ASESSMENT of Client with Diseases in Nervous System

The Neurologic Examination I. Health History An important aspect of the neurologic assessment is the history of present illness. The initial interview provides an excellent opportunity to systematically explore the patients current condition and related events while simultaneously observing overall appearance, mental status, posture, movement and affect. Depending on the patients condition, the nurse may rely on yesor-no questions, a review of medical record, or input from the patients family. It includes details about the onset, character, severity, location, duration, and frequency of symptoms and sign, associated complaints, and relieving factors; progression and remission and exacerbation; and the presence or absence of similar symptoms among family members. It includes system-by-system evaluation. The history-taking portion of the neurologic assessment is critical and, in many cases of neurologic disease, leads to and accurate diagnosis.

II. Clinical Manifestations The clinical manifestations of neurologic disease are as varied as the disease processes themselves. Symptoms maybe subtle or intense, fluctuating or permanent, inconvenient or devastating. A, Pain Pain is considered an unpleasant sensory perception and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is multidimensional and entirely subjective. It can be chronic or acute. B. Seizures Seizures are the result of abnormal paroxysmal discharges in the cerebral cortex, which then manifest as an alteration in sensation, behaviour, movement, perception, or consciousness. C. Dizziness and Vertigo Dizziness is an abnormal sensation of imbalance or movement. It is fairly common in the elderly and one of the most complaints encountered by health professionals. Vertigo is usually a manifestation of vestibular dysfunction. It can be so severe as to result in spatial disorientation, light-headedness, loss of equilibrium, and nausea and vomiting.

D. Visual Disturbances Visual defects that cause people to seek health care can range from the decreased visual acuity associated with aging to sudden blindness caused by glaucoma. Normal vision depends on functioning visual pathways through the retina and optic chiasm and the radiations into the visual cortex in the occipital lobes. E. Weakness Weakness, specifically muscle weakness, is a common manifestation of neurologic disease. Weakness frequently co-exists with other symptoms of disease and can affect a variety of muscles, causing a wide-range of disability. F. Abnormal Sensation Numbness, abnormal sensation, or loss of sensation is a neurologic manifestation of both central and peripheral nervous system disease. Both numbness and weakness can significantly affect balance and coordination.

III. Physical Examination The neurologic examination is a systematic process that includes a variety of clinical tests, observations, and assessments designed to evaluate the neurologic status of a complex system. A. Assessing Cerebral Function a.1 Mental Status It begins by observing the patients appearance and behaviour, noting dress, grooming, and personal hygiene. Posture, gestures, movements, facial expressions, and motor activity often provide important information about the patient. a.2 Intellectual Function A person with an average IQ can repeat seven digits without faltering and can recite five digits backward. The examiner can ask the patient to repeat sets of numbers, show abstract pictures and ask to explain a written situation and interpret, to test the intellectual capacity of a person. a.3 Emotional Status Is the patients affect natural and even, or irritable and angry, anxious, apathetic or flat, or euphoric? Fluctuation of moods are observed, and the appropriate affect is assessed for a given situation, to know the patient emotional status.

a.4 Perception The examiner may now consider more specific areas of higher cortical function. Agnosia is the ability to interpret or recognize objects seen through the special senses. a.5 Motor ability Assessment of cortical motor integration is carried out by asking the patient to perform a skilled act. Successful performances requires the ability to understand the activity desired and normal strength. Failure signals cerebral dysfunction. a.6 Language ability Person with normal neurologic function can understand and communicate in spoken and written language. A deficiency in language function is called aphasia. Different aphasia result from injury to different parts of the brain.

IV. Examining the Cranial Nerves What Are the Cranial Nerves? The Cranial Nerves are made up of 12 pairs of nerves which are located on the ventral surface of the brain. Some control muscles. Some transmit information from the sensory organs to the brain. Others still are connected to glands or organ such as the lungs and heart. Examining the function of the cranial nerves will provide you with pertinent information about your patient's nervous system. The cranial nerves are numbered using Roman Numerals I-XII. There are a number of rhymes or mnemonics to help you remember the names of the nerves. I. Olfactory Nerve Its modality is Special Sensory and its function is smell. In routine examinations this is not usually tested unless the patient complains of loss or changes in a sense of smell. Each nostril should be patent. Have the patient occlude on and then the other during testing. With the eyes closed, a patient should be able to identify common smells such as cinnamon, coffee, vanilla or cloves.

II. Optic Nerve Its modality is Special Sensory and its function is vision. To test visual acuity, have the patient read a Snellen Eye Chart from a distance of 20 feet (6 meters). The patient covers one eye at a time and reads to smallest line possible. To test visual fields, stand about 2 feet (60 cm) away from the patient. Ask the patient to concentrate his gaze on your nose or directly into your eyes. Spread your arms so that your hands are about 2 feet apart and lateral to the patient's ears. Wave your fingers as

you slowly draw your hands in towards the patient's line of gaze. Ask him to tell you when he first visualizes your wiggling fingers. DO this from all quadrants of the visual field. The patient should see both hands simultaneously and from all directions. Cranial Nerves III, IV and VI are tested together. They each control the extraoccular muscles involved in eye movement. III. Oculomotor Nerve Its modality is two-fold; Somatic Motor and Visceral Motor. The Somatic Motor function is eye movement and the Visceral Motor function is pupil dilation. IV. Trochlear Nerve Its modality is Somatic Motor and its function is eye movement. VI. Abducens Nerve Its modality is Somatic Motor and its function is eye movement. To test these nerves, have the patient hold his head steady while you move your finger about 1 foot (30 cm) from his nose to watch his eyes move peripherally and up and down. First move your finger out to the right side then up and down; and back in towards the nose and up and down. Then outward from the left side and up and down; back in towards the nose and up and down. Have the patient follow your finger with his eyes without moving his head.

V. Trigeminal Nerve This nerve has two modalities Brachial Motor and General Sensory. Its function is also two-fold. The Brachial Motor controls the muscles of mastication (chewing). The General Sensory provides sensory information regarding touch and pain in the face to the brain. To test this nerve first have the patient clench jaw muscles by clenching his teeth. Muscle strength in the temporal and masseter muscles of the face should be felt and should be symmetrical. Touch the patient's face at the forehead cheek and chin on each side. The patient should report the sensation as being symmetrical. You can use a clean safety pin or suitable sharp object) for testing pain sensation. A cotton swab can be used to test for dull sensation. You can also test for sensation of temperature using test tubes filled with warm water and ice water.

VII. Facial Nerve This nerve has four modalities and functions. The modalities are Brachial Motor, Visceral Motor, General Sensory and Special Sensory. The functions include taste on the anterior 2/3 of the tongue and salivary glands, transmission of somatosensory information from the ear to the brain, control of muscles used in facial expression.

To test this nerve, have the patient repeat a sentence. Observe his facial expression during normal conversation check for any asymmetry, tics, or other facial movements. Next ask the patient to smile, frown, puff out his cheeks. Look for symmetry especially in the nasolabial folds. Ask him to close his eyes tightly and you try to open them by pulling upward on the eyebrows and downward on the cheeks just below the eyes checking for strength and symmetry. To test for taste, drop a few drops of sweet or salty water on the front part of the tongue and see how it tastes to your patient.

VIII. Acoustic Nerve (also known as Vestibulocochlear or Auditory Nerve) This nerve has one modality; Special Sensory. It has two branches; the Cochlear which transmits sound messages to the brain; and Vestibular which controls balance or equilibrium. To Test this nerve have the patient occlude one ear with a finger. Stand about 1 to 2 feet away (30-60 cm) and softly whisper a word with two distinct syllables such as football, baseball, or doorbell. Make sure the patient can't read your lips. Repeat with the other ear and a different word. Repeat the word slightly louder if necessary and observe for difficulties distinguishing words. Equilibrium can be tested using the Romberg test: Have the patient stand erect with his feet close together and his eyes closed. He might sway slightly, but should not fall. (Stay close to the patient in case he does begin to fall.)

Cranial Nerves IX and X are tested together as they both have a function that innervates the pharynx. IX. Glossopharyngeal Nerve This nerve has four mobilities Brachial Motor, Visceral Motor, General Sensory and Special Sensory. Its function includes taste on the posterior 1/3 of the tongue, some swallowing muscle function, and transmitting somatosensory information from the tongue, tonsils and pharynx. X. Vagus Nerve This nerve also has four modalities: Brachial and Visceral Motor as well as Visceral Sensory and Special Sensory. Its functions include autonomic, sensory and motor functions of viscera such as glands, heart rate and digestion. To test these nerves have the patient swallow some sweet or salty water and test for taste sensation as well as ability to swallow. Then ask the patient to open wide and say "ah" while you observe the uvula and palate. These should move symmetrically and without deviation to one side. Next tell the patient you're going to test his gag reflex. Lightly stimulate the back of the throat on each side with a swab or tongue depressor. The reflex should be present or symmetrically diminished.

XI. Spinal Accessory Nerve (also known as Accessory Nerve) The modality is Brachial Motor and the function is control of the trapezius and sternocleidomastoid muscles in movement of the head.

Place your hands on the patients shoulders from the back. Have him shrug his shoulders upward while you exert slight resistance. The strength and contraction of the trapezius muscles should be symmetrical. Next place one hand on the side of the patient's jaw and the other on the opposite sternocleidomastoid muscle. Have the patient turn his head towards the hand on his jaw while you apply slight resistance. Observe the strength in both muscles. Repeat to the other side.

XII. Hypoglossal Nerve The modality is Somatic Motor and the function is control of the muscles of the tongue. This nerve is tested by listening to the patient's articulation as he speaks as well as observing for any atrophy or deviation of the tongue while speaking. Have the patient stick his tongue out and move it from side to side. Check for symmetry of movement. Have the patient push his tongue against the inside of each cheek and you palpate for strength from the outside of his cheek.

Document your assessment carefully and report all abnormal findings to the physician or other practitioner.

V. Examining the Motor System a.1 Muscle strength Assessing the patients ability to flex or extend the extremities against resistance test muscle strength. The function of an individual muscle or group of muscles is evaluated by placing the muscle at a disadvantage. a.2 Balance and Coordination Cerebellar influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the patient perform rapid, alternating movements and point-to-point testing. Coordination in lower extremities is tested by having run the heel down the anterior surface of the tibia of the other leg. Each leg is tested in turn. Ataxia is defined as an incoordination of voluntary muscle action, particularly of the muscle groups used in activities. Rombergs test is a screening test for balance. Additional cerebellar tests for balance in an ambulatory patient include hopping in place, alternating knee bends, and heel-to-toe walking.

VI. Examining the Reflexes The motor reflexes are involuntary contractions of muscles or muscle groups in response to abrupt stretching near the site of the muscles insertion. The tendon is struck with a reflex

hammer or indirectly by striking the examiners thumb, which is placed firmly against a tendon of a patient. When reflexes are very hyperactive, a phenomenon called clonus may be elicited. Common reflexes that may be tested include the deep tendon reflexes (biceps, brachioradialis, triceps, patellar, and ankle reflexes) and superficial or cutaneous reflexes (abdominal reflexes and plantar or Babinski response). VII. Sensory examination Sensory modalities are carried out in different parts of the spinal cord. It is largely subjective and requires the cooperation of the patient. The examiner should be familiar with dermatones that represent the distribution of the peripheral nerves that arise from the spinal cord. It involves tests for tactile sensation, superficial pain, vibration and position sense.

GERONTOLOGIC CONSIDERATIONS During the normal aging process, the nervous system undergoes many changes, and it extremely vulnerable to general systemic illness. Changes throughout the nervous system that occur with age vary in degree. Nerve fibers that connect directly to muscles show little decline in function with age, as do simple neurologic functions that involve a number of connections in the spinal cord. Disease in the elderly often makes it difficult to distinguish normal from abnormal changes. It is important for clinicians not to attribute abnormality or dysfunction to aging without appropriate investigation. Structural Changes A number of alterations occur with increasing age. Brain weight decreases, as does the number of synapses. A loss of neurons occurs in select regions of the brain. Cerebral blood flow and metabolism are reduced. Temperature regulation becomes less efficient. In the peripheral nervous system, myelin is lost, resulting in a decrease in conduction velocity in some nerves. There is an overall reduction in muscle bulk and the electrical activity within muscles. Taste buds atrophy and nerve cell fibers in the olfactory bulb degenerate. Nerve cells in the vestibular system of the inner ear, cerebellum, and proprioceptive pathways also degenerate. Deep tendon reflexes can be decreased or some case absent. Hypothalamic function is modified such that stage IV sleep is reduced. There is an overall slowing of autonomic nervous system responses. Pupillary responses are reduced or may not appear at all in the presence of cataracts. Motor Alterations This is an overall reduction of muscle bulk, such as atrophy shown in hands. Changes is motor function often result in a flexed posture, shuffling gait, and rigidity of movement. In older

persons, strength and agility are diminished, reaction time and movement time are decreased. Repetitive movements and mild tremors may be noted during an examination and may be of concern to the person. Observation of gait may reveal a wide-based gait with balance difficulties. Sensory Alteration Sensory isolation due to visual and hearing loss can cause confusion, anxiety, disorientation, misinterpretation of the environment, and feelings of inadequacy. Sensory alterations may require modification of the home environment, such as large-print reading materials or sound enhancement for the telephone, as well as extra orientation to new surroundings. Simple explanations of routines, the location of the bathroom, and how to operate the call bell or light are just a few examples of information the elderly patient may need when hospitalized. Temperature Regulation and Pain Perception The temperature regulation and pain are related to other manifestation. The elderly patient may feel cold more readily than heat and may require extra covering when in bed; temperature somewhat higher than usual may be desirable. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older patient may suffer frostbite or burn. Complaints of pain, such as abdominal and chest pain, may be more serious than the patients perception might indicate and thus require careful evaluation. Two pain syndromes that are common in the neurological system in older adults are diabetic neuropathies and postherpetic neuropathies. Taste and Smell Alterations The acuity of the taste buds decreases with age; along with an altered olfactory sense, this may cause a decreased appetite and subsequent weight loss. Extra seasoning often increases food intake as long as it does not cause gastric irritation. A decreased sense of smell due to atrophy of olfactory organs may present a safety hazard, because elderly people living alone may be unable to detect houseold gas leaks or fires. Smoke and carbon monoxide detectors, important for all, are critical for the elderly. Tactile and Visual Alterations Another neurologic alteration in elders is the dulling of tactile sensation due to a decrease in the number of areas of the body to responding to stimuli and in the number and sensitivity of sensory receptors. There may be difficulty in identifying objects by touch, and because fewer tactile cues are received from the bottom of the feet, the person may become confused about body position and location. These factors, combined with sensitivity to glare, decreased peripheral vision, and a constricted visual field, may result in disorientation, especially at night when there is little or no light in the room. Because the elderly person takes longer to recover visual sensitivity when moving from a light to dark area, night-lights and a safe and familiar arrangement of furniture are essential.

Mental Status Mental status is evaluated when obtaining the history. Areas of judgement, intelligence, memory, affect, mood, orientation, speech, and grooming are assessed. Drug toxicity should always be suspected as a causative factor when the patient has a change in mental status. Delirium (mental confusion, usually with delusions and hallucinations) is seen in elderly patients who have underlying central nervous system damage or are experiencing an acute condition such as infection, adverse medication reaction, or dehydration. Depression may produce impairment of attention and memory. In elderly patients, delirium, which is an acute change in mental status attributable to a treatable medical problem, must be differentiated from dementia, which is a chronic and irreversible deterioration of cognitive status.

DIAGNOSTIC EVALUATION Computed Tomography Scanning Computed Tomography (CT) Scanning makes use of narrow x-ray beam to scan the body part in successive layers. The image provide cross-sectional views of the brain, with distinguishing differences in tissue densities of the skull, cortex, subcortical structures, and ventricles. The brightness of the parts of the brain in the image is proportional to the degree which it absorbs xray. Lesions in the brain are seen as variations in tissue density differing from the surrounding normal brain tissue. Abnormalities of tissue indicate possible tumor masses, brain infarction, displacement of the ventricles and cortical atrophy. Whole body CT-scans allows sections of the spinal cord to be visualized. Injection of water soluble iodinated contrast agent into the subarachnoid space through lumbar puncture improves the visualization if the spinal and intracranial contents on these images. The CT scan along with MRI has largely replaced myelography as a diagnostic procedure for the diagnosis of herniated lumbar disks. CT scanning is non-invasive and painless and has a high degree of sensitivity for detecting lesions. With advances in CT scanning, the number of disorders and injuries that can be diagnosed is increasing. Nursing Intervention Preparations for the procedure and for patient monitoring. Preparation includes teaching the patient about the need to lie quietly throughout the procedure. A review of relaxation techniques may be helpful for patients with claustrophobia. Check for allergy on iodine/shellfish allergy, because the contrast agent is iodine based. IV monitoring is needed, and sedation may be helpful for restless patient, but monitoring the patient is needed while being sedate.

Positron Emission Tomography PET is a computer-based nuclear imaging technique that produces images of actual organ functioning. The patient either inhales or is injected with a radioactive substance that emits positively charged particles. When these positrons combine with negatively charged electrons (normally found in the bodys cell), the resultant gamma rays can be detected by a scanning device that produces a series of two-dimensional views at various level of the brain. This information is integrated by a computer and gives a composite picture of the brain at work. PET permits measurement of blood flow, tissue composition, and brain metabolism and thus indirectly evaluates brain function. Brain is one of the most metabolically active, 80% of glucose in the body is consumed by the brain. PET measures this activity in specific areas of the brain and can detect changes in glucose use. It is useful in showing metabolic changes in the brain (Alzheimers disease), locating lesions (brain tumor, epileptogenic lesions), identifying blood flow and oxygen metabolism in patient with strokes, evaluating new theraphies for brain tumors. Nursing Interventions It includes patient preparation, which involves explaining the test and teaching the patient about inhalation techniques and the sensations (eg. Dizziness, light-headedness, and headache) that may occur. The IV injection of the radioactive substance produce similar side-effects. Relaxation exercises may reduce anxiety during the test.

Single Photon Emission Tomography Single photon emission tomography (SPECT) is a three dimensional imaging technique that uses radionuclides and instruments to detect single photons. It is a perfusion study that captures a moment of cerebral blood flow at the time of injection of a radionuclide. Gamma photons are emitted from a radiopharmaceutical agent administered to the patient and are detected by a rotating gamma camera, the image is sent to a minicomputer. This allows areas behind overlying structures or background to be viewed, greatly increasing the contrast between normal and abnormal tissue. It is relatively inexpensive, and the duration is similar to that of a CT scan. SPECT is useful in detecting the extent of that perfused areas of the brain, thus allowing detection, localization and sizing of stroke. Pregnancy and breastfeeding are contraindications to SPECT. Nursing Interventions It includes patient preparation and patient monitoring. Teaching the client what to expect before the test and allay the anxiety and ensure patient cooperation during the test. Premenopausal women are advised to practice contraception before and after the test for several days, and

women under breastfeeding are advised to stop nursing for the time period recommended by the nuclear medicine department. Patients are monitored during and after the test for allergic reactions to the radiopharmaceutical agent.

Magnetic Resonance Imaging Magnetic resonance imaging (MRI) uses a powerful magnetic field to obtain images of different areas of the body. It involves altering hydrogen ions in the body. The patient is place under a powerful magnetic field that causes the hydrogen nuclei (proton) within the body to align like small magnets in a magnetic field. In line with the use of radiofrequency pulses, the protons emit signals, which are converted to images. MRI scan can be done with or without a contrast agent and can identify a cerebral abnormality earlier and more clearly than other diagnostic test. MRI can provide information about the chemical changes within cells, allowing the clinician to monitor a tumors response to treatment. It is specifically useful in diagnosis of multiple sclerosis and can describe the activity and exten of disease in the brain and spinal cord. MRI does not involve ionizing radiation, and it is most valuable in the diagnosis of non-acute conditions, because the test takes up to an hour to complete. Nursing interventions Patient preparation should include teaching relaxation techniques and informing the patient that he will be able to talk to the staff by means of a microphone located inside the scanner. All metal objects and credit cards are removed. This can cause burns if not removed. There should be no any metal objects inside the MRI room, because the magnetic field is too strong that it can pull any metal objects near the machine. This can cause death and severe injury, damage to a very expensive equipment may occur. A patient history is obtained to determine the presence of any metal in the body of the patient (ex. Aneurysm clips, orthopaedic hardware, pacemakers, artificial heart valves, intrauterine devices). These object could malfunction and be dislodged, or heat up during the procedure. The patient may experience claustrophobia during the test; sedation may be prescribed in these circumstances. MRI is painless, but the patient hears loud thumping of the magnetic coils as the magnetic field is being pulsed.

Cerebral Angiography Cerebral angiography is an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery. It is a valuable tool to investigate vascular disease, aneurysms, and arteriovenus malformations. It is frequently done before craniotomy to assess that patency and adequacy of the cerebral circulation and to determine the site, size, and nature of the pathologic processes.

Most of CA are performed by threading a catheter through the femoral artery in the groin and up to the desired vessel. Alternatively, direct puncture of the carotid or vertebral artery or retrograde injection of a contrast agent into the brachial artery may be performed. Nursing Interventions Patient should be well hydrated, and clear liquids are usually permitted up to the time of a regular arteriogram. Voiding is done before having an X-ray. Locations of appropriate peripheral pulses are marked with felt-tip pen. The patient is instructed to be immobile during the angiogram process and is told to expect a brief feeling of warmth in the face, behind the eyes, or in the jaw, teeth, tounge, and lips, and a metallic taste when the contrast agent is injected. Nursing care after cerebral angiography includes observation for signs and symptoms of altered cerebral blood flow. In some instances, patient may experience major or minor arterial blockage due to embolism, thrombosis or haemorrhage, resulting to neurologic defect. Signs of such an occurrence include in alterations in the level of responsiveness and consciousness, weakness of one side of the body, motor or sensory deficits, and speech disturbances. Therefore patient must be monitored frequently and immediately report if such signs occur. Injection site is observed for hematoma, and an ice bag may be applied intermittently to the puncture site to relieve swelling and discomfort.

Myelography A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space and shows any distortion of the spinal cord or spinal dural sac caused by tumors, cysts, herniated vertebral disks, or other lesions. Water-based agents have replaced oil-based agents, and their use has reduced side-effects and complications; these agents disperse upward through the CSF. Nursing Interventions Patient is informed about what to expect during the procedure and should be aware that changes in position may be made during procedure. The meal that normally would be eaten before this procedure is omitted. A sedative may help the patient cope with this lengthy test. After myelography, the patient lie in bed with the head of the bed is elevated 30 to 45 degrees. The patient is advised to remain in bed for 3 hours or as ordered by the physician. Patients are encouraged to drink liberal amounts of fluid fir rehydration and replacement of CSF and to decrease the incidence of post-lumbar headache. Vital signs of the patient are monitored as well the capacity to void. Untoward signs include headache, fever, stiff neck, photophobia, seizures and signs of chemical or bacterial meningitis.

Non-invasive Carotid Flow Studies Non-invasive carotid flow studies use ultrasound imagery and Doppler measurements of arterial blood flow to evaluate carotid and deep orbital circulation. The graph produced indicates blood velocity. Increased blood velocity can indicate stenosis or partial obstruction. These tests are often obtained before arteriography, which carries a higher risk of stroke or death. Carotid Doppler, carotid ultrasonography, oculoplethysomography, and opthalmodynamometry are four common nonivasive vascular techniques that allows arterial blood flow and detection of arterial stenosis, occlusion, and plaques. These vascular studies allow noninvasive imaging of extra and intracranial circulation. Transcranial Doppler Transcranial Doppler uses the same noninvasive techniques as carotid flow studies except that it recors the blood flow velocities of the intracranial vessels. Flow velocities of the basal artery can be measured through thin areas of the temporal and occipital bones of the skull. A handheld Doppler probe emits a pulsed beam; the signal is reflected by the moving red blood cells within the blood vessels. Transcranial Doppler Sonography is a noninvasive technique that is helpful in assessing vasospasm, altered cerebral flow found in occlusive vascular disease or stroke, and other cerebral pathology. Nursing interventions The patient is informed that this is a noninvasive test, that a hand-held transducer will be placed over the neck and the orbits of the eyes, and that some type of water-soluble jelly is used on the transducer.

Electroencephalography An EEG represents a record of the electrical activity generated in the brain. It is obtained through electrodes applied on the scalp or through microelectrodes placed within the brain tissue. It provides a physiologic assessment of cerebral activity. This EEG test is useful for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome. Tumors, blood clots, brain abscesses, and infection may cause abnormal patterns in electrical activity. The EEG is also used in making a determination of brain death. Electrodes are applies to the scalp to record the electrical activity in various regions of the brain. The amplified activitiy of the neurons between any two of these electrodes is recorded on continuously moving paper, this record is called the encephalogram. Nursing Interventions To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep on the night before EEG test. Antiseizure agents, tranquilizers,

stimulants, and depressant should be withheld 24 to 48 hours before an EEG, because it can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, the meal is not omitted, because an altered blood glucose level can also cause changes in the brain wave patterns. Patient preparation is done by explaining what to do during the procedure. Sedation is not advisable, because it may lower the seizure threshold in patients with a seizure disorder and it alters brain wave activity in all patients. The nurse needs to check the physician prescription regarding the administration of antiseizure medication prior to testing.

Electromyography An EMG is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles and the nerves leading to them. The electrical potential are shown on an oscilloscope and amplified so that both the sound and appearance of the waves can be analysed and compared simultaneously. An EMG is useful in determining neuromuscular disorders and myopathies. It helps distinguish weakness due to neuropathy from weakness resulting from other causes. Nursing Intervention The procedure is explained, and the patient is warned to expect a sensation similar to that of an intramuscular injection as the needle is inserted to the muscle. The muscles examined may ache for a short time after the procedure.

Lumbar Puncture and Examination of Cerebrospinal Fluid A lumbar puncture (spinal tap) is carried out by inserting a needle into the lumbar subarachnoid spaced to withdraw CSF. The test may be performed to obtain CSF for examination, to reduce and measure CSF pressure, to determine the presence or absence of blood in the CSF, to detect subarachnoid block, and to administer antibiotics intrathecally in certain cases of infection. The needle is usually inserted into the subarachnoid space between the third and fourth or fourth or fifth lumbar vertebrae. A successful lumbar puncture requires that the patient be relaxed; an anxious patient is tense, and this may increase the pressure reading. CSF pressure with the patient in lateral recumbent position is normally 70 to 200 mm H2O. Pressures of more than 200mm H2O are considered abnormal.

A lumbar puncture may be risky in the presence of an intracranial mass lesion because intracranial pressure is decreased by the removal of CSF, and the brain may herniate downward through the tentorium and the foramen magnum.

I. Queckenstedts Test A lumbar manometric test (Queckenstedts test) may be performed by compressing the jugular veins on each side of the neck during the lumbar puncture. The increase in pressure caused by the compression is noted; then the pressure is released and pressure readings are made at 10second time intervals. Normally, CSF pressure rises rapidly in response to compression of the jugular veins and returns quickly to normal when the compression is released. A slow rise and fall in pressure change, a complete block is indicated. This test is not performed if an intracranial lesion is suspected. II. Cerebrospinal Fluid Analysis The CSF should be clear and colorless. Pink, blood-tinged, or grossly bloody CSF may indicate cerebral contusion, laceration, or subarachnoid haemorrhage. Sometimes with a difficult lumbar puncture, the CSF initially is a bloody because of a local trauma but then becomes clearer. Usually, specimens are obtained for cell count, culture, and glucose and protein testing. The specimens should be sent to the laboratory immediately because changes will take place and alter the result if the specimens are allowed to stand. Value Normal Range Appearance Clear & colourless White Cells 0 - 5 x 106 per litre (all lymphocytes with no neutrophils) Red Cells 0 - 10 x 106 per litre Protein 0.2 - 0.4 grammes per litre (or less than 1% of the serum protein concentration) 3.3 - 4.4 mmol per litre (or 60% of a simultaneously derived plasma glucose Glucose concentration) pH 7.31 Pressure 70 - 180 mmH2O

Condition

Appearance

White Cells Raised neutrophils Raised lymphocytes Raised lymphocytes N

Red Cells N N N VH

Protein H or VH N or H H or VH N or H

Glucose VL N or L VL N or L

Bacterial Meningitis Cloudy & Turbid Viral Meningitis Tuberculous Meningitis Subarachnoid Haemorrhage N N or slightly cloudy Usually blood stained

Guillan-Barr Syndrome Multiple Sclerosis VL = Very Low L = Low N = Normal H = High VH = Very High

N N

N Raised lymphocytes

N N

H (only after 1 N or L week) H N

III. Post Lumbar Puncture Headache A post lumbar puncture headache, ranging from mild to severe, may occur a few hours to several days after the procedure. This is the most common complication, occurring in 15% to 30% of patients. It is a throbbing bifrontal or occipital headache, dull and deep in character. It is particularly severe on sitting or standing but lessens or disappears when the patient lies down. The headache is caused by CSF leakage at the puncture site. The fluid continues to escape into the tissues by way of the needle track from the spinal canal. It is promptly absorbed by the lymphatics. As a result of this leak, the CSF supply in the cranium is depleted to a point at which it is insufficient to maintain proper mechanical stabilization of the brain. The leakage of CSF allows settling of the brain when the patient assumes an upright position, producing tension and stretching the venous sinuses and pain sensitive structures. Post lumbar headache can be avoid by using smaller gauge of needle is used, and if the patient remains prone after the procedure. When a large of CSF volume is removed (more than 20ml) the patient is remain prone for 2 hours, then flat in a side-lying position for 2 to 3 hours, and then supine or prone for 6 more hours. Keeping the patient flat overnight may reduce the incidence of headaches. The postpuncture headache is usually managed by bed rest, analgesics, and hydration. Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the epidural space, usually at the site of the previous spinal puncture. The rationale is that the blood acts as a gelatinous plug to seal the hole in the dura, preventing further loss of CSF.

ABAT,MIKO G. BSN III-2