Foundations of Nursing - Neurologic Assessment

Central Nervous System

brain and spinal cord

Peripheral Nervous System

12 pairs of cranial nerves and peripheral and spinal nerves

What is an important skill to have in the neurologic assessment?

the proper use of standardized assessment tools and other tools of neurological observations, plus accurate recording of the findings

What are the parameters of the neurologic assessment?

-mental status

-cranial nerves

-motor system

-sensory system

-reflexes

What components make up mental status?

-LOC

-appearance and behavior

-speech/language/communication

-thought process/judgement

-mood

How do you assess LOC?

Is the patient awake and alert? A&O?

How do you assess orientation?

Is the patient alert and oriented x3 for person, place, and time? A&Ox4 also assess situation/event.

Person: the patient’s own name, and the names of relatives and professional personnel. “Can you tell me your name?”

Place: the patient’s residence, city, and state. “What is your address?”

Time: the time of day, day of the week, month, season, date and year, duration of hospitalization. “Can you tell me what time it is now? ... and what day it is?”

Situation: what just happened/is happening (frequently used after an accident or anesthesia). “Can you tell me what just happened?”

What should you do if your patient is not alert and oriented?

Assess ABCs, get vital signs, assess any immediate threats/check for safety. Call for help.

What does "lethargic" mean?

Sleepy/drowsy and asleep more than awake. Easily arousable with verbal and tactile stimuli. Will respond to questions, may be appropriate or not appropriate.

What does "obtunded" mean?

Patient will:

• Open their eyes to verbal/tactile stimuli

• Look at you

• Respond slowly, confused

• Become unresponsive if not stimulated

What does "stuporous" mean?

No spontaneous movement if not aroused- must be shaken or shouted at. Inappropriate verbal response. Purposeful response to pain. A stuporous patient is nearly unconscious with apparent mental inactivity and reduced ability to respond to stimulation.

What does "comatose" mean?

Patient will be unconscious and unresponsive. Cannot be aroused- even with pain.

What are the components of a desirable neuro assessment?

AAOX3, appropriate behavior, Pleasant, Cooperative, Follows commands

What would these findings indicate regarding blood glucose levels, blood flow, and oxygenation?

Indicative of normal blood glucose levels, appropriate blood flow, and adequate oxygenation. Changes from baseline can indicative otherwise.

When should you focus your assessment on mental status?

-Patient is confused

-Family/Patient concerns

-Acute behavioral changes

-Long or short-term memory loss

-Aphasia

Beyond LOC, what else can be assessed with mental status?

-General appearance and behavior

-Speech and language

-Mood

-Cognitive Function

How do you assess appearance and behavior?

-Pt has appropriate concerns regarding care

-Body movements - control, symmetry, appropriate, full/limited ROM

-Posture - upright, slumping

-Gait - smooth, unassisted, assisted

-Calm, restless, anxious, combative

-Eye contact and facial expression - appropriate, symmetrical

-Grooming/Dressing - Clean, age appropriate, Weather appropriate, Both sides equal, ability

What can abnormal findings during the appearance and behavior assessment indicate?

Depression, Schizophrenia, Dementia, OCD, CVA,Visual disturbances, MS

How do you assess speech and language?

• Spontaneous/coherent speech?

• Effortless flow?

• Normal intonations, rate, rhythm?

• Content makes sense?

• Able to comprehend and reply appropriately?

What is aphasia?

• loss of ability to understand or express speech, caused by brain damage.

• Impairment of language function- Pt can not produce (expressive) language, understand language (receptive), or both

• A language disorder that affects a person's ability to communicate

What are some causes of aphasia?

-CVA (Stroke)

-Head Injury

-Brain Tumor/Surgery

-Infection (temporary)

-Migraine (temporary)

What is the Mini Mental Status Exam (MMSE)?

A Brief Questionnaire where the patient must be fluent in English and have an 8th grade education. Maximum of 30 points (0-17 points would indicate severe cognitive impairment)

What are the components of the MMSE?

1. Appearance and behavior

2. Speech and language

3. Mood

4. Thoughts and perceptions

5. Cognitive function

What is cognition in the mental status assessment?

Mini Cognitive Test - "Mini-Cog" is a high sensitivity and specificity for detecting cognitive impairment. Screens for cognitive impairment in older individuals. 3-word recall test for memory (unrelated words) and clock drawing test with a specific time.

What are the cranial nerves?

12 pairs of nerves that are grouped by how they are tested/assessed. always assess symmetry.

What are the functions of the cranial nerves?

sensory, motor, or both. sensory cranial nerves help a person to see, smell, and hear. motor cranial nerves help control muscle movements in the head and neck.

Cranial Nerve I - Olfactory

smell

Cranial Nerve II - Optic

vision

Cranial Nerve III - Oculomotor

eye movement (most muscles), pupil constriction, eyelid elevation

Cranial Nerve IV - Trochlear

down and inward movement of eye

Cranial Nerve V - Trigeminal

facial sensation, muscles of chewing

Cranial Nerve VI - Abducens

lateral movement of eye

Cranial Nerve VII - Facial

facial expression/movement, taste on anterior tongue, saliva and tear secretion

Cranial Nerve VIII - Acoustic/Vestibulocochlear

hearing and balance

Cranial Nerve IX - Glossopharyngeal

taste on posterior tongue, swallowing, gag reflex, salivation

Cranial Nerve X - Vagus

autonomic control of heart, lungs, GI tract, swallowing, speech, gag reflex

Cranial Nerve XI - Spinal Accessory

shoulder shrug and neck turn

Cranial Nerve XII - Hypoglossal

tongue symmetry and position

What does assessment of the cranial nerves reveal?

Provides important information about the functioning of the brain. Involves focused, relevant assessments. Requires multi-modal approach. Essential to establish a baseline on which to compare future assessments

What are some brief cranial nerves assessments?

-Visual acuity (if relevant) - CN II- Snellen chart, confrontation

-Eye movements - CN III, IV, VI- 6 cardinal fields of gaze, PERRLA

-Sensation - CN V

-Tongue movement - CN XII

-Facial movement - CN VII

-Shoulder shrug, neck movement - CN XI

What does 20/20 vision mean?

What a person with perfect vision can see at 20 feet, you can also see at 20 feet

How do you assess confrontation with CN II?

- At eye level, face the patient

- Tell the patient to in the eyes

- Instruct the patient to remain looking at the examiner and have them say "now" when the examiner's fingers enter from out of sight, into their peripheral vision

- Repeat upper and lower temporal fields

What are the 6 cardinal fields of gaze?

-Assesses extraocular muscle function and the CNs that control them (CN III, IV, VI)

-Assess for smooth, coordinated eye movements in all 6 directions. Look for symmetry

-No nystagmus, no strabismus, no diplopia

What is nystagmus?

involuntary jerky eye movements

What is strabismus?

misalignment / crossing of the eyes

What is diplopia?

double vision reported by the patient

How do you assess pupillary light reaction?

CN II and III, assess PERRLA

How do you check pupils?

-Ask the patient to focus on an object in the distance

-Observe the diameter of the pupils in a dimly lit room

-Note the symmetry between the pupils

-Next, shine the penlight into one eye at a time and check both the direct and consensual light responses in each pupil

-Also note the rate of these reflexes

What is accommodation?

the eye's ability to adapt for near vision

How do you assess accommodation?

-Ask the patient to focus on the light/object itself while the examiner moves it gradually closer to their nose

-Normally, as you move the light/object closer to them, as the eyes accommodate to the near object and will constrict and converge

What is ptosis?

drooping eyelid - issue with the levator muscle and CN III

How do you assess facial sensation?

CN V. Motor: palpate temporal & masseter muscles as pt clenches teeth, try to separate jaw by pushing down on chin. Sensory: test light sensation with cotton ball forehead, cheeks, chin

How do you assess facial movement?

CN VII: Ask pt to: Raise eyebrows, Close eyes tightly, Smile (show teeth), Puff out cheeks.

CN XII: Ask pt to stick tongue out.

How do you assess hearing and balance?

CN VIII - Whisper test (hearing), Rinne & Weber (use tuning fork differentiate type of hearing loss), Romberg (balance)

How do you assess cranial nerves IX and X?

(taste, swallow, gag, voice), ask Pt if they have a Hoarse voice? Dysphagia?

What are the components of assessing the motor system?

-body position

-involuntary movements

-tone, strength, equality

-coordination

-muscle atrophy/wasting

-hypotonic/flaccid muscles

-increased resistance (spasticity)

What do you look for in body positioning?

relaxed, normal position/shape

What are involuntary movements?

-Tremors

-Tics- brief repetitive movements, winks, shrugging

-Fasciculation- involuntary contraction/twitching, under skin

-Dystonia- grotesque twisted postures

What is paresis?

weakness

What is plegia?

absence of strength or paralysis

What does hemi- mean?

one side of the body

What does para- mean?

trunk and lower limbs

What does quadri- mean?

all 4 limbs and torso

What can cause abnormalities in muscle movement?

stroke, SCI, neurological diseases, nerve damage

What are the components of a coordination assessment?

-Muscle strength

-Cerebellar system for rhythmic movement and steady posture

-Vestibular system for balance and coordinating eye, head, and body movements

-Sensory system for position sense

How do you assess coordination?

-Rapid alternating movements: Tapping alternating fingers together, Right thumb to right fifth finger

-Point to point: Touching examiners finger with patient's finger then touching nose, Decreased coordination when eyes are closed

How do you assess gait?

-Walk heel to toe

-Walk on heals, walk on toes

-Hop in place with shallow knee bend

-Step on stool or rise from seat with out using arms

What is ataxia?

Gross lack of coordination of muscle movements. Dysfunction of parts of the nervous system that coordinate movement

What is Romberg's Test?

-Eyes open- steady stance

-Eyes closed- patient will sway

What is the Pronator Drift Test?

Closed eyes, palms up = arms will pronate as they drift down

What are the components of a sensory assessment?

-pain

-position and vibration

-light touch

-discrimination

How do you assess pain during a sensory assessment?

-Is this sharp or dull

-Use a broken cotton swab or paper clip, sharp side is pain, smooth side is dull

-Avoid the word "pain", it isn't pain in the sense of what people think of pain, it is pain in a nerve sense

How do you assess positioning during a sensory assessment?

-Use patient's great toe. Make sure their eyes are closed

-Have patient move it away from body, up and down

-Ask them to tell you if you are moving their toe up, down, left, right...

How do you assess vibration in a sensory assessment?

-Use tuning fork (we typically don't have these on clinical units and generally don't test this)

-Start distal to save time

How do you assess light touch?

-Use a cotton ball

-Touch cotton ball to patient's skin

-While their eyes are closed, have them tell examiner when they feel the cotton touching their skin

What is discrimination?

the ability to distinguish between different stimuli

What is stereognosis?

recognizing an object using the sense of touch

What is graphesthesia?

recognize writing on the skin using the sense of touch

How do you test the plantar reflex?

-Stroke up the lateral side of the sole & across the ball of the foot to just below the great toe

-Plantar flexion of the toes = normal response.

-Negative Babinski sign

What is a positive Babinski reflex?

abduction of the toes with dorsiflexion of the great toe

What is clonus?

Series of involuntary muscle contractions due to sudden stretching of the muscle. Causes large motions that are usually initiated by a reflex

What is the Glascow Coma Score?

a neuro assessment tool that focuses on eyes, motor response, and verbal scale to gage injury and neurologic damage. perfect score is 15

GCS 1 - Eyes Open

-Spontaneous = 4

-To verbal command = 3

-To pain = 2

-No response =1

GCS 2 - Motor Response

-Obeys commands for movement =6

-Purposeful movement to painful stimulus = 5

-Withdraws in response to pain = 4

-Flexion in response to pain (decorticate posturing) = 3

-Extension response in response to pain (decerebrate posturing) = 2

-No response = 1

GCS 3 - Verbal Scare

-Oriented = 5

-Disoriented/confused = 4

-Inappropriate words = 3

-Incomprehensible sounds = 2

-No response = 1

What is decorticate posturing?

Flexion of the arms and legs pulled toward the core of the body. Closed hands, legs rotated internally, feet turned inward.

What is decerebrate posturing?

Extension of the arms and legs. Head and neck are arched, legs are straight, toes are pointed downwards, hands are curled.

What are some stroke warning signs?

-Sudden numbness or weakness of the face, arm, or leg; especially on one side of the body

-Sudden confusion, trouble speaking/understanding

-Sudden trouble seeing in one or both eyes

-Sudden trouble walking, dizziness, loss of balance/coordination

-Sudden, severe headache with no known cause

What is the FAST acronym stand for as warnings of a stroke?

F = Face Drooping – Does one side of the face droop or is it numb? Ask the person to smile. Is the person's smile uneven?

A = Arm Weakness – Is one arm weak or numb? Ask the person to raise both arms.Does one arm drift downward?

S = Speech Difficulty – Is speech slurred?

T = Time to call 911, what time was the onset?