OBJECTIVES
To describe the method of neurological assessment for the patient with an
acute or potential neurologic injury. Such assessment includes:
1) Establishing a neurologic baseline
2) Determining changes from the baseline
3) Determining emergent neurologic changes
Functional Anatomy
Neurological Assessment
Definition: systematic evaluation of the cranial nerves, motor
and sensory functioning, and mental status to detect
neurologic abnormalities
•0 Critical aspects of a complete neurologic assessment
are generally extracted and compose a "neuro checklist,"
which is used when the nature of the situation does not
warrant complete evaluation
3 Aspects of Assessment
•1 Interview
•2 Physical Exam
•3 Specific Diagnostic Tests
Neurological Assessment
Perform assessment as dictated by the client's needs
a. Cranial nerves
•4 (1) Olfactory (I): ability to identify familiar odors such as mint or
alcohol with eyes closed and one nostril occluded at a time
•5 (2) Optic (II): visual acuity measured by use of Snellen chart or
by gross estimation with reading material; gross comparison of
visual fields with those of examiner; color perception
Neurological Assessment
•6 (3) Oculomotor (III), trochlear (IV), and abducent (VI): ability of the pupils
to react equally to light and to accommodate to varying distances; normal
range of extraocular movement (EOM) evaluated by asking the client to
follow a finger or object with the eyes; should also include assessment for
nystagmus (jerking motion of eyes), particularly when eyes are directed
laterally
•7 (4) Trigeminal (V): sensations of the face evaluated by lightly stroking
cotton across forehead, chin, and cheeks while the client's eyes are closed;
ability to clench the teeth (jaw closure)
Neurological Assessment
•8 (5) Facial (VII): symmetry of the facial muscles as the client speaks or is
asked to make faces
•9 (6) Acoustic or vestibulocochlear (VIII): hearing acuity determined by a
watch tick or whispered numbers; Weber's test may be performed by
holding the stem of a vibrating tuning fork at midline of the skull (should be
heard equally in both ears)
•10 (7) Glossopharyngeal (IX) and vagus (X): uvula should hang in
midline; swallow and gag reflexes should be intact
Neurological Assessment
•11 (8) Spinal accessory (XI): symmetric ability to turn the
head or shrug the shoulders against counterforce of the
examiner's hands
•12 (9) Hypoglossal (XII): ability to protrude the tongue
without deviation to left or right, and without tremors
Neurological Assessment
b. Motor function (including cerebellar function)
(1) Balance
•13 (a) Observation of gait
•14 (b) Romberg test: positive if the client fails to maintain
an upright position with feet together when the eyes are
closed
Neurological Assessment
(2) Coordination: ability to touch the finger to the nose when arms are
extended or to perform similar tasks smoothly
(3) Muscle strength: evaluated by having the client move major
muscle groups against opposition supplied by the examiner
c. Sensory function: bilateral testing of the response to light touch
with cotton, superficial pinprick, vibration of a tuning fork
Neurological Assessment
d. Mental status of cerebral functioning
(1) Level of consciousness: determined by the response to stimuli
(e.g., verbal or physical); a client may be in any state, ranging from
alert to comatose; Glasgow Coma Scale may be used
(2) Orientation to person, place, and time: determined by general
conversation and direct questioning
(3) Judgment, memory, and ability to perform simple calculations
(4) Appropriateness of behavior and mood
Neurological Assessment
e. Reflexes
(1) Deep tendon (biceps, triceps, patellar, Achilles reflexes) with a
reflex hammer (Figure 6-28); classification from 0 (absent) to 4+
(signifying hyperactive)
(2) Plantar (Figure 6-29): plantar flexion of the foot when the sole is
stroked firmly with a hard object such as a tongue blade; abnormal
adult response (dorsiflexion of the foot and fanning of the toes) is
described as a positive Babinski and is indicative of corticospinal
tract disease
Neurological examination: specific features
•15 Stimulus and response
•16 Oculocephalic (doll’s eye)
•17 Caloric test
•18 Pupillary response
•19 Ocular motility
•20 Eye deviation
•21 Spontaneous eye movement
Motor examination
•22 Resting position and spontaneous movement
•23 Decerebrate rigidity
•24 Decorticate posture
•25 Fundal exam
•26 Respiratory pattern
Nursing Process
Assessment
Glasgow Coma Scale
IMPLEMENTATION
•27 Verify Doctor’s Orders.
•28 The check sheet will be utilized for multiple days. Enter
the date and time at the top of the column for each
neurological check.
•29 Place a check mark in the box of the appropriate
observation under the corresponding date and time
column.
IMPLEMENTATION
Observe for eye opening:
•30 Spontaneous
•31 To Speech
•32 To Pain
•33 None
IMPLEMENTATION
Assess level of consciousness:
•34 Full Consciousness
•35 Confused
•36 Lethargic
•37 Obtunded
•38 Stuporous
•39 Comatose
IMPLEMENTATION
Assess verbal response:
•40 Oriented
•41 Confused
•42 Inappropriate
•43 Incomprehensible
•44 None
IMPLEMENTATION
Assess motor response for upper and lower extremities:
•45 Follows Commands
•46 Purposeful Motion
•47 Withdraws to Pain
•48 Abnormal Flexion
•49 Abnormal Extension
•50 None:
IMPLEMENTATION
Strength (0-5):
•51 0: No movement.
•52 1: Minimal muscle movement - A flicker in an extremity
muscle may be noted.
•53 2: Joint movement - Able to drag extremity across bed; no
lifting.
•54 3: Lifting movement - Can lift extremity but drops it when
touched; no strength.
•55 4: Mild resistance - Can push or pull with some strength.
•56 5: Full resistance.
IMPLEMENTATION
Assess pupil size and reaction to light: (See Key on side 2
of check sheet)
•57 Size (mm)
•58 Reaction (+ or -)
Reportable Conditions
Reportable Conditions
NURSING ALERT!!!
Health Teaching
Documentation
COMPLICATIONS
•59 Changes in level of consciousness (LOC)
•60 Loss of detail and orientation
•61 Forgetfulness
•62 Restlessness
•63 Sudden quietness
•64 Pupillary changes
•65 Motor changes
•66 Vital signs
Role of neurological investigations
•67 CT Scan
•68 MRI
•69 EEG
Computerized Tomography (CT)
Computerized Tomography (CT)
APPLICATION: A Case Analysis
Faith Estrada RN received a twenty-one year old, male patient, Mike Arroyo, from the
Emergency Room to the 24 hour observation ward. Post motor vehicle accident, he
appeared beat up and understandably apprehensive, though well controlled. His left arm
was in a cast. Superficial abrasions were scattered about his body, but more generalized
on his left side. A reddened, egg-sized swelling was apparent over his left eyebrow. He
complained of a slight headache, but no blurring of vision or nausea. He said he never saw
the car that ran into his. Looking pensive, he remarked how strange it was that he didn't
remember the accident at all, or even how he arrived to the Emergency Room. He
continued that he felt very fortunate his wife and newborn baby were both fine as they
were well restrained in their car seats during the accident, and on the opposite side of
the impact. He was driving his family home from the hospital after discharge from the
maternity ward for delivery of their first baby. Needless to say, they were very glad
they had the baby seat securely installed.
APPLICATION: A Case Analysis
With a glance, Faith noticed that Mike was moving all his extremities with
coordination, his smile was equal on both sides, and he was conversing
appropriately with his wife. This clinical picture indicated Mike was not in acute
distress at present, so the complete nursing assessment could be implemented.
If patient distress were apparent, a system focal assessment must be done and
reported to the charge nurse and physician. Faith washed her hands, gloved up,
settled her patient into the hospital bed, and connected him to the cardiac
monitoring equipment, then took his vital signs (130/80, 98.4-82-16), while
orienting him to the bed controls and environment. As Mike relaxed, he became
particularly interested in learning the TV controls since there was a football
game on that he “just could not miss!” His wife decided to leave “since
everything seemed O.K.” She had to go breastfeed the baby, who she had left
with the grandmother.
Faith began the assessment interview. Mike had no medical or surgical
history, other than the usual childhood illnesses and a tonsillectomy at age
12. He had never experienced seizures, prolonged or severe headaches,
alterations in his consciousness, or vision, speech or motor problems in the
past. Both his parents were alive, two grandparents had died from heart
ailments and two were still alive, one has diabetes. Otherwise, all of his
immediate family was in good health. He was taking no medications other
than a multivitamin, but he had taken two aspirins this morning for a
“slight tension headache.” He thought it was “a case of nerves about
bringing home the new baby” that had brought on the headache, which was
relieved with the two aspirin.
APPLICATION: A Case Analysis
A physical assessment revealed Mike to be of good general health: lungs
clear, 100% sat on room air; cardiac monitor indicated normal sinus
rhythm; the abdomen was soft, flat, nontender with good bowel sounds,
healthy bowel patterns, no difficulty urinating; all peripheral pulses were
palpable, the left arm cast was intact and the fingers of the left hand
were pink, warm and mobile. An assessment of his generalized abrasions
revealed no unexpected inflammation, drainage or foreign bodies. After
cleansing the superficial wounds with normal saline, she left them open to
air (OTA). The swelling over his eyebrow was tender to touch, but there
was no drainage from the small-abraded area on the peak of the lump, nor
was there drainage from his nose, ears or eyes.
Faith then turned to the Glasgow Coma Scale and began a more specific
neurological assessment.
“Mike, we are going to be assessing your neurological status every hour
tonight since you bumped your head during the accident.”
“O.K. whatever you say - Just not during any touchdowns, I hope.”
“Can you tell me where we are, Mike?”
“Don’t you know?”
Faith laughed, “Well, I know we’re not in Kansas! Mike, these may seem like
dumb questions, but they help us to evaluate you in a quick and efficient
manner. The neurological system can be tricky.”
“O.K. Faith. I’m in Metro Medical Center - but just for the night!”
“Great! Please tell me your full name and the year.”
Mike responded appropriately, so Faith noted that Mike is awake, alert and
oriented to time, person and place, or AA&Ox3.
She asked Mike to squeeze her finger, which he did first with one hand,
then the other. The strength was bilaterally equal. Faith offered only a
finger to be squeezed, as offering her full hand could have been painful
with such a strong patient. Mike could move all extremities(MAE) with no
difficulty.
APPLICATION: A Case Analysis
Faith explained the eye exam and dimmed the lights in the room to inspect his
pupils. Pupils should be round and equal in size, unless there was prior eye
surgery. Eye surgery may alter the shape of the pupil. She asked Mike to look at
her forehead and quickly flashed the light into, then out of, his right eye. The
pupil constricted, then returned to its original size. The pupil exposed to the
light demonstrated a direct response to the light, and the pupil not exposed to
the light demonstrated a similar constriction, known as a consensual response.
Faith then flashed the light into the same eye, and checked for consensual
response in the other eye. She then checked the remaining eye in a similar
fashion. Once assured both pupils were equal and reactive to light, Faith began
her assessment for pupil accommodation or the eye’s ability to focus on both
near and far objects.
She asked Mike to focus on the clock on the wall, then to change his focus
onto her finger, which was six inches from his nose. Mike’s pupils
constricted as he focused on the nearby object. Faith documented
PEARLA on the nursing notes, indicating pupils equal and reactive to light
and accommodation present.
Faith finished the documentation, while Mike called home to check on his
wife and new baby. Presently, he seemed stable.
Faith pulled up the side rails on Mike’s bed before leaving the room. She ensured
the nurse call button was within his reach and instructed him to call her if he
needed anything or experienced any discomfort. He agreed. The football game
would start in an hour and he said he wouldn't need anything other than the TV
control. Faith turned to the chart to ascertain all the orders were properly
noted, sent to the pharmacy, etc.
Half an hour later, Mike was sleeping, but awoke easily. Though he seemed irritable
for having been woke up, the rest of his neurological signs were within normal
limits. At the next thirty minute check, Faith awoke Mike to assess him and to
remind him the football game was starting, but he answered with a slur that he
wasn’t interested in the "****ing football game.” He squinted his eyes and asked
Faith if she had brought along her twin, then he turned away, rubbing his head.
In addition to a change in character, Mike had diplopia.
When Faith asked if Mike's headache had returned, he responded, "Don't put any
pepper on my potatoes,” indicating inappropriate speech. Further neurological
assessment revealed Mike to be disoriented to time and place, and unable to
follow simple commands. When Faith attempted to touch Mike's arm, he pulled
away, and asked, "Who the hell are you?” His Glasgow Coma scale result was 11.
His left pupil was 2mm larger than the right and sluggish to constrict to light.
The vital signs were 190/40, 99.9 - 54 - 36, in contrast to the earlier vitals:
130/80, 98.4 - 82 - 16. Faith pushed the intercom button and asked the
secretary to please place a STAT call to the Mike's primary doctor, and to let
the answering service know there was a life-threatening emergency that
required a prompt response. Within minutes, orders were received for a CT scan
and a neurosurgeon consult. The CT scan revealed an acute subdural hematoma,
the neurosurgeon arrived and Mike was whisked off to the Operating Room for
emergency surgery.
Mike Arroyo had a successful surgical evacuation of subdural hematoma. He
spent a week in the Intensive Care Unit, where the nurses closely
monitored his intracranial pressures with modern, high tech equipment.
He had no complications, and was transferred to the neurology
rehabilitation ward for several weeks. Faith visited him the day before
he went home. Mike told her that the last thing he remembered before
the surgery was her interview.
“Hi there, Angel of Mercy,” Mike said to Faith, with a great big, somewhat
lop-sided smile.
“Hey Mike. It’s good to see you up and about again! Your hair is already
growing back in quickly, I see. ”
Mike rubbed the stubble of hair growing in over the healing suture line on the back
of his head. “Yes mam, I am doing great! I’ can't believe I'm going home
tomorrow. It seems like I've been in the hospital forever. I can’t wait to get
home and to help my wife care for our little baby. What a lucky guy I am! Hey,
can you believe my wonderful wife taped the football games that I missed. I’m
telling you, no guy has a better wife than I... except for your husband, of
course," Mike added, with a blushing smile. "Faith, thanks for saving my life. The
doctor told me that if not for your TLC and invaluable nursing skills, I might have
Jell-O for brains right now. You’re an angel!”
Faith smiled. It's a priceless feeling to make such a positive influence on a
family's life.
•70 The NIH Stroke Scale
SUMMARY
•71 3 Aspects of Neurological Assessment
•72 Interview
•73 Physical Exam
•74 Specific Diagnostic Tests
