a. Differentiate between a full neurologic assessment and focused neurologic assessment. Explain the indication for each type of assessment. (10 points total- 5 for differentiation of assessments and 5 for indications)
A full neurologic assessment examines a patient’s complete neurologic function. It includes a patient history that includes: demographic data (age and gender), past medical history (patient’s medical history and family’s medical history), patient’s current medical history (health problems, allergies, medications, and activities of daily living), and their social history (daily physical activity, alcohol/tobacco use, sleep patterns, work, ethnic background, educational background) (Ignatavicius & Workman, 2016). It also involves assessing the patient’s mental status, their cranial nerve function, motor and sensory function, pupillary response, reflexes, the cerebellum, and vital signs (Rank, 2010).
A focused neurologic assessment is an assessment that examines neurological health issues specific to the patient (Ignatavicius ; Workman, 2016). It focuses on specific areas of concern and is much shorter than a full assessment. Typical areas examined during a focused assessment include: level of conscious, motor strength, and pupillary reactivity (Rank, 2010).
There are a few factors that help determine which kind of assessment should be used. The first factor is what kind of information needs to be collected from the patient. The second factor is the time that can be spent with the patient and in performing the assessment. The third factor is the practitioner’s skill level. The full neurological assessment is typically performed by an advanced practice nurse or health care provider. The focused assessment is typically performed by a nurse. A full assessment is indicated to help find whether there is injury to the CNS, PNS, or both and to provide baseline data (Ignatavicius & Workman, 2016). A focused assessment is used as part of an ongoing assessment and it aids in identifying changes in neurological status (Ignatavicius & Workman, 2016).
b. Describe the peripheral and autonomic nervous systems and their functions. (10 points total- 5 for descriptions and 5 for functions)
The peripheral nervous system is made up of spinal nerves, cranial nerves, and the autonomic nervous system (Ignatavicius & Workman, 2016). There are 31 pairs of nerves that exit the spinal cord. There are 8 cervical nerves, 12 thoracic nerves, 5 lumbar nerves, 5 sacral nerves, and 1 coccygeal nerve (Ignatavicius & Workman, 2016). The nerves have a posterior branch that carries sensory information to the spinal cord (afferent pathway) and an anterior branch that carries motor impulses away from the spinal cord and to the muscles (efferent pathway) (Ignatavicius & Workman, 2016). The nerves leave the spinal cord and form plexuses with other spinal nerves, and eventually form the peripheral nerves throughout the body.
The function of the PNS is to collect sensory information and provide muscle innervation to areas of the body (Ignatavicius & Workman, 2016). The sensory receptors in the PNS detect changes in temperature, pain, touch, vibration, pressure, visceral sensations, proprioception, vision, taste, smell, and hearing (Ignatavicius & Workman, 2016). The PNS also controls the reflex arc and cranial nerves. There are twelve cranial nerves each have a specific function. These functions include: smell (olfactory); central and peripheral vision (optic); eye movement (oculomotor, trochlear, abducens); facial sensation and ability to chew (trigeminal); face and scalp muscles (facial); hearing and equilibrium (vestibulocochlear); muscles of the throat and parotid glands (glossopharyngeal); sensations of the thoracic and abdominal viscera, muscles of the soft palate, larynx, and pharynx, and cardiac and smooth muscle innervation (vagus); muscles of the pharynx, larynx, sternocleidomastoid and trapezius muscles (accessory); and tongue movement (hypoglossal) (Hannity & Foley, 2017).
The autonomic nervous system contains both the sympathetic and parasympathetic nervous systems. The sympathetic nervous system arises from T1 to L2 or 3 from the gray matter of the spinal cord (Ignatavicius & Workman, 2016). The parasympathetic system also arises from the gray matter of the spinal cord. It originates from S2 to S4 and includes portions of some of the cranial nerves (III, VII, IX, X).
The function of the autonomic nervous system is as the name suggests, automatic or not under conscious control. The sympathetic nervous system controls the fight or flight response (heart and respiratory rate/functions not needed in emergent situations) (Ignatavicius & Workman, 2016). The parasympathetic nervous system can slow and preserve body function and aids in digestion and reproduction (Ignatavicius & Workman, 2016).
c. Discuss 2 diagnostic exams covered in chapter 41. Include nursing considerations, and pre/post procedure care. (Try to choose diagnostic exams you do not know much about.) (10 points total- 5 for each diagnostic exam)
1.) Cerebral angiography is used to examine the blood circulation of the arteries and veins in the brain, head, and neck. It is used to detect aneurysms, traumatic injuries, strictures/occlusions, tumors, blood vessel displacement from edema, and arteriovenous malformations (Ignatavicius & Workman, 2016). Nursing considerations: The patient should be assessed for risk factors that can lead to adverse reactions to the iodine-based contrast agent. Some factors that should be considered include: kidney function (creatinine ? 1.5 mg/dL or a GFR of < 60 mL/min are at an increased risk for kidney damage from contrast), presence of chronic kidney disease, diabetic nephropathy, heart failure, dehydration, use of drugs that interfere with perfusion (metformin and NSAIDs), contrast administration in the last 72 hours, older age in patients, allergies, and previous issues with contrast tests (Ignatavicius & Workman, 2016). Informed consent should be gathered/witnessed from the patient. If appropriate/safe, the patient should be well hydrated prior to testing. Also, hearing aids and dentures should be removed prior to the procedure. Vital signs and cardiac rhythms should be monitored before, during, and after the procedure. The patient should be instructed that when the contrast is injected they will feel a warm or hot sensation and this is perfectly normal. Pre-procedure: Ensure the patient is not allergic to the contrast and make sure the patient has been NPO for at least 4-6 hours prior to the test (Ignatavicius & Workman, 2016). The patient is asked to lay on the examining table and made as comfortable as possible. They will be instructed to lay still, and the head will be immobilized. The patient may be given medication to help them relax, but heavy sedation is typically not used (Ignatavicius & Workman, 2016). Procedure: The physician numbs the groin area and inserts a catheter into the femoral artery. The catheter is advanced into the carotid or vertebral artery using fluoroscopic guidance (Ignatavicius & Workman, 2016). The contrast is injected, and images are taken at various angles of the blood vessels in the head and neck. Post-procedure: Always follow agency protocols for the injection site such as: monitoring site for swelling, redness, and bleeding, applying ice packs to the site, keeping the extremity straight and immobilized, and utilizing a pressure dressing for at least 2 hours (Ignatavicius & Workman, 2016). Monitor the extremity frequently for good blood circulation, and if the patient is actively bleeding, maintain pressure on the site and call the physician. Also, monitor the patient’s vital signs and perform neurological checks (provide thorough documentation of assessments and interventions). Lastly, increase fluid intake or IV fluids (if safe for the patient) to flush the contrast out of the body.
2.) Positron emission tomography (PET) is a diagnostic test used to visualize cerebral blood flow and brain function (metabolism of glucose and oxygen). Nursing considerations: The patient should be assessed for risk factors that can lead to adverse reactions to the isotope agent. Some factors that should be considered include: kidney function (creatinine ? 1.5 mg/dL or a GFR of ; 60 mL/min are at an increased risk for kidney damage from contrast), presence of chronic kidney disease, diabetic nephropathy, heart failure, dehydration, use of drugs that interfere with perfusion (metformin and NSAIDs), contrast/isotope administration in the last 72 hours, older age in patients, allergies, and previous issues with contrast tests (Ignatavicius ; Workman, 2016). Informed consent should be gathered/witnessed from the patient. If appropriate/safe, the patient should be well hydrated prior to testing. The patient’s vital signs should be monitored. Pre-procedure: The patient should be asked if they are claustrophobic and should be informed that the machine will make knocking sounds (assure them this is normal). Let the patient know that they will be able to communicate with the technician while in the procedure room. Make sure the patient knows that they need to be NPO for 4-12 hours before the procedure and they should avoid caffeine, alcohol and tobacco for at least 24 hours before the test (Ignatavicius & Workman, 2016). If the patient is diabetic, they should have their test first thing in the morning and avoid taking their diabetic medication before the test. The patient should be instructed to remove all hairpins, hairpieces, and wigs prior to the procedure. Also, no drugs or glucose solutions should be given to the patient because it will interfere with glucose metabolism results. Also, two IV lines should be established before the procedure begins. Procedure: The patient is taken into the examining room and asked to lay on the examining table. They are instructed to lay still as the physician injects an isotope called IV deoxyglucose. This isotope emits activity in the form of positrons, which are scanned and converted into color images on a computer (the more active a part of the brain is, the greater the glucose uptake) (Ignatavicius & Workman, 2016). This test can take 2 to 3 hours to complete and the patient may be blindfolded and asked to put earplugs in (for all or part of the testing). They will also be asked to do certain mental functions to illicit brain activity in different regions of the brain as well (Ignatavicius & Workman, 2016). Post-procedure: The isotope is eliminated via urination. Therefore, the patient should increase fluid intake (if safe for patient) to encourage the excretion of the isotope.
d. Describe how the Glasgow Coma Scale is used to score a patient’s neurologic status. When is a change in the GCS score considered significant? (10 total- 5 for the description of the GCS and 5 for change significance)
The Glasgow Coma Scale assesses three main areas of neurological function—eye opening, motor response, and verbal response. Each area that is tested is given a score based on the patient’s response. Eye opening is scored on a scale of 1-4 (4 indicating eyes open spontaneously (best outcome) and 1 indicating no eye opening to speech or painful stimuli (worst outcome)). Motor response is scored on a scale of 1-6 (6 indicating the patient obeys and reacts to verbal commands (best outcome) and 1 indicating the patient does not produce a response (worst outcome)). Verbal response is scored on a scale of 1-5 (5 indicating the patient is oriented and can converse (best outcome) and 1 indicating the patient elicits no response (worst outcome)). Eye opening and motor responses may have to be elicited by using painful stimuli and verbal response may have to be elicited by increasing the tone of the examiners voice (Rank, 2010). The highest score a patient can receive is a 15 (Ignatavicius & Workman, 2016). High scores are indicative of no neurological impairment, while low scores indicate neurological deficits.
Change in the Glasgow Coma Scale is significant when there has been a decrease of 2 or more points and it should immediately be reported to the physician (Ignatavicius & Workman, 2016). Also, other significant changes include pinpoint, dilated, and nonreactive pupils, decorticate/decerebrate posturing, and mental status changes (Ignatavicius & Workman, 2016). Cognition changes are the earliest signs of neurological problems!