BSC NURSING III YEAR - MEDICAL SURGICAL NURSING - II

1. Mr. Manikandan.T,
RN., RM., M.Sc(N)., D.C.A .,(Ph.D)
Assistant Professor,
Dept. of Medical Surgical Nursing,
VMCON, Puducherry.

2. HISTORY
• Health history
• Symptoms – pain,seizure, dizziness, visual
disturbances, muscle weakness, abnormal
sensation

3. NEUROLOGICAL ASSESSMENT
Level of
consciousness and
cognition
Cranial nerves
Motor functionSensory function
Reflexes

4. I. CONSCIOUSNESS AND COGNITION
1. MENTAL STATUS
• observing the patient’s appearance and behavior, noting
dress, grooming and personal hygiene. Posture, gestures,
movements, and facial expressions often provide important
information about the patient.
• Assessing orientation to time, place, and person
• Assessment of immediate and remote memory is also
important.
• Immediate – asking the patient to repeat 6 digit forward &
backward
• Recent – what was the breakfast/ dinner
• Remote – birthday / childhood

5. 2. INTELLECTUAL FUNCTION
• A person with an average IQ can repeat seven digits
without faltering and can recite five digits backward.
• The examiner might ask the patient to count backward
from 100 or to subtract 7 from 100, then 7 from that,
and so forth (called serial 7s).
• The capacity to interpret well-known proverbs tests
abstract reasoning, which is a higher intellectual
function. for example, does the patient know what is
meant by “a stitch in time saves nine”?
• assess intellectual capacity - for example, how are a
mouse and dog or pen and pencil alike?
• Can the patient make judgments about situations: for
example, if the patient arrived home without a house
key, what alternatives are there?

6. 3. THOUGHT CONTENT
• interview -Are the patient’s thoughts
spontaneous, natural, clear, relevant, and
coherent?
• Does the patient have any fixed ideas, illusions,
or preoccupations?
• What are his or her insights into these thoughts?
• Preoccupation with death or morbid events,
hallucinations, and paranoid ideation are
examples of unusual thoughts or perceptions
that require further evaluation.

7. 4. EMOTIONAL STATUS
• Is the patient’s affect (external manifestation of
mood) natural and even, or irritable and angry,
anxious, apathetic or flat, or euphoric?
• Does his or her mood fluctuate normally, or does
the patient unpredictably swing from joy to sadness
during the interview?
• Is affect appropriate to words and thought content?
• Are verbal communications consistent with
nonverbal cues?

8. 5. LANGUAGE ABILITY
• The person with normal neurologic function can
understand and communicate in spoken and
written language.
• Does the patient answer questions appropriately?
• Can he or she read a sentence from a newspaper
and explain its meaning?
• Can the patient write his or her name or copy a
simple figure that the examiner has drawn?
• A deficiency in language function is called aphasia.

9. 6. IMPACT ON LIFESTYLE
• The patient’s role in society, including family
and community roles.

10. 7.LEVEL OF CONSCIOUSNESS
• Consciousness is the patient’s wakefulness
and ability to respond to the environment.
• Level of consciousness is the most sensitive
indicator of neurologic function.
• To assess level of consciousness, the examiner
observes for alertness and ability to follow
commands.
• GCS

11. • Tongue depressor
• Flashlight
• Sugar and salt samples
• Watch
• Cotton-tipped swab
• Snellen chart
• Ophthalmoscope
• Samples of familiar odors
• Tuning fork

12. Cranial Nerve I: OLFACTORY NERVE.
1. The sense of smell is tested by having the
patient occlude one nostril and close his or her
eyes.
2. The examiner then takes a non irritating
substance and places it near the non occluded
nostril. patient is asked to identify familiar odors
(coffee, tobacco). Each nostril is tested
separately
3. Repeat the process for the opposite side using a
different scent.

13. Cranial nerve II: OPTIC NERVE.
1. The optic nerve testing includes assessment of
both visual acuity and visual fields.
2. Each eye is examined separately while the patient
covers the other one.
3. Visual acuity is tested by having the patient read
a snellen chart from 20 feet away
4. Have the patient start with one eye covered and
read the lines from top to bottom (largest to
smallest letters).
5. Record the lowest line that the patient can read
with 50% accuracy.

14. CN III : OCOULOMOTOR NERVE
• Test for eye movement toward the nose
• inspect for conjugate movements and Evaluate
papillary size and test for pupillary reactivity to
light
• inspect ability to open eyelids.

15. CN IV : TROCHLEAR NERVE
• Trochlear - Test for upward eye movement
inspect for conjugate movements and
nystagmus

16. CN V: TRIGEMINAL NERVE.
• Steps:
The trigeminal nerve is the largest of the cranial nerves
1. The patient should have his or her eyes closed during the testing
procedure. Touch cotton to forehead, cheeks, and jaw. Sensitivity
to superficial pain is tested in these same three areas by using the
sharp and dull ends of a broken tongue blade. Alternate between
the sharp point and the dull end. Patient reports “sharp” or “dull”
with each movement. If responses are incorrect, test for
temperature sensation.
2. Test tubes of cold and hot water are used alternately. While
patient looks up, lightly touch a wisp of cotton against the
temporal surface of each cornea. A blink and tearing are normal
responses.
3. have patient clench and move the jaw from side to side. Palpate
the masseter and temporal muscles, noting strength and equality.

17. CN VI : ABDUCENS NERVE.
• Abducens - Test for lateral eye movement
• 3 cranial nerves are usually tested together
because they control the function of the extra
ocular eye muscles.
• The functions include eyelid elevation,
constriction of the pupils, and movement of the
eye through the six cardinal directions.

18. CN VII: FACIAL NERVE.
Sensory test
• The facial nerve is also a mixed cranial nerve with both sensory and
motor components.
• The sensory component includes the sense of taste on the anterior two-
thirds of the tongue. The testing of the sensory component is often
deferred, unless changes are noted in the health history interview.
• When tested, have the patient stick out his or her tongue and test each
side separately.
• The taste is sweet and pleasant, but different from the standard sweet
taste. Test ability to discriminate between sugar and salt.
Motor :
• Observe for facial tics. Then, ask the patient to perform the following
movements: raise his or her eyebrows, close his or her eyelids tightly, puff
out his or her cheeks, smile, and frown. Observe for weakness or
asymmetry of muscle movement.
• Abnormal findings of upper motor neuron lesion, lower motor neuron
lesion, or a stroke can cause weakness or paralysis of the facial muscles.
• Have the patient rinse his or her mouth with water between tests.

19. CN VIII : ACOUSTIC NERVE.
The acoustic nerve has two divisions: cochlear
and vestibular.
1. The cochlear division is involved in hearing-
Do weber and rinnes test
2. The vestibular division is involved in the
sense of balance, which includes equilibrium,
coordination, and orientation is space. First,
examine the patient’s ear canals for obvious
blockages or malformation.

20. CN IX: GLOSSOPHARYNGEAL NERVE
Assess patient’s ability to swallow and
discriminate between sugar and salt on
posterior third of the tongue.

21. CN X: VAGUS NERVE.
• The glosso pharyngeal and vagus nerves are usually tested
together. In the pharynx, CN IX is primarily sensory, and CN X
is mostly motor.
• observe the patient as he or she swallows a small amount of
water. Ask if he or she frequently chokes on food or has
trouble swallowing. Dysphagia (difficulty swallowing ) can
often be seen after neurosurgical procedures or CVA (stroke.)
• Depress a tongue blade on posterior tongue, or stimulate
posterior pharynx to elicit gag reflex. Note any hoarseness in
voice. Check ability to swallow. Have patient say “ah.”
Observe for symmetric rise of uvula and soft palate

22. XI SPINAL ACCESSORY
• Assess the trapezius & sternocleidomastoid
• Trapezius – examiner place the hands on
patient shoulder, ask the patient TO shrug his
/her shoulder. Observe strength
• Sternocledoid- examiner place hands on one
cheek and ask the patient to turn his/her head
against hand as the movement is resisted
• Repeat the test on opposite
• Abnormality - CVA

23. CN XII: HYPOGLOSSAL NERVE.
• The hypoglossal nerve is tested by asking the patient to
open his or her mouth, stick out his or her tongue, and
wiggle it side to side.
• While patient protrudes the tongue, note any deviation
or tremors. Test the strength of the tongue by having
patient move the protruded tongue from side to side
against a tongue depressor.
• The tongue should be midline. Observe for asymmetry,
atrophy, or fasciculations. Carotid endarterectomy is a
common cause of dysfunction of CN XIII.

24. Touch sensation Pain sensation
Temperature
sensation
Position or
kinesthetic
(proprioception)
Vibration

25. SENSATION
• Tactile sensation is assessed by lightly touching a cotton wisp or
fingertip to corresponding areas on each side of the body. The
sensitivity of proximal parts of the extremities is compared with
that of distal parts, and the right and left sides are compared.

26. PAIN AND TEMPERATURE SENSATIONS
• Determining the patient’s sensitivity to a sharp object can
assess superficial pain perception.
• The patient is asked to differentiate between the sharp and
dull ends of a broken wooden cotton swab or tongue blade;
using a safety pin is inadvisable because it breaks the integrity
of the skin.
• Both the sharp and dull sides of the object are applied with
equal intensity at all times, and the two sides are compared.
• Use the hot and cold object for skin to determine the hot and
clod sensation.

27. VIBRATION AND PROPRIOCEPTION
• Are transmitted together in the posterior part of the cord.
• The handle of the vibrating fork is placed against a bony
prominence, and the patient is asked if he or she feels a
sensation and is instructed to signal the examiner when the
sensation ceases.
• Common locations used to test for vibratory sense include
the distal joint of the great toe and the proximal thumb
joint.
• If the patient does not perceive the vibrations at the distal
bony prominences, the examiner progresses upward with
the tuning fork until the patient perceives the vibrations.
• As with all measurements of sensation, a side-to-side
comparison is made.

28. POSITION SENSE OR PROPRIOCEPTION
• May be determined by asking the patient to
close both eyes and indicate, as the great toe
or index finger is alternately moved up and
down, in which direction movement has taken
place. Vibration and position sense are often
lost together, frequently in circumstances in
which all other sensation remains intact.

29. Motor
ability
Muscle
strength
Balance &
coordination
Gait

30. MOTOR ABILITY
• A thorough examination of the motor system includes an
assessment of muscle size and tone as well as strength,
coordination, and balance.
• The patient is instructed to walk across the room, if possible, while
the examiner observes posture and gait. The muscles are inspected,
and palpated if necessary, for their size and symmetry.
• Any evidence of atrophy or involuntary movements (tremors, tics) is
noted.
• Muscle tone (the tension present in a muscle at rest) is evaluated
by palpating various muscle groups at rest and during passive
movement.
• Resistance to these movements is assessed and documented.
Abnormalities in tone include spasticity (increased muscle tone),
rigidity (resistance to passive stretch), and flaccidity.

31. MUSCLE STRENGTH
• Assessing the patient’s ability to flex or extend the extremities against resistance
tests muscle strength.
• The function of an individual muscle or group of muscles is evaluated by placing
the muscle at a disadvantage. The quadriceps, for example, is a powerful muscle
responsible for straightening the leg.
• Once the leg is straightened, it is exceedingly difficult for the examiner to flex the
knee. If the knee is flexed and the patient is asked to straighten the leg against
resistance,
• weakness can be elicited. The evaluation of muscle strength compares the sides
of the body to each other. For example, the right upper extremity is compared to
the left
• upper extremity. Subtle differences in strength may be evaluated by testing for
drift. For example, both arms are out in front of the patient with palms up; drift is
seen as pronation of the palm, indicating a subtle weakness that may not have
been detected on the resistance examination.

32. 5-point scale to rate muscle strength.
• 5 indicates full power of contraction against gravity and
resistance or normal muscle strength;
• 4 indicates fair but not full strength against gravity and
a moderate amount of resistance or slight weakness;
• 3 indicates just sufficient strength to overcome the
force of gravity or moderate weakness;
• 2 indicates the ability to move but not to overcome the
force of gravity or severe weakness;
• 1 indicates minimal contractile power (weak muscle
contraction can be palpated but no movement is
noted) or very severe weakness;
• 0 indicates no movement.

33. COORDINATION
• Cerebellar and basal ganglia 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.
• First, the patient is instructed to pat his or her thigh as fast as
possible with each hand separately.
• Then the patient is instructed to alternately pronate and supinate
the hand as rapidly as possible.
• Last, the patient is asked to touch each of the fingers with the
thumb in a consecutive motion. Speed, symmetry, and degree of
difficulty are noted.
• Point-to-point testing is accomplished by having the patient touch
the examiner’s extended finger and then his or her own nose. This
is repeated several times.

34. • Coordination in the lower extremities is tested by
having the patient run the heel down the anterior
surface of the tibia of the other leg. Each leg is tested
in turn.
• Ataxia is defined as incoordination of voluntary muscle
action, particularly of the muscle groups used in
activities such as walking or reaching for objects.
• Tremors (rhythmic, involuntary movements) noted at
rest or during movement suggest a problem in the
anatomic areas responsible for balance and
coordination.

35. BALANCE /ROMBERG TEST
• Ask the clients stand still with their heels
together. Ask the clients to remain still and
close their eyes.
• Result: if the clients loses their balance after
standing still with their eye closed. This is
positive Romberg.

36. GAIT TESTING
• To check ability to stand and walk:
• Ask the patient to walk across the room, turn, and
come back towards you. Pay particular attention to,
difficult to walk and indicate upper extremities
weakness.
• Difficulty getting up from a chair, Can the patient easily
arise from a sitting position. Problems with this activity
might suggest proximal muscle weakness, a balance
problem, or difficulty initiating movements.
• Ask the clients to walk on heels is the most sensitive
way to test foot dorsiflextion.

37. • Biceps reflex
• Triceps reflex
• Brachio radialis reflex
• Patellar reflex
• Achilles reflex

38. BICEPS REFLEX TESTING:
• Triceps (C7C8- Radial Nerve):
• This is most easily done with the client seated.
• The biceps reflex is elicited by striking the biceps tendon over
a slightly flexed elbow
• The examiner supports the forearm with one arm while
placing the thumb against the tendon and striking the thumb
with the reflex hammer.
• The normal response is flexion at the elbow and contraction
of the biceps.

39. TRICEPS REFLEX
• To elicit a triceps reflex, the patient’s arm is flexed at the elbow
and positioned in front of the chest.
• The examiner supports the patient’s arm and identifies the
triceps tendon by palpating 2.5 to 5 cm (1 to 2 inches) above
the elbow.
• A direct blow on the tendon normally produces contraction of
the triceps muscle and extension of the elbow.

40. BRACHIO RADIALIS
• With the patient’s forearm resting on the lap
or across the abdomen, the brachioradialis
reflex is assessed.
• A gentle strike of the hammer 2.5 to 5 cm (1
to 2 inches) above the wrist results in flexion
and supination of the forearm

41. PATELLAR REFLEX TESTING
• Achilles (s1,s2- Sciatic Nerve):
• This is most easily done with the clients seated, feet dangling over
the edge of the exam table.
• The patellar reflex is elicited by striking the patellar tendon just
below the patella.
• The patient may be in a sitting or a lying position. If the patient is
supine, the examiner supports the legs to facilitate relaxation of the
muscles (see Fig. 60-13C).
• Contractions of the quadriceps and knee extension are normal
responses.

42. ACHILLES REFLEX TESTING
• To elicit an Achilles reflex, the foot is dorsiflexed at the ankle
and the hammer strikes the stretched Achilles tendon
• This reflex normally produces plantar flexion.
• If the examiner cannot elicit the ankle reflex and suspects that
the patient cannot relax, the patient is instructed to kneel on
a chair or similar elevated, flat surface.
• This position places the ankles in dorsiflexion and reduces any
muscle tension in the gastrocnemius.
• The Achilles tendons are struck in turn, and plantar flexion is
usually demonstrated

43. BABINSKI REFLEX:
• The clients may either sit or lies supine.
• Use the handle end of your reflex hammer, which is solid and
comes to a point.
• Start at the lateral aspects of the foot, near the apply gentle,
steady pressure with the end of the hammer as you move medial,
stroking across this area.
• A well-known pathologic reflex indicative of central nervous system
disease affecting the corticospinal tract

44. SUPERFICIAL REFLEXES
• The corneal reflex : using a clean wisp of cotton and lightly
touching the outer corner of each eye on the sclera. The
reflex is present if the action elicits a blink. A stroke or brain
injury might result in loss of this reflex, either unilaterally or
bilaterally.
• The gag reflex is elicited by gently touching the back of the
pharynx with a cotton-tipped applicator, first on one side of
the uvula and then the other. Positive response is an equal
elevation of the uvula and “gag” with stimulation. Absent
response on one or both sides can be seen following a
stroke
• The plantar reflex is elicited by stroking the sole of the foot
with a tongue blade or the handle of a reflex hammer.
Stimulation normally causes toe flexion.

45. DIAGNOSTIC PROCEDURES
CT SCAN :
• Computed tomography (CT) scan is a structural imaging study
that uses a computer-based X-ray to provide a cross-sectional
image of the brain.
• A computer calculates differences in tissue absorption of the X-
ray beams. The CT produces a three dimensional view of
structures in the brain and distinguishes between soft tissues
and water. I.V. contrast dye may be used to examine the integrity
of the blood – brain barrier.
• CT is primarily used to detect tumors and inflammatory
disorders. Spinal CT scan may be used to evaluate lower back
pain due to herniated intervertebral disk or other spinal lesions.

46. Magnetic resonance imaging (MRI)
• Magnetic resonance imaging (MRI) uses computer generated
radio waves and a powerful magnetic field to produce detailed
images of body structures including tissues, organs, bones, and
nerves.
• Neurological uses include the diagnosis of brain and spinal cord
tumors, eye disease, inflammation, infection, and vascular
irregularities that may lead to stroke.
• MRI can also detect and monitor degenerative disorders such
as multiple sclerosis and can document brain injury from
trauma.

47. Single photon emission computed
tomography (SPECT),
• A nuclear imaging test involving blood flow to tissue, is used to evaluate
certain brain functions.
• The test may be ordered as a follow-up to an MRI to diagnose tumors,
infections, degenerative spinal disease, and stress fractures.
• As with a PET scan, a radioactive isotope, which binds to chemicals that
flow to the brain, is injected intravenously into the body, Areas of
increased blood flow will collect more of the isotope.
• As the patient lies on a table, a gamma camera rotates around the head
and records where the radioisotope has traveled.
• That information is converted by computer into cross-sectional slices
that are stacked to produce a detailed three-dimensional image of
blood flow and activity within the brain. The test is performed at either
an imaging center or a hospital.

48. Angiography
• Angiography is a test used to detect blockages of the arteries or
veins.
• A cerebral angiogram can detect the degree of narrowing or
obstruction of artery or blood vessel in the brain, head, or neck.
• It is used to diagnose stroke and to determine the location and size
of a brain tumor, aneurysm, or vascular malformation.
• This test is usually performed in a hospital outpatient setting and
takes up to 3 hours, followed by a 9- to 8- hour resting period.
• The patient, wearing a hospital or imaging gown, lies on a table that
is wheeled into the imaging area.
• While the patient is awake, a physician anesthetizes a small area of
the leg near the groin and then inserts a catheter into a major artery
located there.

49. Lumbar puncture
• Sampling of cerebrospinal fluid (CSF) via
lumbar puncture is crucial for accurate
diagnosis of meningeal infections and
carcinomatosis.
• CSF analysis is also helpful in evaluating
patients with central or peripheral nervous
system demyelinating disorder and with
intracranial hemorrhage particularly when
imaging studies are inconclusive.

50. Purpose
• To diagnose central nervous system infections,
subarachnoid hemorrhages, and many other
neurologic pathologies.

51. Equipment Needed
• Spinal or lumbar puncture tray (specifically the items listed below)
• Sterile gloves
• Manometer
• Three-way stopcock
• Sterile dressing
• Antiseptic solution with skin swabs
• sterile drape
• 1% Lidocaine
• 3-cc syringe
• 20 – and 25 gauge needle
• 20 – and 22 gauge spinal needle
• Four plastic test tubes, numbered 1 to 4, with caps.

52. Technique
• Obtain informed consent from the patient or next of
kin.
• Obtain a CT scan of the head or perform a fundoscopic
exam to check for papilledema. It is absolutely
necessary to rule out increased intracranial pressure
before proceeding.
• Locate the L3 – L4 space. To do this, find the iliac crests
and move your fingers medially from the crests to the
spine.
• Mark the entry site with your thumbnail or a marker.
• Open and prepare the spinal tray in a sterile manner.

53. Complications
• Post- spinal puncture headache
• Brain herniation
• Bloody tap (may lead to hematoma)
• meningitis

54. Post-procedure care:
• Send the four tubes for the following labs:
a) Tube 1, bacteriology: Gram stain, culture and
sensitivity, acid-fast bacilli, fungal cultures and stains,
cell count (compare with tube 3 to differentiate
traumatic tap from subrachnoid hemorrhage).
b) Tube 2, biochemistry: glucose, protein, and
electrophoresis (if working up for multiple sclerosis to
detect oligoclonal banding).
c) Tube 3, hematology: cell count with differential .
d) Tube 4, special studies if needed: VDRL
(neurosyphilis), India ilk (cryptococcus neoformans.)

55. Electroencephalgraphy (EEG)
• Eletroencephaloghaphy is the recording and measurement
of scalp potential in orders to evaluate baseline brain
funtioning as well as paroxysmal brain electrical activity
suggestive of a seizure disorder.
• An EEG is performed by securing 20 electrodes to scalp at
prodetrmined locations based on an international system
theta uses standardized percentage of the head
circumferences, the 10-20 .
• Each elector is labelled using a letter and a number, the
letter identifying the skull region (FP= Fronttopolar,
F=frontal, P=parietal, T=temporal, O=Occipital, V=vertex)
and the number the specific location, with odd numbers
representing the left sided electrodes.

56. Nerve Conduction Study (NCS)
• A Nerve conduction study is the recording the
measuring of the compound nerve and muscle
action potentials elicited in response to an
electrical stimulus.
• to perform a motor NCS, a surface (activate)
electrode is placed over the belly of a distal
muscle that is innervated by the nerve is
question,

57. Repetitive stimulation study
• The repetitive stimulation study is a method
of measuring electrical conduction properties
at the neuromuscular junction. To perform a
RSS a surface recording electrode is placed
over a muscle belly and the nerve innervating
that muscle is electrically stimulated with a
superamaximal stimulus at a certain
frequency.

58. Electromyography
• Electromyography is the recording and study
of insertional, spontaneous and voluntary
electrical activity of muscle. This test allows
one to physiologically evaluate the motor unit,
including the anterior horn cell, peripheral
nerve and muscle.

59. Evoked potentials
• Evoked potentials are ways of measuring
conduction velocities fro sensory pathways in the
central nervous system by means of computer
averaging techniques. Three types of evoked
potentials are routinely performed; visual, brain
stem auditory, and somatosensory evoked
responses.
1. Pattern reversals visual evoked responses(PVER)
2. Brain stem auditory evoked responses (BAER)