Introduction

Assessment of the Lungs and Thorax

Mental Status Assessment

Neurological Assessment
Cardiovascular Assessment

Recording the Physical Assessment

Special Nursing Situations Finding

The EKG Paper

Post Examination

NEUROLOGICAL ASSESSMENTS CONTINUED

SPECIFIC DISEASE CONDITIONS

Neurological Assessment of the Cardiac Surgery Patient

Assessment of this type of patient can be difficult, especially immediately after surgery.  These patients will usually be admitted directly to the ICU after surgery.  Usually after the first 24-48 hours, they will be stabilized and may be transferred to a less acute unit, depending upon their condition.

The neuro assessment of these patients will be performed along with the usual assessment of cardiovascular and respiratory assessment.  The problem being that many nurses may forget to give the neuro assessment the proper consideration.  They are primarily concerned with cardio status and may forget to perform a thorough assessment.  One of the most severe complications of this type of surgery is that of “postcardiotomy delirium.”  It is characterized by impairment of orientation, memory, judgment, perception, visual and/or auditory hallucinations, and paranoid delusions.

Neuro Assessment, first 24-48 hours, (usually in the ICU, along with the usual general physical assessment)

  1. Restlessness              3.    Confusion                      5.   Hypotension
  2. Headache                 4.    Dyspnea                         6.    Cyanosis

You will remember that immediately after surgery, patients are subject to hypo perfusion and microembolli (air emboli).  The nurse should also perform an assessment every hour, then less frequently as the patient stabilizes.  Also pay attention to the emotional needs by offering reassurance, orientation to time and place, and by just talking to the patient in order to help prevent delirium.

Neuro Assessment, after the first 48 hours:

  1. Orientation                            3.    Depression (mental status)
  2. Sleep patterns                      4.    Postoperative cardiac status

Patients who will be confined in the acute care setting for long periods of time, can possibly develop a psychosis due to disturbances of sleep and rest periods.  They can often become depressed due to the fact that they have had a life-threatening illness for a long period of time.  The nurse must constantly assess the cardiac status and the mental status even after the first 48 hours.

Try to include the family in the patient’s recovery plan.  Provide as many distractions as possible for the patient, also taking into consideration their age, culture and other factors.  These patients are still in danger of developing psychosis because of sleep deprivation, increased sensory input, disorientation to night and day and due to the prolonger inability to speak due to the endotracheal tube.

BRAIN TUMORS

Brain tumors may be either benign or malignant, but any tumor which is located in the closed cranium can be fatal.  The greatest incidence of brain tumors is in persons between 30 and 50 years of age.  Brain tumors can be localized to a very specific area of the brain and a Glioma type of tumor, can also affect large areas of the brain.  Gliomas are the most common types of brain tumors, and they can invade all types of brain tissues, unlike some types of tumors which are very specific to a type of brain tissues.

Assessment of the patient with a brain tumor is centered around the fact that the tumor will affect those parts of the body that are controlled by those specific areas of the brain that are also afflicted by the tumor.  Tumors can invade brain tissues directly or they can compress the brain tissues.  For example, tumors of the coverings of the brain are usually well-defined and encapsulated, and will compress the brain as it grows.  Other tumors may block blood vessels or affect nerve transmissions such as with the cranial nerves.

Neuro Assessment, suspected brain tumors (early in disease process)

  1. Headache                                               5.    Papilledema
  2. Sensory abnormalities                          6.    Lethargy
  3. Vomiting                                                  7.    Confusion
  4. Motor abnormalities                               8.    Paralysis

In the person with suspected tumors, the nurse will carefully assess for progression of the symptoms.  In the beginning, the tumor will usually cause increasingly severe symptoms which can usually be assessed and reported by the nurse.  This accurate reporting of the symptoms can help to localize the tumor, the physician will be able to localize it to a specific area of the brain, and then begin tests to substantiate that fact.

Neuro Assessment, diagnoses tumors:  (later in the disease process)

The prognosis of the tumor, of course, depends upon early diagnosis and treatment.  Some tumors are not treatable if they are widespread and/or invasive.  The nurse will continue to give emotional support to the patient and the family, and referrals when needed.  Some tumors can be treated effectively, depending upon the age and condition of the patient.  Radiation, surgery and/or chemotherapy can be used.

CVA’s (stroke, or cerebrovascular accident)

Persons acutely ill with a CVA need special attention paid to the neurological assessment.  The nurse will maintain life support systems as necessary, since the cardiovascular and respiratory systems will usually be compromised.  The nurse should also keep in mind the underlying cause of the stroke.  There will be a different treatment for strokes caused by hemorrhagic disorders as opposed to the thrombo-embolitic disorder.

Neurological Assessment, CVA victim, Acute Phase

During the acute phase, the nurse should perform all assessment and interventions necessary.  If the patient is unconscious, the nurse will need to maintain the airway and all other aspects of the unconscious patient.  The neuro assessment is to ensure that the patient’s brain is being adequately oxygenated, and to prevent further neurological damage.

During the rehabilitation phase, the nurse will still need to perform detailed neuro exams.  They need not be as frequent as in the acute phase.  However, the patient’s progress still must be recorded accurately at regular intervals.

MENINGITIS

Meningitis can be caused by bacteria, mycobacterium or viral agents.  We know that the patient will be isolated, will usually have a high fever and could have numerous neurological symptoms.  The following guide to the assessment of the patient will be helpful for the acute phase of the disease.

In the acute phase, the patient may be in the ICU, and will have life support as needed.  The nurse should still perform a complete neuro assessment at least every hour and record these findings, in order to obtain a baseline of information during the acute phase of the illness.  When the acute phase is over, the neuro assessment will not have to be performed as frequently, but still be alter to changes in neuro status.

Polyradiculitis, (Guillain-Barre’ Syndrome)

This disorder is a clinical syndrome, possibly caused by allergic response or immunological reaction, involving the peripheral nervous system and cranial nerves.  It is characterized by muscle weakness and paralysis and parasthesias of extremities.

Neurological Assessment includes:

  1. Paresthesia - tingling and numbness of lower extremities
  2. Muscle weakness starts in legs and can progress up the trunk
  3. Face difficulty chewing, swallowing, talking, facial muscle paralysis can occur
  4. Incontinence loss of sphincter control; bladder and rectum
  5. Deep Tendon Reflexes may be absent

In severe cases, the disease may cause cardiac and respiratory failure.  Assess for progressive respiratory weakness, irregular breathing, rapid pulse rate and arrhythmias.  The disease usually causes deteriorating functions.  You should always record assessment findings so as to chart the progress of the disease.  The prognosis can be better if treated early and complications are prevented.

SUBDURAL HEHATOMA

The dangers from this disorder manifest themselves in the onset of symptoms from the original injury that caused the bleeding into the subdural potential space.  Severe symptoms can occur two to four weeks after the presumed injury took place.  Whenever the symptoms occur, the nurse must carefully assess the patient when the symptoms become acute; often, intervention is required to prevent life-threatening complications from subsequent pressure on the brain and/or stem.  Causes of subdural hematoma include accidental or purposeful injury, birth injury or meningitis.

Neurological Assessment includes:

Again, symptoms may develop rapidly.  Even death can occur quickly; but the above assessment assumes the patient is stable and is developing the symptoms slowly.  In cases where the patient is not stable, resuscitation or other such measures may be necessary.

 DIABETIC NEUROPATHY

This condition is a long-term complication of diabetes; however, there may be some acute complications.  Affected are the peripheral and autonomic nervous systems.

Neuro Assessment for the following:

Since most of these conditions usually are not life-threatening, they will usually need no immediate intervention.  The nurse should be aware that all diabetic patients will have these and other long-term complications of diabetes, and that the assessment should include all of the above criteria plus careful assessment of the general medical status of the patient.  The feet, skin and extremities will be of special importance.

PEDIATRICS CONSIDERATIONS

This section is a guide to assessment of the infant and small child with these possible neurological disorders.  It should be used in conjunction with any existing guidelines at your facility.

Cerebral Palsy: Malfunction of the motor centers of the brain and of the pathways.

Assess for the following:

  1. Asymmetry in motion or contour
  2. Generalized muscle weakness
  3. Listless or irritability
  4. Abnormal postures
  5. Difficulty in feeding or swallowing
  6. Defective speech
  7. Excessive or feeble cry
  8. Long, thin infants who are slow in gaining weight
  9. Delayed motor development

These areas above are some of the clinical manifestations of the disorder.  Also associated with this are seizures, hearing deficits, visual defects, perceptual disorders, language disorders and others.  These latter problems will be apparent in the older infant/child, and a generalized lack of motor development will also be noted.  There are several types of palsy, exhibiting spastic symptoms or “jerky” movements.  Be aware of abnormal motor symptoms.

Hydrocephalus:  Increased amount of cerebrospinal fluid within the closed cranial cavity, causing enlargement of the child’s head and the related symptoms.

Recording the Examination

Each hospital has its own form for recording the results of your examination.  Usually it will call for the general observation first, then the more specific findings.  If your facility has no model for charting the results, you can use this as a guide.

This is one way to organize your exam.  The most important tool is that of observation.  If any of the above general items is found to be abnormal, the nurse should investigate it further.  Use your common sense and test the patient in an area where you feel the person may have some abnormalities.  For example, if the patient seems to have a “crooked” smile, you should test the face in detail.  Ask them to open mouth wide; to make faces or some other movements, so that you can further test for weakness.  Use this common sense approach for all parts of the neuro exam, and carefully chart the results.  You are not diagnosing, but rather you are carefully describing a suspected problem.

Summary of Neurological Assessment

General Exam

  1. Obtain history (include medical problems/neuro problems)
  2. Medication history
  3. Any adverse symptoms

Cerebral function

  1. Behavior
  2. Level of consciousness
  3. Intellectual function
  4. Emotional status
  5. Thought content
  6. Language

Cranial Nerve Testing

  1. Olfactory
  2. Optic
  3. Oculomotor
  4. Others (as mentioned earlier)

Cerebral Function

  1. Finger to nose with eyes open and shut
  2. Fine finger movement
  3. Walking in a straight line (heel-to-toe)
  4. General coordination

Motor Testing

  1. Muscle size and tone
  2. Muscle strength

Sensory Testing

  1. Pain (superficial and deep pain testing)
  2. Motion and position
  3. Point localization
  4. Texture discrimination
  5. Temperature

Reflex Testing

  1. Stretch reflex
  2. Cutaneous reflex
  3. Corneal reflex
  4. Gag reflex
  5. Babinski reflex

Next: CARDIOVASCULAR ASSESSMENT