Assessment of the Neurologic System PDF

Assessment of the Neurologic System Nour A. Abdallah, MSN, RN, AGCNS-BC NURS 302 Spring 2024-2025 1 Outline - Recap - Collection of Subjective Data - Collection of Objective Data Level of Consciousness (LOC) and Mental Statu...

Assessment of the Neurologic System Nour A. Abdallah, MSN, RN, AGCNS-BC NURS 302 Spring 2024-2025 1 Outline - Recap - Collection of Subjective Data - Collection of Objective Data Level of Consciousness (LOC) and Mental Status Cranial Nerves Cerebellar and motor function Sensory System Reflexes - References 2 Recap: The Nervous system The Nervous system is composed of: - The central nervous system: Brain and Spinal Cord - Peripheral nervous system: 12 pairs of Cranial nerves and 31 pairs of peripheral Nerves - Basic Functional Unit: The neuron - Controls all motor, sensory, autonomic, cognitive, and behavioral activities 3 Recap: The Brain 4 Recap: The Brain (Cont’d) The CNS is covered by three layers of connective tissue that protect and nourish the CNS. They are called the “meninges”: - Dura Mater - Arachnoid - Pia Mater 5 Recap: The Spinal Cord - Located in the vertebral canal and extends from the medulla oblongata to the first Lumbar vertebra. - Made up of grey matter and a surrounding white matter. - Conducts sensory impulses up ascending tracts and motor impulses down descending tracts. 6 Recap: Cranial Nerves 7 Recap: Cranial Nerves Cranial Type of Function Nerve impulse Cranial Nerve Sensory Carries smell impulses from nasal mucous I (Olfactory) membrane to brain. Cranial Nerve Sensory Carries visual impulses from eye to brain. II (Optic) Cranial Nerve Motor Contracts eye muscles to control eye III movements, constricts pupils and elevates (oculomotor) eyelids. Cranial Nerve Motor Controls one eye muscle responsible for IV inferomedial eye movement. (Trochlear) Cranial Nerve Sensory Carries sensory impulses of pain, touch and V (Trigeminal) Motor temperature from the face to the brain; influences clenching and lateral jaw movement. 8 Recap: Cranial Nerves Cranial Nerve Type of Function impulse Cranial Nerve VI Motor Controls lateral eye movement. (Abducens) Cranial Nerve VII Sensory Stimulates secretions from salivary glands, tears (Facial) from lacrimal glands and contains sensory fibers for taste on anterior two thirds of the tongue. Cranial Nerve VIII Sensory Contains sensory fibers for hearing and balance. (Acoustic/vestibulo cochlear) Cranial Nerve IX Sensory - Contains sensory fibers for taste on posterior (Glossopharyngeal) Motor third of tongue and sensory fibers of the pharynx responsible for gag reflex when stimulated. - Provides secretory fibers for saliva from parotid gland 9 Recap: Cranial Nerves Cranial Nerve Type of Function impulse Cranial Nerve X Sensory Carries sensation from throat, larynx, heart, (Vagus) Motor lungs, GI tract and abdominal viscera. Promotes swallowing, talking and production of digestive juices. Cranial Nerve XI Motor Innervates neck muscles (sternocleidomastoid (Spinal Accessory) and trapezius), promote movement of head (rotation), neck and shoulders. Cranial Nerve XII Motor Innervates tongue muscles that provide the (Hypoglossal) movement of food and talking. 10 Assessment: Collection of Subjective Data Past Health History (e.g., medications, history of head injury or trauma…) Past Family History (e.g., Alzheimer's disease, dementia, epilepsy…) Lifestyle and health practices (e.g., smoking, exercise/weightlifting,…) History of Present Concern: - C = Characteristics (e.g., Describe the sensation) - O = Onset (e.g., When does it begin?) - L = Location (e.g., Where do you have this sensation?) - D= Duration (e.g., How long did it last?) - S = Severity (e.g., How did it affect your ability to carry out activities?) - P= Palliative/aggravating Factors (e.g., what makes it better? What makes it worse? - Associated Factors (e.g., Does it occur with other symptoms?) 11 Assessment: Collection of Objective Data A complete Neurologic Assessment consists of evaluating the following five areas: LOC and Cranial Mental Nerves Status Motor and Sensory cerebellar System systems Reflexes 12 Assessment: LOC and Mental Status - Level of Consciousness (e.g., alert, lethargic…). - Checking Mental Status: Orientation to time, place and person (e.g., what’s your name, where are you right now, what year is it,…). - Observe dress and grooming. - Observe hygiene. - Observe facial expressions, eye contact and affect. - Assess speech (tone, clarity and pace of speech). - Observe thought processes and perceptions. 13 Assessment: Level of consciousness - Consciousness is defined as being awake and aware of both oneself and one’s surroundings. It is the human awareness of both internal and external stimuli. - Level of consciousness = measurement of one’s arousability and responsiveness to stimuli from the environment. - A change in LOC is usually one of the first clue of a deteriorating condition. Conscious Alert Lethargic Stuporous Obtunded Comatose 14 Assessment: Level of consciousness (Cont’d) LOC Level Definition Opens eyes, answers questions and Lethargy follows command but inattentively, and falls back asleep. Opens eyes to loud voice. Difficult to arouse, responds slowly with confusion, Obtunded seems unaware of the environment and will drift back to sleep. Awakens to vigorous shake or painful Stuporous stimuli, does not follow command. May try to withdraw from painful stimulation Comatose Remains unresponsive to all stimuli. 15 Level of consciousness: Glasgow Coma Scale Specifically, it is useful in evaluating patients during the acute stages of head injury or trauma. 16 Assessment: Cranial Nerves Cranial Nerve Assessment Cranial Nerve I - Assess the patient’s ability to identify smells. (Olfactory) Cranial Nerve II - Use the Snellen chart to assess vision. (Optic) - Assess near vision. Cranial Nerve III - Assess extraocular movements (position test). (oculomotor), IV - Assess pupillary response to light (direct and (trochlear) and VI indirect). (Abducens) - Accommodation test. Cranial Nerve V - Motor function: palpate the contraction of the (Trigeminal) temporal and masseter muscles as the patient clenches their teeth. - Sensory: assess sharp and dull sensation over the patient’s forehead, cheeks and chin while their eyes are closed. - Corneal reflex: note blinking as you lightly touch the patient’s cornea with a fine wisp of cotton. 17 Assessment: Cranial Nerves Cranial Nerve Assessment Cranial Nerve VII (Facial) - Motor: ask the patient to smile, frown and wrinkle forehead, show teeth, puff out cheeks, raise eyebrows and close eyes tightly. - Sensory: assess taste on the anterior two thirds of the tongue (not routinely indicated) Cranial Nerve VIII - Whisper test (Acoustic) - Rinne and weber test to assess the cochlear component of Cranial nerve VIII. Cranial Nerve IX - Motor: check the movement of the uvula as the patient (glossopharyngeal) and X opens their mouth and says “AH” (vagus) - Assess the patient’s ability to swallow & Gag Reflex Cranial Nerve XI (Spinal - Ask the patient to shrug their shoulders against Accessory) resistance (assess trapezius muscles) - Ask the patient to turn head to both sides against resistance (assess sternocleidomastoid) Cranial Nerve XII - To assess strength and mobility of the tongue. (Hypoglossal) 18 Assessment: Eyes & Pupils - Assessment of pupils is especially important in patients with impaired LOC. - Changes in pupil size, shape or reactivity may indicate increased ICP due to a mass or fluid. - Pupillary Light Reflex is governed by Cranial Nerves II and III - Eye Movement is governed by Cranial Nerves III, IV and VI 19 Assessment: Eyes & Pupils (cont’d) - Ptosis = drooping of eyelid. May indicate dysfunction in Cranial Nerve III.  Common in patients with Myasthenia Gravis. - Nystagmus = condition in which the eyes make repetitive, uncontrolled movements.  Often results in reduced vision and may affect balance and coordination. 20 Assessment: Motor Function Patient must be awake, willing to cooperate, & able to understand what you are asking With patient in bed, assess motor strength bilaterally. Ask the patient to: Flex and extend arms against your hand  Squeeze your fingers  Hold leg straight and lift against gravity  Lift leg while you press down on thigh  Flex and extend foot against your hand. What if the patient is unconscious? 21 Assessment: Muscle Tone Muscle Tone is ‘defined as the resistance felt upon passive movement of part of the body’. Assessed by placing a joint through a full range of motion. Hypotonia is characterized by decreased resistance to passive movement and hyperextension at the joints Flaccidity is absent resistance to passive movement. Spasticity and rigidity are two types of increased resistance. Increased tone that is spastic in nature (abnormal lengthening-shortening reaction to stretch) tends to accompany pyramidal tract lesions. Increased tone that is characterized by muscle rigidity (has a "lead pipe" or "cog wheel" feel during the range of motion) suggests extrapyramidal lesions. 22 Assessment: Muscle Tone 23 Assessment: Muscle Strength Weakness is elicited by asking the patient to move a part of the body against resistance (gravity or gravity plus resistance). Paresis = weakness or diminished strength Palaysis/plegia = absence of strength Scale for Muscle Strength Rating Explanation Strength Classification 5 Active motion against full resistance Normal Active motion against some 4 Slight weakness resistance 3 Active motion against gravity Average weakness Passive ROM (gravity removed and 2 Poor ROM assisted by examiner) 1 Slight flicker of contraction Severe Weakness 0 No muscular Contraction Paralysis 24 Assessment: Muscle Size Muscle Atrophy: Decreased muscle mass. E.g. disuse of a muscle leads to an increased rate of degradation of proteins in muscle exceeding rate of replacement leading to atrophy. Muscle Hypertrophy: Increased muscle mass where rate of synthesis is greater than rate of degradation. Usually due to isometric exercises and resistance training. 25 Assessment: Cerebellar function - Evaluate gait and balance. Note posture, freedom of movement, symmetry, rhythm and balance. Tandem walk (heel-to-toe). - Perform Romberg’s test - Assess coordination: finger to nose test - Assess rapid alternating movements Rapid pronation/supination of the palms Thumb to fingers - Perform the heel to shin test 26 Assessment: Gait - Ask the client to: Walk across the room, turn and come back Walk heel-to-toe in a straight line Walk on toes in a straight line Walk on their heel in a straight line Do a shallow knee bend Hop in place on each foot - Abnormal findings: Stiff, immobile posture Wide base of support Lack of arm swing (arms moving back and forth) / Rigid arms Unequal rhythm of steps Ataxia: unsteady gait 27 Romberg’s Test Ask the person to stand up with feet together and arms at the sides Once in stable position, ask the person to close eyes and hold the position Stand close to catch the person in case he or she falls Wait about 20 seconds  Normal Finding: The patient maintains their posture and balance  Abnormal Finding (positive): Positive Romberg sign is loss of balance by closing of the eyes  A positive Romberg’s test occurs in patients with multiple sclerosis, alcohol intoxication and loss of vestibular function. 28 Assessment: Sensory System - Assess light touch, pain and temperature sensations: with the patient’s eyes closed, apply stimuli over every part of the arms, legs and trunk; then, ask the patient to tell you what they feel and where they feel it. - Test vibratory sensation: activate the tuning fork and place its base on the patient’s distal radius, forefinger tip, medial malleolus and tip of the great toe. 29 Assessment: Sensory System (Cont’d) - Test Sensitivity to position (proprioception): Ask the patient to close both eyes. Then, hold the patient’s finger or toe from the lateral sides and move it up or down. Ask the patient to tell you the direction it is moved. Repeat on the other side. - Assess tactile discrimination: Stereognosis: With the patient’s eyes closed, place a familiar object in their hand and ask him/her to identify it. Point localization: With the patient’s eyes closed, briefly touch the patient and ask the patient to identify the points touched. Graphesthesia: With the patient’s eyes close, use a blunt object to write a number on the patient’s palm. Ask the patient to identify the number. 30 Assessment: Deep Tendon Reflexes The mechanism for the assessment of deep tendon reflexes is the same for all:  Use a reflex hammer to strike the intended tendon and observe response. Brachioradiali Biceps Triceps s Patellar Achilles 31 Assessment: Deep Tendon Reflexes (Cont’d) Reflexes +1 Present but decreased +2 Normal Increased or brisk not indicative of a +3 disorder Hyperactive, very brisk, clonus, indicative of +4 a disorder 32 Assessment: Brain Stem Reflex - Protective Reflexes: Cough and gag reflexes Corneal Response - Oculocephalic reflex (Doll’s eye reflex) Turn the patient’s head briskly from side to side; the eyes should move to the left while head is turned to the right and vice versa. No eye movement means that the reflex is absent. 33 Assessment: Superficial Reflexes - Plantar (Babinski) Reflex: using the end of the reflex hammer, stroke the lateral aspect of the sole from the heel to the ball of the foot. A negative Babinski is normal = flexion of the toes occur. A positive Babinski is abnormal = the toes will fan out (except in infants). Positive Babinski occurs with upper motor neuron disease of the corticospinal or pyramidal tract 34 Assessment: Postures Decorticate Rigidity Flexion of arms, wrist and fingers Adduction of arms to chest Extension, internal rotation, plantar flexion of lower extremities. Possible Cause: Lesion in the cerebral cortex Decerebrate Rigidity Extended, adducted internal rotation Palm pronation of upper extremities Extended lower extremities Teeth clenched Hyperextended Neck Possible Cause: Lesion in brainstem, midbrain 35 or upper pons. Assessment: Postures (Postures) Flaccid Quadriplegia Complete loss of muscle tone : Completely nonfunctional brain stem 36 Assessment: Vital Signs and Neurologic State -Cushing’s Triad: Late sign of Increased ICP. When is happens, brain stem herniation is probably already taking place and is most likely irreversible. Cushing’s Triad includes:  Change in breathing pattern (irregular, slow and deep e.g. Cheyne Stokes)  Bradycardia  Increased BP with a widening pulse pressure To detect increase in ICP, note any changes in neurologic states such as subtle changes in LOC and pupils. 37 References Weber, J. R. (2022). Nurse's Handbook of Health Assessment (Tenth). Wolters Kluwer. Weber, J., & Kelley, J. (2022). Health Assessment in Nursing. Wolters Kluwer. Kotagal, S., & Morse, A. M. (2023). Detailed neurologic assessment of infants and children. UpToDate. https://www.uptodate.com/contents/detailed-neurologic-assessment-of-infants-and- children 38