NCM 118 – SEMIFINALS

Neurologic Assessment
Collecting Subjective Data

The Nursing Health History

• Clients who are experiencing symptoms associated with

the neurologic system (such as headaches or memory
loss) may be very fearful that they have a serious
condition such as a metastatic brain tumor or a difficult-
to-treat disease such as Alzheimer’s.

• Fear of losing control and independence, along with

threatened self-esteem or role performance, are
common.

• The examiner needs to be sensitive to these fears and

concerns because the client may decline to share
important information with the examiner if these fears
and concerns are not addressed.

Collecting Objective Data
The Physical Assessment
• A complete neurologic examination consists of evaluating the following
five areas:
1. Mental Status
2. Cranial Nerves
3. Motor and Cerebral Systems
4. Sensory Systems
5. Reflexes
• A neuro check is useful in an emergency situation and when frequent
assessments are needed during an acute phase of illness to detect rapid
changes in neurologic status
• scan. It is used to identify blockages or narrowing of blood vessels,
• Mental status examinations provide information about cerebral cortex
function. Cerebral abnormalities disturb the client’s intellectual ability,
communication ability, or emotional behaviors.
• The cranial nerve evaluation provides information regarding the
transmission of motor and sensory messages, primarily to the head and
neck.
• The motor and cerebellar systems are assessed to determine functioning
of the pyramidal and extrapyramidal tracts. The cerebellar system is
assessed to determine the client’s level of balance and coordination.
• Examining the sensory system provides information regarding the
integrity of the spinothalamic tract, posterior columns of the spinal cord,
and parietal lobes of the brain.
• Testing reflexes provides clues to the integrity of deep and superficial
reflexes. Deep reflexes depend on an intact sensory nerve, a functional
synapse in the spinal cord, an intact motor nerve, a neuromuscular
junction, and competent muscles.
Assessment of Mental Status
• Mental status assessment is generally divided into assessment of
consciousness and cognition.
• Consciousness is the ability to be aware of the environment, an
object, and oneself; it is often documented as one's level of
consciousness.
• Level of consciousness (LOC) usually refers to the degree of
alertness or amount of stimulation needed to engage a patient's
attention and can range from alert to coma.
• The patient who is described as alert is awake, engaged, and
responsive. A patient may be alert but not oriented to person, place,
or time.
• Patients who are less than alert are labeled lethargic, stuporous,
or comatose.
• A lethargic patient is drowsy but is easily awakened. One who is
arousable only with vigorous or painful stimulation is stuporous.
The comatose patient is unconscious and cannot be aroused
despite vigorous or noxious simulation.
endd
Computed Tomography
• Computed tomography (CT) scanning is an accurate, quick, easy,
noninvasive, painless, and least expensive method of diagnosing
neurologic problems.
• CT angiography involves administering contrast dye IV before the CT
aneurysms, and other blood vessel abnormalities.
• CT perfusion study is an important tool in the evaluation of patients with
acute stroke-like symptoms.
• An intrathecal contrast-enhanced CT scan is performed to diagnose
disorders of the spine and spinal nerve roots. A lumbar puncture is
performed so a small amount of spinal fluid can be removed and mixed
with contrast dye and injected.
Magnetic Resonance Imaging
• Magnetic resonance imaging (MRI or MR) has advantages over CT.
– Multiple sets of images are taken that are used to
determine normal and abnormal anatomy.
– Images may be enhanced with the use of gadolinium, a
non–iodine-based contrast medium
• Magnetic resonance angiography (MRA) - is used to evaluate
PERFUSION and blood vessel abnormalities such as an arterial
blockage, intracranial aneurysms, and AV malformations.
• Magnetic resonance spectroscopy (MRS) - is used to detect
abnormalities in the brain's biochemical processes, such as that
which occurs in epilepsy, Alzheimer's disease, and brain attack
(stroke).
• Diffusion imaging (DI) - DI uses MRI techniques to evaluate
ischemia in the brain to determine the location and severity of a
stroke.
 Assessment of Reflex Activity

• The deep tendon reflexes of the biceps, triceps, brachioradialis, and

quadriceps muscles and of the Achilles tendon can be tested as part
of the complete neurologic assessment (Jarvis, 2014).

− Striking the tendon with the reflex hammer should cause

contraction of the muscle. The appropriate muscle
contraction indicates an intact reflex arc.

• The cutaneous (superficial) reflexes usually tested are the plantar

reflexes and sometimes the abdominal reflexes. The plantar reflex
is tested with a pointed (but not sharp) object, such as the handle
end of the reflex hammer or the rounded end of bandage scissors.
The normal response is plantar flexion of all toes.

• Babinski's sign, a dorsiflexion of the great toe and fanning of the

other toes, is abnormal in anyone older than 2 years and represents
the presence of central nervous system (CNS) disease.

• Hyperactive reflexes indicate possible upper motor neuron disease

(damage to the brain or upper spinal cord).

• Hypoactive reflexes may result from lower motor neuron disease

(damage to the lower spinal cord) or neuromuscular diseases.

• Asymmetry of reflexes is an important finding because it probably

indicates a disease process or injury.

• Clonus (also called myoclonus) is the sudden, brief, jerking

contraction of a muscle or muscle group often seen in seizures.

Assessment of Motor Function

• Decortication is abnormal motor movement seen in the patient with

lesions that interrupt the corticospinal pathways.

− The patient's arms, wrists, and fingers are flexed with internal
rotation and plantar flexion of the legs.

• Decerebration is abnormal movement with rigidity characterized by

extension of the arms and legs, pronation of the arms, plantar flexion,
and opisthotonos (body spasm in which the body is bowed forward)
Focused Assessment
• The FOUR Score is a clinical grading scale designed for use by medical
professionals in the assessment of patients with impaired level of
consciousness.
• It was developed by Dr. Eelco F.M. Wijdicks and colleagues in
Neurocritical care at the Mayo Clinic in Rochester, Minnesota.
• "FOUR" in this context is an acronym for "Full Outline of
UnResponsiveness".
• The FOUR Score is a 17-point scale (with potential scores ranging from 0
- 16).
• Decreasing FOUR Score is associated with worsening level of
consciousness.
• The FOUR Score assesses four domains of neurological function: eye
responses, motor responses, brainstem reflexes, and breathing pattern.
Diagnostic Assessment
Imaging Assessment
• In general, for any image that involves being placed in a scanner,
the nurse needs to be aware of special circumstances that can
either prevent the procedure from taking place or interfere with it.
– Sedative for alert patients if needed
– Presence of any metal in the patient’s body.
• If he or she does have any type of metal object in the body part to
be examined, the nurse must notify the radiology department
immediately because the procedure may need to be cancelled.
Plain X-Rays
• Plain x-rays of the skull and spine are used to determine bony fractures,
curvatures, bone erosion, bone dislocation, and possible calcification of
soft tissue, which can damage the nervous system (anteroposterior,
lateral, oblique, and, when necessary, special views of the facial bones.
– In head trauma and multiple injuries, after assessing the ABCs
(airway, breathing, and circulation), one of the first priorities
is to rule out cervical spine fracture.
• Explain that the x-ray procedure for the skull and spine is similar to that
for a chest x-ray
Cerebral Angiography
• Cerebral angiography (arteriography) is done to visualize the cerebral
circulation to detect blockages in the arteries or veins in the brain, head,
or neck that impair PERFUSION.
• It remains the gold standard for the diagnosis of intracranial vascular
disease and is required for any transcatheter therapy or for surgical
intervention.
Patient Preparation
• Ask patient for any food and drug allergy.
• Presence of co-morbidities (Diabetic nephropathy, Heart failure,
Dehydration, Older age, Drugs such as metformin or, NSAIDs
• Evaluating current kidney function.
• Communicating with the health care provider before diagnostic
testing when risk factors and allergic reaction to iodinated contrast
are present.
• Providing adequate hydration before and after contrast
administration
Patient Preparation
• Assess for the presence of nausea or recent vomiting and medicate
as needed before the test
• Ensure that the patient is NPO 4 to 6 hours before the test.
• Reinforce these important points:
– Your head is immobilized during the procedure.
– Do not move during the procedure.
– Contrast dye is injected through a catheter placed in the
femoral artery. You will feel a warm or hot sensation
when the dye is injected; this is normal.
– You will be able to talk to the physician; let him or her
know if you are in pain or have any concerns.
Procedure
• The patient is placed on an examining table and made as
comfortable as possible
• He or she is then connected to cardiac monitoring throughout the
procedure.
• The interventional radiologist or other specially trained physician
numbs the area at the groin and inserts a catheter into the femoral
artery
• Then the physician injects contrast material into each vessel while
recording images from different angles over the head and neck.
• After all the vessels have been imaged, the radiologist reviews all
the images and consults with the referring physician to decide
whether the patient could benefit from a therapeutic radiologic
procedure or surgery to treat the problem.