the hands, Pay particular attention to the hands,

shoulders, and thighs. shoulders, and thighs. Gait Gait

Muscle ToneMuscle Tone Ask the patient to relax. Ask the patient to relax. Flex and extend the patient's fingers, Flex and extend the patient's fingers,

wrist, and elbow. wrist, and elbow. Flex and extend patient's ankle and Flex and extend patient's ankle and

knee. knee. There is normally a small, continuous There is normally a small, continuous

resistance to passive movement. resistance to passive movement. Observe for decreased (flaccid) or Observe for decreased (flaccid) or

increased (rigid/spastic) tone. increased (rigid/spastic) tone.

Muscle StrengthMuscle Strength

Test strength by having the patient Test strength by having the patient move against your resistance. move against your resistance.

Always compare one side to the Always compare one side to the other. other.

Grade strength on a scale from 0 to 5 Grade strength on a scale from 0 to 5 "out of five": "out of five":

2. Cerebral Angiogram2. Cerebral Angiogram

DefinitionDefinition  

Cerebral Angiography is an x-ray Cerebral Angiography is an x-ray procedure used to visualize the blood procedure used to visualize the blood vessels of the neck, head and brain vessels of the neck, head and brain (cerebral = head, angio = blood vessel, (cerebral = head, angio = blood vessel, graphy = picture). graphy = picture).

What is it used for?What is it used for?  

This test may be used for evaluating This test may be used for evaluating any disease which effects the blood any disease which effects the blood vessels of the head, neck or brain. vessels of the head, neck or brain. Most commonly it is used to look for Most commonly it is used to look for narrowing of the blood vessels in the narrowing of the blood vessels in the neck that can be associated with a neck that can be associated with a risk of stroke, or in looking for weak risk of stroke, or in looking for weak points in the vessels that might points in the vessels that might cause hemorrhage.cause hemorrhage.

PreparationPreparation

   shower the evening before or morning of shower the evening before or morning of

testing to ensure skin is clean (the area will be testing to ensure skin is clean (the area will be further cleaned with antiseptic solution at the further cleaned with antiseptic solution at the time of the test). time of the test).

Some medications need to be withheld before Some medications need to be withheld before the examination because they may interact the examination because they may interact with the dye - ask for instructions from the with the dye - ask for instructions from the radiology. radiology.

NPO / light breakfastNPO / light breakfast Declare any history of asthma, allergies, Declare any history of asthma, allergies,

diabetes mellitus, or any medications,diabetes mellitus, or any medications,

Are there side effects?Are there side effects?   groin areas will be shaved. groin areas will be shaved. Some discomfort when the freezing is injected Some discomfort when the freezing is injected

to numb the area in the groin, Remainder of the to numb the area in the groin, Remainder of the test is usually painless. test is usually painless.

Injection of the dye = associated with a warm Injection of the dye = associated with a warm feeling in the head or a metallic taste in the feeling in the head or a metallic taste in the mouth. mouth.

Rarely people note flashes of light in their Rarely people note flashes of light in their vision. vision.

Serious side effects can include allergic reaction Serious side effects can include allergic reaction to the dye, bleeding or haematoma at the to the dye, bleeding or haematoma at the catheter insertion site or stroke. Bleeding at the catheter insertion site or stroke. Bleeding at the insertion site is avoided by firm compression of insertion site is avoided by firm compression of the site for 15 minutes, application of a tight the site for 15 minutes, application of a tight pressure bandage for several hours, lying with pressure bandage for several hours, lying with the hip and leg straight for about 6 hours and the hip and leg straight for about 6 hours and staying mostly in bed for about 24 hours.staying mostly in bed for about 24 hours.

3. CAT scan3. CAT scan

DefinitionDefinition

Computed Tomography (CT) is a Computed Tomography (CT) is a computer assisted X-ray in which two computer assisted X-ray in which two dimensional pictures are obtained of dimensional pictures are obtained of parts of the body. parts of the body. 

What is it used for?What is it used for? computer is able to produce a two computer is able to produce a two

dimensional view or 'slice' of the area dimensional view or 'slice' of the area scanned, allowing a better view of the scanned, allowing a better view of the individual structures. individual structures.

used to identify any structural used to identify any structural abnormality of the tissue including abnormality of the tissue including tumors, swelling, strokes, scarring, tumors, swelling, strokes, scarring, bleeding, protrusion of discs in the back bleeding, protrusion of discs in the back etc.etc.

PreparationPreparation

Preparation depends upon the area Preparation depends upon the area being scanned. For CT of the brain being scanned. For CT of the brain and spinal column there is usually no and spinal column there is usually no preparation.preparation.

Are there side effects?Are there side effects?

Apart from the needle to inject the dye Apart from the needle to inject the dye CT scanning is painless. CT scanning is painless.

no adverse reactions to the scan, but no adverse reactions to the scan, but there can be rare allergic reactions to there can be rare allergic reactions to the dye. the dye.

Inform docter of history of allergiesInform docter of history of allergies

4. MRI scan4. MRI scan

DefinitionDefinition

employs powerful magnetic fields and employs powerful magnetic fields and radio waves to produce detailed radio waves to produce detailed images of body structures. images of body structures.

What's it used for?What's it used for?

Images from MRI are often superior to Images from MRI are often superior to those from CT scanning,those from CT scanning,

particularly for soft tissues, brain, particularly for soft tissues, brain, spinal cord, joints and the abdomen,spinal cord, joints and the abdomen,

and in certain conditions such as and in certain conditions such as Multiple sclerosis. Multiple sclerosis.

PreparationPreparation

Do not wear any makeup the day of Do not wear any makeup the day of the scan (some brands contain metal the scan (some brands contain metal components).components).

Are there side effects?Are there side effects? painless procedure with no side effects. painless procedure with no side effects. involves a magnetic field it can not be done involves a magnetic field it can not be done

on people who have any implanted devices on people who have any implanted devices such as a cardiac pacemaker, a cerebral such as a cardiac pacemaker, a cerebral aneurysm clip, a neuro stimulator or an aneurysm clip, a neuro stimulator or an implanted hearing aid.implanted hearing aid.

presence of fragments or shrapnel in the presence of fragments or shrapnel in the body would have to be excluded for the MRI body would have to be excluded for the MRI to be done. to be done.

persons subject to claustrophobia  or unable persons subject to claustrophobia  or unable to lie flat for an extended period of time may to lie flat for an extended period of time may not be able to tolerate a scan. not be able to tolerate a scan. 

5. Electro-encephalogram5. Electro-encephalogram

DefinitionDefinition Electroencephalography measures Electroencephalography measures

the electrical activity of the brain the electrical activity of the brain derived from leads (electrodes) on derived from leads (electrodes) on the scalp.the scalp.

What is it used for?What is it used for?

primarily in the diagnosis and monitoring primarily in the diagnosis and monitoring of seizures and epilepsy.of seizures and epilepsy.

It is also useful in other circumstances It is also useful in other circumstances including sleeping disorders, encephalitis including sleeping disorders, encephalitis (inflammation of the brain), (inflammation of the brain),

some metabolic or chemical disturbances some metabolic or chemical disturbances of the brain and of the brain and

in recognizing large structural in recognizing large structural abnormalities such as tumors.abnormalities such as tumors.

PreparationPreparation

usually no preparation needed and the test usually no preparation needed and the test itself is painless. itself is painless. 

The electrodes that are placed on the scalp The electrodes that are placed on the scalp are often glued on with a paste which can be are often glued on with a paste which can be difficult to remove and causes the hair to be difficult to remove and causes the hair to be messy. A cap or hat to cover the hair is a messy. A cap or hat to cover the hair is a good idea.good idea.

Sometimes the study is done in a 'sleep Sometimes the study is done in a 'sleep deprived' or over tired state. This increases deprived' or over tired state. This increases the sensitivity of the EEG in picking up the sensitivity of the EEG in picking up seizure activity. In these cases the patient seizure activity. In these cases the patient will need to stay up all night without the will need to stay up all night without the benefit of any stimulants such as coffee and benefit of any stimulants such as coffee and have the test done first thing in the morning.have the test done first thing in the morning.

6. Lumber puncture6. Lumber puncture

DefinitionDefinition

Lumbar puncture (LP) is the insertion of Lumbar puncture (LP) is the insertion of a needle into the sub arachnoid space a needle into the sub arachnoid space of the lumbar region for diagnostic or of the lumbar region for diagnostic or therapeutic purposes. therapeutic purposes.

What's it used for?What's it used for?

to obtain a sample of CSF for testing. to obtain a sample of CSF for testing. identifying infections such as identifying infections such as

meningitis and encephalitis and in meningitis and encephalitis and in cases where they are suspected cases where they are suspected must be carried out quickly. must be carried out quickly.

identifying CSF abnormalities in other identifying CSF abnormalities in other diseases of the nervous system diseases of the nervous system including multiple sclerosis, including multiple sclerosis,

PreparationPreparation

There is no preparation required. If going There is no preparation required. If going home after the test - ensure that the home after the test - ensure that the patient has a ride and not drive himself.patient has a ride and not drive himself.

The test is usually done with the patient The test is usually done with the patient lying on their side, with their knees drawn lying on their side, with their knees drawn up and their back arched towards the up and their back arched towards the doctor. This spreads apart the bones doctor. This spreads apart the bones between which the needle is passed. between which the needle is passed.

Occasionally it is done in the sitting position Occasionally it is done in the sitting position or under X-ray guidance.or under X-ray guidance.

Are there side effects?Are there side effects? There is minor discomfortThere is minor discomfort Local anesthetic is usually injected before Local anesthetic is usually injected before

the spinal needle is inserted. the spinal needle is inserted.  anxiety - anxiety - serious side effects are serious side effects are

remarkably rareremarkably rare.. most common is headache which occurs most common is headache which occurs

in about 40% of people and begins within in about 40% of people and begins within 48 hours and resolves spontaneously in  48 hours and resolves spontaneously in  less than 5 days. It is typically better with less than 5 days. It is typically better with lying flat and worse while standing. lying flat and worse while standing.

7. Myelogram7. Myelogram

What is it?What is it? older test that is still used to examine older test that is still used to examine

the spinal canal and spinal cord. the spinal canal and spinal cord. A special dye A special dye myelogram is used only for very special myelogram is used only for very special

purposes, such as for complicated purposes, such as for complicated revision spine surgeries. It is rarely the revision spine surgeries. It is rarely the first test usedfirst test used

Why is it done?Why is it done?

unusual indentations or abnormal unusual indentations or abnormal shapes in the spinal cord. shapes in the spinal cord.

The myelogram is useful for patients The myelogram is useful for patients who have metal plates and screws in who have metal plates and screws in their spine, which prevents them from their spine, which prevents them from having either a CT or MRI scan.having either a CT or MRI scan.

What are the limitations?What are the limitations?

does not show the soft tissuesdoes not show the soft tissues shows only the bones and the spinal fluid shows only the bones and the spinal fluid

where the dye has mixed with the fluid. where the dye has mixed with the fluid.

What are the risks?What are the risks? Myelogram requires a spinal tap - more Myelogram requires a spinal tap - more

risks associated with it than most other risks associated with it than most other tests. tests. – meningitis, spinal headache, and allergic meningitis, spinal headache, and allergic

reaction to the dye. reaction to the dye.