Neurological
Screening Neurological Exam
Purpose: Perform a detailed neurological exam in clients who are well or report no significant subjective history to establish a baseline or to identify unnoticed neurological deficits.
Sequence of Examination:
Mental Status: Assess cognitive functions, mood, and thought processes to determine overall mental health.
Cranial Nerves: Examine individual functions of the twelve cranial nerves.
Motor System: Evaluate muscle strength, tone, and coordination.
Sensory System: Assess the ability to feel various stimuli across different body parts.
Reflexes: Test basic reflexes to evaluate the integrity of the neural pathways.
Complete Neuro Exam and Recheck
Indication: Conduct a complete neurological assessment and recheck for clients with neurological deficits, experience acute changes, or those at risk for neurological issues.
Key Elements to Assess:
Level of Consciousness (LOC): Changes in LOC is critical for assessment.
Orientation: Assess awareness of person, place, and time.
Motor Function: Test strength and coordination of voluntary muscle movements.
Pupillary Response: Check for pupil reactivity and response to light.
Vital Signs: Monitor physiological parameters to detect signs of distress or abnormalities.
Important Signs of Increased Intracranial Pressure (ICP): Look for late signs indicating urgent medical attention is needed.
Pronator Drift
Procedure: Client extends both arms forward for 10-20 seconds, palms up.
Normal Response: Both hands remain steady without drift.
Abnormal Response: Downward unilateral drift coupled with forearm turning in signifies possible hemiparesis, necessitating further evaluation.
Glasgow Coma Scale (GCS)
Eye Opening Response:
Spontaneously: 4 points
To verbal command: 3 points
To pain: 2 points
None: 1 point
Verbal Response:
Oriented: 5 points
Confused conversation: 4 points
Inappropriate responses: 3 points
Incomprehensible sounds: 2 points
None: 1 point
Motor Response:
Obeys commands: 6 points
Purposeful movement to pain: 5 points
Withdraws from pain: 4 points
Abnormal flexion/extension posture: 3 points/2 points
None: 1 point
Scoring Interpretation:
Minor Brain Injury: 13-15 points
Moderate Brain Injury: 9-12 points
Severe Brain Injury: 3-8 points.
Posturing
Decorticate Posture: Arms flexed towards the body, suggests disruption in cervical spinal tract pathways.
Decerebrate Posture: Arms extended, indicative of midbrain or pontine dysfunction indicating a more severe injury.
Sample Nurse Check
Scenario: A client admitted after suffering a ground-level fall opens their eyes in response to speech, obeys commands, and inaccurately states the year.
Expected GCS Score: Determined based on the client's psychomotor responses during the assessment.
Cranial Nerves Summary
Cranial Nerves Overview: Each of the twelve cranial nerves is responsible for specific sensory and motor functions:
I (Olfactory): Smell sense
II (Optic): Visual acuity and field of vision
III (Oculomotor): Pupil dilation and eye movement
IV (Trochlear): Eye movement downward and inward
V (Trigeminal): Facial sensation and motor function for chewing
VI (Abducens): Lateral eye movement
VII (Facial): Taste sensations from the anterior 2/3 of the tongue and facial expressions
VIII (Acoustic): Hearing and balance
IX (Glossopharyngeal): Taste, pharyngeal sensation, and motor function for swallowing
X (Vagus): Gag reflex, uvula position, and autonomic functions for the heart and digestive tract
XI (Spinal Accessory): Motor function for shoulder shrugging and head rotation
XII (Hypoglossal): Tongue movement and speech articulation.
Detailed Assessment of Cranial Nerves
CN I - Olfactory: Assess smell sensation using familiar scents for higher accuracy.
CN II - Optic: Perform visual acuity tests using the Snellen chart and assess visual fields using confrontation method.
CN III, IV, VI - Oculomotor, Trochlear, Abducens: Check PERRLA (pupils equal, round, reactive to light and accommodation) along with performing various eye movements.
CN V - Trigeminal: Evaluate sensory and motor functions by testing facial sensation and asking the patient to clench teeth while palpating the masseter muscle.
CN VII - Facial: Assess symmetry by asking the client to raise eyebrows, smile, and close eyes tightly.
CN VIII - Acoustic (Vestibulocochlear): Perform hearing acuity tests, including Rinne and Weber tests.
CN IX & X - Glossopharyngeal & Vagus: Examine uvula position and gag reflex to test motor functions.
CN XI - Spinal Accessory: Assess muscular strength in shoulder shrug and head rotation against resistance.
CN XII - Hypoglossal: Evaluate midline tongue protrusion and observe articulation of speech, noting any slurring.
Cerebellar Function
Tests for Coordination Include:
Rapid Alternating Movements (RAM): Tests dexterity and coordination.
Finger to Nose Test (point-to-point): Checks for fine motor skills.
Heel to Shin Test: Assesses coordination of leg movements.
Balance Tests:
Normal gait: Can the patient walk without stumbling?
Tandem walking: Walking heel-to-toe in a straight line.
Romberg test: Standing with eyes closed; check for sway or falls, indicating balance issues.
Sensory Tests
Assess Alongside Cerebellar Function Tests:
Touch & Pain Sensation: Use light touch and sharp stimuli to test responsiveness.
Vibration Sense: Utilizing a tuning fork on bony prominences.
Position Sense (Kinesthesia): Assessing awareness of body position.
Stereognosis: Recognizing objects by feeling them with eyes closed.
Graphesthesia: Ability to recognize numbers or letters traced on the skin.
Filament Testing: Using a monofilament to evaluate sensation on feet for diabetic neuropathy screening.
Reflexes
Overview: Basic defense mechanisms of the nervous system allowing involuntary reactions to stimuli, which helps assess the integrity of the reflex pathways.
Deep Tendon Reflexes Grading System:
0: Absent
1+: Hyporeflexive
2+: Normal
3+: Brisk (without clonus)
4+: Brisk (with clonus).
Reflex Locations:
A: Biceps
B: Brachioradialis
C: Triceps
D: Quadriceps/Patellar
E: Achilles
F: Clonus.
Developmental Competence
Infancy: The neurologic system is underdeveloped at birth, showing gradual improvement with myelination over time.
Aging: In older adults, neuronal loss may lead to decreased motor coordination, muscle strength, and reflex responses, which can contribute to a higher risk of falls and other neurological complications.
Sensory Changes: These often accompany aging, impacting touch, pain, taste, and smell, which can affect quality of life and health outcomes.
Health Promotion & Client Teaching
Stroke Awareness: Highlight the importance of recognizing the symptoms of a stroke, often termed as a “brain attack” due to disrupted blood flow.
Risk Factors for Stroke:
Hypertension: Chronic high blood pressure is a significant risk factor.
Smoking: Carcinogenic compounds contribute to vascular damage.
Heart Disorders: Conditions such as atrial fibrillation and hyperlipidemia escalate the risk significantly.
Tremors Vs. Seizures
Tremors: Involuntary, rhythmic motions that vary with muscle state, including resting (which often indicates Parkinson's disease) vs. intention tremors (which become more apparent during purposeful movements).
Seizures: Characterized by excessive neuronal discharge. Phases of seizure activity include:
Prodromal: Early signs indicating an impending seizure.
Ictal: The active phase of a seizure.
Postictal: Recovery period following the seizure, which may include confusion, fatigue, or decreased responsiveness.
Documentation: Critical for tracking the patient's neurological status and planning future