Neurologic Assessment

Neurologic Assessment
Unit 9

Neuro system controls cognitive and voluntary behavioral processes and subconscious and involuntary bodily functions

Neurologic Assessment

Anatomy & Physiology
Neurologic Exam
- Developmental Considerations
- History
- Physical exam

Neurologic Exam

Organized into 6 major areas:

Mental Status

Cranial Nerves

Sensory System

Motor System

Cerebellar

Reflexes

Neurologic Exam

Pre-exam considerations
condition of pt
- cooperation/ability to follow directions
- developmental
- language
- level of consciousness (LOC)
- chief complaint
knowledge of A & P

Anatomy & Physiology Nervous System

Central

Brain

cerebrum

cerbellum

brainstem

Spinal Cord

Peripheral

spinal nerves
cranial nerves

Central Nervous System

Cerebrum

mental status
highest mental function
largest
sensory and motor function
memory
CN 1 (Olfactory)

Frontal lobe
Parietal
Occipital
Temporal

Cerebellum

balance, equilibrium, coordination, posture,
role in muscle tone
role in voluntary muscular activities

Brainstem controls subconscious and reflex activity

all afferent/efferent tracks
spinal cord to brain
cranial nerves
(all except olfactory)

Peripheral Nervous System

Spinal nerves - 31 pair

8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal

Each has afferent and efferent component
Area of skin supplied by a single peripheral/spinal nerve is called a
DERMATOME

Cranial nerves - 12 pair

some sensory
some motor
some both

SensorySystem

Testing for interruption in sensory reception or pathways
Dermatomes
intact peripheral nerve to receive message
intact spinal cord to send message
intact cerebral function to interpret message

Motor System

Cerebrum

cerebral cortex has important role in motor function
but if damage to

Cerebellum

movement becomes uncontrolled, uncoordinated

Reflexes

Need intact spinal cord function
intact reflex arc

Developmental Considerations

Infants

prenatal history

developmental milestones

birth history

Children

developmental milestones

behavior

learning abilities

Pregnancy

headaches

seizures

nutritional status

Older adults

ADL’s

decreased function ?

tremors

incontinence

Elderly

dementia

decline in memory, mental functioning

Depression

Decline in ability to meet ADLs

Incontinence

Falls

Medication use

Neurologic Assessment

Begins with initial "meet and greet"
many components done with other areas of assessment
Assess general mental status
Do specific tests later

Is CC related to neuro function?

History

Head injury, loss of consciousness
headaches
vertigo, dizziness, fainting
paresthesia - Numbness, tingling, loss of feeling
decreased strength
recent changes in ability to perform ADLs
change in mental status, vision, speech
gait abnormalities/

changes in balance, coordination - Falls ?

drooling, difficulty swallowing
seizures, tremors
ETOH, drug use
infections- meningitis, encephalitis
circulatory problems
medications which affect coordination, mental status, etc.

Family History

Hereditary disorders
Tay Sach’s
muscular dystrophy
PKU
mental retardation
Alzheimer’s

Neurologic Exam

Organized into 6 major areas:

Mental Status
Cranial Nerves
Sensory System
Motor System
Cerebellar
Reflexes

1. Mental Status

general appearance and movement

posture

gait, movement

dress, hygiene

facial expression, speech

mood

appropriate, labile

thought process

logical, realistic

follows directions

Cognition

level of consciousness

memory

abstract reasoning

judgment

perception, coordination

Cognition

level of consciousness describes orientation

" level of arousability:
alert
lethargic
stuporous
semicomatose
comatose

"AAO X 3"

Glasgow Coma Scale (see syllabus pg. )

Best eye-opening response

purposeful/spontaneous 4
to voice 3
to pain 2
no response 1

Best verbal response

oriented 5
disoriented 4
inappropriate words 3
incomprehensible words 2
no response 1

Best motor response

obeys commands 6
localizes pain 5
withdraws to pain 4
flexion/extension to pain 3/2
no response 1

Cognition

memory - recent, remote

abstract reasoning - proverbs

serial 7s, 3s

cultural considerations

judgment

perception, coordination

children < 6 - DDST

gross and fine motor

language skills

social skills

Mental status tests

Mini-mental screening- Bates p 120

Glasgow coma scale- p

Standardized tests

2. Cranial nerves

CN I - Olfactory
- tested only when suspect a problem
CN II - Optic
- visual acuity
- direct and peripheral vision
CN III, IV & VI - Oculomotor, Trochlear, Abducens
- tested together
- ocular motility
- pupil constriction

CN V - Trigeminal

Motor component - clench teeth

palpate muscle tone

observe vertical alignment of superior and inferior incisors

Sensory

sharp and light touch of 3 divisions

corneal reflex (Unconscious or problem only)

Cranial Nerve VII - Facial
Motor component
6 facial movements:

raise eyebrows

smile

frown

show teeth

close eyes tightly, resist opening

puff out cheeks

During 6 facial movements

observe for flaccid paralysis, asymmetry - nasolabial folds - palpebral fissures

tics

muscle weakness

Sensory component Same presentation as Motor Component alone

taste anterior 2/3 of tongue

Cranial Nerve VII - Acoustic

Done with assessment of ears
Can be done during neuro exam

Cranial Nerve IX- X

Glassopharyngeal & Vagus

Sensory function (9)

taste posterior 1/3 tongue

Motor function (9 & 10)

gag reflex (unconscious or problem)

tongue movement

"ah" - observe soft palate and uvula rise

assess speech for hoarseness

Cranial Nerve XI - Spinal Accessory

size and strength of trapezius and sternocleidomastoid muscles
shrug shoulders against examiner’s hands
turn head against hands

Cranial Nerve XII - Hypoglossal

Motor function

position of tongue

observe tongue resting on floor of mouth and extended

observe for fasciculation or deviations from midline

Usual documentation ?

3. Sensory System

Testing ability to localize sensations

Compare bilaterally

Stimuli should be random but symmetrical

Test proximal or distal first ?
Testing ability to localize sensations

Compare bilaterally

Test proximal or distal first ?

Identify

light touch, sharp, dull pain, vibration, tactile discrimination,
        2-point
        object (stereognosis)
        number (graphesthesia)
position sense

4. Motor System

Done with musculoskeletal
muscle size, tone, movement
voluntary movements
strength

5. Proprioception and Cerebellar Function

Assess coordination of upper and lower extremities

Arms extended (position sense)
Point-to-point
- Finger to nose
- Finger- nose- finger
- Heel to shin
RRAM
Romberg test
Gait, walk, hop
- include tandem walk (heel to toe)

6. Reflexes

Testing intact reflex arcs
Useful to determine level of spinal cord lesions

Deep tendon reflexes (DTR)

Infant reflexes

Pathological reflexes

Deep tendon reflexes (intact reflex arc)

biceps, triceps, brachioradialis, patellar, Achilles

test with reflex hammer

looking for symmetry

may need to use reinforcement prn

Grade 0 - 4

0 = no response
+1 = below normal, slightly diminished
+2 = average
+3 = more brisk than normal
+4 = very intense (clonus)

document on stick figure

Neonatal Reflexes (< 1 year)

rooting

extension

palmar

Babinski

Moro

startle

crawling

dance

tonic neck (fencing)

Pathological Reflexes (> 1 year)

Babinski

ankle clonus

decorticate posture

decerebrate posture

Nursing Diagnoses

Confusion

Risk for altered development

Impaired memory

Impaired mobility

Sensory/perceptual alteration: tactile

Impaired swallowing

Ineffective thermoregulation

Neuro exam/ frequent neuro check

Teaching Opportunities

Neuro symptoms to look for after trauma

Intervention with seizures

Medications

Coping with neurologic problem

Prevention- use of safety items