Week 7: neurological assessment

Structure and function of the nervous system

1. Central nervous system

2. peripheral nervous system

information flow of NS

1. Afferent (Sensory)

2. Efferent (Motor)

central nervous system

(CNS) consists of…

1. brain: Controls thinking, memory, emotions, movement, and many body functions.

2. spinal cord: Carries messages between the brain and the rest of the body and coordinates certain reflexes

3. integration and control center: is the body's control center. It receives information, processes it, and decides how the body should respond

4. fight or flight

peripheral nervous system

(PNS) consists of…

1. 12 cranial nerves: Nerves that originate from the brain.

2. 31 spinal nerves: Nerves that branch from the spinal cord

3. connects body to CNS: is the body's communication network. It connects the CNS to the rest of the body.

4. rest and digest

afferent

(sensory) = receptors to CNS

goes from body to CNS to body

efferent

(motor) = muscle and glands

body to body

two functional divisions (of PNS)

1. somatic system

2. autonomic system

somatic system

controls skeletal muscles (voluntary)

• Controls voluntary movements, such as walking, and carries sensory information.

autonomic system

controls smooth muscle, cardiac muscles and glands

• works unconsciously and maintains homeostasis

• Controls involuntary functions, such as heart rate, digestion, and sweating.

developmental competence (infants)

Neurologic system is not completely developed at birth

• Movement is directed by reflexes (should disappear by 1 y.o)​

• Persistence of primitive reflexes is an indication of CNS dysfunction​

• Sensation is also limited at birth​

• Sensory and motor development proceed with gradual acquisition of myelin (more accurate responses with myelination)​

primitive reflexes of infant

1. stepping: 0-2 months

2. rooting: 0-4 months

3. moro: 0-6 months

4. grasp: 0-6 months

5. tonic neck: 0-7 months

6. babinski: 0-12 months

neurologic changes in older adults

• Neuron loss leads to loss of muscle tone, impaired fine coordination and agility, loss of vibratory sense at the ankle, decreased reflexes.​

• Velocity of nerve conduction decreases causing slower reaction times.​

• Delayed impulse conduction at synapses can cause diminished sensation to touch and pain, taste, and smell.​

subjective neurologic assessment

1. headache history

2. head injury details

3. dizziness and vertigo

4. seizure characteristics

5. tremors and weakness

6. sensory and speech issues

headache history

Frequency, onset timing, pattern recognition, presence of auras or premonitory feelings, associated symptoms like light/sound sensitivity, nausea/vomiting, and red flags 'worst headache of my life' (WHOL).​

head injury details

Mechanism of injury, eyewitness or observer descriptions, and, if repetitive, the number of head injuries sustained.​

dizziness and vertigo

Dizziness includes lightheadedness, wooziness, and spinning sensations; vertigo specifically refers to a rotational or spinning sensation affecting either the patient or the environment. Syncope involves fainting or near-fainting episodes.​

seizure characteristics

Course and duration, warning signs, motor activity onset and progression, associated symptoms such as color changes, loss of consciousness, automatisms, incontinence, postictal phase details, precipitating factors, medications, and coping strategies.​

tremors and weakness

Tremors: involuntary shaking, vibrating, or trembling caused by anxiety, intention, or resting.

Weakness: paresis (partial paralysis) or paralysis (total motor loss).​

sensory and speech issues

Incoordination, numbness or tingling (paresthesia), difficulty swallowing (dysphagia), saliva management, difficulty speaking (dysarthria, dysphasia), vision changes, and relevant past medical history.​

objective assessment

1. mental status

2. cranial nerves

3. muscle strength

mnemonic for nerve names

Oh Once One Takes The Anatomy Final Very Good Vacations Are Happening

cranial nerves

1. Olfactory (I)

2. Optic (II)

3. Oculomotor (III)

4. Trochlear (IV)

5. Trigeminal (V)

6. Abducens (VI)

7. Facial (VII)

8. Vestibulocochlear (Acoustic)​ (VIII)

9. Glossopharyngeal​ (IX)

10. Vagus (X)

11. Spinal Accessory (XI)

12. Hypoglossal (XII)
    

cranial nerve I

olfactory

main function: smell

type: sensory

simple test: identify familiar scents

cranial nerve II

optic

main function: vision

type: sensory

simple test: Suellen chart, visual fields

cranial nerve III

oculomotor

main function: eye movement, pupil constriction

type: motor

simple test: PERRLA, extra ocular movements

cranial nerve IV

trochlear

main function: downward and inward eye movement

type: motor

simple test: follow finger down toward nose

cranial nerve V

trigeminal

main function: facial sensation, chewing

type: both

simple test: light touch on face; clench teeth

cranial nerve VI

abducens

main function: lateral eye movement

type: motor

simple test: move eyes side to side

cranial nerve VII

facial

main function: facial expression, taste (ant. 2/3 tongue)

type: both

simple test: smile, frown, puff cheeks, taste test

cranial nerve VIII

vestibulocochlear

main function: hearing and balance

type: sensory

simple test: whisper test, tuning fork, balance

cranial nerve IX

Glossopharyngeal​

main function: taste (post 1/3), swallowing, gag

type: both

simple test: test gag reflex, assess swallowing

cranial nerve X

vagus

main function: speech, swallowing, autonomic control

type: both

simple test: say ahhh observe uvula rise midline

cranial nerve XI

spinal accessory

main function: shoulder and neck movement

type: motor

simple test: shrug shoulders, turn head

cranial nerve XII

hypoglossal

main function: tongue movement and articulation

type: motor

simple test: stick out tongue, note deviation

olfactory (I)

function: smell

sensory

Have the client close their eyes, block one nostril, and identify a familiar scent (like coffee or vanilla)

optic (II)

function: vision and visual fields

sensory

Test visual acuity using a Snellen eye chart, test peripheral visual fields by confrontation, and inspect the ocular fundus with an ophthalmoscope

oculomotor (III)

Extraocular eye movements, pupil constriction, and eyelid elevation

motor

Check pupils for size, shape, direct/consensual reaction to light, and accommodation (PERRLA), and inspect for ptosis (drooping eyelid)

trochlear (IV)

downward and inward eye movement

motor

Ask the client to follow your finger as you move it down toward their nose

trigeminal (V)

Facial sensation; motor control of chewing muscles

both

• Motor: Have the client clench their teeth while you palpate the masseter and temporalis muscles for strength and symmetry.

• Sensory: Lightly touch a cotton wisp to the client's forehead, cheeks, and chin while their eyes are closed

abducens (VI)

Lateral (outward) eye movement

motor

Ask the client to move their eyes side-to-side.
(Note: CN III, IV, and VI are commonly assessed together during extraocular movement testing.)

Facial (VII)

Facial expressions; taste on the anterior 2/3 of the tongue

both

• Motor: Observe facial symmetry while asking the client to smile, frown, close eyes tightly, raise eyebrows, and puff out cheeks.

• Sensory: Taste test on the anterior portion of the tongue

Vestibulocochlear (VIII)

Hearing and balance

sensory

Assess hearing using normal conversation, the whispered voice test, or a tuning fork

glossopharyngeal (IX)

Swallowing, gag reflex, and taste on the posterior 1/3 of the tongue

both

Test swallowing and taste on the back of the tongue. Works closely with CN X

vagus (X)

Speech, swallowing, gag reflex, and parasympathetic autonomic control

both

Ask the client to say "ahh" and observe that the uvula and soft palate rise symmetrically in the midline; touch the posterior pharynx to test the gag reflex

spinal accessory (XI)

Movement of sternocleidomastoid and trapezius muscles (neck and shoulder)

motor

Ask the client to shrug shoulders against your downward resistance and turn their head side-to-side against your hand's resistance

hypoglossal (XII)

Tongue movement and speech articulation

motor

Ask the client to stick out their tongue. Look for midline alignment and note any tremor or deviation to one side

examine pupils

check for PERRLA

PERRLA

Pupils

Equal

Round

Reactive to Light (direct and consensual response)

and

Accommodation

normal pupil size

Generally 3–5 mm in ambient light

anisocoria

Unequal pupil sizes (can be a normal anatomical variation in ~20% of people or a sign of increased intracranial pressure)

ptosis

Drooping of the upper eyelid (CN III defect or neuromuscular disease)

nystagmus

Back-and-forth oscillation of the eyes (mild end-point nystagmus at extreme lateral gaze can be normal, but persistent nystagmus is abnormal)

motor system evaluation

1. muscle size

2. muscle strength

3. muscle tone

4. involuntary movements and pronator drift

muscle size

Evaluate the size of muscles to identify any atrophy or hypertrophy which may indicate underlying neurological or muscular conditions.​

muscle strength

Assess muscle strength by testing resistance against force in various muscle groups to detect weakness or asymmetry.​

• using the 0-5 muscle strength scale

using the 0-5 muscle strength scale

5: Normal strength​

4: Slight weakness​

3: Movement against gravity only​

2: Movement with gravity eliminated​

1: Flicker of contraction​: trace

0: No movement​: no muscle contraction at all

muscle tone

Check for muscle tone abnormalities including limited range of motion, flaccidity (decreased resistance, hypotonia), spasticity, and rigidity which indicate central nervous system dysfunction.​

involuntary movements and pronator drift

• Observe for involuntary movements such as tics, tremors, fasciculations, myoclonus, and chorea. ​

• Tics - sudden, brief and repetitive movements (e.g. blinking)​

• Tremors - rhythmic shaking, common in Parkinsons​

• Fasciculations -Small muscle twitches seen under the skin (ALS)​

• Myoclonus - sudden quick jerks​

• Chorea-irregular jerky, dance-like movements (Huntington’s)​

• Test for pronator drift in upper and lower extremities as a sign of subtle motor weakness.​

Tics

sudden, brief and repetitive movements (e.g. blinking)​

tremors

rhythmic shaking, common in Parkinsons​

fasciculations

small muscle twitches seen under the skin (ALS)​

myoclonus

sudden quick jerks​

cerebellar function tests

cerebellum: controls motor coordination, smooth movements, and balance.

• balance tests

balance tests

1. gait

2. normal

3. tandem walking

4. the romberg test

gait

observe as the person walks 10 to 20 feet, turns, and returns to starting point​

normal gait

gait is smooth, rhythmic, and effortless; opposing arm swing is coordinated; the person turns smooth; step length about 15 inches from heel to heel

tandem walking

Ask the person to walk straight line in heel-to-toe fashion

romberg test

Ask the person to stand up with feet together and arms at sides; when in stable position, ask the person to close eyes and to hold position for about 20 seconds​

pronator drift

The client stands with arms extended forward, palms up, and eyes closed for 20 seconds. A positive drift occurs when one arm downwardly drifts and pronates (palms turn down), indicating an upper motor neuron lesion (e.g., stroke)

negative romberg test

A negative Romberg (expected) means the client maintains posture with minimal swaying. A positive Romberg means the client loses balance or steps out when eyes are closed (indicates sensory ataxia or vestibular impairment)

sensory system assessment

Tests sensory pathways conveying pain, temperature, touch, position, and vibration from peripheral nerves to the brain.

1. sharp vs dull sensation

2. light touch

3. vibration sense

4. stereognosis

5. graphesthesia

sharp vs dull sensation

Test patients by distinguishing sharp sensations from dull sensations to evaluate pain perception and sensory nerve function.​

light touch

Use a wisp of cotton to lightly touch the skin in multiple dermatomes to assess the patient's ability to perceive gentle tactile stimuli.

vibration sense

Apply a tuning fork over bony prominences using lower pitch frequencies (128Hz or 256Hz) to assess vibration sense as these have a slower decay.​

stereognosis

Evaluate the patient's ability to identify familiar objects by touch without looking, testing finely localized touch perception

graphesthesia

Test the patient's ability to recognize numbers or letters traced on the palm, assessing cortical sensory processing.​

deep tendon reflexes

• Automatic body responses that happen when a tendon is tapped with a reflex hammer.​

• Help nurses to check functions of nerves and spinal cord. ​

• Limb should be relaxed on assessment, and muscle partially stretched​

  • Bilateral comparison: responses should be equal

DTR 4-Point Grading Scale

reflex response graded on 4 point scale

• 4+: Very brisk, hyperactive with clonus (indicates CNS disease).

• 3+: Brisker than average (may be normal or indicative of disease).

• 2+: Average / Normal.

• 1+: Diminished / low normal.

• 0: Absent (no response)

biceps reflex

• C5 to C6​

• Support the person’s forearm on yours; place your thumb on biceps tendon and strike a blow on your thumb​

• Normal response is contraction of biceps muscle and flexion of forearm​

triceps reflex

• C7 to C8​

• Tell the person to let arm “just go dead” as you strike triceps tendon directly just above the elbow​

• Normal response is extension of forearm​

brachioradialis reflex

• C5 to C6​

• Hold the person’s thumbs to suspend forearms in relaxation and strike forearm directly, about 2 to 3 cm above radial styloid process​

• Normal response is flexion and supination of forearm​

quadriceps reflex

• L2 to L4 (“Knee Jerk”)​

• Let lower legs dangle freely to flex knee and stretch tendons; strike tendon directly just below patella​

• Normal response is extension of lower leg​

achilles reflex

• (“Ankle Jerk”)​

• Position the person with knee flexed; hold foot in dorsiflexion and strike Achilles tendon directly​

• Normal response is foot plantar flexes against your hand​

glasgow coma scale (GCS)

is a neurological assessment tool nurses use to determine a patient's level of consciousness and how well they respond to stimulation and it measures 3 responses: Eye Opening, Motor Response, and Verbal Response.

It is commonly used for patients with:

• Head injuries or brain trauma

• Stroke

• Altered mental status

• Unconsciousness or coma

eye opening

This measures how easily the patient opens their eyes, (maximum 4 points)

4 = Spontaneous, Opens eyes without being asked

3 = To speech, Opens eyes when spoken to

2 = To pain, Opens eyes only with painful stimulation

1 = No response, Does not open eyes

motor response

This measures how well the patient can move their body in response to commands or stimulation (max 6 points)

6 = Obeys commands, Follows instructions, such as squeezing your hand

5 = Localizes pain, Purposefully reaches toward the painful stimulus to remove it

4 = Withdraws from pain, Pulls the affected body part away from pain

3 = Abnormal flexion, Arms bend inward abnormally (decorticate posturing)

2 = Abnormal extension, Arms straighten and extend abnormally (decerebrate posturing)

1 = No response, No movement

verbal response

This measures how well the patient can speak and whether their responses make sense (max 5 points)

5 = Oriented, Knows who they are, where they are, and the time or situation

4 = Confused conversation, Can speak but is confused or disoriented

3 = Inappropriate words, Says random words that do not make sense in the conversation

2 = Incomprehensible sounds, Makes sounds such as moaning but no understandable words

1 = No response, Makes no verbal sounds

EVM

eyes, verbal, motor

scoring maximum is 15

• decreasing GCS score is a warning sign that the patient's neurological condition may be worsening and needs prompt reassessment and escalation

neuro check

1. mental status

2. orientation

3. cranial nerves tested

4. strength and movement

mental status

Evaluate the patient's level of consciousness, alertness, and cognitive function to establish baseline neurologic status.​

orientation

Check patient's awareness of person, place, and time to evaluate cognitive orientation and neurological status

cranial nerves tested

Examine cranial nerves 2, 3/4/6, 7, and 8 through visual acuity, eye movements, facial muscle function, and hearing assessments.​

strength and movement

Assess muscle strength and voluntary movements to identify any weakness or abnormal motor function.​

diabetic neuropathy screening

• Use a monofilament to touch the skin at each numbered site for 1-2 seconds.​

• Ask the patient to identify when and where they feel the touch.​

• This test helps assess the presence of neuropathy by detecting sensory loss.​

• Perform at multiple standardized sites on the feet to ensure comprehensive screening.​

• Early detection through this screening can prevent complications such as ulcers or infections

stroke symptoms

• Weakness or numbness in face, arms, legs; especially on one side of body​

• Confusion, trouble speaking or understanding​

• Changes in vision, such as blurry vision or partial/complete vision loss in one or both eyes​

• Trouble with walking, dizziness, loss of balance or coordination​

• Severe headache with no explanation​

stroke

occurs due to a sudden interruption of blood flow to the brain.​

FAST tool

is a quick assessment used by nurses and other healthcare professionals to recognize the warning signs of a stroke

Face, Arms, Speech, Time

Face

face drooping

ask the patient to smile.

• Does one side of their face droop?

• Is their smile uneven?

Abnormal: One side of the face does not move normally.

Arms

arm weakness

Ask the patient to raise both arms.

• Does one arm drift downward?

• Is one arm weaker than the other?

Abnormal: The patient cannot keep both arms raised equally

Speech

speech difficulty

Ask the patient to repeat a simple sentence, such as "The sky is blue."

• Is their speech slurred?

• Are they having trouble speaking?

• Are they using incorrect words?

Abnormal: Speech is slurred, unusual, or difficult to understand