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NEUROLOGICAL

ASSESSMENT

Objectives of a Neuro Assessment


1. Gather data about the functioning of the
nervous system
2. Correlate and trend the data over time
3. Analyze the data to develop a list of
potential or actual diagnoses
4. Determine the effect of dysfunction on the
patients daily activities of living

Assessment
Review of systems
Dizziness, headaches, vision changes,
sensitivity to light, auditory changes, sinus
infections, difficulty swallowing, hoarseness,
slurred speech, sinusitis, infection
Pertinent medical history:
Family history
Surgical history
Social history
Medications

Assessment of Nervous System

Subjective Data

Important Health Information


Past health history.
Medications.
Surgery or other treatment.

Mental Status
Assess level of consciousness (LOC).
Glasgow Coma Scale
Score of 15= fully awake & alert.
Score of 8 or less= is associated with coma.
Score of 3= completely unresponsive patient.

Motor System
Strength.
Coordination.
Command.

Pupillary changes.
Changes in vital signs.
Late findings in neurological deterioration.

COMPONENTS OF
NEUROLOGICAL ASSESSMENT
1.
2.
3.
4.
5.
6.

Mental Status
Level of Consciousness
Reflexes
Motor Functions
Sensory Functions
Cranial Nerves

I. Mental Status:

a.
b.
c.
d.
e.

Reveals cerebral function (intellectual and


affective)
Major areas of assessment:
Language
Orientation
Memory
Attention span
Calculation

NEUROLOGICAL ASSESSMENT
A. Language
Aphasia inability to express oneself by
speech, writing or comprehend spoken or
written language due to disease of
cerebral cortex
Two Categories:
1. Sensory or receptive aphasia
2. Motor or expressive aphasia

NEUROLOGICAL ASSESSMENT
1.

Sensory/receptive aphasia
- loss of ability to comprehend written or
spoken words
Two types:
a. Auditory aphasia unable to understand
symbolic content associated with sounds
b. Visual aphasia unable to understand printed
or written figures

NEUROLOGICAL ASSESSMENT
2. Motor/ expressive aphasia
- loss of power to express oneself by writing,
making signs or speaking
How to assess language deficits:
Point to common objects and name them
Read some words and match printed and written
words with pictures
Respond to verbal/written commands

NEUROLOGICAL ASSESSMENT
Speech Patterns:
- pace, clarity, spontaneity
Abnormalities:
a. Perseveration
- repeating the same response as different
questions are asked
b. Paraphasia
- speech appropriately expressed but contains
incorrect words

NEUROLOGICAL ASSESSMENT
B. Orientation 3 spheres (person, time & place)
C. Memory
- Listen for lapses of memory
- If problems are present:
Three categories of memory:
1. Immediate recall
N: can repeat series of 5 8 digits in sequence
and 4 6 digits in reverse order

NEUROLOGICAL ASSESSMENT
C. Memory
2. Recent memory
- Ask to recall the events of the day
- Recall information given early in the
interview
- Provide 3 facts to recall (color, object,
address), then ask later

NEUROLOGICAL ASSESSMENT
C. Memory
3. Remote memory
- Previous illness or surgery (years ago), birthday,
anniversary
D. Attention Span
- Tests the ability to concentrate
(alphabet, count backward from 100)

NEUROLOGICAL ASSESSMENT
E. Calculation
- Serial seven or serial three test
N: can complete serial seven in 90 seconds
with 3 or less errors

THE CRANIAL NERVES


CN I:
CN II:
CN III:
CN IV:
CN V:
CN VI:
CN VII:
CN VIII:
CN IX:
CN X:
CN XI:
CN XII:

Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear/Acoustic
Glossopharyngeal
Vagus
Spinal Accessory
Hypoglossal

The 12 CRANIAL NERVES

CN I-Olfactory
- Smell
CN II-Optic
- Visual acuity
CN III-Oculomotor
- Pupil response
CN IV-Trochlear) - Downward, inward eye movement
CN V-Trigeminal
- Jaw opening, chewing
CN VI-Abducens - Lateral Eye movement
CN VII-Facial
- Facial expression, close jaw
CN VIII-Acoustic - Hearing
CN IX-Glossopharyngeal - Swallowing, gag reflex
CN X-Vagus
- Speech
CN XI-Spinal Accessory - Shrug shoulders
CN XII-Hypoglossal
- Tongue movement

NEUROLOGIC ASSESSMENT
Level of Consciousness
Ease of arousal
State of awareness
Orientation

Motor Function

Person
Place
Time
Squeeze hand, smile,
stick out tongue, raise
eyebrows

NEUROLOGIC ASSESSMENT
Pupillary Response

Size
Shape
Symmetry of pupils
Document degree of
constriction to light
5/4

Glasgow Coma Scale (GCS)


Best Eye-Opening Response
Spontaneously
To speech
To pain
No response
Best Motor Response
Obeys commands
Localizes stimuli
Withdrawal from stimulus
Abnormal flexion (decorticate)
Abnormal extension (decerebrate)
No response
Best Verbal Response
Oriented
Confused conversation
Inappropriate words
Garbled sounds
No response

Score
4
3
2
1
Score
6
5
4
3
2
1
Score
5
4
3
2
1

A total score of:


3 to 8 suggests severe
impairment/comatose
9 to 12 suggests moderate
impairment/ semi-conscious
13 to 15 suggests mild
impairment/ conscious

Nsg Role during Motor function Examination


Motor strength and coordination:
Muscle weakness is a cardinal sign of
dysfunction in many neurological disorders.
Muscle groups should be assessed
individually, initially without resistance and
then against resistance.
The nurse also assesses each extremity for
size, muscle tone, and smoothness of passive
movement.
The nurse also should be alert to involuntary
movements

Motor function
Motor strength and coordination:

Hemiparesis (weakness) and hemiplegia (paralysis)


Paraplegia may result from thoracic or lumbar spinal cord
or peripheral nerve dysfunctions. Quadriplegia is
associated with high cervical spinal cord lesions, brainstem
dysfunction, and large bilateral lesions in the cerebrum.
The cerebellum is responsible for smooth synchronization,
balance, and ordering of movements.
Romberg test.
Finger-to-nose test.
Rapidly alternating movement (RAM) test.
The Heel-to-chin test.

Motor Response to Stimuli


Normal Motor Response:
Localization.
Withdrawal.

Abnormal Motor Response:


Decorticate rigidity due to lesions to:
Internal capsule, basal ganglia, thalamus, corticospinal pathways.
Flexion of the arms, wrists & fingers; adduction of upper extremities; & extension,
internal rotation, & planter flexion of lower extremities.

Decerebrate rigidity due to injury to:


Mid brains & Pons.
Extension, adduction & hyperpronation of the upper extremities; extension of
lower extremities with planter flexion; clenched teeth.
Tonic Contraction: consistent muscle contraction.
Clonus: alternate muscle plasticity & relaxation.

Mental Status Assessment


Attention
Digit span forward & back.

Remembering.
Short-term: recall after 5 minutes.
Long-term: recall events of previous day.

Feeling (Affect).
Facial & body expression & mood.
Verbal description of affect.
Congruence of verbal, body indicators of mood.

Language.
Spontaneous speech, repetition, naming objects, writing, reading.

Thinking.
Orientation, information, knowledge of current events, calculations, problem solving.

Spatial Perception.
Copy drawings, demonstrate putting a coat, using a toothbrush; point out right
& left side.

Pupillary Changes:
Pupils are examined for size (best specified in
millimeters) and shape.
Anisocoria (unequal pupils).
The normal response to testing is
documented as PERRLA, or Pupils Equal,
Round, Reactive to Light and
Accommodation.
The assessment of pupillary response for
comatose patients is the same as for conscious
patients. Pupil reactivity to light, by direct and
consensual response, is easily obtained.

Pupillary Changes
Small Reactive: Metabolic &/ or
diencephalic dysfunction.
Dilated Fixed (unilateral): Blown,
dysfunction of CN III (Oculomotor).
Midposition, Fixed: Mid brain damage.
Large Fixed: Midbrain damage.

Vital Signs Changes


Respiration:
Cheyne_Stokes.
Hyperventilation.
Hypoventilation.

Temperature.
Very high hyperthermia due to CNS damage.
Hypothermia due to metabolic, pituitary & spinal cord injury.

Pulse.
Dysrhythmias.
Tachycardia as a result of increase ICP.
As ICP rises; Bradycardia occurs (terminal condition).

Blood Pressure: controlled at the level of medulla

Hypertension is more commonly occurs.


As BP increases, cerebral blood flow & volume increase leading to increased ICP.

Assessment of Ocular Movement


Oculocephalic reflex (Dolls Eye):
Quickly rotate the Pts head to one side
Abnormal or Absence of reflexes indicates
brainstem dysfunction.
This test is not performed for patients with
cervical spinal injury.

Assessment of Ocular
Movement

Oculovestebular reflex (Caloric Ice-water Test)

Elevate the patient head 30 degree & irrigate each ear


separately with 30-50 ml of ice water.
Normally, the eyes moves horizontal nystagmus with
slow, conjugated movement toward irrigated ear
followed by rapid movement away from the stimulus.
Abnormal, both eyes remain fixed in midline position
indicating midbrain & Pons dysfunction.
This test is not performed for patients who does not
have intact ear drum or who has blood or fluid collected
behind the ear drum.

Oculovestebular Reflex

Continue.

Assess Signs of Trauma or Infection


Signs of Trauma:

Signs of Trauma:

BATTLES

RACCOONS EYE
- (periorbital edema and
bruising) suggests a
frontobasilar fracture.

SIGN (bruising over


the mastoid areas) suggests
a basal skull fracture.

Assess Signs of Trauma or Infection


Signs of Trauma:
Rhinorrhea
(drainage of CSF from the
nose) suggests fracture of
the cribriform plate with
herniation of a fragment of
the dura and arachnoid
through the fracture.

Signs of Trauma:
Otorrhea

drainage of CSF from


the ear) usually is
associated with fracture
of the petrous portion of
the temporal bone.

Signs of Meningeal irritation


Kernigs signs:
+ POSITIVE= Neck pain after knee flexion.
Brudzinkis sign:
+ POSITIVE = involuntary hip flexion after
neck flexion.

Kernigs sign

Brudzinksis sign

Diagnostic Studies of the Nervous System


Computed Tomography (CT scan).
Magnetic Resonance imaging (MRI).
CSF analysis.
Lumber Punctures.
L3-4, L4-5.
Used to diagnose autoimune, infection,
subarachnoid hemorrhage.