Neurologic Assessment Basics

• A neurologic assessment is valuable as small changes can indicate neurologic injury, and early intervention can prevent permanent damage.
• The article reviews how to perform a basic neurologic assessment and tailor it as needed.

Comprehensive Assessment

• A complete neurologic assessment includes mental status, cranial nerves, motor/sensory function, pupillary response, reflexes, cerebellum, and vital signs.
• In non-neuro units, sensory and cerebellar assessments aren't always needed.
• Vital sign changes usually signify end-stage neurologic injury.
• Assessment focuses on mental status, cranial nerves, motor function, and pupillary response.

Assessing Mental Status

• Mental status includes level of consciousness (LOC), orientation, and memory.
• The Glasgow Coma Scale is used to assess LOC, which is the first indicator of neurologic injury.
• First, speak the patient's name in a normal tone, then louder if needed.
• Note if the patient is hearing-impaired.
• Gently shake the patient if there's no response.
• Use painful stimuli if there's still no response.
• A decreased Glasgow Coma Scale score may indicate a neurologic crisis.
• A total score of less than 9 indicates severe brain injury.
• Eye-opening scored as: Spontaneous (4), to speech (3), to pain (2), none (1).
• Motor response scored as: Obeys (6), localizes (5), withdraws (4), abnormal flexion (3), abnormal extension (2), none (1).
• Verbal response scored as: Oriented (5), confused (4), inappropriate words (3), incomprehensible (2), none (1).
• Techniques for Painful Stimuli: Trapezius squeeze, sternal rub, supraorbital pressure can be used.
• The patient who requires painful stimuli isn't following commands; therefore, if he reacts to the painful stimuli with only one side of his body, you'll need to assess the nonreactive side.
• Assess nonreactive side by pressing a pencil into the cuticle of one of your patient's fingers.
• Responses can be purposeful (pulling away), nonpurposeful (moving without meaning), or no response at all.
• Apply painful stimuli for 15 to 30 seconds.
• Determine orientation with detailed questions about name, location, and date, being specific.
• Vary questions to avoid rote answers.
• Assessing orientation also evaluates speech.
• Memory is divided into immediate, short-term, and remote memory.
• Assess immediate memory by giving three unrelated words, having the patient repeat, then recall them after 5 minutes.
• To assess short-term memory, ask about an event from the last few days, verifying the response if possible.
• For remote memory, verify information like wedding dates or birth dates.

Assessing Cranial Nerves

• CN I (olfactory): Identify common substances like coffee and cinnamon. Often deferred.
• CN II (optic): Test visual acuity using Snellen and Rosenbaum charts.
• CN III (oculomotor), CN IV (trochlear), CN VI (abducens): Assess together using corneal light reflex, six cardinal positions of gaze, and cover-uncover test.
• Also inspect pupil size, shape, and symmetry, and reactions to light
• CN V (trigeminal): Sensory component - touch forehead, cheek, and jaw with cotton and safety pin, asking the patient to describe the sensations.
• Motor component - clench teeth while palpating temporal and masseter muscles, noting strength; if not alert, test corneal reflex with cotton wisp, looking for blinking.
• CN VII (facial): Sensory - test taste on the anterior tongue (sweet, sour, bitter).
• Motor - observe face for symmetry at rest and during facial expressions; have the patient close eyes tightly and test muscle strength by attempting to open them.
• CN VIII (acoustic): Use Weber's and Rinne tests.
• CN IX (glossopharyngeal) and CN X (vagus): Test together (innervation overlaps). Listen to voice and check gag reflex; watch for symmetrical upward movement of the soft palate and uvula.
• CN XI (spinal accessory): Test strength of sternocleidomastoid and upper trapezius muscles.
• CN XII (hypoglossal): Observe tongue for symmetry, tremors, twitching; test strength by pushing tongue against cheek with resistance.

Assessing Motor Function

• Look bilaterally for muscle asymmetry or atrophy.
• To assess upper extremities, have the patient raise arms and resist downward pressure.
• Repeat with lower extremities.
• Have the patient grasp fingers and release on command; inability to release indicates neurologic injury.

Assessing Pupillary Response

• Pupillary response, along with eye motion, is controlled by cranial nerves III, IV, and VI.
• Normal pupils are 2-6 mm, equal, and round.
• Anisocoria (unequal pupils) is normal in 15% of people.
• Check reactivity by shining light from outer canthus; both pupils should react equally and briskly.
• Medications, surgery, and blindness can affect pupil size, shape, and reactivity.
• A key sign of severe neurologic injury is a change in pupil size and reactivity.
• Eye motion is tested by tracing the letter H with a finger, checking extraocular movement (EOM); document any inability to follow.

Focused Assessment

• Only assess LOC, motor strength, and pupillary reactivity unless indicated otherwise.

Helpful Tips

• Use a cheat sheet for cranial nerve functions and deficit terminology.
• Explain the assessment process to the patient and family to ease anxiety.
• Instruct family not to answer for the patient.