Unit 5A.19: Neurologic Assessment

Alert

Level of Consciousness

Awake & responsive

Lethargic

Level of Consciousness

Easily aroused with mild stimulation and can maintain arousal without need of continuous stimulations

Somnolent

Level of Consciousness

Aroused by voice or touch; can follow commands, but need constant stimulation to maintain arousal

Obtunded

Level of Consciousness

Aroused by verbal and painful stimulation; verbal output unintelligible

Stuporous

Level of Consciousness

Unresponsive; only aroused by vigorous repeated painful stimuli; no response to verbal stimuli

Comatose

Level of Consciousness

Unresponsive to any type of stimulus; deep tendon reflex absent

Spontaneous Opening: 4

To verbal command: 3

To pain: 2

No response: 1

Glasgow Coma Scale

Eye Opening Responses

Oriented: 5

Confused: 4

Inappropriate words: 3

Incoherent: 2

No response: 1

Glasgow Coma Scale

Most Appropriate Verbal Response

Obeys verbal commands: 6

Localizes pain: 5

Withdraws from pain: 4

Flexion (decorticate rigidity): 3

Extension (decerebrate rigidity): 2

No response: 1

Glasgow Coma Scale

Most Integral Motor Response (Arm)

Decorticate

Posture in which arm are flexed, abducted, and is internally rotated

Decerebrate

Posture in which arms are extended, pronated palms, and is flexed

Elevated Mood

Characterized by an unusually cheerful, euphoric, or grandiose demeanor, often incongruent with the surrounding context or situation

Mood & Affect

What does these questions assess:

How are you feeling today?

How did you feel when this happened?

Anxious Mood

Clients with this express excessive worry or fear, which can manifest as restlessness, difficulty concentrating, or physical signs such as fidgeting or sweating

Flat Mood

Refers to emotional numbness, where the client may report feeling void of any emotions

Blunted Affect

Involves some degree of emotional expression, but it is significantly reduced in intensity

Inappropriate Affect

Client’s emotional response does not match the context of the situation

Labile Affect

Marked by rapid and high extreme emotional shifts, where a client’s mood may fluctuate between extremes, such as crying one moment and laughing the next

Incongruent Affect

Client’s observed emotional expression does not align with their verbal statements of the context of the interaction

Aphasia

Language disorder that affects a client’s ability to communicate

Expressive aphasia (Broca’s Aphasia)

• Difficulty in speaking or writing

• Client understands language but struggles to find the words or from sentences

Receptive Aphasia (Wenicke’s Aphasia)

• Difficulty in understanding spoken or written language

• Speech production remains fluent but bonsensical

Global Aphasia

• Severe form where both expressive and receptive abilities are impaired

Dysarthria

• Motor speech disorder caused by weakness or in coordination of the speech muscles

• Associate with neurological conditions like: stroke, Parkinson’s, multiple sclerosis

Anomia/Word-Finding Difficulty

• Difficulty in retrieving words, leading to frequent pauses or use of vague terms like “thing” or “stuff” instead of specific nouns

• Can indicate dementia or stroke

Circumlocution

• Tendency to describe a concept of object in a roundabout way, usually when the client cannot recall the correct word

• Often seen in clients with aphasia or cognitive decline

Neologism

• Use of made-up or non-existent words that have no meaning to others

• Could indicate a thought disorder, like schizophrenia, or may occur in neurological conditions affecting speech

Logorrhea (Pressured Speech

• Excessive, rapid and often incoherent speech that may be difficult to interrupt

• Typically seen in manic episodes of bipolar disorder or certain types of anxiety disorders

Monotone Speech

• Client speaks in a flat, emotionless toned with little variation in pitch

• Commonly seen in depression, Parkinson’s or other neurological conditions that affect speech

Inappropriate Vocabulary

• Client uses words that are either too complex or too simple for their context or developmental stage

• Could be a sign of cognitive impairment or intellectual disability

speech Delay

• May be observed in children or adults with developmental delays, hearing impairments, or neurological disorders

• Characterized by slower language development or difficulty in verbal expression compared to peers of the same age

Tangential Thought Process

• Client starts answering a question that deviates to unrelated topics making it difficult to follow the conversation

• Can be indicative of thought disorders or anxiety

Disorganized Speech

• Client’s speech may jump from one topic to another with little or no logical connection

• Often seen in conditions such as schizophrenia or mania

Circumstantial thinking

• Client provided unnecessary, irrelevant details before reaching the point, which may cause the conversation to become unnecessarily complex

• Can indicate anxiety or OCD

Flight of Ideas

• Client exhibits rapid; abrupt transitions between topics

• Their thoughts appear to race and nag be difficult to follow, commonly associated with mania or high levels of anxiety

Delusions

• Client expresses fixed, false beliefs that are not grounded on reality

• May be paranoid (e.g., believing they are being followed) or grandiose (e.g., believing they have special powers or abilities)

• Often seen in psychotic disorders like schizophrenia

Hallucinations

• Client may report hearing voices or seein things that others do not, which can be indicative of a psychotic episode or severe mental illness, like schizophrenia or drug-induced psychosis

Incoherent/Fragmented Thought Process

• client’s thoughts are not connected logically and are difficult to understand

• Speech may be jumbled or fragmented, indicative of severe disorganization, often seen in acute psychosis or certain neurodegenerative diseases

Alogia/Poverty of Speech

• Client speaks very little, with brief or monosyllabic answers

• May be indicative of depression, schizophrenia, or other disorders where thought processes are inhibited

Thought Blocking

• Client may suddenly stop speaking mid-sentence as if their thoughts have disappeared

• Can indicate a thought disorder or severe anxiety

Ideas of Reference

• Client may believe that common events or actions are directly related to them, such as interpreting a news broadcast as being abt them specifically

• Often a sign of psychosis

Ability to maintain focus and perform mental operations

What does the following assess:

Count backward from 100 by fives

Assesses their concentration and ability to switch attention from one task to another

What does the following assess:

Reciting months of the year in reverse

Agnosia

Inability to recognize familiar objects or identify colors and shapes

Visual-Spatial Deficit

Difficulty with spatial awareness, such as trouble distinguishing depth or orientation

Constructional Apraxia

Errors or inability to replicate simple drawings or shapes

Rapid Alternating Movements

Test in which clients puts palms og both hands down on both legs then turn the palms up and down

Dysdiadochokinesia

Rapid Alternating Movement test: uncoordinated movements of tremors are seen with what

Romberg Test

Test in which client stands erect and the nurse needs to note whether the client has any unsteadiness or swaying

Anesthesia

Absence of touch sensation

Hypesthesia

Decreased sensitivity to touch

Hyperesthesia

Increased sensitivity to touch

Analgesia

Absence of pain sensation

Hypalgesia

Decreased sensitivity to pain

Hyperalgesia

Increased sensitivity to pain

2-5 mm

Normal two-point discrimination of fingertips

40 mm

Normal two-point discrimination of forearms

20-30 mm

Normal two-point discrimination of dorsal hands

40 mm

Normal two-point discrimination of back

70 mm

Normal two-point discrimination of thighs

4+

Grading Deep Tendon Reflexes

Hyperactive, very brisk, rhythmic oscillations (clonus); abnormal and indicative of disorder

3+

Grading Deep Tendon Reflexes

More brisk or active than normal, but not indicative of a disorder

2+

Grading Deep Tendon Reflexes

Normal, usual response

1+

Grading Deep Tendon Reflexes

Decreased, less active than normal

0

Grading Deep Tendon Reflexes

No response

Neurogenic Anosmia

Inability to smell

Frontal Lobe

If an abnormality when testing CN I (Olfactory) is noted, what lobe of the brain may have been affected?

Parietal Cortex

If an abnormality when testing CN II (Optic) is noted, what lobe of the brain may have been affected?

Papilledema

Swelling of the optic nerve that results in blurred optic disc margins and dilated, pulsating veins

Increased intracranial pressure

What does limited eye movement in the 6 cardinal fields indicate?

Paralytic Strabismus

Paralysis of the oculomotor, trochlear, or abducens nerve

Dilated Pupil (6-7 mm)

Indicates oculomotor nerve paralysis

Argyll Robertson Pupils

Caused by CNS syphilis, meningitis, brain tumor, alcoholism

Constricted, fixed pupils

Caused by narcotics abuse or damage to the pons

Unilaterally dilated pupil unresponsive to light or accommodation

Caused by damage to CN III (Oculomotor)

Constricted pupil unresponsive to light or accommodation

Caused by lesions of the sympathetic nervous system

Bilateral Muscle Weakness

Seen with peripheral or CNS dysfunction

Unilateral Muscle Weakness

May indicate a lesion of CN V (Trigeminal)

Ophthalmic: corneal reflex

Maxillary: facial sensation

Mandibular: biting and chewing

Components of the Trigeminal Nerve

CN VII (Facial)

Inability to identify correct flavor on anterior 2/3’s of the tongue suggests impairment of what nerve

Sensorineural Hearing Loss

Vibratory sound lateralizes to the good ear in what type of hearing loss?

Bilateral Lesions of CN X (Vagus)

Soft palate does not rise

Unilateral Lesion of CN X (Vagus)

Unilateral rising of the soft palate and deviation of the uvula to the normal side

CN IX (Glossopharyngeal) or X (Vagus)

Absent gag reflex may be seen in lesions with have nerves?

CN IX (Glossopharyngeal) or X (Vagus)

Dysphagia or hoarsness may be seen in lesions with have nerves?

torticollis

Asymmetric muscle contraction or drooping of the shoulder may be seen with paralysis or muscle weakness due to neck injury or ___

C5 & C6

What does the biceps and brachioradialis reflexes evaluate the function of?

C6, C7, C8

What does the triceps reflex evaluate the function of?

L2, L3, L4

What does the patellar reflex evaluate the function of?

S1, S2

What does the achilles reflex evaluate the function of?

T8, T9, T10

What does the upper abdominal reflex evaluate the function of?

T10, T11, T12

What does the lower abdominal reflex evaluate the function of?

T12, L1, L2

What does the cremasteric reflex evaluate the function of?

L4, L5, S1, S2

What does the plantar reflex evaluate the function of?

Brudzinski’s Sign

Test in which the nurse flexes the neck and watches the hips and knees in reaction to the maneuver

Meningeal Inflammation

Positive Brudzinski’s Sign indicates what?

Kernig’s Sign

Test in which the nurse flexes the client’s leg at both the hip and knee then straightens the knee

Meningeal Irritation

Positive bilateral Kernig’s Sign indicates what?