2-17. SKULL X-RAYS
a. Skull X-rays are the oldest, non-invasive neurological test used to evaluate the bones, which make up the skull. Because of complex anatomy of the skull, a series of films is usually required for a complete evaluation.
b. Diagnostic uses for skull X-rays:
(1) To detect fractures in patient’s with head trauma.
(2) To help detect and assess increased intracranial pressure, tumors, bleeding, and infection.
(3) To aid diagnosis of pituitary tumors.
(4) To detect congenital anomalies.
c. Nursing implications.
(1) Review the patient’s clinical record to determine the reason (purpose) for the specific scheduled skull x-rays.
(2) Approach and identify the patient.
(3) Interview the patient to determine his/her knowledge of the purpose of the skull x-rays.
(4) As indicated, explain to the patient the specific purpose of the skull x-rays in his/her situation. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient.
(5) Explain to the patient the events which will occur prior to the skull x-rays.
(a) Patient is not required to restrict food and fluids before x-rays.
(b) All jewelry and other metal objects must be removed from patient’s head and neck and placed in safekeeping.
(c) Tell the patient where and when the x-rays will be performed.
(6) Explain to the patient events which will occur during the skull x-ray procedure.
(a) Patient will be placed in a supine position on a radiographic table, or seated in a chair, and instructed to remain still.
(b) A headband, foam pads, or sandbags may be used to immobilize the patient’s head and increase patient comfort.
(c) Tell the patient that several (usually five) x-ray films of the skull will be taken from various angles.
(d) Reassure patient that the procedure will cause no discomfort.
(e) Films will be developed and checked before patient leaves the x-ray department.
(7) Explain to the patient events, which will occur after the procedure.
(a) Patient will be returned to his/her room.
(b) Physician will report the results of the x-rays to the patient when they are available.
2-18. LUMBAR PUNCTURE
a. Lumbar puncture is the insertion of a sterile needle into the subarachnoid space of the spinal canal, usually between the third and fourth vertebra, to reach the cerebral spinal fluid. This test requires sterile technique and careful patient positioning. It is performed therapeutically to administer drugs or anesthetics and to relieve intracranial pressure.
b. Diagnostic uses for lumbar puncture:
(1) To determine the pressure of the cerebral spinal fluid.
(2) To detect increased intracranial pressure.
(3) To detect presence of blood in the cerebral spinal fluid which indicates cerebral hemorrhage.
(4) To obtain cerebral spinal fluid specimens for laboratory analysis.
c. Nursing implications.
(1) Review the patient’s clinical record to determine the reason for the patient’s scheduled lumbar puncture procedure and what the patient has been told about the procedure.
(2) Assemble the necessary equipment.
(a) Sterile disposable lumbar tray.
(b) Overbed table.
(c) Sterile gloves.
(d) Betaine solution.
(e) Local anesthetic.
(f) Labels.
(g) Laboratory request slips.
(3) Approach and identify the patient.
(4) Interview the patient to determine his/her knowledge of the purpose of the lumbar puncture procedure.
(5) As indicated, explain to the patient the specific purpose of the lumbar puncture procedure. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient.
(6) Explain the procedure to the patient.
d. Procedure.
(1) Ask the patient to empty his/her bladder.
(2) Position the patient.
(a) Lateral recumbent, at the edge of the bed, knees drawn up to abdomen, and chin tucked to chest.
(b) To help the patient maintain this position, the nursing paraprofessional places one hand behind the patient’s neck and the other behind patient’s knees to help support the patient’s position throughout the procedure.
(3) The physician will clean the puncture site area with sterile applicators from the lumbar puncture tray.
(4) The physician will drape the area with a fenestrated drape to provide a sterile field.
(5) The physician will inject local anesthetic into the planned needle puncture site.
(6) The physician will insert the spinal needle. The patient will feel some pressure at this time.
(7) If the procedure is being performed to administer contrast media for radiologic studies or spinal anesthetic, the physician will inject the dye or anesthetic.
(8) When the needle is in place, the physician will attach a manometer with stopcock to the needle hub to read CSF pressure. (The patient may need to extend his legs to provide a more accurate pressure reading.)
(9) The physician will detach the manometer and allow the fluid to drain from the needle hub into four collection tubes.
(10) When there is approximately 2 or 3 ml of fluid in each tube, the physician will hand them to the assistant, who will mark the tubes in sequence, stopper them securely, and label them properly, as such:
(a) Gram stain.
(b) Culture, sensitivity.
(c) Cell count.
(c) Protein and glucose.
(11) The physician will remove the spinal needle, apply pressure to the area briefly, and apply a band-aid or small dressing.
(12) The entire procedure will last approximately 15 minutes.
e. Follow-up.
(1) Send the CSF specimens to the laboratory immediately.
(2) Instruct the patient to lie flat for several hours to reduce chance of headache.
(3) Monitor the patient carefully following the procedure. Adverse reactions including headache, vertigo, syncope, nausea, tinnitus, respiratory distress, change in vital signs, meningitis, and fever should be reported to the professional nurse.
(4) Give the patient increased fluids for at least 24 hours after the procedure.
(5) Inform the patient that the physician will report the results of the lumbar puncture as soon as they are available.
(6) Ensure the comfort and safety of the patient.
(7) Remove equipment from bedside and dispose of properly.
(8) Record the procedure in the patient’s chart.
2-19. ELECTROENCEPHALOGRAM
a. An electroencephalogram (EEG) is a recording of brain wave activity.
(1) Electrodes are attached to specific areas of a patient’s scalp.
(2) Electrical impulses are received and transmitted to a machine called an electroencephalograph, which magnifies the impulses and records them on moving strips of paper. (Much the same as an electrocardiogram.)
b. Diagnostic uses for EEG.
(1) To determine the presence and type of epilepsy.
(2) Aid in diagnosis of intracranial lesions.
(3) To evaluate the brain’s electrical activity in metabolic disease, head injury, meningitis, and encephalitis.
(4) To confirm brain death.
c. Nursing implications.
(1) Review the patient’s clinical record to determine the reason for the patient’s scheduled electroencephalography and what the patient has been told about the procedure.
(2) Check the patient’s medication history for drugs that may interfere with test results, and report positive findings to charge nurse.
(a) Anticonvulsants.
(b) Tranquilizers.
(c) Barbiturates.
(d) Other sedatives.
(3) Approach and identify the patient.
(4) Interview the patient to determine his/her knowledge of the purpose of the electroencephalogram procedure.
(5) As indicated, explain to the patient the specific purpose of the electroencephalogram.
(6) Explain to the patient events which will occur prior to the electroencephalogram.
(a) Food or fluids need not be restricted.
(b) Tell the patient when and where the test will be performed, and who will do it.
(c) Patient will be transported to electroencephalogram clinic.
(7) Explain to the patient events that will occur during the procedure.
(a) Patient will be asked to relax in a reclining chair or lie on a bed, and electrodes will be attached to the scalp.
(b) Assure the patient that the electrodes will not cause electrical shocks.
(c) If needle electrodes are used, the patient will feel pricking sensations when they are inserted.
(d) Before the recording procedure starts, the patient is instructed to relax with the eyes closed and remain still.
(8) Explain to the patient events which will occur after the electroencephalogram procedure.
(a) Patient will return to his/her room.
(b) Physician will report the results of the electroencephalogram to the patient when they are available.
2-20. BRAIN SCAN
a. Brain scanning is the use of a specialized camera to provide images of the brain after an I.V. injection of a radionucleotide. Normally, the radionucleotide cannot permeate the blood-brain barriers, but if pathologic changes have destroyed the barrier, the radionucleotide may concentrate in the abnormal area.
b. Diagnostic uses:
(1) To detect an intracranial mass or vascular lesion.
(2) To locate areas of ischemia, cerebral infarction, or hemorrhage.
(3) To evaluate the course of certain lesions postoperatively and during chemotherapy.
c. Nursing implications.
(1) Review the patient’s clinical record to determine the reason (purpose) for the specific patient’s scheduled brain scanning procedure and what the patient has been told about the procedure.
(2) Approach and identify the patient.
(3) Interview the patient to determine his/her knowledge of the purpose of the brain scanning procedure.
(4) As indicated, explain to the patient the specific purpose of the brain scan. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient.
(5) Explain to the patient events that will occur prior to the brain scanning procedure.
(a) Patient will not have to restrict food or fluids before test.
(b) Patient will be asked to empty his/her bladder prior to the procedure.
(c) All jewelry or metal in the x-ray field will be removed and placed in safe keeping.
(d) Describe the scanning machine and explain it will move back and forth close to the patient’s head.
(e) Explain that the procedure is painless and that the radiation poses no danger to the patient or visitors.
(f) A radioactive drug will be injected intravenously at least one hour before the scan begins.
(6) Explain to the patient events that will occur during the brain scanning procedure.
(a) The patient will be transported to the nuclear medicine department.
(b) Films will be taken of the brain at various time intervals.
(c) The patient can expect to be in the nuclear medicine department at least an hour and a half.
(7) Explain to the patient events that will occur after the brain scan.
(a) Patient will be transported back to his/her room.
(b) Physician will report the results of the brain scan to the patient when available.
2-21. CEREBRAL ANGIOGRAPHY
a. A cerebral angiogram is a radiographic examination of the cerebral vasculature after injection of a contrast medium. Common injection sites are the carotid, brachial, and femoral arteries.
b. Diagnostic uses for cerebral angiography.
(1) To detect cerebrovascular abnormalities.
(2) To study vascular displacement caused by tumor, hematoma, edema, arterial spasm, or increased intracranial pressure.
(3) To locate surgical clips applied to blood vessels during surgery and to evaluate the postoperative status of the vessels.
c. Nursing implications.
(1) Review the patient’s clinical record to determine the reason (purpose) for the specific patient’s scheduled cerebral angiography and what the patient has been told about the procedure.
(2) Check the patient’s medication history for hypersensitivity to iodine, seafoods, or the dyes used for other local tests, and report significant findings to the Professional Nurse.
(3) Approach and identify the patient.
(4) Interview the patient to determine his/her knowledge of the purpose of the cerebral antiography procedure.
(5) As indicated, explain to the patient the specific purpose of the cerebral angiography in his/her situation. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient.
(6) Explain to the patient events that will occur prior to the cerebral angiography procedure.
(a) Patient will be required to fast 8-10 hours before test.
(b) All jewelry, dentures, and hair pins will be removed and placed in safekeeping.
(c) Patient will wear a hospital gown.
(d) Patient will be asked to empty his/her bladder prior to the procedure.
(e) Patient (or responsible family member) must sign a consent form.
(f) The test will take approximately two hours.
(g) If ordered, medication such as a sedative may be administered prior to the test.
(7) Explain to the patient events that will occur during the cerebral angiography procedure.
(a) Patient will be transported to the x-ray department.
(b) The patient will be placed in a supine position on the x-ray table and asked to remain still.
(c) Contrast medium will be injected intravenously.
(d) The patient may experience a transient burning sensation at the injection site during the injection.
(e) The patient may become flushed, warm, or nauseated after injection of the contrast medium. A transient headache or salty taste in the mouth may also be experienced.
(8) Explain to the patient events, which will occur after the cerebral angiography.
(a) Patient will be returned to his/her room.
(b) Physician will report the results of the cerebral angiography test to the patient, when they are available.
(9) Document the completion of the examination and the patient’s return to the nursing unit.