Neurological Assessment

Neurological Assessment

 

Nervous System

Divided into two regions

1. Central Nervous System (CNS)

2. Peripheral Nervous System (PNS)

 

CNS – Brain

  • Control center of body
  • Covered and protected by scalp, skull, and
  • meninges “ dura matter – arachnoid – pia mater”
  • Blood brain barrier
  • Cerebrum – right and left hemispheres, frontal, parietal, occipital and temporal lobes
  • Diencephalon – (thalamus , hypothalamus and posterior lob of pituitary gland) that responsible on body temperature and sleep.
  • Cerebellum – consist of two hemisphere that position sense, posture & equilibrium/balance
  • Brain Stem – (medulla oblongata, pons & midbrain) respiratory and cardiac regulation, sneezing, level of conscious.

Lobes of the Cerebrum

1. Parietal – somatic sensory center

2. Frontal – higher intellect, speech production, personality, behavior, emotions, voluntary movement

3. Temporal – hearing, memory, speech perception and translation

4. Occipital – vision

5. Limbic – emotion

 

Lobes of the Cerebrum

 

CNS – Spinal Cord

  • Extends from medulla to the level of the first lumbar vertebra
  • Cord protected by vertebra, meninges and cerebral spinal fluid located between pia and arachnoid mater
  • Gray matter is on the inside and white matter on the outside
  • Mediates deep tendon reflexes

 

Spinal Roots

Cervical, thoracic, lumbar nerves

  • Posterior (sensory) roots
  • Anterior (motor) roots

Note :

  • Damage to posterior – loss of sensation
  • Damage to anterior – flaccid paralysis

 

Peripheral Nervous System (PNS)

  • The PNS links CNS with the rest of the body
  • Carrying information to and from the CNS and external environmental information received and transmitted via PNS

 

Spinal Nerves

Cervical 8 pairs C1-C8
Thoracic 12 pairs T1-T12
Lumbar 5 pairs L1-L5
Sacral 5 pairs S1-S5
Coccygeal 1 pair Coccyx

 

3. Autonomic Nervous System (ANS)

ANS impulse are carried by both cranial and spinal nerves. These impulse are carried from the CNS to involuntary , smooth muscle “wall of the heart , glands”

1. Sympathetic nerves system : (fight or flight)

2. Parasympathetic nerves system: control of normal daily body function” e.g. muscle tone, maintains secretion, maintain heart beat normal , maintain peristalsis

 

Dermatome

Dermatome

  • Area of skin that is innervated by cutaneous branches of a single spinal nerve.
  • Useful in identifying neurological lesions.

4. Cranial Nerves (CNS)

  • CN I- Olfactory
  • CN II- Ophthalmic
  • CN III- Occulomotor
  • CN IV- Trochlear
  • CN V- Trigeminal
  • CN VI- Abducens
  • CN VII- Facial
  • CN VIII- Vestibulocochlear
  • CN IX- Glossopharyngeal
  • CN X- Vagus
  • CN XI- Spinal Accessory
  • CN XII- Hypoglossal

Nursing History

Current Health History

  • Headaches, memory and concentration, visual disturbances, hearing, balance, dizzy spells, speech, muscle strength, abnormal sensations

Past Health History

  • Head injury, spinal cord injury, surgery, seizures

Family History

  • Neurological diseases, headaches, HTN, stroke, DM

Social History and Habits

  • Diet, vitamin deficiencies, ability to read or concentrate, exposure to toxins or chemicals, alcohol or drug use, sexual difficulties, sleep problems

Medication History-neuro as well as all others

 

Preparation and Equipment

image

1. Asking to the client to remove all clothing and jewelry and put on an exam gown

2. Comfortable position. (several position).

3. Explain before the start of the particular examination

4. In elderly client , the examination can divided into parts and performed over two different time period

Equipment

  • Glove
  • Cotton – tipped applicator ,
  • Senllen chart ,
  • Tuning fork
  • Otoscope
  • Pen light
  • Tongue depressor
  • Tape measure
  • A quarter or key / pins
  • Percussion hammer

Complete Neurological Assessment

5 Components

1. Cerebral Function

2. Cranial Nerve Function: I-XII

3. Cerebellar and Motor Function

4. Sensory System

5. Reflexes

 

Neuro Check

The nurse should be able to perform a very brief neurologic assessment called neuro check

  • Level of consciousness (LOC)
  • Pupil response and size
  • Verbal responsiveness
  • Extremity strength and movement
  • Vital signs

Establishing BASELINE and regularly re-evaluating key indictors reveals trends and detects changes à warning signs of problems

 

1. Cerebral Function

– Level of consciousness: level of arousal and orientation

1. Level of arousal

  • Alert à lethargic à unresponsive
  • Auditory àtactile à painful stimuli to elicit response

2. Level of orientation: Cortex activity

  • Person, place, time

Speech

  • Quality: Clear, slurred
  • Rate
  • Volume
  • Fluency – Abnormal patterns

– Verbal responses appropriate or nonsensical

– Ability to understand and follow commands

– Awareness of and difficulties with communication

Speech abnormalities

  • Dysarthria: difficulty with mechanics of speech
  • Aphasia:
  • TEMPORAL-receptive : (Wernicke’s)

Ability to express self, but cannot understand others :

Auditory: spoken word

Visual: written word

  • FRONTAL-expressive (Broca’s )
  • Understands, but cannot speak

 

  • GLOBAL – ( both receptive and expressive): severe form, absent/reduced speech, and understanding

 

PHYSICAL

Appearance

Motor Activity

Behavior

EMOTIONAL

Attitude

Mood and Affect

COGNITIVE

Orientation

Attention and Concentration

Memory

Speech and Language

Thought (Form and Content)

Perception

Insight and Judgment

Intelligence and Abstraction

 

Mental Status Examination

1. General Appearance.

2. Motor Activity ( hyper /hypo/normal activity)

3. Mood (elated , depressed , sad , elevation , swing mood)

4. Affect ( inappropriate , flat affect)

5. Self Concept (attitude)

6. Speech (speed, articulation and rhythm)

7. Thought Processes ( flight of idea , blocking thinking)

8. Thought Content and Perception (illusion , delusion and hallucination)

9. Sensorium and cognition( level of consciousness , orientation , memory )

10. Intellectual Functioning

11. Judgment and Impulse Control

12. Insight: degree of the patients awareness that he is ill

13. Reliability and Summary

 

Cognitive Abilities and Mentation

1. Immediate (second- less than minute) – Ask to repeat 6 object or words

2. Short memory (5- 10 minute) – Ask the patient about last meal, repeat 3-4 unrelated word (wait)

3. Long memory : ask the patient what he did yesterday

4. Remote memory – Ask about childhood, school

  • Abstract thinking : ability to deal with concept Meaning of a proverb, simple math
  • Interpretation of stimuli – Visual, auditory, tactile

 

2. Cranial Nerve Function: I-XII

Cranial Nerve I

Olfactory nerve

  • Type of impulse :(sensory)
  • Carries smell impulse from nasal mucus member to brain
  • Vulnerable to damage in frontal head, basilar, and facial injuries

 

Cranial Nerve II

Optic nerve

  • Type of impulse : (sensory)
  • Carries visual impulse from eyes to brain
  • Visual acuity, visual fields, ophthalmic exam of retinal structures

 

Cranial Nerve III

Oculomotor nerve

  • Type of impulse : (motor)
  • Contract eye muscle to control eye movments (inferior lateral ,medial and superior.
  • Elevation of eyelid
  • Contract pupil ; assess size, shape, response to light and accommodationà parasympathetic inervation
  • Assesses midbrain
  • Normal response: PERRLA- pupils equal round reactive to light and accommodation

 

CN III, CN IV, CN VI

Oculomotor, trochlear, abducens nerves

  • Type of impulse :(motor)
  • Assess Eye Of Movement’s
  • Assesses midbrain and pons

 

CN V: Trigeminal Nerve

(sensory and motor)

Type of impulse :

  • Sensory: three branches:
  • Opthalmic, Maxillary, Mandibular ;
  • carry sensory impulse pain touch and temperature from the face to the brain

Motor:

  • Influences clenching and lateral jaw movement (biting, chewing)
  • Palpate temporal and masters muscles
  • Open mouth —> assess if symmetry or not

– Corneal reflex

– Contact wearers

image

 

 

CN VII: Facial Nerve (sensory and motor)

Type of impulse :

  • Sensory: taste to anterior 2/3 of tongue

Motor:

  • Facial expression and secretion of saliva
  • Wrinkle forehead, raise and lower eyebrows, smile and show teeth, puff cheeks, close eyes
  • Observe for symmetry
  • Observe UMN (upper motor neuron) problems vs. facial nerve paralysis

In cranial nerve VII Facial

  • If CVA or tumor causes cortex (UMN) damage, pt. Will still be able to wrinkle forehead
  • If facial nerve damage, unable to wrinkle forehead or close eye

Vestibulocochlear nerve:

  • Hearing (cochlear) and balance (vestibular)

Testing: Tuning Fork:

1. Weber: tuning fork to center of forehead:

  • NORMAL: hear equally in both ears

2. RINNE: tuning fork to mastoid process then auditory canal

  • NORMAL: hear air conduction (Rinne positive)

 

CN IX and CN X

image

 

Glossopharyngeal and Vagus

Type of impulse : Sensory and motor

  • Assess together
  • Taste posterior 1/3 of tongue
  • Swallowing, gag reflex
  • Movement of pharynx (ask pt to say ahhhhh)
  • Assesses medulla

 

CN XI: Spinal Accessory Nerve

Spinal Accessory Nerve

Type of impulse : Motor

  • Shrug shouldersà trapezius
  • Turn headà sternocleidomastoid

 

CN XII: Hypoglossal Nerve

Hypoglossal Nerve

 

Type of impulse : Motor

  • Tongue movements, strength
  • Speech sounds: d, l, n, t

 

3. Cerebellar Function

  • Gait and Balance:
  • Tandem, heel-toe walking
  • Romberg test (feet together, eyes closed)
  • Coordination:
  • Rapid alternating movements
  • Finger to nose to finger test
  • Heel down shin

Coordination in extremities

finger nose to finger

finger nose to finger

 

heel down-shin

heel down-shin

Gait Abnormalities

1. Spastic hemiparesis : stroke, immobile arm against body, stiff/extended leg, toe drag

2. Cerebellar ataxia : loss of position sense, staggering, alcohol (barbiturate)

3. Parkinsonian : basal ganglia defects, curved posture, trunk forward, short/shuffling steps, rigid body

4. Scissors: knees cross/in contact, CP

5. Foot drop : lower motor neuron defect

6. Waddling : Dislocation of hips, lordosis & protruding abdomen

7. Short leg >1inch

 

Deep Tendon Reflexes

Assessing Spinal Cord Level

a) Upper Extremities:

  • Biceps
  • Triceps
  • Brachioradialis Tendon

b) Lower Extremities:

  • Quadriceps reflex
  • Achilles reflex

image

image

Biceps Reflex

  • Support the client’s forearm
  • Client’s arm flexed at 45-90 degree angle
  • Hold arm loosely
  • Strike tendon with a fast wrist motion on top of your thumb

Biceps Reflex

Brachioradialis Reflex

Brachioradialis Reflex

 

Triceps Reflex

  • Relaxed arm required.
  • extension of the forearm.

Triceps Reflex

 

Patellar Reflex

  • Sit on edge of table with leg hanging free.
  • Place hand over quadriceps muscle
  • Strike patellar tendon just below the patella – blunt end of hammer

Patellar Reflex

Achilles Reflex

  • Loosely support foot in hand.
  • quickly strike Achilles tendon.
  • Plantar flexion of the foot.

Achilles Reflex

 

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.

Plantar Reflex

 

Meningeal Irritation

1. Nuchal rigidity

  • Severe pain, spasms and resistance with gentle neck flexion

2. Kernig’s sign

  • Thigh on abdomen, knee flexed to 90 degrees, resistance with pain

3. Brudzinski’s sign

  • Chin to chest – involuntary hip flexion and pain

 

Superficial Reflexes

Graded as present or absent

Corneal Reflex (CN-V)

  • Present à Brisk blink
  • Loss in stroke, coma, contact wearers
  • Eye protection

Gag Reflex (CN X)

  • Present à Elevation of uvula bilaterally
  • Loss in stroke
  • Aspiration precautions

Plantar Reflex:
Babinski Response

Babinski Response

 

  • Stroke lateral aspect of sole of foot
  • NORMAL response à plantar FLEXION
  • BABINSKI response à pathological in adult
  • POSITIVE BABINSKI: Dorsiflexion of great toe with fanning of other toes
  • Indicates upper motor neuron disease

 

Grasp Reflex: Significance

COMA: Stimulation of palm of hand

  • POSITIVE: Pt will grasp firmly
  • Will not let go to command
  • Indicates frontal lobe damage, thalamic degeneration, cerebral atrophy

 

Newborn Reflexes

Rooting 3-4 months
Sucking 10-12 months
Palmar Grasp 3-4 months
Plantar Grasp 8-10 months
Moro 1-4 months
Tonic neck appear 2-3 m, disappear 3-4 m
Babinski 24 months
Placing appears 4 days
Stepping disappears before walking

 

Moro Reflex

Moro Reflex

Babinski

  • Positive Babinski reflex – normal with infant
  • Abduction of the toes with dorsiflexion of the great toe

Babinski

 

Placing & Stepping Reflex

Placing & Stepping Reflex

 

4. Sensory Assessment

  • Exteroceptive sensation
  • Light touch, superficial pain (sharp/dull), summation effect, temperature
  • Proprioceptive sensation
  • Motion, position, vibration
  • Cortical sensation
  • Sterognosis, graphesthesia, extinction, two-point discrimination (2-3 mm is normal), point location

 

Light Touch

  • Client sitting
  • Eyes closed
  • “Say where you are touched.”
  • Compare bilaterally, and distally to proximally.

Light Touch

 

Vibratory Sensation

  • Close eyes
  • Strike fork & start on most distal bony prominence & work medially with neuropathy
  • Ask when do you feel the vibration start and when do you feel the vibration stop.

Vibratory Sensation

 

 

Stereognosis

  • Close eyes
  • Place object in hand
  • “Identify object.”
  • Test bilaterally with different objects.
  • Note speed and accuracy
  • Astereognosis – unable to identify object

Stereognosis

 

Graphesthesia (Parietal Lobe)

  • Close eyes
  • Draw letter or number on hand
  • “Identify figure.”
  • Test bilaterally
  • Note speed and accuracy
  • Agraphesthesia – inability to identify figure

Graphesthesia

 

Two-point discrimination

  • To assess extinction, touch two corresponding parts on the client (such as the forearms just above the wrist) simultaneously, as shown ask the client to describe the location of the touch
  • Normal : sense the touch in both location

Two-point discrimination

 

Common laboratory studies and other test

1. Electrolytes

Na : 135 – 145 mEq/liter ,

K : 3.8 – 5.5 mEq/liter

Ca : 4.5 -5.5 mEq/liter

Magnesium: 1.5 – 2.5 mEq/liter

2. Cerebrospinal fluid (CSF)

3. Skull and Spinal X-rays

4. Computerized Tomography (CT)

5. Magnetic resonance image (MRI)

6. Cerebral Angiography

7. Myelogram

8. Lumbar Puncture

9. Electroencephalogram (EEG)

10. Glasgow coma scale (GCS)

 

Lumbar Puncture

  • Insertion of needle into subarachnoid space between L2 and S1
  • Withdrawal of small amount CSF for diagnostic evaluation
  • Measurement of CSF pressure
  • Should not be performed if evidence of greatly increased CSF pressure (papilledema)

Lumbar Puncture

 

Patient preparation:

  • No diet or fluid restrictions
  • Empty bowel and bladder before
  • Careful instructions regarding cooperation during test
  • Signed consent required

Positioning

Lumbar Puncture Positioning

Post-procedure care:

  • Prone with pillow under abdomen for 1 hr
  • Flat in bed 6-24 hours (30 degrees)
  • Increased fluid intake
  • Observe site for swelling, leakage
  • Observe for post spinal headache

Post LP Complication

  • Most common complication is headache
  • CSF leaks from needle track à depleted
  • Treatment: bed rest, analgesics, hydration

 

CSF Fluid Analysis

Appearance: clear and colorless

  • Bloody: traumatic tap (will clear)
  • Cloudy: infection
  • Orange or yellow: RBC breakdown, elevated protein

Cell Count: 0-5 WBC and no RBC’s

  • Elevated WBCà infection, abscess, tumor, chronic illness
  • RBC’sà traumatic

Protein: 15-45 mg/dl

  • Lower than plasma because of blood brain barrier
  • Elevated: infection, tumor, degenerative brain disease

Glucose: 50-75 mg/dl

  • Elevated: DM or diabetic coma
  • Decreased: acute bacterial meningitis, tumor

 

Level Of Consciousness

Comatose [Stuporous Patient]

Glasgow Coma Scale

Glasgow Coma Scale

 

Pupil reaction

• Fixed [no reaction]

• Sluggish [slow]

• Unequal

• Dilated [wide]

• Constricted [small]

• Pinpoint [very small]

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