H&PA Exam 2 - Neurologic Assessment

Neurological

Comes from neurology, which deals with problems affecting the nervous system.

Nervous System

Includes the brain, spinal cord, and all the nerves branching out to the rest of the body, can be affected by damage to the patients neurological system.

Central Nervous System (CNS)

Brain + Spinal Cord

Parasympathetic Nervous System (PNS)

Cranial Nerves + Spinal Nerves

Frontal Lobe

• Personality, behavior, emotions, intellectual function

• Broca’s Area – Speech production

• Motor Cortex

Parietal Lobe

Sensation

Occipital Lobe

Visual reception

Temporal Lobe

• Auditory reception (hearing), taste, smell

• Wernicke’s Area – Language comprehension

Hypothalamus

Vital Functions:

• To keep your body in a stable state called homeostasis (the state of balance among all the body systems, that allows the body to function correctly and survive.

• Influences your autonomic nervous system, including:

  • Respiratory center, temperature, appetite, sex drive, heart rate.

  • Regulates anterior/posterior pituitary

    • Hormone regulation

Cerebellum

Vital Functions:

• Most directly involved in coordinating voluntary movements.

• Also responsible for a number of functions including motor skills such as balance, coordination, and posture.

Neurons

• Basic unit of nervous system

• Receives/transmits electrochemical nerve impulses

Afferent Neurons

• Sensory nerves

• Carry impulses from the body to the brain

Efferent Neurons

• Motor nerves

• Carry impulses from the brain to the body

Common Neurological Changes in The Aging Adult

• Loss of muscle from decreased use and atrophy (shrinking of the brain)

• Decreased Cerebral Blood Flow due to impaired gas exchanges secondary to cardiac and vascular issues

Shift Assessment

All patients regardless of:

• Chief complaint

• Admitting diagnosis

• PMH

Focused Assessment

Any patient presenting with:

• Neurologic concerns

• Significant neurologic PMH

• Basic neurologic assessment reveals an abnormality or change from previous assessment

Chronic Disease of Brain, Spine or Nerves:

Parkinson’s Disease, Multiple Sclerosis, Stroke (CVA), TIA

Headache:

Observe for onset, frequency and severity, description, location, quality and other associated factors such as weakness and aphasia.

Head Injury:

• Assess for signs of brain injury

• Loss of consciousness, dizziness, blurred vision, trouble speaking?

Dizziness/Vertigo:

• Onset, duration, description, frequency

• Associated with change in activity or medication?

Memory:

• Onset, duration, chronic vs. acute

• ↓ mental function or ↑

Seizures:

• Onset, duration, and motor assessment during body movement

• Associated clinical presentations?

  • Postictal phase: A temporary group of symptoms you feel immediately after a seizure and before you feel well again. Common symptoms include exhaustion, confusion and sore muscles, increased lethargy and slurred speech.

• Precipitating factors/auras?

• Medication therapy and strategies

Weakness:

• Localized or generalized, distal or proximal extremities

• Impact on mobility or ADLs

Tremors:

• Onset, type, duration, location, and frequency

• Precipitating and alleviating factors

Sudden Vision Changes:

• Onset, duration, and frequency

• Loss of consciousness?

Incoordination:

• Problems with balance while standing or ambulating

• Lateral drifting of extremities, stumbling, or falling

• Legs giving way and/or decreased movement

Numbness or Tingling:

• Onset, duration, and location

• Occurs with activity?

Difficulty Swallowing:

• With solids or liquids

• Drooling

Difficulty Speaking:

• Onset, pattern, and duration

• Clarity

• Forming words or saying what you want to say

Patient-Centered Care:

• Information regarding past medical history 

• Alcohol abuse history

• Substance Abuse/Drug history

Assessing Mental Status = Cognition

• Level of Consciousness

• Level of Arousal

• Orientation Status

• GCS: Glascow Coma Scale

Assessing Brain Function

• Symmetry at Rest

• Speech

• Pupillary Responses

  • PERRLA

• Strength

• Sensation

Alert

• Awake, eyes open, answers questions appropriately

• Aware of external and internal stimuli

Lethargic

• Can’t keep eyes open/stay awake

• Excessive drowsiness

• Able to wake to verbal stimuli

Obtunded

• Sleeps most of the time

• Responds only to loud name calling or vigorous shaking

• No interest in surroundings

Stuporous

• Little response to verbal stimuli

• Requires persistent/vigorous stimulation

• Requires painful stimuli to respond

• Moans in response to stimuli

Comatose

• Unable to be aroused

• No response to stimuli

Level of Arousal: Spontaneously (Awake)

No stimuli needed

Level of Arousal: Verbal Stimuli

Name calling

Level of Arousal: Light Touch

Place hand on patient’s arm/leg, gently rub/shake patient

Level of Arousal: Vigorous Stimuli

• Shaking - Grasp shoulders, shake vigorously

• Sternal Rub - Use knuckles, apply pressure to sternum and rub

Is the person oriented to: Person

• Name

• Date of Birth

  • A&OX1 (Person)

Is the person oriented to: Place

• Location

• Unit/Facility

  • A&OX2 (Person + Place)

Is the person oriented to: Time

• Day of Week

• Date (Month, Day, and Year)

• Season

  • A&OX3 (Person + Place + Time)

Is the person oriented to: Situation (event)

• Current problem

• Why are they here?

• Medical diagnosis

  • A&OX4 (Person + Place + Time + Situation)

Glasgow Coma Scale (GCS)

• Eye opening response

• Verbal response

• Motor response

Glasgow Coma Scale - Scoring: 

• 13-15: Mild brain injury

• 9-12: Moderate brain injury

• 3-8: Severe brain injury

  • A higher GCS score means the patient is more alert and has better brain function.

  • A lower GCS score indicates decreased consciousness and more severe brain injury.

Assessing Brain Function: Symmetry at Rest

• Facial structures

  • Eyebrows

  • Eyes

  • Nose

  • Ears

  • Mouth

• Observe for:

  • Shape

  • Size Comparison

  • Placement

  • Drooping

Assessing Brain Function: Pupillary Responses

• PERRLA

  • Pupils Clear

  • Pupils Equal

  • Round

  • Reactive to Light

  • Accommodation

Assessing Brain Function: Speech

• What is the patient’s quality/rate of speech?

  • Normal tone and word finding

  • Abnormal/Unexpected:

    • Slow vs. rapid

  • Word Choice – Appropriateness of answers

• What is the patient’s verbal clarity?

  • Understandability

  • Normal/Expected: Clear and concise

  • Abnormal/Unexpected:

    • Garbled

    • Slurred

    • Incomprehensible

Causes of Speech Disorder

• Vocal cord damage

• Brain damage

• Muscle weakness

• Strokes

• Respiratory weakness

• Drug abuse

• Hearing loss

Speech Disorders - Articulation Disorders (common)

• Phonological - mental representation problem (can make sound, but doesn't)

• Articulation - structural problem (can't make sound)

• Substitutions, omissions, additions, distortions

Speech Disorders - Fluency Disorders

Interruptions in the flow of speaking (stuttering)

Speech Disorders - Voice Disorders

Pitch, duration, intensity, resonance, vocal quality

Speech Disorders - Motor Speech Disorders

• Apraxia - lack of coordinated muscle movement

• Dysarthria - weak, slow, or paralyzed muscles

Aphasia

Difficulty with language comprehension and production of sounds.

Receptive Aphasia

• Cannot understand written or spoken language

• Hears sounds/reads words but does not understand the words

• Can speak fluently and effortlessly with clear speech but they say the wrong or made-up words when speaking

Expressive Aphasia

• Understands spoken and written language

• Cannot express oneself verbally or transcribed

Global Aphasia

Experiences components of both expressive and receptive aphasia

Stroke / Cerebral Vascular Accident (CVA)

• A medical condition in which poor blood flow to the brain causes cell death.

• Two main types:

  • Ischemic: due to lack of blood flow

  • Hemorrhagic: due to bleeding

    • Both cause parts of the brain to stop functioning properly.

BE FAST

• B = balance: Loss of balance or coordination.

• E = eyes: Changes in your vision, like losing sight in one or both eyes or starting to see double vision.

• F = face: Drooping facial features on one side of the face.

• A = arms (and legs): Weakness in one of your (or someone else’s) limbs.

• S = speech: Slurring words or otherwise having difficulty speaking or understanding others.

• T = time: Don’t take a “wait and see” approach. Call 911 or emergency services immediately.

Culture (Strokes):

• Dietary beliefs

• Poor food options

• Food intolerances

• Taste changes

• Sedentary lifestyles

  • All the above equal an increased risk for stroke

Genetics (Stroke):

No Specific Genetic Link

Likelihood for strokes based on ethnicity:

• Racial/Ethnic Disparity

  • 1.3% Asian/Pacific

  • 2.3% Hispanics

  • 2.5% Whites

  • 4% African Americans

  • 4.6% American Indians

CVA: Health Promotion and Risk Behaviors

• Alcohol Intake/Drug Use

• Diets high in fat, sodium, and sugar

• Smoking

• Poor physical activity, starting in elementary school

• Increased sedentary activities, limited outside activities

• Non-compliance with medication or medical routines

Assessing Strength

• Where to Test?

  • Upper Extremities

    • Hand Grasps

      • Pt. squeezes examiners fingers bilaterally for comparison

  • Lower Extremities

    • Plantarflexion/Dorsiflexion

      • Pt. points toes towards floor and then up towards nose against resistance bilaterally for comparison

• How to Rate?

  • Strong, Moderate (Average), Weak, or Absent

Assessing Sensation

• Palpate arms, legs, and feet bilaterally

• Determine if sensation is equal on both sides

Observe facial features for symmetry

Ask the patient to:

• Smile

• Frown

• Close eyes tightly

• Lift eyebrows

• Puff cheeks

• Stick out tongue

Cotton Ball

• Patient’s eyes remain closed

• Nurse gently touches the cotton ball along the patient’s forehead, cheeks, and chin

• Patient verbalizes when they can feel the cotton ball

Paper Clip or Tongue Blade

• Patient’s eyes remain closed

• Nurse gentle pokes/touches the tool against various points on the upper and lower extremities

• Patient verbalizes when they can feel the touch AND sharp vs. soft sensation

Deep Tendon Reflexes - Equipment

• Reflex Hammer - Used to strike tendon at muscle

  • Two sides

    • Pointed end – small target areas (upper extremities)

    • Flat end – wider targets (lower extremities)

4-Point Reflex Response Grading

• 4+ Brisk/Hyperactive

• 3+ Brisker than average

• 2+ Average (Normal)

• 1+ Diminished

• 0 No Response

Deep Tendon Reflexes - Optimize Results

• Extremity should be relaxed

• Muscle partially stretched

• Swing hammer by moving your wrist

• Excess force is not needed

Clonus

Rapid, rhythmic contraction of muscle

Hyperreflexia

Exaggerated reflex

Hyporeflexia

Diminished or absent reflex

Assessing Balance in Motion

Heel-to-Toe Walking

Assessing Stationary Balance

• Romberg’s Test

  • Pt. stands with feet together, arms at their sides, and eyes closed

  • Nurse assesses for loss of balance

Babinski Test

• Pt. lies supine in bed

• Nurse uses a blunt object (for ex. Reflex hammer) to gently touch the lateral side of the sole of the foot from the heel to the base of the big toe

• Nurse assesses the response of the toes