neological system power will discuss the diagnostic test CAT scan stands for computerized axial tomography the CT scan uses a narrow x-ray beam to scan body parts in successive layers the images use a cross-sectional view of the brain and this allows us to evaluate and differentiate and follow up on abnormalities that we can find in the cranial structures it is especially good for vascular lesions small lesions and it helps us to Define lesion borders it may be done as unenhanced without contrast or enhanced so the unenhanced would be done first a couple of things that are very important in nursing is the nursa tell the client that they must lie still we need to assess for any iodine or contrast allergies if they are to receive an enhanced scan and some facilities in fact I think the majority of facilities require written consents if an enhanced scan is done the image on the left shows an epidural hematoma and you can see um the abnormal coloration we can see the area of the bleed as well as again the size the image on the right shows a brain tumor and so what the CT does is allow us to see the size the borders and the location while the CT angiography or CTA of the head is not listed in in your textbook in the diagnostic section I did want to address it as part of the ctas it is a diagnostic imaging that combines the use of the high-tech rotating machine where it actually will again go in a circle around taking sliced pictures of the brain and we also inject a contrast D into the vein and so that we can see the different vessels and the or organs some of the reasons that we can perform the CTA is when we're looking for abnormalities that involve the blood vessels of the brain we also can see um use it for the heart the lungs and the kidneys again when we're looking at different structures and the vascularization we can look at to find aneurysms um we also can look at for narrowed vessels due to atherosclerosis which again put people at risk for TI and strokes it is still important to screen kidney function so checking B and creatinine as again these people will be getting a d we also need to check for allergies to contrast material and if they are currently taking medications such as metformin MRI or magnetic resonance imaging uses a magnet and radio frequency signals and then the computer makes a picture the magnet actually affects the hydrogen nuclei and so they basically stand up and become tiny um magnetic transmitters that help make this picture the nice thing about this test is that it can reveal very subtle changes in soft tissues in the brain the spinal cord the blood vessels that we cannot pick up as clearly on some of our other procedures and so this test actually allows us to get clearer pictures at an earlier um time and so it is very very good um the M scan can take an hour longer to actually complete and so it may not be their first choice in emergent situations is one of the downsides of it some of the other things that are very um important to do is that when we're talking about the nursing and the preparation you do have to instruct the client that they have to lie very still and while this sounds very easy the MRI can be very noisy and you have to let the client know that because the magnet kind of knocks depending on where they are having the procedure done most of them are a very enclosed kind of like a giant Granite block some of them the newer ones are more open but because of the noise it's very important to usually include earplugs and this prevents Dam damage to their hearing as well as decreases some of that anxiety some clients may require sedation again it's going to be important to assess if that's going to affect being able to monitor their neurologic condition my children because we were questioning seizures um both had these done and my daughter they had not chose not to sedate her at first and I believe she was around six and they put her in there and I think it was maybe 1 minute as the knocking started and we saw these little feet kind of bicycling and it was like yep that's not going to work so they brought her back out and gave her some IV sedation so that she would lie still so you do need to have them lying very still to be able to perform this procedure because the test uses a strong magnet there can be no metal in the room and so we start um teaching and screening the client before the procedure for any ferromagnetic substances and these can be things such as implanted prosthetic devices um as well as things like Pac makers or artificial heart valves um inra uterine devices and we also know that implanted metal devices can heat up and so when you're screening the client it's very important to ask them about piercings both those that are visible and not visible and inform them that they do need to be removed or they will heat up and they can tear the tissue if they're not moved the other thing is is that it's important that we utilize the provided facility checklist and so that we ask and identify again if there's pacemaker artificial heart valves um stance again um depending on how long it's been after 6 months most times they can have this procedure with stance but we have to wait for the tissue overgrow and so we want to kind of know what procedures they've had done and the length of time for those procedures our newer prosthetics for knees and hips are usually made out of titanium and they can actually go in the MRI but again we do have to know and there will usually be a paper that they have been provided with or it will be in their medical records listing the product number so we can double check that it is safe to go into the MRI machine this procedure can be done with or without die it is most commonly done without so the magnetic resonance image shows a subdural hematoma on the left as you can see with the arrows and then a tumor on the right the Pet Scan or positron emission tomography will actually show metabolic function the patient either inhales a radioactive gas or is injected with a radioactive substance and these substances emit a positively charged particle when these particles or positrons combined with the negatively charged electrons that are normally found in the body cells then we get gamma rays and these are actually what is detected by the scanning device and it produces these two-dimensional views at the levels of the brain and then this information is actually sent into the computer and it gives us this picture of the brain at work we can actually combine this with an MRI and then have the computer generate a 3D picture as well and so these gives us some ideas of where we have activity or increased activity in the brain that could indicate certain abnormalities or activities that we're looking for in our course of treatment the lp or lumbar puncture is used to measure cerebral spinal fluid pressure and this pressure is going to be measured at the opening um when they stick the needle in then we actually can hook up a device that will allow us to see the pressure so so it'll be measured um at the beginning or when we first open and then at the end the pressure will be measured again before again ending the lumbar puncture we also can use a lumbar puncture to obtain samples of the cerebral spinal fluid and this can be used to diagnose orders such as disorders such as menitis um we look at the coloration of the cerebral spinal fluid and this helps us to know if maybe they've had a subarid hemorrhage if the blood is pink or grossly bloody now you may see discoloration upon initial insertion of the needle but usually if there is not of active bleed that will clear as we get our samples if it continues to be discolored or becomes more discolored then that is an indication of a bleed um we also can use it for somebody that we are questioning gon beret some of the common laboratory tests that can be done on the Cs fluid are we look for things that such as glucose um protein we look for the type of cells and then cultures and sensitivity that will help us to know if there's possibly infections we can also administer medication through the device um we can either insert it inject it then or they can thread a catheter in which is an ineal catheter some of the medications that can be administered are spinal anesthesia and then we can give antibiotics um some antibiotics need to be given directly into the CSF so that we can get adequate levels um so that they can cross the blood brain barrier we had a patient that had quite a large Brain absis um she had been in a third world country and had had some dental work done for an abscess tooth and they had not cleared up the infection adequately before capping the tooth and it was up on the upper and so the bacteria continued to go up in through the sinuses and into her brain and she had a huge absis the problem was is that we needed to be able to get the medication up there so that we could treat it in high enough levels and so we did devices like this and thread an interthal catheter to allow us to get that bloodb brain barrier um the antibiotics at a high enough level to treat her other medications you may see are chemotherapy agents can actually be given during an LP now some of the things is that if there is increased inter cranial pressure we do not want to do a lumbar puncture and the reason is is that if they have high pressure in the brain and we insert a needle and allow that pressure you will actually have herniations of the brain because that high pressure will push down and so it is contra indicated if there is increased Dental cradio pressure the care provider will actually insert a spinal needle and these are about 68 in long between the L3 and L4 vertebrae or The L4 and L5 vertebrae we don't go down below that because again then we won't be able to adequately access the spinal um area and so you want to make sure that when you're positioning the patient that we usually will curve them and what we call it a knee chest position where we curve their head down and their knees up and then we put the back along the side of the bed so that the care provider actually can feel the vertebrae so they have good markings wants to obtain the necessary supplies and again it's usually going to be a disposable tray that can be located on the material supply card it's important that you get informed consent um after the care provider has explained the procedure we want to make sure that the patient understands it and because it is a highly invasive procedure and then you need to make sure that the patient understands they're going to be lying still one of the things that you can do is you assist the position patient into the appropriate position and as mentioned PE previously it's going to be in knee chest position as you can see it in the photo here how you can help is actually putting your hands on the patient's shoulder or neck and then again on their hip or on their knees and because the minute they start feeling that coldness or they feel the numbing it's very customary for patients to want to rear back and we need to keep them in that position so that again the care provider can insert the needle it's important that you make a note the order that the specimens were taken and that they are appropriately marked we do not want the containers to sit for any length of time um because again it can actually grow bacteria or show bacterial growth that may not actually be there and so the specimens have to be kept sterile and for culture and sensitivity and then they must be taken to the lab immediately just so you know this is not a procedure you usually want to risk getting the specimens lost in some tube system they usually your hand carried by someone to the lab post care for the patient it's important that they lay flat for 6 to8 hours after the procedure and this is because we want that area where we actually inserted the needle to seal and so we want that pressure to realign and we don't want leaking of the cerebral spinal fluid as that can result in a headache it's important that we check Vital Signs and neurologic iCal alertness condition and it compare it to the assessments that were done pre-procedure into our Baseline so we want to do them every 2 hours and then every 4 hours and this is for 24 hours it's important to encourage fluids and this will actually decrease the risk of the client getting the neurological headache that we see and then monitor for complications some of the complications that they can have is again the risk of infection so temperature and monitoring any labs nerve damages is there any changes in sensation the most common complaint that we do have is headache and so what we actually um will do is we encourage the client to be in a darkened room and we encourage them to increase their fluids about 10% of people that have a lumbar puncture will get a postlumbar puncture headache and what this is due to is the CSF we actually get cerebral spinal fluid and it will leak at the side and it actually puts increased pool or traction on the meninges and this is where they get this throbbing headache it can last several hours to several days now while they are mild for some people I will tell you that most patients that I've had say that they do make them very nauseated and they are very miserable and so what we will usually do is put them in a darkened room um on bed rest because the throbbing in the frontal and occipital loes actually seems to be aggravated by sitting or standing we can give them narcotic analgesics usually you will see them using something um like coating that is not going to be our strongest analgesic and the reason for this is that it makes it does not cause the same level of neurological sedation that we see with some of our other analgesics such as morphine if nothing else is working you can see a blood patch done and this is exactly what it says they will actually draw some blood from the patients vein and then they will go back now they usually go back in the exact same hole they need to go back exactly where the original needle insertion was and they will just insert a couple of millimet very small amount of blood and the reason for this is you've got to remember that blood clots and so because all of this was due to the leak then putting that blood in allows it to clot and it closes off the leak and what this does is it seals it now the patient does need to lay flat after the procedure usually for an hour or so but I will tell you that most patients that I have seen it works very well and they get really good results from it electromyography or EMG and of the Nerf supplying them we use needles that again are going to be with these electrodes and they insert them into the skeletal muscle and then we will use a stimulator that's going to go over the nerve and it sends that signal through and it's going to make a graph like an EKG for skeletal muscle now we can use it to diagnose neuromuscular diseases such as myia gravis we use it with multiple sclerosis um again but what's it it's going to tell us is the potential of the nerve as well as the strength of the signal reaching the nerve so we can see it with um demyelination it gives us an indication if there are problems there as well angiogram is much like a coronary angiogram except the catheter is threaded to the ceds and dye is injected So It Goes To The Head they will thread the catheter through the femal AR in the groin and then up into the desired vessel occasionally we can see direct puncture of the cored artery and threading of a catheter there though it's much less common due to some of the risk factors pre-procedure is very similar to that discussed in coronary Angels it's important to entain conformed consent because it is an invasive procedure and we do need to assess for iodine or contrast allergies the patient should be no for about 8 hours prior to the procedure we also need to make sure that prior to the procedure as we will be using contrast that we've checked for bu and creatinin levels to ensure that the die and the contrast is going to be able to be excreted when we talk about an assessment it's really important that we get Baseline vitals and a baseline um pulses and especially to do a neural a really good neural assessment because that's where we see um some of our complications after the very last thing is we want to make sure we have the client void post procedure the site care is the same as for coronary angel you're going to be monitoring the site for hematomas checking pulses and again um assessing circulation secondary to threading that catheter in in addition now you're really going to want to focus on the neural we want to be looking for any complications that can indicate a change in neurological status so any changes in Behavior level of Consciousness movement sensation um language dis dysfunction hesitancy changes so you really have want to have done a good Baseline before and then when we will be revisiting this neuro assessment frequently every 15 minutes to half hour we're going to be asking them some of these questions we want to increase fluids and push po fluids if they can take them to clear that die and make sure you're monitoring renal function and excretion look for any indications of a DI allergy dmia itching a [Music] rash if you are unsure about the monitoring then you might want to again review the coronary Andre unit from unit one an EEG or an electro inogram measures the electrical impulses of the brains as clients can frequently have seizures within the brain that we cannot see because we're not seeing the outward movements so they can be having these neurological insults that we're unaware of other than often times especially in children they can have speech that doesn't go to long-term memory and we can see that Interruption of short-term to long-term memory in adults frequent forget foress um disorientation so these sticky electrodes are placed um on an unshaven scalp and then we use this to diagnose seizures we can also see changes in the waves related to brain tumors um people who have migraines or frequent headaches Sleep Disorders people with head injuries we can see slowing in the brain in the injured area and again it is also one of the ways that we confirm somebody for brain death so an EEG or an electro andram these are actually done in four different states and my children they were questioning if they were having seizures and that was while they um my son was not speaking and so we got to to do this with a three a 2 and 1/2 to three-year-old and can I just tell you the joys of doing a sleep deprived study you do keep them up all night the night before and then they will actually um sedate them when you get there they want them to go to sleep so they will do an at rest this is where you get your Baseline now when they put the electrodes on people think they're sticking needles into their brain and they are not they are like little suction cups one of the important things to teach the patient is that they don't want to use any conditioner on their hair because it can actually make them so they don't stick right but they will put a little lotion in there and then it's like a little suction cup um and then they will go through and do the estate my son got a little bit uncooperative because he kept flopping all over the place and saying how handsome he looked which made it totally impossible to get him to settle down do the um procedure but they will do a Baseline and then they have them hyperventilate one of the causes that we can see for seizure disorders is actually acid base imbalances and remember that hyperventilation can cause them to blow off the CO2 and they will all get a rapid respiratory um alkalosis the one of the ways that they stimulated the hyperventilation for my children is they had them they held a tissue up in front of them and told them to blow on it very rapidly they wanted the tissue waving and that again was blowing off that air they will also do the phic and this is where they will have a black light in there and they Flash the black light again one of the biggest causes we see in for seizures this is why people are usually cautioned with video games things like going to the Fright mares is because they do have these black lights so again they will do that and then they may do the sleep they wake them up from a sound sleep um or lack of sleep with the sleep deprived to see if we can elicit seizure activity it's important to instruct the client that this is painless and non-invasive we don't put electricity into the brains and we can't read their thoughts again we are just going to be using these to um kind of look at the uh brain wave tracings we should ask the care provider before the procedure um if the patient is to hold any anti-convulsant medications because again they can change the level of the brain activity that we see and then again if we did hold them we need to give the medications immediately after we need to make sure that we hold any stimulants and teach the patient they shouldn't have stimulants before such as coffee or caffeinated beverages um because again these can change the tracings that we get cored Doppler studies are basically an ultrasound of the coted arteries it shows the blood flow and allows us to kind of visualize the vessel stenosis if we see narrowing if we see a lack of blood flow then we can identify that it also allows us to visualize or to identify occlusions and these things can all increased a patient risk for cvas so again the nice thing about this is it is noninvasive it is painless and there's no pre-or post care