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Neurological Assessment-Urden

Clinical Assessment
Imperative for the early identification and treatment of a neuro
disorder and
serves as a source for comparison for ongoing assessments
The most important finding is changereport promptly
Early identification of neuro deterioration is vital to preventing
secondary brain
History-of events preceding hospitalization
Common to all neuro assessments
Includes information about clinical manifestations, associated
precipitating factors, progression, and familial occurrences.
If patient is unable to providefamily/significant others who have daily
with the patient should be contacted ASAP.
Allows nurse to focus on certain aspects of the patients clinical
o Common neuro symptoms (e.g., fainting, dizziness, seizures,
pain, numbness
o Events preceding onset of symptoms (e.g., travel, falls, infection,
o Progression of symptoms (initial onset, evolution, frequency,
duration, associated activities/aggravating factors)
o Family history
o Medical history
o Surgical history
o Traumatic history
o Allergies
o Patient profile (personal habits, recent life changes,
conditions, exposure to toxins/chemicals, temperament)
o Current medication use
Physical Examination-5 Components
1) Level of consciousness
Most important aspect of the neuro exam
LOC deteriorates before any other neuro changes are noted

Categories: Alert, confused, delirious, lethargic, obtunded,

Glasgow Coma Scale most widely recognized tool for assessing
o Based on evaluation of 3 categories: eye opening, verbal
response and
best motor response.
o The highest possible score is 15 and the lowest is 3
o A score <7 indicates coma
o Not a sensitive tool for evaluation of an altered sensorium
and doesnt
account for possible aphasia/intubation. It also is a
poor indicator of lateralization of neuro deterioration
(involves decreasing motor response on 1 side or
unilateral changes in papillary reaction)
Assessment focuses on 2 areas:
a) Evaluation of Arousal
Evaluating the reticular activating system and its
connection to the
thalamus and the cerebral cortex
Arousal is the lowest LOC, and observation centers on
the patients
ability to respond to verbal or noxious stimuli in
appropriate manner.
To stimulate a patient: being with verbal stimuli in
normal tone.
Then increase by talking very loudly. Then shake the
patient. Then noxious stimuli should follow.
Central Stimulation Trapezius pinch, sternal rub
Peripheral Stimulation Nail bed pressure, pinching of
aspect of arm/leg
b) Appraisal of Awareness
Content of consciousness is a higher level function, and
of awareness is concerned with assessment of the
patients orientation to person, place, time, and
Requires the patient to give appropriate answers to a
variety of
Change in the patients answers indicate increasing
degrees of

confusion/disorientation and may be the 1st sign of

neuro deterioration
2) Motor function
--Assess each side individually and compare with other side
a) Evaluation of Muscle Size/Tone
Inspect size/shape..note atrophy.
Assess tone by evaluating opposition to passive movement (pt.
the extremity and nurse performs passive ROM and
evaluates degree of resistance)
Assess tone by looking for signs of flaccidity, hypotonia, hypertonia,
spasticity or rigidity
b) Estimation of Muscle Strength
Pt performs movement against resistance and assess muscle
Pt extends both arms with palms up and holds position with eyes
If patient has a weaker sidethat arm will drift
Test lower extremities by having patient push and pull the feet
resistance or to elevated the legs
Muscle Strength Grading Scale
0/5, 1/5, 2/5, 3/5, 4/5, 5/5
c)Abnormal Motor Responses
Peripheral stimulation is used to assess motor function
Motor responses elicited by noxious stimuli are interpreted different
from those elicited by voluntary demonstration
Spontaneous, localization, withdrawal, decortication,
decerebration, flaccid
Decorticate posturing upper extremities exhibit
flexion of the arm, wrist, and fingers, with adduction
of the limb. The lower extremity exhibits extension,
internal rotation, and plantar flexion. Occurs with
lesions above the midbrain, located in the
thalamus/cerebral hemispheres.
Decerebrate Rigidity/Posturing teeth clench, arms
are stiffly extended, adducted, and hyperpronated.
Legs are stiffly extended, with plantar flexion of the
feet. Occurs with lesions in the area of the brainstem.
Worse prognosis.
d) Evaluation of Reflexes
Achilles (ankle jerk), Quadriceps (knee jerk), Biceps, Triceps

Graded on a scale from 0 (absent) to 4 (hyperactive) 2=normal

Hyperreflexia=associated with lesions of the lower motor neurons
Superficial reflexes are tested by stimulating cutaneous receptors of
skin, cornea, or mucus membranes.
Grasp reflex present in an adult indicates cortical damage
Babinski reflex is a pathological sign if >2y/o and indicates an upper
motor neuron lesion in the brain, brainstem, or spinal
3) Pupillary Function
An extension of the ANS.
Pupillary changes provide a valuable assessment tool because of pathway
--The oculomotor nerve lies at the junction of the midbrain and the
tentorial notch and any increase of pressure that exerts force down through
the tentorial notch compresses the oculomotor nerve. Oculomotor nerve
compression results in a dilated, nonreactive pupil.
--Sympathetic pathway disruption occurs with involvement in the
brainstem. Loss of sympathetic control leads to pinpoint, nonreactive pupils.
a) Estimation of Pupil Size/Shape
Normal: 2-5 mm and a discrepancy up to 1 mm between the 2 pupils
normal (anisocoria)
Change in size or inequality is significant and may indicate
danger of herniation
Pupil size/reactivity play a key role in the physical assessment of ICP
changes and herniation syndromes
Initial stages of CN III compression from elevated ICP can cause the
to have an oval shape
b) Evaluation of Pupillary Reaction to Light
Depends on the optic and oculomotor nerve function
Reaction to light is described as: brisk, sluggish, or
The consensual papillary response is constriction in response
to a light shined into the opposite eye.
c) Assessment of Eye Movement
If consciousfollow finger through the full range of eye
motion. If they eyes move together into all 6 fields, EOM
are intact
If unconsciouselicit the dolls eyes reflex. Make sure of
absence of cervical injury prior. To assess the

oculocephalic reflex: hold patients eyelids open and

briskly turn the head to one side while observing the
eye movement and then briskly turn the head to the
other side and observe the movement again. If eye
movement deviates to the opposite direction in which
the head is turned, the dolls eyes reflex is present, and
the oculocephalic reflex arc is intact. If the
oculocephalic reflex arc is not intact, the reflex is absent
and eyes remain midline and move with the head
(indicating significant brainstem injury or severe
metabolic coma)
The Oculovestibular Reflex often performed as one of the
final assessments of brainstem function. Confirm the
tympanic membrane is intact then raise HOB to 30
degrees and inject 20-100 mL of ice water into the
external auditory canal. The normal eye movement
response is a conjugate, slow, tonic nystagmus,
deviating toward the irrigated ear and lasting 30-120
seconds (indicates brainstem integrity) An abnormal
response is disconjugate eye movement, which
indicates a brainstem lesion, or no response, which
indicates little/no brainstem function. (This reflex may
be temporarily absent in reversible metabolic
encephalopathy) May cause posturing if unconscious
and may cause n/v or dizziness if conscious

4) Respiratory Function
Respiration is a highly integrated function that receives input from the
brainstem and metabolic mechanisms.
Correlations exist between altered LOC, the level of brain/brainstem injury,
and the
patients respiratory pattern
3 brainstem centers control respirations
-The lowest centerMedullary Respiratory Center sends impulses
through the
vagus nerve to innervate muscles of inspiration/expiration
--The apneustic and pneumotaxic centers of the pons are
responsible for the
length of inspiration/expiration and the underlying respiratory
a) Observation of Respiratory Pattern
Changes in pattern assist in identifying the level of brainstem

Cheyne-Strokes, Central neurogenic hyperventilation,

Cluster breathing, Ataxic respirations
Includes: assessment of the effectiveness of gas exchange in
maintaining adequate oxygen and carbon dioxide levels.
b) Evaluation of Airway Status
Cough, gag, and swallow reflexes responsible for protection of
the airway may be absent or diminished if a patient has
neuro deficit

5) Vital Signs
As a result of brain/brainstem influences on cardiac, respiratory, and body
temp functions, changes in vital signs could be signs of deterioration in
neuro status
a) Evaluation of Blood Pressure
A common sx of intracranial injury is systemic hypertension
When controlling systemic hypertension, the mean arterial
pressure must be maintained at a level sufficient to
produce adequate CBF in the presence of elevated ICP.
Also pay attention to the pulse pressure because
widening of this may occur in the late stages of
intracranial hypertension.
b) Observation of Heart Rate and Rhythm
The medulla/vagus nerve provide parasympathetic control to
the heart. When stimulated, it produces bradycardia
Sympathetic stimulation increases the rate and contractility.
Cushing Reflex/Triad/Phenomena (systolic hypertension,
bradycardia, abnormal respirations) related to pressure
on the medullary area of the brainstem. This may occur
in response to intracranial hypertension or a herniation