Neurological Assessment

Nervous system functions

Imitation/coordination of movement

• Coordination = cerebellum

• Movement = musculoskeletal reception/perception of sensory stimuli organization of thought processes (judgement calls)

• Control of speech storage of memory (long & short-term)

When assessing mental & emotional status of a pt you should assess ___ as well as ___

Alertness/orientation, level of consciousness

Alertness/orientation

A&O x4 = Normal

• Person: name

• Place: “in a hospital”

• Time/date

• Reason/circumstance: understand why they are at where they are

A&O x1 = Only can state name

Level of consciousness

• Glasglow coma scale

• The four score

Glasglow coma scale

• Objective numerical scale

• Measures level of consciousness overtime

Limits

• No intubated pts

• Doesn’t evaluate the brain stem

  • Score of 15 = fully alert and conscious

  • Score of <7 = comatose

The four score

• Full outline of unresponsiveness

• Combines most important neurologic signs into a scale w/ 4 components

• Max score in each component is 4

  • Eye response

  • Motor response

  • Brain stem reflex

  • Respirations

• Can be used for intubated pts

• No assessment of verbal

Assessing behavior/appearance

Behavior- Non-verbal cues, Varying mood, Inappropriate reactions

• Mood

• Hygiene

• Grooming

• Choice of dress (weather)

Assessing language

Evaluates cerebral cortex function

• Normal: understands both forms & expression of words

• Ability to understand spoken/written words

• Ability to express thoughts

  • Writing, word, gestures, voice inflection, tone, manner of speech

• Normal: coherent & not slurred

• Listen for little things that don’t make sense/misusing words

Aphasia

Without speech; injury to cerebral cortex

Sensory (receptive) aphasia

Inability to understand written/verbal speech

• Can hear/see words but can’t make sense of meaning

Motor (expressive) aphasia

Inability to write/speak appropriately

• Know what they want to say but can’t speak it

Motor & sensory aphasia

Depends on area of cerebral cortex damage - could be result of stroke; CVA

Assess for aphasia

• Point to an object & have pt name it

• Ask pt simple questions: “can you nod yes”

Intellectual function assessment

• Memory

• Knowledge

• Abstract thinking

• Association

• Judgement

Memory

• Recent/short-term & remote/long-term

• Immediate recall assessment

  • Ask pt to repeat words back to you

  • Pt should be able to repeat words after a few seconds

Knowledge

Pts ability to learn/understand

• Assess through teaching

• Ask pt follow up questions after teaching opportunity

Abstract thinking

Interprets colloquialisms

• Ask pt to explain things like: “Don’t count your chicken before they hatch”

• Abnormal: pt will take it literally/repeat it back to you w/ different words

Association

Identifies related concepts

• Ask pt: “A dog is to a beagle as a cat is to a ___”

• Normal: pt connect do and provides correct answer

Judgement

Logical decision making

• Comparison of facts and ideas

• Ask pt questions: “What would you do if you became ill at home” or “What would you do if you locked yourself out”

Olfactory (1)

Sense of smell

• Sensory

• Assess potency of both nasals

• Have pt close eyes & inhale

• Assess smell: alcohol pad/coffee beans

• Bilateral decreased smell

Bilateral decreased smell

Affects olfactory nerve

• Results of smoking, age, chronic, allergies

Optic (2)

Visual acuity

• Sensory

• Transmits visual information to the brain via the optic canal

• To assess: Snellen chart, Check visual fields

Oculomotor (3)

Extraocular eye movement

• PERLA

Pupil size

• Constriction

• Dilation

Trochlear (4)

Up/down eyeball movement

• Motor

To assess

• “Can you look up/down w/ just your eyes”

Trigeminal (5)

Sensory nerve to face

To assess:

• Gently touch cotton ball to areas of face

• Pt should have eyes closed

• Have pt tell when they can feel & which side it’s felt on

Motor nerve jaw muscles:

• Clench teeth

Abducens (6)

Lateral eye movement

• Motor

To assess:

• “Can you move your eyes laterally”

• Hold gaze to side to look for an astigmatism

Facial (7)

Facial expression

• Sensory/motor

Test for symmetry

• Frown, lift eyebrows, puff out cheeks

Taste on front of tongue

• Sensory

• Have pt taste sugar, salt, lemon juice

Auditory (8)

Hearing

• Sensory

• Whisper test

Glossopharyngeal (9)

Gag reflex/swallow

• Motor

• Assess w/ tongue blade

• Abnormal: Dysphagia

Taste on back of tongue

• Sensory

• Have pt taste something salty/sour

Dysphagia

Inability/difficult swallowing

• Seen w/ stroke pts

• Increases risk for aspiration

Vagus (11)

Sensory/motor

• Swallowing - hoarseness?

• Movement of vocal cords

  • Have pt swallow/speak - sensations of pharynx

  • Sensory

Spinal accessory (11)

Motor

• Movement of head & shoulders

• To assess: Rotate head, Shrug shoulders against applied pressure from hands

Hypoglossal (12)

Motor

• Position of tongue

• To assess: Stick out tongue - move it side to side

Sensory function assessment

• Pain

• Temperature - hot/cold

• Stimuli

• Position

• Vibration - tuning fork

• Numbness/tingling

• Crude/fine localized touch

• Assess both sides of body

Radiculopathy

Pain that travels along nerve line

Sciatica

Damage/disease to sciatic nerve

• Presents in butt pain

Stenosis

Narrowing of nerve pathway

Assessing crude/fine localized touch

• Can be accomplished during other exams

• Note presence/absence of bilateral symmetry

• Pt should be able to identify if a sensation is dull/sharp

• Assess both side of body

When assessing

• Have pt close eyes

• Pt should identify dull/sharp

• Utilize dermatome zones to assess sensation related to specific spinal location (what level of cord is having injuries)

Motor function

• Interrelated to musculoskeletal system

• Determine cerebellar function

• Smoothness/steadiness/efficiency of movement

  • Balance

  • Equilibrium

  • Posture

Coordination

• Fine motor

• Performance of rapid, rhythmical, alternating movements

To assess

• Extend arm & touch nose w/ eye closed

• Touch nose then nurse’s finger

• Toe tapping

• Knee slapping

Balance

Romberg test

• Evaluate amount of swaying

• Abnormality: loss of balance; indicates cerebellum lesion/dysfunction

  • Have pt close eyes & stand on one foot than another

• Should be able to hold position for 5 seconds

• Slight swaying

• Walking in a straight line w/ eye open

• Heal to toe

• Tandem walking

Reflexes

Evaluated by advanced practitioners using reflex hammer

assess deep tendon & cutaneous

• Pt should relax as much as possible

• No movement/tension

• Interlock fingers to distract when doing patellar

Data:

• Integrity of sensory & motor pathways of the reflex arch

• The specific spinal cord segment

• Older people is not unusual to have diminished

Hyperactive reflex

Results from use of cocaine, alcohol, opioids intoxication

Preterm labor & reflexed

• Hypertension → seizures

• IV med of magnesium sulfate will be administered

  • Leads to hypo-activity of DTR

  • Should be closely monitored