NU 126 Health Assessment: Neurological System + Assessment

Basic Assessment for the Neurological System

1. Level of Consciousness

2. Speech

3. Mood and affect

4. Attention

Level of Consciousness (LOC)

A&Ox4

Speech should be?

normal and clear

Mood and affect should be?

appropriate to the situation

Normal findings for attention

Patient can follow along with the conversation

If abnormalities are found, the nurse should?

Document them

When does the neuro assessment begin?

When the nurse meets the patient, simple greetings can tell a lot about the patient

A basic neurological assessment should be used for who?

An otherwise healthy patient

Focused Neurological Assessment

1. Chief Complaint

2. History of present illness

3. Family history

4. Past medical/surgical history

5. Allergies

6. Medications

7. Review of systems

8. Physical exam

Chief Complaint

the main reason for the patient's visit, the response to "What brings you into the hospital today?"

If the patient cannot vocalize the chief complaint (aphasic, TBI, stroke, etc), what should the nurse do?

Find someone who can give them the chief complaint

For history of present illness, what can the nurse use?

OLDCARTS acronym

OLDCARTS

Onset

Location

Duration

Characteristics

Aggravating and Alleviating Factors

Related Symptoms

Treatment

Severity

Why is knowing a patient's medications important?

Medications may help or make their current issue worse, such as Warfarin for bleeding

While evaluating past medical history, what key points should the nurse evaluate?

Lifestyle risk factors, such as alcohol abuse

Cognitive defects (dementia)

Exposures and travel history

Comorbidities

The nurses knows that it is important to know the patient's _______ when evaluating the history.

BASELINE

Why is a baseline important?

a baseline allows the nurse to identify changes within a patients condition, and whether an abnormal finding may be normal for them

Patient history is...

CRUCIAL

For the review of systems, what should the nurse ask generally?

Hand dominance

Travel

Sleep issues

Behavioral issues

Stress

Why is hand dominance important for strokes?

Strokes are contralateral, meaning they affect the opposite side of the body, therefore hand dominance indicates which side of the brain was likely affected

For the review of systems, what should the nurse ask regarding HEENT?

Does the patient have vision loss?

Hearing loss?

Hallucinations?

For the review of systems, what should the nurse ask regarding the cardiovascular system?

Does the patient have peripheral vascular disease?

Does the patient have carotid disease?

Have they had past strokes?

Does the patient have heart palpitations, such as A-Fib?

A-Fib

atrial fibrillation, very irregular heart rhythm that can cause blood clots that move to the brain

Do the respiratory and gastrointestinal system correlate closely to tge neurological system?

No, not many questions asked about these systems during a neuro assessment

For the review of systems, what should the nurse ask regarding the musculoskeletal system?

Assess gait

What does the patient do for exercise?

How is the patient's mobility?

For the review of systems, what should the nurse ask regarding the neurological system?

Has the patient had past strokes?

Does the patient have any other neurological conditions, such as multiple sclerosis?

For the review of systems, what should the nurse ask regarding the endocrine system?

Does the patient have an endocrine disease, such as diabetes or thyroid issues?

For the review of systems, what should the nurse ask regarding the hematologic system?

Does the patient have a clotting disorder?

Are they on blood thinners?

Do they bleed easily?

The review of systems is a great way for the nurse to..

Gain more knowledge regarding the patient's past medical/surgical history

Why is family history important to gather during a neurological assessment?

There may be a genetic predisposition to strokes or other neurological issues

During a neurological assessment, the physical assessment contains what five aspects?

1. Mental status

2. Cranial nerves

3. Motor system (coordination and gait)

4. Sensory system

5. Deep tendon reflexes

What equipment is needed for a neurological assessment?

Penlight

Tongue blade

Cotton swab

Cotton ball

Tuning fork

Percussion hammer

1. Mental Status Exam

Evaluates level of consciousness, language, mood and affect, orientation, attention, and memory

What kind of scales can be used for the mental status exam?

Mini Mental Status Exam and Glasgow Coma Scale

Mini-Mental Status Examination (MMSE)

brief screening test for cognitive abilities

Glasgow Coma Scale (GCS)

a neurologic scale used to assess level of consciousness

Levels of Glasgow Coma Scale

1. Eye opening

2. Verbal response

3. Motor response

The lower score for MMSE and Glasgow means..

the worse their cognitive functioning is

Normal findings for the mental status exam

A&Ox4, normal cognitive abilities

Abnormal findings for the mental status exam

Confused, lethargic, obtunded, comatose

Obtunded

barely responsive

Comatose

non-responsive

Why is it important to know the patient's baseline during the mental status evaluation?

A dementia patient would not be A&Ox4

2. Cranial Nerves

12 pairs

12 pairs of cranial nerves

1. Olfactory

2. Optic

3. Oculomotor

4. Trochlear

5. Trigeminal

6. Abucent

7. Facial

8. Vestibulocochlear

9. Glossopharyngeal

10. Vagus

11. Accessory

12. Hypoglossal

Mneumonic for cranial nerves

Oh

Oh

Oh

To

Touch

And

Feel

Very

Good

Velvet

Ah!

Ha!

CNI Olfactory

tests sense of smell and nasal patency

CNI Olfactory Nerve Test

Ask pt. to identify smells in each nostril

Normal findings for CNI

Bilateral identification

Abnormal findings for CNI

Anosomia, or decreased/loss of smell can indicate loss of olfactory nerve function

CNII Optic

tests vision and peripheral vision

What is being tested while testing the Optic nerve?

Vision by chart and peripheral vision

CNII Optic Nerve Test

Confrontation visual field for peripheral vision and visual acuity using the Snellan or E chart

How to test peripheral vision?

patient and nurse face each other, nurse moves fingers into visual field and patient says when object can be seen

What if patient is wearing glasses?

Remove for baseline

CNIII Oculomotor

tests pupillary light reflex and accommodation

PERRLA

pupils equal, round, reactive to light and accommodation

Accomodation

the process by which the eye's lens changes shape to focus near or far objects on the retina

Normal finding for CNIII

PERRLA

Abnormal findings for CNIII

Anisocoria

Mydriasis

Miosis

Anisocoria

unequal pupil size

Mydriasis

dilation of the pupil

Miosis

constricted pupils

CNIV Trochlear and CNVI Abducens

Assess ocular muscle function through assessing eye movement in the 6 cardinal fields

Normal findings for CNIV Trochlear and CNVI Abducens

Eyes move smoothly with movement

Abnormal findings for CNIIV Trochlear and CNVI Abducens

Nystragmus

Ophthalmoplegia

Nystragmus

rapid movement of the eyeball that can indicate a cranial nerve deficit

Ophthalmoplegia

paralysis of the eye

Abnormal findings of CNIV Trochlear and CNVI Abducens can indicate issues with..

Cerebellum

Brainstem

Vestibular system

CNI V Trigeminal

Assesses motor function and sensory function through assessing jaw movement and light touch sensations

Normal findings for CNI V

Equal bilateral strength, masseter muscles equal and the patient can clench jaw

Abnormal findings for CNI V

asymmetry, pain, or decreased sensation

CNVII Facial

Assesses facial movement

Normal findings for CNVII

Symmetrical with movement and rest, strength

Abnormal findings for CNVII

Asymmetry

CNVIII Vestibulocochlear

Assesses hearing

Ways to assess CNVIII

Whisper test

Weber and Rinne test

Whisper test

nurse whisper in patient's ear, asks them to repeat it, to evaluate if they can hear

Weber test and Rinne test

Assesses for conductive or neurosensory hearing loss

CNIX Glossopharyngeal and X Vagus

Assesses pharyngeal sensation and gag reflex

What should be examined while evaluating CNIX and X?

Uvula movement and positive gag reflex

Quality of speech and voice

When should the gag reflex be evaluated?

BEFORE giving the patient anything by mouth to reduce risk of aspiration

Normal findings for CNIX and X

Positive gag reflex

Positive pharyngeal sensation

Clear voice

Ability to swallow

Abnormal findings for CNIX and X

Asymmetrical uvula

Absent gag reflex

Difficulty swallowing

Hoarse/brassy voice (vocal cord damage)

CN XI Spinal Accessory

Assess sternocleidomastoid and trapezius for muscle strength by having patient move head side to side and shrug shoulders against resistance

Normal findings for CNXI

Can shrug shoulders with equal strength against resistance

Can turn head both ways with equal strength

Abnormal findings for CNXI

Inability to shrug or turn the head against resistance

Atrophy, paralysis, stroke, neuropathy

CNXII Hypoglossal

Assess the movement of tongue by asking patient to stick tongue out

Normal findings for CNXII

Tongue is symmetrical and midline, moves easily from side to side with no tremor

Abnormal findings for CNXII

Tongue can only move to one side, profound tremors

Abnormal findings for CNXII may indicate..

paralysis, stroke, or lesion on CNXII

Why is swallowing constantly assessed for safety?

Many cranial nerves result in successful swallowing, reduces risk of aspiration

3. Motor System (Muscle Strength)

Assesses muscle strength, range of motion, appearance, tone, and involuntary movements

Passive range of motion

movement that is performed completely by the nurse to assess resistance

Active range of motion

the process whereby a patient puts a joint through its full extent of movement

Abnormal findings for motor system

Atrophy/hypertrophy

Limited ROM

Pain

Flaccidity, spasticity, rigidity

Paresis or paralysis

Decorticate or decerebrate posturing

Spasticity

muscle spasms

Paresis

weakness

Decorticate posturing

arms flexed inward and bent in toward the body and the legs are extended

Decerebrate posturing

position of an unconscious person where the upper extremities and lower extremities are flexed out and the wrists are flexed