NU 126 Health Assessment: Neurological System Part II

Healthy Patient Neuro Assessment (5 steps)

1. Mental status

2. Cranial nerves

3. Motor function

4. Sensation

5. Reflexes

Mental status exam includes..

Level of alertness, appropriate responses, orientation to date and place

Cranial nerve assessment (basic) includes..

CNI Olfactory - nasal patency and sense of smell

CNII Optic - Visual acuity, pupillary light reflex

CNIII Oculomotor, CNIV Trochlear, and CNVI Abducens - Eye movements (PERRLA)

CNV Trigeminal - Jaw movements, strength

CNVII Facial - Facial strength

CNVIII Vestibulocochlear - Hearing

Motor function assessment includes..

Strength, range of motion

Gait, coordination

Sensation assessment includes...

touch, pain, vibration, stereognosis

Reflex assessment includes..

Deep tendon reflexes scored 0-4

Mini-Cog Assessment

can be used to detect cognitive impairment quickly during both routine visits and hospitalization

Components of the Mini-Cog

3 word registration, clock drawing, 3 word recall

Abnormal clock drawing is how many points?

0

Normal clock drawing is how many points?

2

Each word recalled without cues is how many points?

1

Total score of Mini-Cog =

Clock drawing (0 or 2) + 3 word recall (0-3)

Score 0-2 of Mini-Cog

HIGHER likelihood of cognitive impairement

Score 3-5 of Mini-Cog

Lower likelihood of cognitive impairment

Normal score of Mini-Cog

5/5

Mental Status Exam in Children

- Simple reflex progresses into complex logical and abstract thought

Why is developmental testing done?

To assess milestones and growth

When do depression/anxiety screenings occur?

Adolescent years

How many children have mental health disorders?

1 in 5

Mental Status Exam in Aging Adult

- Note slower responses, leave extra time

- Sensory perceptions can affect mental status

- Decreased RECENT memory, not LONG TERM

- Increased chronic illness prevalence = higher depression rates

With increased depression rates in aging adults and adolescents, what must always occur?

Screenings

With the aging adult, what else should be considered?

Can the patient hear what I am asking or is there something else going on?

Sexual and Gender Minority Exam Considerations

Rejection + discrimination increase mental health risk

Avoid heteronormative language

Infant Neuro Exam

Movement assessed by primitive reflexes, assess elimination at appropriate times

Note milestones

Is the neurological system developed completely at birth?

NO

Can cranial nerves be tested in infants?

not directly

What should be assessed regarding the motor system in infants?

Smoothness, symmetry

Sensory testing in infants

very little

Primitive reflexes

Rooting

Sucking

Palmar Grasp

Tonic neck

Moro

Babinski

Rooting reflex

Birth to 3-4 months

Sucking reflex

birth to 10-12 months

Palmar grasp reflex

Birth to 3-4 months

Tonic neck reflex

2-3 months to 4-6 months

Moro reflex

Birth to 1-4 months

Babinski reflex

Birth to 24 months

How to perform neuro assesment for preschoolers/school age children

Assess during play

Normal wide base gait for toddler/preschoolers

Supine > Sit > Stand

Balancing on 1 foot by 4 years

No DTRS under 5

6 years + sensory testing and coordination

If preschooler/child is feverish, sick, or irritable what should be tested?

Nuchal rigidity

Nuchal rigidity

neck stiffness that can be a sign of meningitis

Considerations for neuro assesment in aging adult

Atrophy of neuron structure in the CNS

Loss of muscle strength, slower gait, impaired coordination, and agility

Slowed reaction time

Diminished sensation

Less brisk DTRs

Irregular pupils

Essential tremors

Essential tremors in aging adult

Normal finding

Benign intention tremor of hands, head nodding, tongue protrusion

A GCS of 12-15 indicates

the patient is alert, arouses easily

GCS 9-12 indicates

Patient is lethargic or obtunded, slow to response

GCS 3-8 indicates

Semi-coma or coma, vigorous force needed to stimulate or completely unconscious

GCS Variable 13-15 indicates

Delirium (acute confusion), dulled cognition and impaired alertness

Abnormalities in mood/affect

Anxiety disorders

Alzheimer's

3 Ds

Speech disorders

Generalized vs. Social Anxiety

Generalized is not specific while social is worries about other's perception of them

Alzheimer's Disease

a progressive and irreversible brain disorder characterized by gradual deterioration of memory, reasoning, language, social withdrawal, mood swings, and confusion

What is the most common form of Alzheimer's?

Dementia

3 D's

delirium, dementia, depression

Delirium

Onset in hours to days and can be reversible, usually lasting under 1 month

Presents as confused, impaired attention, and hypoactive/hyperactive consciousness

Dementia

Onset is months to years, is progressive and fatal lasting years to decades

While mild, orientation and attention intact and declines over time

Consciousness is normal

Depression

Onset weeks to months, chronic but responds to treatment

Orientation, attention, and consciousness normal

When differentiating between dementia and depression, what could the nurse do?

Perform a depression screening, gain more information about cognitive functioning

Broca's aphasia

condition resulting from damage to Broca's area, meaning they can understand speech but struggle to form sentences

Wernicke's Aphasia

condition resulting from damage to Wernicke's area, receptive aphasia that causes difficulty understanding speech

Cranial nerve abnormalities

Bells Palsy

Trigeminal Neuralgia

Nystagmus

Bells Palsy

temporary paralysis of the seventh cranial nerve that causes paralysis and asymmetry only on the affected side of the face

Trigeminal neuralgia

characterized by debilitating nerve pain due to an inflammation of the trigeminal nerve

Nystagmus

involuntary, jerking movements of the eyes

How is nystagmus evaluated?

Amplitude (fine, medium, coarse)

Frequency (constant? fading?)

Plane of movement (horizontal, vertical, rotary, combination)

Muscle tone abnormalities

Size (atrophy, hypertrophy)

Strength (paralysis, plegia)

Tone (Limited ROM, pain, flaccidity, rigidity, spasticity)

Cerebellar Abnormalities

Gait

Romberg Test

Shallow Knee Bend/Hop

Gait abnormalities

stiff, wide, staggering, lack of arm swing, ataxia crooked walk, loss of balance, muscle weakness

Romberg test abnormalities

sway, falls, widens base

Shallow knee bend/hop abnormalities

unable to bend or hop bilaterally, weakness

Positive Babinski, or plantar reflex, over 2 years is..

ABNORMAL, tell provider immediately

Possible meaning of positive babinski sign

ALS

Stroke

Brain tumor/injury

Multiple sclerosis

Spinal cord injury

Meningitis

Cerebral Palsy

Cerebral Vascular Accident (CVA)

Blood flow is interrupted to the brain, can be ishemic or hemorrhagic

Ischemic

pertaining to a lack of blood flow

Hemorrhagic

pertaining to profuse or excessive bleeding

What type of stroke is more common?

Ischemic

Transient ischemic attack

temporary interruption in the blood supply to the brain

Risk factors for CVA

Family history

Age

Obesity

Smoking

High BP

A-Fib

BE FAST scale purpose

Initial assessment for stroke symptoms

BE FAST

Balance

Eyes

Face

Arms and legs

Speech

Time

Worst headache of their life may indicate..

hemmorrhagic stroke

Primary Prevention

Efforts to prevent an injury or illness from ever occurring

Examples of primary prevention

Vaccinations, seatbelts, wear a helmet

Secondary prevention

Efforts to limit the effects of an injury or illness that you cannot completely prevent

Examples of secondary prevention

Health screenings

Diabetes management

Tobacco cessation

Tertiary prevention

actions taken to contain damage, or manage symptoms, once a disease or disability has progressed beyond its early stages

Example of tertiary prevention

Rehab and further prevention for a stroke

Documentation for the Neurological Assessment

Appearance

Behavior

Cognitive function

Thought process

Mini-cog score