NEUROLOGICAL ASSESSMENT

Objectives of a Neuro Assessment

Gather data about the functioning of the nervous system

Correlate and trend the data over time

Analyze the data to develop a list of potential or actual diagnoses

Determine the effect of dysfunction on the patients daily activities of living

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Assessment

Review of systems

Dizziness, headaches, vision changes,

sensitivity to light, auditory changes, sinus infections, difficulty swallowing, hoarseness, slurred speech, sinusitis, infection

Pertinent medical history:Family historySurgical historySocial historyMedications

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Assessment of Nervous System

Subjective Data

Important Health Information

Past health history.

Medications.

Surgery or other treatment.

Mental Status

Assess level of consciousness (LOC).

Glasgow Coma Scale

Score of 15= fully awake & alert.

Score of 8 or less= is associated with coma.

Score of 3= completely unresponsive patient.

Motor System

Strength.

Coordination.

Command.

Pupillary changes.Changes in vital signs.

Late findings in neurological deterioration.

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COMPONENTS OF
NEUROLOGICAL ASSESSMENT

Mental Status

Level of Consciousness

Reflexes

Motor Functions

Sensory Functions

Cranial Nerves

I. Mental Status:

Reveals cerebral function (intellectual and affective)Major areas of assessment:

Language

Orientation

Memory

Attention span

Calculation

NEUROLOGICAL ASSESSMENT

Language

Aphasia inability to express oneself by speech, writing or comprehend spoken or written language due to disease of cerebral cortex

Two Categories:

Sensory or receptive aphasia

Motor or expressive aphasia

NEUROLOGICAL ASSESSMENT

Sensory/receptive aphasia

- loss of ability to comprehend written or spoken words

Two types:

Auditory aphasia unable to understand symbolic content associated with sounds

Visual aphasia unable to understand printed or written figures

NEUROLOGICAL ASSESSMENT

2. Motor/ expressive aphasia

- loss of power to express oneself by writing, making signs or speaking

How to assess language deficits:

Point to common objects and name themRead some words and match printed and written words with picturesRespond to verbal/written commands

NEUROLOGICAL ASSESSMENT

Speech Patterns:

- pace, clarity, spontaneity

Abnormalities:

Perseveration

- repeating the same response as different questions are asked

b.Paraphasia

- speech appropriately expressed but contains incorrect words

NEUROLOGICAL ASSESSMENT

B. Orientation 3 spheres (person, time & place)

C. Memory

Listen for lapses of memory

If problems are present:

Three categories of memory:

1. Immediate recall

N: can repeat series of 5 8 digits in sequence and 4 6 digits in reverse order

NEUROLOGICAL ASSESSMENT

C. Memory

2. Recent memory

Ask to recall the events of the day

Recall information given early in the interview

Provide 3 facts to recall (color, object, address), then ask later

NEUROLOGICAL ASSESSMENT

C. Memory

3. Remote memory

Previous illness or surgery (years ago), birthday, anniversary

D. Attention Span

Tests the ability to concentrate

(alphabet, count backward from 100)

NEUROLOGICAL ASSESSMENT

E. Calculation

Serial seven or serial three test

N: can complete serial seven in 90 seconds with 3 or less errors

THE CRANIAL NERVES

CN I: Olfactory

CN II: Optic

CN III: Oculomotor

CN IV:Trochlear

CN V:Trigeminal

CN VI:Abducens

CN VII: Facial

CN VIII:Vestibulocochlear/Acoustic

CN IX:Glossopharyngeal

CN X:Vagus

CN XI:Spinal Accessory

CN XII: Hypoglossal

The 12 CRANIAL NERVES

CN I-Olfactory - SmellCN II-Optic - Visual acuityCN III-Oculomotor - Pupil responseCN IV-Trochlear) - Downward, inward eye movementCN V-Trigeminal - Jaw opening, chewingCN VI-Abducens - Lateral Eye movementCN VII-Facial - Facial expression, close jawCN VIII-Acoustic - HearingCN IX-Glossopharyngeal - Swallowing, gag reflexCN X-Vagus - SpeechCN XI-Spinal Accessory- Shrug shouldersCN XII-Hypoglossal- Tongue movement

NEUROLOGIC ASSESSMENT

Level of ConsciousnessEase of arousalState of awarenessOrientationMotor FunctionPersonPlace TimeSqueeze hand, smile, stick out tongue, raise eyebrows

NEUROLOGIC ASSESSMENT

Pupillary ResponseSizeShapeSymmetry of pupilsDocument degree of constriction to light5/4

Glasgow Coma Scale (GCS)

Best Eye-Opening Response Score

Spontaneously 4

To speech 3

To pain 2

No response 1

Best Motor Response Score

Obeys commands 6

Localizes stimuli 5

Withdrawal from stimulus 4

Abnormal flexion (decorticate) 3

Abnormal extension (decerebrate) 2

No response 1

Best Verbal Response Score

Oriented 5

Confused conversation 4

Inappropriate words 3

Garbled sounds 2

No response 1

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A total score of:

3 to 8 suggests severe impairment/comatose

9 to 12 suggests moderate impairment/ semi-conscious

13 to 15 suggests mild impairment/ conscious

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Nsg Role during Motor function Examination

Motor strength and coordination:

Muscle weakness is a cardinal sign of dysfunction in many neurological disorders.

Muscle groups should be assessed individually, initially without resistance and then against resistance.

The nurse also assesses each extremity for size, muscle tone, and smoothness of passive movement.

The nurse also should be alert to involuntary movements

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Motor function

Motor strength and coordination:Hemiparesis (weakness) and hemiplegia (paralysis) Paraplegia may result from thoracic or lumbar spinal cord or peripheral nerve dysfunctions. Quadriplegia is associated with high cervical spinal cord lesions, brainstem dysfunction, and large bilateral lesions in the cerebrum.The cerebellum is responsible for smooth synchronization,

balance, and ordering of movements.

Romberg test.

Finger-to-nose test.

Rapidly alternating movement (RAM) test.

The Heel-to-chin test.

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Motor Response to Stimuli

Normal Motor Response:

Localization.

Withdrawal.

Abnormal Motor Response:

Decorticate rigidity due to lesions to:

Internal capsule, basal ganglia, thalamus, corticospinal pathways.

Flexion of the arms, wrists & fingers; adduction of upper extremities; & extension, internal rotation, & planter flexion of lower extremities.

Decerebrate rigidity due to injury to:

Mid brains & Pons.

Extension, adduction & hyperpronation of the upper extremities; extension of lower extremities with planter flexion; clenched teeth.

Tonic Contraction: consistent muscle contraction.

Clonus: alternate muscle plasticity & relaxation.

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Mental Status Assessment

Attention

Digit span forward & back.

Remembering.

Short-term: recall after 5 minutes.

Long-term: recall events of previous day.

Feeling (Affect).

Facial & body expression & mood.

Verbal description of affect.

Congruence of verbal, body indicators of mood.

Language.

Spontaneous speech, repetition, naming objects, writing, reading.

Thinking.

Orientation, information, knowledge of current events, calculations, problem solving.

Spatial Perception.

Copy drawings, demonstrate putting a coat, using a toothbrush; point out right & left side.

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Pupillary Changes:

Pupils are examined for size (best specified in millimeters) and shape.

Anisocoria (unequal pupils).

The normal response to testing is documented as PERRLA, or Pupils Equal, Round, Reactive to Light and Accommodation.

The assessment of pupillary response for comatose patients is the same as for conscious patients. Pupil reactivity to light, by direct and consensual response, is easily obtained.

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Pupillary Changes

Small Reactive: Metabolic &/ or diencephalic dysfunction.Dilated Fixed (unilateral): Blown, dysfunction of CN III (Oculomotor).Midposition, Fixed: Mid brain damage.Large Fixed: Midbrain damage.

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Vital Signs Changes

Respiration:

Cheyne_Stokes.

Hyperventilation.

Hypoventilation.

Temperature.

Very high hyperthermia due to CNS damage.

Hypothermia due to metabolic, pituitary & spinal cord injury.

Pulse.

Dysrhythmias.

Tachycardia as a result of increase ICP.

As ICP rises; Bradycardia occurs (terminal condition).

Blood Pressure: controlled at the level of medulla

Hypertension is more commonly occurs.

As BP increases, cerebral blood flow & volume increase leading to increased ICP.

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Assessment of Ocular Movement

Oculocephalic reflex (Dolls Eye):

Quickly rotate the Pts head to one side

Abnormal or Absence of reflexes indicates brainstem dysfunction.This test is not performed for patients with cervical spinal injury.

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Assessment of Ocular Movement

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Oculovestebular reflex (Caloric Ice-water Test)

Elevate the patient head 30 degree & irrigate each ear separately with 30-50 ml of ice water.Normally, the eyes moves horizontal nystagmus with slow, conjugated movement toward irrigated ear followed by rapid movement away from the stimulus.Abnormal, both eyes remain fixed in midline position indicating midbrain & Pons dysfunction.This test is not performed for patients who does not have intact ear drum or who has blood or fluid collected behind the ear drum.

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Oculovestebular Reflex

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Continue.

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Assess Signs of Trauma or Infection

Signs of Trauma:

BATTLES SIGN (bruising over the mastoid areas) suggests a basal skull fracture.

Signs of Trauma:

RACCOONS EYE

- (periorbital edema and bruising) suggests a frontobasilar fracture.

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Assess Signs of Trauma or Infection

Signs of Trauma:

Rhinorrhea

(drainage of CSF from the nose) suggests fracture of the cribriform plate with herniation of a fragment of the dura and arachnoid through the fracture.

Signs of Trauma:

Otorrhea

drainage of CSF from the ear) usually is associated with fracture of the petrous portion of the temporal bone.

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Signs of Meningeal irritation

Kernigs signs:

+ POSITIVE= Neck pain after knee flexion.

Brudzinkis sign:

+ POSITIVE = involuntary hip flexion after neck flexion.

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Kernigs sign

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Brudzinksis sign

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Diagnostic Studies of the Nervous System

Computed Tomography (CT scan).Magnetic Resonance imaging (MRI).CSF analysis.Lumber Punctures.

L3-4, L4-5.

Used to diagnose autoimune, infection, subarachnoid hemorrhage.

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