Assessing Neurological System

What major functions are evaluated during a neurologic assessment?

Sensory function, motor function, reflexes, and cognitive function of the central and peripheral nervous systems.

What are the five core domains of a neurologic assessment?

Mental status, cranial nerves, motor/cerebellar systems, sensory system, and reflexes.

What is included in a brief acute-care neurologic check?

Level of consciousness, pupil symmetry and response, extremity motor movement and strength, peripheral sensation in the upper and lower extremities, and vital signs.

What is the function of the frontal lobe?

Voluntary skeletal movement, speech, motor function, judgment, and higher cognitive function.

What is the function of the parietal lobe?

Processes touch, pressure, temperature, pain, spatial awareness, and sensory discrimination.

What is the function of the temporal lobe?

Auditory reception and interpretation, language comprehension, and memory.

What is the function of the occipital lobe?

Vision.

What is the function of the thalamus?

Sensory relay.

What is the function of the hypothalamus?

Regulates autonomic functions, temperature, appetite, fluid balance, sleep-wake cycles, and endocrine functions.

What are the major functions of the midbrain, pons, and medulla?

Midbrain = motor function and visual/auditory reflexes; pons = connects brain regions and contains respiratory centers; medulla = heart rate, blood pressure, respiration, swallowing, and vomiting.

What is the major function of the cerebellum?

Coordinates smooth voluntary movement, equilibrium, posture, and fine motor activity.

What are the major functions of the spinal cord?

Contains ascending sensory pathways and descending motor pathways and integrates reflexes.

What information does the spinothalamic tract carry?

Pain, temperature, and crude touch.

What information do the posterior columns carry?

Proprioception, fine touch, and vibration.

What is the function of the corticospinal tract?

Voluntary skeletal movement.

What is the function of the extrapyramidal system?

Muscle tone, balance, posture, and locomotion.

What is the progression of decreasing level of consciousness?

Alert and oriented → Lethargic → Obtunded → Stupor → Coma.

What does alert and oriented mean?

Fully awake and attentive, able to follow simple commands, and if asleep arouses easily and remains awake.

What does lethargic mean?

Drowsy, slow to respond or inattentive, and easily drifts back to sleep when unstimulated.

What does obtunded mean?

Difficult to arouse and requires constant and repeated stimulation to follow simple commands.

What does stupor mean?

Requires continuous, vigorous, often painful stimulation to produce a purposeful or protective response.

What does coma mean?

Completely unarousable and unresponsive to external stimuli with no voluntary verbal or physical responses.

What is CN I and how is it assessed?

Olfactory; assess smell using a familiar, non-irritating odor after checking nasal patency.

What is CN II and how is it assessed?

Optic; assess visual acuity with a Snellen chart or near-vision card and visual fields with confrontation testing.

What is normal distant visual acuity and how far away is the Snellen chart?

20/20 at 20 feet.

At what distance is the near-vision card held?

14 inches from the eyes.

Which cranial nerves control extraocular movements and how are they assessed?

CN III oculomotor, CN IV trochlear, and CN VI abducens; assess the six cardinal fields of gaze and pupillary responses.

What is a normal extraocular movement finding?

Smooth, conjugated, symmetric eye movements without nystagmus.

What does PERRLA stand for?

Pupils equal, round, reactive to light and accommodation.

What pupil size is identified as normal in the notes?

Approximately 3–5 mm.

What is CN V and how is it assessed?

Trigeminal; assess mastication by clenching the teeth while palpating the masseter and temporal muscles and assess facial sensation in V1, V2, and V3.

What is CN VII and how is it assessed?

Facial; ask the client to smile, frown, puff out the cheeks, and raise the eyebrows while assessing symmetry.

What is CN VIII and how is it assessed?

Vestibulocochlear; assess hearing using the whisper or finger-rub test.

What result is identified for the whisper test?

The client correctly identifies 3 of 6 items per ear.

What are CN IX and X and how are they assessed?

Glossopharyngeal and vagus; ask the client to say "ah" and observe symmetric palate and uvula elevation and assess swallowing and vocal clarity.

What is CN XI and how is it assessed?

Spinal accessory; ask the client to shrug the shoulders and turn the head against resistance.

What is CN XII and how is it assessed?

Hypoglossal; ask the client to protrude the tongue and move it side to side while assessing for deviation, tremor, or atrophy.

What is a normal CN XII finding?

The tongue protrudes at midline and moves symmetrically.

Are the corneal and gag reflexes included in the standard lab assessment in the notes?

No. The corneal reflex and gag reflex are omitted from the standard lab assessment.

How is the pronator drift test performed and what is an abnormal finding?

Extend both arms forward with palms up and close the eyes for 20–30 seconds; downward drifting and pronation of an arm is abnormal and may indicate upper motor weakness.

What does muscle strength grade 5 indicate?

Full range of motion against gravity and full resistance; normal strength.

What does muscle strength grade 4 indicate?

Full movement against gravity with some resistance; slight weakness.

What does muscle strength grade 3 indicate?

Movement against gravity but not against added resistance.

What does muscle strength grade 2 indicate?

Range of motion with gravity eliminated.

What does muscle strength grade 1 indicate?

A trace or flicker of muscle contraction without joint movement.

What does muscle strength grade 0 indicate?

No muscle contraction or paralysis.

What does the cerebellar examination assess?

Coordination, equilibrium, posture, gait, and fine motor control.

What should be observed when assessing gait?

Stability, posture, arm swing, and base of support.

What is tandem walking?

Walking heel-to-toe to assess balance and coordination.

How is the Romberg test performed and what is a positive finding?

The client stands with feet together and arms at the sides, closes the eyes, and maintains the position for about 20 seconds; sudden loss of balance is positive.

What tests can be used to assess cerebellar coordination?

Finger-to-nose, rapid alternating movements, and heel-to-shin testing.

What is the normal deep tendon reflex rating identified in the notes?

2/4 bilaterally.

Which deep tendon reflexes are identified in the notes?

Biceps, brachioradialis, triceps, patellar, and Achilles.

What is the normal adult plantar response?

The toes flex downward.

What is a positive Babinski response in an adult and what can it indicate?

Dorsiflexion of the great toe with fanning of the other toes; it can indicate upper motor neuron disease.

How is the Brudzinski sign assessed and what is a positive response?

Passively flex the neck while the client is supine; involuntary flexion of the hips and knees is positive.

How is the Kernig sign assessed and what is a positive response?

Flex the hip and knee to 90 degrees and attempt to extend the knee; resistance to extension or severe hamstring pain is positive.

What do positive Brudzinski and Kernig signs suggest?

Meningeal irritation or inflammation.

What is an ischemic stroke?

A stroke caused by occlusion of a blood vessel by a thrombus or embolus.

What is a hemorrhagic stroke?

A stroke caused by rupture of a blood vessel.

What is a TIA?

Temporary focal ischemia without infarction that can serve as a warning sign.

What does BE FAST stand for?

Balance → Eyes → Face → Arms → Speech → Time.

What does Balance mean in BE FAST?

Sudden loss of balance, dizziness, or unsteadiness.

What does Eyes mean in BE FAST?

Sudden visual change or vision loss.

What does Face mean in BE FAST?

Facial drooping or an asymmetric smile.

What does Arms mean in BE FAST?

Unilateral arm weakness or numbness.

What does Speech mean in BE FAST?

Slurred speech, difficulty speaking, or difficulty understanding speech.

What does Time mean in BE FAST?

Activate emergency response immediately.

What stroke risk factors are identified in the notes?

Hypertension, high cholesterol, diabetes mellitus, smoking, physical inactivity, obesity, atrial fibrillation, advanced age, and family history.

What stroke-prevention teaching is included in the notes?

Stop smoking, limit alcohol, control blood pressure and blood glucose, get at least 30 minutes of moderate activity per day, and emphasize fruits, vegetables, whole grains, and lean protein while limiting sodium and saturated/trans fats.

What does a cerebellar ataxic gait look like?

Wide-based, staggering, and unsteady.

What does a Parkinsonian gait look like?

Stooped and rigid posture with short, rapid, shuffling steps and diminished arm swing.

What does a spastic hemiparetic gait look like?

The affected arm is flexed and adducted while the affected leg remains extended and is dragged in a semicircle or circumduction pattern.

What does a footdrop gait look like?

Inability to dorsiflex the foot produces a high-stepping pattern or dragging of the foot.

What is decorticate posturing?

Flexor posturing with the upper extremities flexed and adducted toward the chest and the lower extremities extended, internally rotated, and plantar flexed.

What is decerebrate posturing?

Extensor posturing with the upper extremities extended, adducted, and pronated and the lower extremities extended and plantar flexed.

What primitive reflexes may be present in newborns or infants?

Rooting, sucking, Moro, and Babinski reflexes.

Approximately how much adult brain capacity is present by ages 1 and 7 according to the notes?

About 50% by age 1 and about 90% by age 7.

What neurologic changes may occur during childbearing?

Peripheral nerve compression causing foot pain or paresthesia, carpal tunnel symptoms, leg cramps, and transient dizziness.

What neurologic concerns are especially important in older adults?

Concentration, falls, syncope, lightheadedness, and gait.

What tools are identified for assessing cognition or concentration in older adults?

SLUMS and CAM.

How may gait change with aging?

It may become slower, more deliberate, and uncertain.

What are normal neurologic motor and coordination findings in the notes?

Upper and lower extremity strength 5/5 bilaterally, normal finger-to-nose and heel-to-shin testing, normal rapid alternating movements, and a steady gait.

What nursing concern is associated with impaired swallowing after a stroke?

Risk for aspiration.

What nursing concern is associated with aphasia after a stroke?

Impaired verbal communication.

What cranial nerves are especially relevant when a stroke client has dysphagia?

CN IX and CN X.

What additional assessments are identified in the stroke case?

Bedside swallowing assessment, speech and language assessment, NIHSS, complete strength assessment, and cranial nerve assessment.