NEUROLOGICAL ASSESSMENT

Objectives

Utilizing a body systems approach, the student

will:
a. Apply anatomy, physiology, biology, chemistry, psychology,
developmental psychology, and sociology concepts to the assessment
of the neurological system of the adult
b. Apply health history and physical examination principles for
holistic assessment of the neurological system of the adult
c. Conduct and document (EMR) a health history and physical
examination of the adult while applying the principles of caring,
therapeutic communication, interprofessional communication, and
professionalism
d. Utilize concepts of genetics and genomics when assessing the
neurological system of the adult
Objectives

e. Interpret common laboratory and diagnostic findings for the neurological system
of the adult
f. Based on national guidelines (Healthy People 2020, AHRQ Clinical Prevention
Guidelines, and other appropriate national standards), recommend the appropriate
health promotion and clinical prevention strategies for the adult
g. Assess self and patient scenarios utilizing the clinical reasoning model for the
neurological system of the adult
h. Demonstrate professionalism in the clinical simulation laboratory by: honoring
confidentiality of scenarios and other’s health histories; respecting other’s self-
determination and human dignity; and exhibiting integrity by abiding by
laboratory guidelines, equipment use, and dress code
i. Describe expected and unexpected findings in each body system to include ethnic,
cultural, and age variations
The Nervous System
 Central Nervous System
 Brain and spinal cord

 Peripheral Nervous System

 Cranial and spinal nerves

 Autonomic Nervous System

 Sympathetic
 Parasympathetic
A & P Review- Protective
Structures
 Skull protects brain.
 Foramen magnum is large oval opening at base of skull in
occipital bone.
 Spinal cord extends through from medulla oblongata.

 Meninges, three layers between skull and brain

 Dura mater, outer double layer
 Arachnoid, middle meningeal layer
 Pia mater, inner meningeal layer
 Between arachnoid and pia mater is subarachnoid space where
cerebrospinal fluid (CSF) circulates.

 CSF is colorless, odorless fluid containing:

 Glucose, electrolytes, oxygen, water, carbon dioxide, and
leukocytes
A & P Review- Brain

 Brain consists of cerebrum,

diencephalon, cerebellum, and brainstem.

 Carotid arteries supply most of blood to

brain, and branch off into posterior
cerebral, middle cerebral, and anterior
cerebral arteries.
Internal Structure of the Brain

Occipital
CEREBRUM

• Largest part of brain consisting of

two hemispheres, each divided into
four lobes:
 Frontal
 Parietal
 Temporal
 Occipital
Frontal Lobe

• Contains primary motor cortex and functions

related to voluntary motor activity.

 Broca’s area contains left frontal lobe

involved in formulation of words.

 Frontal lobe also controls intellectual

function, awareness of self, personality, and
autonomic responses related to emotion.
Parietal lobe
 Contains primary somesthetic (sensory) cortex
that receives sensory input such as position,
touch, shape, and texture of objects.
Temporal lobe
 Contains primary auditory cortex.
 Wernicke’s area located in left temporal lobe,
responsible for comprehension of spoken and
written language
 Also interprets auditory, visual, and somatic
sensory inputs that are stored in thought and
memory
Occipital lobe
 Contains primary visual cortex which receives
and interprets visual information.
 Diencephalon

• Made up of thalamus, hypothalamus,

epithalamus, and subthalamus.

• Hypothalamus is important to maintaining homeostasis

• Functions include:
• regulation of body temperature
• hunger, and thirst
• formation of autonomic nervous system responses
• storage and secretion of hormones from pituitary
gland
Basal ganglia
Function is balancing production of
two neurotransmitters — acetylcholine
and dopamine — that create smooth,
coordinated voluntary movement
Brainstem
 Made up of midbrain, pons, and medulla oblongata.
 Ten of twelve cranial nerves (CNs) originate from brainstem.

 Midbrain functions to relay stimuli concerning muscle movement to

other brain structures
 Contains part of motor tract pathways that control reflex motor movements in
response to visual and auditory stimuli

 Pons relays impulses to brain centers and lower spinal nerves.

Brainstem con’t
 Medulla oblongata contains reflex centers for
controlling involuntary functions such as breathing,
sneezing, swallowing, coughing, vomiting, and
vasoconstriction.

 Motor and sensory tracts from frontal and parietal

lobes cross from one side to other in medulla; lesions
on right side create abnormal movement and sensation
Cerebellum
 Separated from cerebral cortex by tentorium
cerebelli.
 Functions of cerebellum include coordinating
movement, equilibrium, muscle tone, and
proprioception.

 Each cerebellar hemisphere controls movement for

same (ipsilateral) side of body.
Spinal Cord
 Posterior (dorsal) column carries sensations of
touch, deep pressure, vibration, position of joints,
stereognosis, and two-point discrimination.

 Lateral spinothalamic tract carries fibers for

sensations of light touch, pressure, temperature,
and pain.

 https://youtu.be/6fyiGUAg2GY (Stereognosis)
 https://youtu.be/CEiVbK31wj0 (two point)
Spinal Cord
 31 pairs of spinal nerves emerge from spinal cord
Cranial Nerves

 12 pairs of cranial nerves

 Five pairs have only motor fibers.
 Three pairs have only sensory fibers.
 Four pairs have both motor and sensory fibers.
Reflex Arcs
 Tested by observing muscle movement in response to
sensory stimuli.
 Deep tendon reflexes are responses to stimulation of tendon
that stretches neuromuscular spindles of muscle group.
 Striking a deep tendon stimulates a sensory neuron that travels to
spinal cord where it stimulates an interneuron, which stimulates a
motor neuron to create movement.
 Superficial reflexes tested similarly.
 Each reflex corresponds to a specific spinal segment.
See Fig 15-8 p314
The Autonomic Nervous System

Sympathetic Nervous System Parasympathetic Nervous System

 Fight or Flight
 Dominates during
calm, non-stressful
times
A & P Review- ANS
Sympathetic
 Sympathetic nervous system
(SNS) arises from thoracolumbar
segments of spinal cord and is
activated during stress (the “fight-
or-flight” response).
 SNS actions include:
 Increasing blood pressure and heart
rate
 Vasoconstricting peripheral blood
vessels
 Inhibiting gastrointestinal peristalsis
 Dilating bronchi
Parasympathetic
 Parasympathetic nervous system
(PNS) arises from craniosacral
segments of the spinal cord and
controls vegetative functions
(“breed and feed”).
 PNS actions associated with
conserving energy such as:
 Decreasing heart rate and force of
myocardial contraction
 Decreasing blood pressure and
respiration
 Stimulating gastrointestinal peristalsis
Neurotransmitters
 Communicate messages from one neuron to another
or from a neuron to a specific target tissue
 Excite or inhibit the target cell’s activity
 Usually MULTIPLE neurotransmitters at
work in the neural synapse
Examples- dopamine, serotonin, GABA,
Epinephrine, and many others
 Do you know how your brain
works?

 https://youtu.be/_krtukeNB-w
Functional Organization of the Brain

 Localization of
function

 Multiple systems can

overlap

 Can be assessed by
various techniques
(e.g., physiology,
imaging, neurological
exam,
neuropsychological
exam, post mortem)
Brain lateralization – the two halves of
the human brain are not exactly alike

Functional specializations – some

functions have neural mechanisms are
localized primarily in one hemisphere
Lateralization
 Left Brain  Right Brain
 Logical  Random
Sequential Intuitive
Rational Holistic
Analytical Synthesizing
Objective Subjective
Looks at parts Looks at wholes
Damage to Broca’s Area vs. Wernicke’s Area
Broca's Aphasia
 Prevents a person from producing
speech
 Person can understand language
 Words are not properly formed
 Speech is slow and slurred
Wernicke's Aphasia
 Loss of the ability to understand
language
 Person can speak clearly, but the words
that are put together make no sense.
This way of speaking has been called
"word salad" because it appears that the
words are all mixed up like the
vegetables in a salad.
Responses to same picture
Broca’s Area vs. Wernicke’s Area
The Neurological Exam
Components of the
Neurological Exam
Health History – Focused Neuro

 Health History
 Prenatal or birth events
 Exposures (toxins, drugs)
 Illnesses (Epstein-Barr, Bell’s Palsy, Rocky
Mountain Spotted Fever, Lyme disease,
encephalitis, etc.)
 Injuries (concussion, closed head, etc.)
Health History – Focused Neuro

 Health History
 Clinical manifestations or symptoms
 Abnormal sensation
 Dizziness
 Visual or sensory disturbances
 Tremors or other motor tics
 Pain
 Weakness
 Seizures
Health History – Focused Neuro

 Family History
 Diseases
Amyotrophic Lateral
Sclerosis Myasthenia Gravis
Parkinson’s Migraine
Multiple Sclerosis Neurofibromatosis
Seizure disorders Guillain-Barré
Tumors Syndrome
Alzheimer’s disease
Tourette syndrome
Muscular Dystrophy
 American Academy of
Neurology
 Mental Status
 Level of alertness, appropriate responses
 Orientation
 Cranial Nerves
 Motor System
 Strength
 Gait
 Coordination
 Sensory System
 Light touch,
 Pain/temperature
 Proprioception
 Reflexes
 DTRs-biceps, patellar, Achilles
 Plantar
Mental Status
 Orientation
 If orientation is a concern during history, determine if
oriented to time, place, person.
 Date and time is first orientation to disappear.
 Only a problem if remains disoriented after being reoriented
 Place is second orientation to disappear.
 Person is last orientation to disappear.
 Orientations returns in opposite order in which is lost.
 Appearance, general behavior, mood
 Thought content, memory, recall
 Intellectual/functional ability
Level of Consciousness (LOC)
 Altered level of consciousness
 Nurse can determine if client alert and oriented by way
questions are answered during interview.
 Change in level of consciousness (LOC) is earliest and
most sensitive indicator of alterations in cerebral
function.
 Awareness is higher level function controlled by reticular
activating system.
 Wakefulness is controlled by brainstem.
 When client’s awareness cannot be assessed because
unconscious, arousal is assessed.
LOC (Arousal)

 Alertness
 Lethargy
 Obtunded
 Stupor
 Coma
LOC
 Glasgow Coma Scale: assess LOC using 15-point
scale.
 Assess for best response to eye opening, motor
response, and verbal response.
 Determine stimulation/pain required to elicit response.
 Only time acceptable to inflict pain on client
 Glasgow Coma Scale
Glasgow Coma Scale
1 2 3 4 5 6

Opens
Opens eyes in Opens eyes in
Does not eyes
Eyes response to response to N/A N/A
open eyes spontaneo
painful stimuli voice
usly

Utters Oriented,
Makes no Incomprehensibl Confused,
Verbal inappropriate converses N/A
sounds e sounds disoriented
words normally

Abnormal
Extension to
flexion to Flexion /
painful stimuli ( Localizes
Makes no painful stimuli Withdrawa Obeys
Motor decerebrate painful
movements ( l to painful commands
response) stimuli
decorticate resp stimuli
onse
)
Abnormal Posturing
Cranial Nerves Group Activity
Cranial Nerves (12)
 OnOld
Olympus’
Towering Tops,
A Fin And
German
Viewed Some
Hops
Abnormalities of Cranial Nerves
 I- anosmia  VII- asymmetrical facial
movements, loss of taste
 II- defect in vision  VIII- decrease or loss of
(central or peripheral) hearing
 III, IV, VI- pupil  IX & X- uvula deviates to
one side, no gag, hoarse or
abnormalities, EOM brassy voice, dysphagia
abnormalities  XI- absent movement of
 V- absent touch & pain, sternomastoid or trapezius
no blink, weakness of muscles
masseter or temporalis
 XII- tongue deviates to one
side , slow rate of
muscles movement
Motor System
Motor System
 Includes brain and spinal
cord motor pathways
 Includes all major muscle
groups distal and
proximal
 Muscle tone, strength,
symmetry
 Unusual movements,
fasciculations, tics,
twitching
Gait and Posture
Gait
 Walking or ambulating
requires coordination of
multiple voluntary and
involuntary functions

 Strength, coordination,
symmetry, balance, stance,
speed, stride length, arm
movement, foot placement,
initiation & cessation
Coordination and
the Cerebellum
Cerebellum-
Cerebellum responsible for voluntary movement and motor
coordination

Tests for balance Tests for coordination

 Romberg test (client  Tests for coordination of upper

standing)—feet together,
arms at side, eyes open/closed
 Pronator drift
 Eyes closed, stand on one
foot
 Tandem walking
 Hop on one foot, then other
 Knee bends
 Walk on toes and then on
heels
extremity
 Rapid pronation/supination on
thighs
 Alternately touch nose with index
fingers (eyes closed)
 Touch each finger to thumb in
rapid sequence
 Move index finger between nose
and examiner finger
 Tests for coordination of lower
extremity
 Heel to shin of opposite leg
Sensory System (Peripheral
Nerves)
 Assess for sensation.
 Areas routinely assessed are the hands, lower arms,
abdomen, lower legs, and feet
 Flex muscles, then resist against opposite force
 Dermatome map to identify spinal nerve providing
sensation
 Light touch with cotton tipped swab
 Vibration using tuning fork on bony prominence; feel
vibration and when it stops
 Kinesthetic sensation (proprioception) by moving finger/toe
up/down
 Stereognosis
 Two-point discrimination
 Graphesthesia
Dermatome Map
Reflexes

Babinski Also called Plantar reflex

 stroke bottom of foot heal

to toe; note big toe
movement- EXPECTED
FINDING- plantar flexion
 if toes fan upward-
UNEXPECTED
FINDING- indicates CNS
dysfunction, present before
2 years of age
Deep Tendon Reflexes
 Reflex–involuntary action in response to impulse sent to CNS
 Often first sign of dysfunction
 Deep tendon reflexes – muscle stretch reflexes respond to
stretching tendons
 Rated as normal, hypo-reflexic, hyper-reflexic
 Scored as:
 0

 1+

 2+

 3+

 4+
 Meningeal Signs

 Neck Mobility
 Brudzinski’s Sign
 Kernig’s Sign
Diagnostic Evaluation
 CT Scan
 Positron Emission
Tomography
 Magnetic Resonance
Imaging
 Lumbar Puncture
 http://www.youtube.com/wa
tch?v=L9IvVRZdI9I
(3:51)
 Cerebral Angiography
 Myelography
 https://www.youtube.com/watch?v
=OZaoNof_CsY
 Noninvasive Carotid Flow
Studies
 Transcranial Doppler
 EEG
 https://youtu.be/KXS268XsRic
(1:22)
 EMG
 https://www.youtube.com/watch?v
=xdKwSymCpws
 Nerve Conduction Studies
Sample documentation
 Mental Status: alert, relaxed, and cooperative.
Thought processes coherent. Client oriented to
person, place, and time. Cranial Nerves: I-
deferred; CN II-XII- intact. Motor: Good muscle
bulk and tone. Strength 5/5 throughout. Cerebellar-
RAMs, F to N, H to S, intact. Gait steady with
normal base. Romberg- maintains balance with
eyes closed. No pronator drift. Sensory: light
touch, position, and vibration intact. Reflexes: 2+
and symmetric with plantar flexion of bilateral feet.
 Pediatric Considerations

 Timing and mastery of developmental

milestones can reveal much
information
 Loss of abilities after achievement of
milestones is a red flag
 Failure of reflexes to extinguish
(disappear) can also be a red flag
Geriatric Considerations

 Factors to consider
 General health and nutritional status
 History of head injury, trauma, or neurological
disease
 Smoking history
 Substance use/abuse
 Educational level
 Social support
Geriatric Considerations
 Decrease in taste &  Loss of vibration
smell sense at the ankle
 Decrease in muscle level
bulk  Decrease position
 Senile tremors sense
 Dyskinesias  DTRs less brisk
 More deliberate
movements
 Longer recall
Geriatric Considerations
 Some decline in memory and
cognition is expected
 Sensory processing may diminish
with aging
 Rapid or dramatic declines, or
significant personality changes are
red flags
 Tests for balance and gait are often
assessed for older adults to identify
those at risk for falls.
Health Promotion- CVA
 Older adulthood; risk double each decade after 55
 Male sex (slightly higher risk)
 AA
 HTN
 Smoking
 Chronic ETOH intake (>2 drinks/day)
 Hx of CV disease
 Sleep apnea
 DM
 Drug abuse
 High estrogen levels
 Overweight
 Sedentary lifestyle
 Family hx of CVA
Terminology
 Clonus involuntary, rhythmic muscle contractions.
 Agnosia Inability to recognize by sight (visual agnosia), touch (tactile agnosia), or hearing (auditory agnosia.)

 Akinesia complete or partial loss of voluntary muscle movement

 Apraxia inability to carry out learned sequential movements or commands
 Dysarthria defective speech; inability to articulate words; impairment of tongue or other
muscles needed for speech
 Dysphasia (not to be confused with dysphagia) impaired or difficult speech
 Dysphonia difficulty with quality of voice; hoarseness
 Proprioception Awareness of body posture, movement and changes in equilibrium
 Aphasia absence or impairment of ability to communicate through speech, writing, or signs
 Expressive (Broca’s or motor)- inability to express language even though person
knows what he wants to say. Frontal lobe usually affected

 Receptive (Wernicke’s or sensory)-inability to comprehend written or spoken words. Temporal

lobe in auditory-receptive; parieto-occipital in visual receptive
Considerations for the hospitalized patient

 Patient who is unconscious:

 Assess CN responses where applicable (pupillary
response), any stimulus responses, last resort-painful
stimuli (W & G, pg. 495), assess risk for DVT

 Describing levels of consciousness:

 Glascow coma scale (W & G: pg. 496 Figure 24-24)
 Adjectives (lethargy, obtunded, stuporous,
semicomitose and comatose)
ARE YOU READY TO
PRACTICE WHAT YOU
LEARNED?
CASE STUDY
 Case Study #1
 Ruth, a 72 year old Caucasian female is
brought to the ED via EMS accompanied
by his family. They state she has had
confusion x 1 hour. Her family states she
was watching TV and suddenly started
drooling and “staring off.” Vital signs are
190/98 left arm, sitting; pulse- 84 bpm,
radial; temp- 99.0 F-oral; resp- 18
breaths/minute. She is taken to the
treatment area and the physician orders a
CT of her head, carotid dopplers, and
blood studies.
Case Study #1
 1. What is the chief complaint?
 2. What is the subjective data?
 3. What is the objective data?
 4. What questions should the nurse ask?
 5. What other objective data should the nurse
gather from her physical exam?
Case Study #1
 The family inquires why the CT scan of the head
and the carotid dopplers are ordered. What should
the nurse tell them?
Case Study #2

 Blanche, a 65 year old female comes to a

cholesterol and blood pressure screening at the
Health Department. She states she has been
having intermittent periods where she is unable
to speak and has numbness on her left side.
 What are the most important questions the nurse
should ask?
 What additional questions should you ask to assess
her risk for CVA? What are her risk factors?
 What should the nurse teach for health promotion
and disease prevention?
Case Study #3

• George Washington is a 25 year

old male presents to the ED with
a headache.
• What should the nurse ask?
• What objective data should the nurse
collect?
• The physician orders a lumbar
puncture. Why?
• What is the nurse’s role in the
LP?
References

Jarvis, C. (2016). Physical examination & health

assessment (7th ed.) Saunders Elsevier: St. Louis, MO.

Pagana, K.D. & Pagana, T.J. (2018). Mosby’s manual of

diagnostic and laboratory Tests (6th ed.). St. Louis, MO:
Mosby.

Wilson, S.F. & Giddens, J.F. (2017). Health assessment for

nursing Practice (7th ed.). St. Louis, MO: Mosby.