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Neurological Assessment

Clinical Assessment in Respiratory


Care
Chapter 6, Wilkins 7th Edition
Exercise due Friday January 29,2016
Upload to FOL RESP3012 Dropbox before
midnight
NAME: __Mohamad Rahman

Overview

Injuries of the nervous system


May affect respiratory system
May affect patient cooperation with
respiratory procedures

History may indicate nature of


dysfunction
Exam localizes and quantifies severity
of dysfunction
Initial interaction with patient is first
step in neurologic assessment

Overview (contd)

Neurologic assessment evaluates:

Mental status
Cranial nerve function
Motor system
Coordination
Sensory system
Reflexes

Meaningful neurologic assessment


requires adequate _neurologic history and
examination.

Functional
Neuroanatomy

Neurologic system
Central nervous system
Brain
Spinal cord

Peripheral nervous system


Cranial Nerve How many? _12
Spinal Nerve__ How many? _31

Functional Neuroanatomy
(contd)
Functional division
Sensory system (afferent )

Motor system

(efferent )

Cerebrum
Functions: movement, LOC, ability to speak
and write, emotions, memory

Functional Neuroanatomy
(contd)
Brainstem

Consists of midbrain, pons, and


medulla.
Most cranial nerves originate in
Brainstem.
Regulation of heart rate, blood
pressure, and breathing.

Functional Neuroanatomy
(contd)
Cerebellum

Posterior part of the brain


Responsible for equilibrium, muscle
tone, and coordination of muscle
movements.
Cerebellar lesions cause:
_

Loss of coordination (ataxia)


Tremors
Disturbances in gait and balance.

Functional Neuroanatomy
(contd)
Spinal

cord

From base of the brain down to the

level of the first lumbar (L1) vertebra.


(_45 cm long)
Connects brain to the body for
motor and sensory function

pairs of spinal nerves


C1-C8, T1-T12, L1-L5, S1-S5, one
coccygeal
Posterior (dorsal) roots = _carry
sensory information into spinal cord.

Functional Neuroanatomy
(contd)
Spinal

cord

Herniated vertebral disk is the most


common spinal nerve root pathology
Involvement of multiple nerve roots
Guillain-Barr

Phrenic nerves arise from spinal


roots
Where? _cervical spine roots of C3
to C5.
Damage can result in in complete
paralysis of the diaphragm as well as
the intercostal muscles and make the

Mental Status and LOC


LOC and mentation: most important
parts of the neurologic exam
Changes due to CNS dysfunction
Initial goal of exam is to determine
patients awareness

Starts with patient encounter

Compromise of LOC may be due to:


Lesions inthe cerebrum
Abnormality in specific area.

Glasgow Coma Scale


(GCS)
Most widely used instrument to
quantify __Neurologic impairment.
Test

Eye_movement
verbal response

Poorly suited for patients with impaired verbal


response (e.g., aphasia, hearing loss, tracheal
intubation)

Motor response.

Glasgow Coma Scale (contd)

Scale goes from __3 (deep coma) to 15


(fully awake)

GCS of 12-15 = non-ICU observation

GCS of 9-12 = significant insult

GCS <9 = severe coma = requires


endotracheal intubation

Mini-Mental State
Examination

MMSE or Folstein test

30-point questionnaire to assess cognition.


Samples various functions

including arithmetic, memory, and


orientation.
Score interpretation

>27/30 = normal
20-26 = mild dementia
10-19 = moderate dementia
<10 = severe dementia

Sedation and Delirium in


the ICU

Delirium occurs in 60 % to80 % of


mechanically ventilated patients

Associated with:

Longer hospital stay.


_ higher mortality .
Poor long-term cognitive function.

Sedation and Delirium in the ICU


(contd)

Richmond Agitation Sedation Scale


(RASS)
Titrate sedation medications.
___________________

Confusion Assessment Method for the


ICU (CAM-ICU)
Evaluates ___ Delirium

Cranial Nerve Exam

__12 cranial nerves

Sensory and motor function


Midbrain (CN _III and IV)
Pons (CN V to VIII)
Medulla (CN IX to _XII)

Name this posture:____ Decorticate posture


____________________

Decerebrate posture

Superficial Reflexes
Plantar

reflex
Tested when suspected _L4-L5 or
S1-S2 injury.
Babinskis sign
Dorseflexion of the great toe with
fanning of remaining toes
Normal in children _upto 12 to 18
months of age.

Babinski sign.

Brainstem Reflexes
Gag

reflex (CN __IX_ )

Its absence may increase risk for


aspiration.
Insert tongue depressor into back of
throat.
Cough

reflex (CN _X_)

Check while suctioning.

Brainstem Reflexes
(contd)

Pupillary reflex (CN _II and III_ )


PERRLA

Pupils equal round reactive to light and


accommodation

Anosocoria(one pupil larger than other)


Miosis pontine hemorrhage, narcotics
Mydriasis ___ brain injury, anticholinergics
Mid-position fixed pupils = severe cerebral
damage

Corneal reflex (CN V, VII)

Corneal Reflex (CN V and VII)

Coordination, Balance, and


Gait
Assessment

of _Cerebellum
Patient should be able to follow
commands during exam
Disintegration of movement= under
and overshooting of goal-directed
movements
Romberg test = balance