ASSESSMENT OF THE NEUROLOGIC SYSTEM-assessment of the neurologic system is a challenge

because of the complexity of the nervous system. Neurologic assessment becomes multifaceted and lengthy.

Perception-conscious recognition and interpretation (awareness) of the sensory stimuli that serve as a basis for understanding, learning and knowing or for the motivation of a particular action or reaction

Coordination-when action or reaction towards a stimulus is occurring in a purposeful, orderly fashion, appropriate response to a stimulus

3 essential components of skull:1. Brain tissue-78%2. Blood -12 %3. CSF-10%

Monro-Kellie HypothesisIf volume added to the cranial vault equals the volume

displaced from it, the total intracranial volume will not change

Normal ICP: 60-150 mmH20 or 0-15 mmHg

Cerebral Blood FlowAmount of blood in milliliters passing through 100g of brain tissue in 1 minuteGlobal CBF-approximately 50 ml/minBrain needs constant supply of oxygen and glucose (20% of body’s oxygen, 25% of body’s glucose)

More than 10 minutes of oxygen deprivation-brain death

Mean arterial pressure at which autoregulation is effective (70-105 mmHg)

-Upper limit is 150 mmHg

MAP SBP 2 (DBP) 3

Cerebral perfusion pressure needed to ensure blood flow to the brain

CPPMAP-ICP -30 mmHg is incompatible with life

Cranium and Cerebral column

Cranial meningesDura materArachnoidPia mater

Falx cerebri-divides the left from right hemispheres

Subdural-more bleeding

NEUROLOGIC ASSESSMENTComprehensive History Taking1. Biographical and demographic data- it includes personal

profile of the patient, source of history and the clients mental status

2. Current health

a. Chief complaint- obtains a detailed description of the event that have led the client to seek care. Use open ended question.

b. Symptom analysis-3. Past health historya. Childhood infectious disease and immunizations

Rubella and rubeola Meningitis Herpes simplex virus cytomegalovirus influenza

b. Major illnesses and hospitalizations Pernicious anemia Cancer DM Infections Hypertension Liver and renal disease F & E imbalances Acid-Base Imbalances Head trauma Seizures and stroke

c. Medications- CNS stimulants Sedatives and hypnotics Antideppressives Analgesics Anti hypertensive and stroke

d. Growth and development

Mental Status Examination

An indication of how patient is functioning as a whole and how the patient is adapting to the environment

1. General appearance-2. Intellectual capacity or performance- consists of fund

of knowledge and calculation activity3. LOC-the most sensitive indicator of changes in the

neurologic status-begin by observing spontaneous behavior-visual cue -verbal cues-tactile-Noxious agent- use of central stimulus rather than peripheral (nail bed pressure) because it may elicit a reflexa. sterna pressureb. supraorbital ridge pressurec. sternocleidomastoid muscle pinch

4. Orientation- to time, place and event or situation5. Memory- retrograde (long-term memory) and

anterograde (recent memory or short-term)6. Mood/affect7. Judgment/Insight- include reasoning, abstract

thinking, problem solving and the clients’ perception of the situation.

8. Language/communication

MENTAL STATUS ASSESSMENT WITH ABNORMAL FINDINGS

Unilateral neglect (lack of caring of the other side of the body); strokes involving middle cerebral artery.

Poor hygiene and grooming: dementing disordersAbnormal gait and posture: transient ischemic attacks(TIAs) , strokes, and Parkinson’s diseaseEmotional swings, personality changes: strokesAphasia-defective or absent language function: TIA’s, strokes involving anterior/posterior artery; general term for impairment of languageDysphonia- change in tone of voiceDysarthria- (different in speaking); is indistinctness of words in word articulation resulting from interference with the peripheral speech mechanisms (e.g. muscles of the tongue, palate, pharynx, or lips) [Phipps, 1998, p. 1901]Decreased level of consciousnessConfusion, Coma

COGNITIVE FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Disorientation to time and place: stroke of right cerebral hemisphere

1. Memory deficits2. Emotional defense

CRANIAL NERVE ASSESSMENTSCranial I (Olfactory): Anosmia

1. lesions of frontal lobes2. impaired blood flow to middle cerebral artery.

Cranial II (Optic)1. blindness in eye: strokes of internal carotid

artery, TIA’s2. Homonymous hemianopia - impaired vision or

blindness in one side of both eyes; blockage of posterior cerebral artery.

3. Impaired vision: strokes of anterior cerebral artery; brain tumors

Note:Visual acuity-mediated by the cones of the retinaField of vision or peripheral vision-portion of space in which objects are visible during the fixation of vision in one direction. The receptors for peripheral fields are the rod neurons of the retina. (Phipps, 1998, p. 1906)

Cranial nerve III, IV, VI (Oculomotor, Trochlear, Abducens)-motor nerves that arise from the brainstem

1. Nystagmus –- involuntary eye movement; strokes of anterior, inferior, superior, cerebellar arteries

2. Constricted pupils: may signify impaired blood flow to vertebralbasilar arteries.

3. Ptosis (eyelid falldown); dropping of the upper eyelid over the globe—strokes of posterior inferior cerebellar artery; myasthenia gravis, palsy of CN III

Cranial nerve V (Trigeminal)—largest cranial nerve with motor and sensory components: changes in facial sensations; impaired blood flow to carotid artery

1. Decreased sensation of face and cornea on same side of body; strokes of posterior inferior cerebral artery

2. Lip and mouth numbness3. Loss of facial sensation: contraction of masseter and

temporal muscles, lesions CN V4. Severe facial pain: trigeminal neuralgia (tic dorlourex)Cranial VII (Facial nerve)—mixed nerve concerned with

facial movement and sensation of taste

1. Loss of ability to taste2. Decreased movement of facial muscles3. Inability to close eyes, flat nasolabial fold, paralysis

of lower face, inability to wrinkle the forehead 4. Eyelid weakness; paralysis of lower face; paralysis of

upper motor neuron5. Pain, paralysis, sagging of facial muscles: affected

side in Bell’s palsyCranial VIII (Acoustic)—composed of a cochlear

division related to hearing and a vestibular division related to equilibrium (Phipps, 1998, p. 1909)

Decreased hearing or deafness: strokes of vertebralbasilar arteries or tumors of CN VIII

Cranial IX(Glossopharyngeal) and cranial X (Vagus)—chief function of cranial nerve IX is sensory to the pharynx and taste to the posterior third of tongue; cranial nerve X is the chief motor nerve to the soft palatal, pharyngeal and laryngeal muscles (Phipps, 1998, p. 1909)

1. Dysphagia (difficulty swallowing)2. Unilateral loss of gag reflex

Cranial XI (Spinal accessory)—motor nerve that supplies the sternocleidomastoid muscle and upper part of trapezius muscles

1. Muscle weakness2. Cortralateral hemiparesis: strokes affecting middle

cerebral artery and internal arteryCranial XII (Hypoglossal)1. Atrophy, fasciculations (twitches): LMN disease2. Tongue deviation toward involved side of the body

SENSORY FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Altered sensation occurs with variety of neurologic pathology

Altered sense of position: lesions of posterior column of spinal cord

Inability to discriminate fine touch: injury to posterior columns

MOTOR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Muscle atrophy: LMNs diseaseTremors (groups, large of muscle fibers)-

Parkinson’s disease (tremors at rest), multiple sclerosis (tremors observed in activity)

Fasciculations (single muscle fiber): disease or trauma to LMN, side effects of medications, fever, sodium deficiency, anemia

Flaccidity (decreased muscle tone): disease or trauma to LMN and early stroke

Spasticity (increased muscle tone): disease of corticospinal motor tract

Muscle rigidity: disease of EP motor tractCogwheel rigidity (muscular movement with small

regular jerky movement; parkinson’s diseaseMuscle weakness-in arms, legs, hands: TIAsHemiplegia-paralysis of half of body verticallyFlaccid paralysis: strokes of anterior spinal artery,

multiple sclerosis or myasthenia gravisTotal loss of motor function: below level of injurySpasticity of muscle: incomplete cord injuries

CEREBELLAR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Ataxia (lack of coordination and clumsiness of movement, staggering, wide-based and unbalanced gait)

Steppage gait (client drags or lifts foot high, then slaps foot onto floor; inability to walk on heels; disease of LMN

Sensory ataxia (client walks on heels before bringing down toes and feet are held wide apart; gait worsens with eyes closed

Parkinsonian gait (stooped over position while walking with shuffling gait with arms held close to the side)

Romberg’s test (Positive)- With feet approximated, the patient stands with eyes open and then closed; if closing the eyes increases the unsteadiness, a loss of proprioceptive control is indicated

REFLEXHyperactive: reflexesDecreased reflexesClonus of foot (Hyperactive, rhythmic dorsiflexion

and plantar flexion of foot)Superficial reflexes (such as abdominal) and

cremasteric reflex Positive Babinski reflex (dorsiflexion of big toe)

(plantiflexion- Normal)

Special Neurologic Assessment

Brudzinski’s sign (pain, resistance, flexion of hips and knees when head flexed to chest with client supine)

Positive Kernig’s sign-excessive pain when examiner attempts to straighten knees with client supine and knees and hips flexed

Decorticate posturing (up)- decorticate response, mummy baby, flexor posturing- damage to mesencephalic region and the corticospinal tract

Decerebrate posturing (down)- extensor posturing- the head is arched back, the arms are extended by the sides, and the legs are extended.

Decerebrate posturing indicates brain stem damage or rather damage below the level of the red nucleus (eg. mid-collicular lesion)

#Altered Level of consciousness1. Consciousness

Requires:1. Arousal: alertness; dependent upon reticular

activating system (RAS); system of neurons in thalamus and upper brain stem

2. Cognition: complex process, involving all mental activities; controlled by cerebral hemispheres

Process that affect LOC:a. Increased ICPb. Stroke, hematoma, intracranial hemorrhagec. Tumorsd. Infectionse. Demyelinating disorders

Systemic Conditions affecting LOC Hypoglycemia F/E imbalance Accumulated waste products from liver or renal

failure Drugs affecting CNS: alcohol, analgesics,

anesthetics Seizure activity: exhausts energy metabolites Level of Consciousness

AlertLethargic-very sleepyObtunded

StuporousComa Death

Client Assessment with Decreased LOCa. Increased stimulation required to elicit response from

clientb. More difficult to arouse; client agitated and confused

when awakenedc. Orientation changes: losses orientation to time first,

then place, persond. Continuous stimulation required to maintain

wakefulnesse. Client has no response, even to painful stimulation

Loss of Simultaneous Eye MovementLoss of normal reflex functioning:1. Doll’s eye movement: eye movement in opposite

direction of head rotation (normal function of brain stem)

2. Oculocephalic reflex: eye move upward with passive flexion of neck; downward with passive neck extension (normal function)

3. Oculovestibular response (cold caloric testing): instillation of cold water in ear canal cause nystagmus (lateral tonic deviation of eyes) toward stimulus (normal function)

Glasgow Coma Scale

1 2 3 4 5 6

Eyes

Does not open eyes

Opens eyes in response to painful

stimuli

Opens eyes in response to

voice

Opens eyes spontaneously

N/A N/A

Verbal

Makes no sounds

Incomprehensible sounds

Utters inappropriate

words

Confused, disoriented

Oriented, converses normally

N/A

Mot

or

Makes no movements

Extension to painful stimuli

(decerebrate response)

Abnormal flexion to

painful stimuli (decorticate response)

Flexion / Withdrawal to painful stimuli

Localizes painful stimuli

Obeys commands

Interpretation

Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".

Generally, brain injury is classified as:

Severe, with GCS ≤ 8 Moderate, GCS 9 - 12 Minor, GCS ≥ 13.

Intubation and severe facial/eye swelling or damage makes it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. 'E1c' where 'c' = closed, or 'V1t' where t = tube.

A composite might be 'GCS 5tc'. This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for 'abnormal flexion'. Often the 1 is left out, so the scale reads Ec or Vt.

MOTOR FUNCTION ASSESSMENTa. Client follows verbal commandsb. Pushes away purposely from noxious stimulic. Movements are more generalized and less purposeful

(withdrawal, grimacing)d. Reflexive motor responsese. Flaccid with little or no motor response

COMA

Use CPOMR to evaluate the lesion C: Conscious P: Pupil O: Ocular movementM: Motor responseR: Respiratory pattern

Irreversible coma - vegetative statePermanent condition of complete unawareness of

self and environment, death of cerebral hemispheres with continued function of brain stem and cerebellum

Client does not respond meaningfully to environment but has sleep-wake cycles and retains ability to chew, swallow and cough

Eyes may wander but cannot track objectsMinimally conscious state: client aware of

environment, can follow simple commands,

indicates yes/no responses; make meaningful movements (blink, smile)

Often results from severe head injury or global anoxia

Locked-in syndrome1. Client is alert and fully aware of environment; intact

cognitive abilities but unable to communicate through speech or movement because of blocked efferent pathways from brain

2. Motor paralysis but cranial nerves may be intact allowing client to communicate through eye movement and blinking

3. Occurs with hemorrhage or infarction of pons, disorders of lower motor neurons or muscles

Brain Death1. Cessation and irreversibility of all brain functions2. General criteria:

a. Absent motor and reflex movementsb. Apneac. Fixed and dilated pupilsd. No ocular responses to head turning and caloric stimulatione. Flat EEG

ICP Increased blood volume, increased brain volume,

increased CSF volume Normal pressure: 5-15 mmHg, with pressure

tranducer with head elevated 30˚; 60-180

cmH20, water manometer with client lateral recumbent

Manifestations:Decreasing level of sensorium-most sensitive,

reliable and earliest indicator: due to cerebral hypoxia, interference with RAS function

Increasing BP, decreasing pulsePupillary changes (a reflection of tissue shiftsCushing’s triad-increasing systolic pressure,

widening pulse pressure and bradycardia (final compensatory mechanism to maintain CSF)

Papilledema-due to the compression of optic discRespiratory changes-dependent on site of pressureMotor changes-dependent on site of pressure;

usually starts contralaterally; then hemiplegia, decortication or decerebation depending on pressure on brain stem

Late signs: coma, apnea, unilateral pupil changes

ICP monitoring Continuous intracranial pressure monitor is used for

continual assessment of ICP and to monitor effects of medical therapy and nursing interventions

STROKE

Right brain damage Left brain damageParalyzed left

sideParalyzed right

side

Spatial-perceptual deficits

Tend to deny or minimize problems

Impaired judgment

Impaired time concepts

Short term span

Impaired speech/language

Impaired right and left discrimination

Aware of deficits, depression, anxiety

Impaired comprehension

Slow performance, cautious

SPINAL CORD INJURYA. Early symptoms of spinal shock

Absence of reflexes below level of lesionFlaccid paralysis below level of injury

Hypotonia results in bowel and bladder distentionInability to perspire in affected partsHypotension

B. Later symptoms of spinal cord injuryReflex hyperexcitabilityState of diminished reflex hyperexcitability below

site in all instances of cord damage following hyperreflexia

In total cord damage-loss of motor and sensory function is permanent

Sacral region-atonic bladder and bowel with impairment of sphincter control

Lumbar region- spastic bladder and loss of bladder and anal sphincter control

Thoracic-trunk below the diaphragmCervical-from neck down, if above C4 respirations

and depressedIn partial cord damage, depends on the type of

neurons affected (spastic vs. flaccid)

MUSCLE FUNCTION AFTER SPINAL CORD INJURY (((log-rolling)

Spinal Cord Injury

Muscle Functioning remaining

Muscle Function

LossCervical, above C4

None All including respiration

C5 Neck, scapular elevation

Arm, chest, all below

chestC6-C7 Neck, some

chest movement, some arm movement

Some arm, fingers, some

chest movement all below chest

Thoracic Neck, arms (full), some

chest

Trunk, all below chest

Lumbo-sacral

Neck, arms, chest, turnk

Legs