Neurological Assessment

NURS 347Towson University

Nervous SystemCentral Nervous

System (CNS)Peripheral Nervous

System (PNS)

0Brain0Spinal Cord

012 pair of cranial nerves

031 pair of spinal nerves

0Nerve branches

Central Nervous System0Cerebral Cortex: Outer layer of cerebrum0Gray Matter0Area of highest functioning: through, memory,

reasoning, sensation, and voluntary movement

0Cerebrum: Right and Left hemispheres0Left dominant in 95% of people: Right handed

0Four lobes per hemisphere:0 frontal parietal0 temporal occipital

Assessing the Cerebral Cortex

0Begin with subjective data and history.

Neurological System

Questions to ask the patient:1. Orientation: Person, Place, Time, Situation2. Headache3. Head Injury4. Dizziness/Vertigo5. Seizures6. Tremors7. Weakness8. Incoordination9. Numbness or tingling10. Difficulty swallowing (Dysphagia)11. Difficulty speaking (Dysphasia)12. Significant Past History13. Environmental or occupational hazards14. Review medications: anticonvulsants,

antitremors, antivertigos, and pain medications

Subjective Data

Level of Consciousness (LOC)0 Alert: Easily awakened with

minimal stimulation0 Lethargic: Drowsy, vigorous

stimulation necessary for brief, but appropriate response

0 Stupor: Sluggish response to aggressive verbal, visual, or painful stimuli

0 Comatose: Response of reflex motor activity only to painful stimuli

Sternal Rub: Painful Stimuli used with a stuporous or comatose patient

Glasgow Coma Scale (GCS)

The Glasgow Coma Scale (GCS) minimizes the ambiguity of level of consciousness assessments,

The GCS is a quantitative tool that standardizes patient’s responses with a numerical value

Peripheral Nervous System Function

0 Carries sensory messages TO the central nervous system’s sensory receptors

0 Transmits messages FROM the CNS to the muscles and glands throughout the body

Cranial Nerves

Neurological Assessment

0 Inspection:0 Symmetry of skull (normocephalic)0 Symmetry of face

0 observe palpebral fissures, nasolabial folds

0 Scalp: Mobility0 Neck: Range of Motion (ROM)

0Palpation:0Scalp: Lesions0Neck: Tenderness

Objective Data: Head & Neck

CN I: Olfactory Nerve

0 Do not test routinely0 Test among those who report

loss of smell or had experienced head trauma

0 Step I: Occlude one nostril at a time and ask the patient to sniff0 Establishes baseline

and patency0 Step II: With patient’s eyes

closed, present an aromatic substance that is easily identified beneath one nostril

0 Step III: Repeat on opposite side

CNV: Trigeminal Nerve

Both a sensory and motor nerve!0Motor:

0 Symmetrical jaw movement0Mastication (chewing)

0 Assess: 0 Palpate temporal and masseter muscles bilaterally as patient clenches

teeth. 0Attempt to push down on chin to separate jaws.

0Sensation:0Three nerve divisions:

0 1) Opthalmic, 2) Maxillary, 3) Mandibular

0Assess: Touch cotton wisp to bilateral areas of forehead, cheek, and chin and request patient to state when sensation is felt.

CN VII: Facial Nerve

0 Mixed Motor and Sensory Nerve0 MOTOR Assessed by observing

bilateral movement when a patient:0 Smiles!0 Frowns0 Closes eyes tightly0 Lifts eyebrows0 Shows teeth0 Puffs cheeks0 When you press puffed cheeks in, assess

for equal bilateral, evacuation of air

CN VII: Facial Nerve

0SENSORY nerve:0Assessed when facial

nerve injury is suspected0Apply a cotton applicator

that has been covered with a solution of sugar, salt, or lemon juice to patient’s tongue- ask patient to identify taste.

CN IX & X:Glossopharyngeal & Vagus

0Assess the nerves’ motor function by:0 Depress tongue with a tongue blade: watch for

pharyngeal movement as the patient says “ahh” or yawns:

0 Uvula and soft-palate should rise midline0 Tonsillar pillars should move medially

0 Touch the posterior pharyngeal walls with tongue blade:0Note positive gag reflex0 Voice clear, no evidence of straining

0Assess sensory motor:0 Posterior third of tongue: bitter taste

CN XI: Spinal Accessory

0Spinal accessory motor nerve transmits communication between the PNS and CNS.

0Prior to testing nerve, assess sternomastoid and trapezius muscles for equal, bilateral size

01. Ask patient to forcibly rotate head against resistance applied at chin, repeated on both sides.

02. Ask patient to shrug shoulders against bilateral resistance

0An intact CN XI should provide motor responses of equal, bilateral strength.

CN XII: Hypoglossal0 Inspect the tongue:

should be free from tremors or wasting

0Forward thrust of tongue should remain midline

0Listen for clear l, t, d sounds with speech of “light, tight, dynamite”

The Eye: Subjective Assessment

1. Vision difficulty (blurring, blind spots, decreased acuity)

2. Pain3. Strabismus, diplopia4. Redness, swelling5. Watering, discharge6. History of ocular problems7. Glaucoma8. Use of glasses or contact lenses9. Self-Care Behaviors10. Surgeries

The Eye: Objective Assessment

Prior to testing neurological reflexes, inspect anatomy of the

eye for:0 Symmetry, position, discharge0 External Structures:

0 Lid, lashes, and brow0 Color0 Conjunctive0 Sclera

0Anterior Structures:0 Cornea and Lens0 Iris and Pupils

Inspecting the Ocular Fundus

0 In a darkened room using an opthalmoscope:

0 Elicit Red Reflex0 Assess retinal vessels for

0 Nicking0 Hemorrhages0 Exudates

0 Visualize the optic disc for:0 Color0 Size0 Shape

CN II: The Optic NerveSnellen Acuity Test

(Distant)Confrontation Test

Visual Fields

Visual Acuity0 “Near Sighted”

0 Decreased visual acuity at a distance

0 Assessed via Snellen Chart0 “Far Sighted”

0 Decreased visual acuity in a close range.

0 Assessed via Jaeger card0Peripheral Vision

0 Assessed via Confrontation Test

CN III, IV & VI: Oculomotor, Trochlear & Abducens

0CN III: Responsible for the eye’s up and down movement, movement of the pupil

0CV IV: Superior and oblique eye movement0CN VI: Outward eye movement

0Assess for:0 Strabismus: Deviated gaze or limited movement0 Nystagmus: Involuntary back and forth or cyclical

movement

Corneal Light Reflex: Hirschberg Test

Cover/Uncover Test

PERRLA

0Assessment of the CN III, IV and VI via the PUPILS

0 Pupils0 Equal0 Round0 React to0 Light and0 Accommodation

The Ear:Subjective Assessment

1. Earaches2. Infections3. Discharge4. Hearing loss5. Environmental Noise6. Tinnitus7. Vertigo8. Self-Care Behaviors

The External Ear:Objective Assessment

0 INSPECTION0 Size and Shape: Equal size

bilaterally, free from swelling or thickness

0 Skin color of ears matches facial skin color, skin intact, free from lumps or lesions

0 External auditory meatus: Note opening size, any swelling, redness, or discharge

0 PALPATION0 Mastoid process0 Move pinna and push on tragus0 Palpation should reveal firm

structures that move without producing pain

Inspection of the Tympanic Membrane

Otoscope0 Otoscope size depends on the diameter of the

auditory meatus: choose the largest speculum that will fit comfortably in the ear canal

0 Have the patient tilt head away from you and towards opposite shoulder

0 With the adult patient, pull pinna up and back

0 Infant or child under 3 years old, pull pinna down

0 Holding the otoscope in a position that seems upside down helps you balance the otoscope during the exam, decreasing risk of injury to the tympanic membrane.

CN VIII: Vestibulocochlear Assessment

Begins with subjective assessment: How well does the patient hear conversational speech?

o Voice Testo Tuning Fork TestoWeber Testo Rinne Test

Voice Test

1. Test one ear at a time by muffling sound in one ear by placing finger over tragus and rapidly pushing it in and out of auditory meatus

2. Stand behind patient so lip-reading cannot occur3. In the other ear, with your hear 2-3” from patient’s

ear, slowly whisper two-syllable words and have patient repeat words; repeat on opposite ear• Ex. Tuesday, armchair, baseball, and fourteen

Tuning Fork Tests: Weber & Rinne

Hearing Loss0 Conductive: Mechanical dysfunction of the external or inner

ear resulting in partial hearing loss. May be caused by impacted cerumen, foreign bodies, or a perforated tympanic membrane; inner ear pus or serum, and otosclerosis.

0 Sensorineural: Pathology associated with inner ear, CNVIII, or cerebral cortex ; gradual nerve degeneration (presbycusis) caused by aging; ototoxic medications (Lasix) that affect cochlear hair cells.

0 Mixed: Combination of both conductive and sensorineural hearing loss in the same ear.

CN VIII: Romberg Test

0CN VIII is also a nerve with a “special sense.”0The inner ear provides information regarding your

body’s position in space (proprioception).0 If the inner ear is inflamed, incorrect information is

transmitted (via the PNS) to the brain (CNS), causing the sensation of vertigo and an unsteady gait.

0Equilibrium and vertigo can be assessed via the Romberg Test.

Romberg Test

Cerebellar Functioning Assessment

BALANCE:0 The Romberg Test (CN VIII) assesses

balance, an extension of the CNS and the functionality of the cerebellum.

0 Gait: Have the patient walk 10-20 feet, turn and walk back. Gait should be smooth, rhythmic, and effortless with coordinated swing in the opposing arm and 15” from heel to heel.

0 Tandem Walking: Walk in a straight line in a heel-to-toe fashion. If intact, the person will walk straight and maintain balance, even with a decreased support base.

Cerebellar Functioning

Coordination and Skilled Movements:0Rapid Altering Movements (RAM)0Finger-to-Finger Test0Finger-to-Nose Test0Heel-to-Shin Test

Finger-to-Finger Test &Rapid Alternating Movement

Heel-to-Shin Test

Sensation: Superficial Pain

0 Use a tongue blade with both a sharp and dull point, lightly apply the sharp and dull points to the patient’s body in random, unpredictable manner.

0 Provide a 2-second break between application to prevent summation, when a frequent but separate stimuli are perceived as one, strong stimulus.

Sensation: Light Touch

0 Apply a wisp of cotton to the skin and brush it over the patient’s body in a random order at irregular intervals. Asl the patient to report when the touch is felt by stating “now” or “yes.”

0 Compare symmetric points bilaterally.

Sensation: Vibration

0Use a low-pitch tuning fork and strike against the heel of your hand.

0Apply the base of the tuning fork to a body surface of the fingers or great toe.

0Ask patient to report when the vibration starts and stops.

0 If no vibration is felt in those locations, move proximally, testing the ulnar processes, ankles, patellae, and iliac crests.

0Compare findings bilaterally.

Motor Strength

0 Assess via inspection the muscle groups for symmetry and size; if asymmetric, measure each in centimeters and compare difference. Measurements greater than 1 centimeter is significant.

0 Assess strength by assessing bilaterally muscle groups in the extremities, neck, and trunk, continuing to compare bilateral findings in each group.

0 Tone is the normal degree of contraction at rest. Assessment involves inspection and observation. Watch for resistance of the muscles during passive range of motion, assess bilaterally and compare.

Deep Tendon Reflexes (DTR)

0 Use the reflex hammer and use a short, snapping flow to the muscle’s insertion tendon.

0 Do not rest the hammer on the tendon.

0 Use the pointed end for smaller targets; the flat end on wider targets or to prevent pain

0 Compare bilateral responses

Grading4+ Very brisk, hyperactive with clonus. Indicates presence of disease process3+ Brisker than average; may indicate need for further work-up2+ Average, normal1+ Diminished, low-normal0 No response

Upper Extremity DTR

0Biceps0Triceps0Brachioradialis

Abdominal Reflexes

Lower Extremity DTR

0Patellar0Achilles0Ankle Clonus

Plantar Assessment

Plantar ReflexBabinski Sign:

Normal only in infants

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