Chapter 6

Neurologic Assessment

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 1
 Learning Objectives
After reading this chapter you will be able to:
Define key terms related to neurologic

assessment
Describe functional anatomy of the

nervous system
Explain the cortical function of different

lobes of the brain

Describe common techniques used to

assess the mental status

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 2
 Learning Objectives (contd)
Describe functions of the brainstem, the
cerebellum, and 12 pairs of cranial nerves
Identify the parameters necessary to
obtain a Glasgow Coma Scale and be able
to interpret the results
Describe common techniques to assess
the cranial nerves, the sensory system, the
motor system, coordination, and gait

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 3
 Learning Objectives (contd)
Describe the importance of assessing
sedation and delirium in the ICU
Describe techniques used to assess deep,
superficial, and brainstem reflexes
Explain the relationship between vital signs
and neurologic status
Identify the importance of ICP monitoring
and the value of assessing cerebral
perfusion pressure

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 4
 Overview
Injuries of the nervous system
May affect respiratory system
May affect patient cooperation with respiratory
procedures
History may indicate nature of dysfunction
Exam localizes and quantifies severity of
dysfunction
Initial interaction with patient is first step in
neurologic assessment

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 5
 Overview (contd)
Neurologic assessment evaluates:
Mental status
Cranial nerve function
Motor system
Coordination
Sensory system
Reflexes
Meaningful neurologic assessment
requires adequate stimulation

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 6
 Functional Neuroanatomy
Neurologic system
Central nervous system
Brain: cerebrum, brainstem, cerebellum
Spinal cord
Peripheral nervous system
Cranial nerves
Spinal nerves

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 7
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 8
Functional Neuroanatomy (contd)
Functional division
Sensory system (afferent)
Motor system (efferent)
Cerebrum
Functions: movement, LOC, ability to speak
and write, emotions, memory

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 9
Functional Neuroanatomy (contd)
Brainstem
Consists of midbrain, pons, medulla oblongata
Most cranial nerves originate in brainstem
Regulation of heart rate, blood pressure, and
breathing

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 10
Functional Neuroanatomy (contd)
Cerebellum
Posterior part of the brain
Responsible for equilibrium, muscle tone, and
coordination
Cerebellar lesions cause:
Loss of coordination (ataxia)
Tremors
Disturbances in gait and balance

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 11
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 12
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 13
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 14
Functional Neuroanatomy (contd)
Spinal cord
From base of the brain down to L1 (45 cm)
Connects brain to the body for motor and
sensory function
31 spinal nerves
C1-C8, T1-T12, L1-L5, S1-S5, one coccygeal
Posterior (dorsal) roots = sensory
Anterior (ventral) roots = motor

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 15
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 16
Functional Neuroanatomy (contd)
Spinal cord
Herniated vertebral disk is the most common
spinal nerve root pathology
Involvement of multiple nerve roots
Guillain-Barr
Phrenic nerves arise from spinal roots C3 to
C5
Damage can result in diaphragmatic paralysis

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 17
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 18
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 19
 Mental Status and LOC
LOC and mentation: most important parts
of the neurologic exam
Changes due to CNS dysfunction
Initial goal of exam is to determine
patients awareness
Starts with patient encounter
Compromise of LOC may be due to:
Generalized dysfunction (e.g., overdose)
Abnormality in specific area

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 20
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 21
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 22
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 23
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 24
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 25
 Glasgow Coma Scale (GCS)
Most widely used instrument to quantify
neurologic impairment
Test
Motor response
Verbal response
Poorly suited for patients with impaired verbal
response (e.g., aphasia, hearing loss, tracheal
intubation)
Eye opening

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 26
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 27
 Glasgow Coma Scale (contd)
Scale goes from 3 (deep coma) to 15 (fully
awake)
GCS of 12-15 = non-ICU observation
GCS of 9-12 = significant insult
GCS <9 = severe coma = requires
endotracheal intubation

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 28
Mini-Mental State Examination
MMSE or Folstein test
30-point questionnaire to assess cognition
Samples various functions
Arithmetic, memory, orientation
Score interpretation
>27/30 = normal
20-26 = mild dementia
10-19 = moderate dementia
<10 = severe dementia

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 29
 Sedation and Delirium in the ICU
Delirium occurs in 60% to 80% of
mechanically ventilated patients
Associated with:
Longer hospital stay
Higher mortality
Poor long-term cognitive function

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 30
 Sedation and Delirium in the ICU
(contd)
Richmond Agitation Sedation Scale
(RASS)
Titrate sedation
Confusion Assessment Method for the ICU
(CAM-ICU)
Evaluates delirium

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 31
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 32
 Cranial Nerve Exam
12 cranial nerves = sensory and motor
function
Midbrain (CN III, IV)
Pons (CN VIII)
Medulla (CN IX to XII)

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 33
 Cranial Nerve Exam (contd)
Ipsilateral findings except on CN V
Acoustic problem (CN VII, VIII)
Pupillary response (CN II, III)
Corneal reflex (CN V, VII)
Gag reflex (CN IX, X)

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 34
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 35
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 36
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 37
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 38
 Sensory Exam
Somatosensory pathways
Spinothalamic (ST) = pain, temperature
Dorsal column-medial lemniscus (DCML) =
vibration, position sense (proprioception)
Evaluates ability to perceive sensations
with eyes closed
Assessment of light touch, pinprick, and
temperature

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 39
 Motor Exam
Patients ability to move on command
Motor strength and range of motion
Scale from 0 (no movement) to +5 (full
range of motion and full strength)
If unconscious = response to pain

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 40
 Motor Exam (contd)
Upper motor neuron (UMN)
Babinskis sign, hyperreflexia, clasp-knife
Decorticate and decerebrate posture
Lower motor neuron (LMN)
Loss of strength, tone and reflexes, muscle
waste and fasciculations

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 41
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 42
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 43
 Deep Tendon Reflexes
Evaluate spinal nerves
Triceps, biceps, brachioradialis, patellar,
Achilles tendon
Westphals sign = absence of patellar reflex
Scale from 0 (no reflex), +2 (normal), +5
(hyperreflexia)
Myasthenia gravis and botulism have
abnormal deep tendon reflexes

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 44
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 45
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 46
 Superficial Reflexes
Plantar reflex
Tested when suspected L4-L5 or S1-S2
injury
Babinskis sign
Dorsiflexion of the great toe with fanning of
remaining toes
Normal in children 12 to 18 months of age

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 47
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 48
 Brainstem Reflexes
Gag reflex (CN IX, X)
Its absence may increase risk for aspiration
Cough reflex (CN X)

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 49
 Brainstem Reflexes (contd)
Pupillary reflex (CN II, III)
PERRLA
Pupils equal round reactive to light and
accommodation
Anisocoria
Myosis = pontine hemorrhage, narcotics
Mydriasis = brain injury, anticholinergics
Mid-position fixed pupils = severe cerebral
damage
Corneal reflex (CN V, VII)

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 50
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 51
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 52
 Coordination, Balance, and Gait
Assessment of cerebellar function
Patient should be able to follow commands
during exam
Dysmetria = under- and overshooting of goal-
directed movements
Romberg test = balance

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 53
Vital Signs and Neurologic System
Brainstem = breathing
Lesions from cerebrum to cervical cord
cause changes of breathing patterns
Cheyne-Stokes respiration
Intracranial cause, hypoxemia, cardiac failure

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 54
Vital Signs and Neurologic System
(contd)
Ataxic breathing: marker of brainstem
dysfunction
Increased ICP = Cushings triad
Hypertension, widening pulse pressure,
bradycardia, bradypnea

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 55
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 56
 Intracranial Pressure Monitoring
Indications
Monitor patients at risk for life-threatening
intracranial hypertension
Monitor evidence of infection
Assess effects of therapy for reducing ICP
Although hyperventilation decreases ICP,
cerebral perfusion pressure (CPP) is the
most critical element to monitor

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 57