Neurological Assessment

1
Neurological Assessment Diagnostic Studies

• NET 2420
• Neuro Lecture Handout
• S. Compton RN, MSN

2
Nursing History

• Current Health History
• Headaches, memory and concentration, visual
  disturbances, hearing, balance, dizzy spells,
  speech, muscle strength, abnormal sensations
• Past Health History
• Head injury, spinal cord injury, surgery,
  seizures
• Family History
• Neurological diseases, headaches, HTN, stroke, DM
• Social History and Habits
• Diet, vitamin deficiencies, ability to read or
  concentrate, exposure to toxins or chemicals,
  alcohol or drug use, sexual difficulties, sleep
  problems
• Medication History-neuro as well as all others

3
Complete Neurological Assessment5 Components

• Cerebral Function
• Cranial Nerve Function I-XII
• Cerebellar and Motor Function
• Sensory System
• Reflexes

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Neuro Check

• Level of consciousness (LOC)
• Pupil response and size
• Verbal responsiveness
• Extremity strength and movement
• Vital signs
• Establishing BASELINE and regularly
  re-evaluating key indictors reveals trends and
  detects changes ? warning signs of problems

5
Cerebral Function

• Level of consciousness
• Level of arousal Subcortical RAS
• Alert ? lethargic ? unresponsive
• Auditory?tactile? painful stimuli to elicit
  response
• Level of orientation Cortex activity
• Person, place, time
• Speech
• Quality Clear, slurred
• Verbal responses appropriate or nonsensical
• Ability to understand and follow commands
• Awareness of and difficulties with communication

6
Cerebral FunctionVerbal Responsiveness and
Speech

• Dysarthria difficulty with mechanics of speech
• Aphasia
• TEMPORAL-receptive
• Inability to understand or process speech?
  Wernickes
• Auditory spoken word
• Visual written word
• FRONTAL-expressive
• Inability to form or use language? Brocas Area
• Spoken OR written or BOTH
• GLOBAL both receptive and expressive

7
Mini-Mental State

• Widely used tool
• Assesses only cognitive abilities
• LOC, abstract reasoning, arithmetic calculations,
  writing ability, memory and judgment
• Objective score based on results

8
Cranial Nerves (CNs)Smeltzer Bare Table 60-5
p 1837

• CN VII- Facial
• CN VIII- Vestibulocochlear
• CN IX- Glossopharyngeal
• CN X- Vagus
• CN XI- Spinal Accessory
• CN XII- Hypoglossal

• CN I- Olfactory
• CN II- Ophthalmic
• CN III- Occulomotor
• CN IV- Trochlear
• CN V- Trigeminal
• CN VI- Abducens

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Cranial Nerve I

• Olfactory nerve (sensory)
• Vulnerable to damage in frontal head, basilar,
  and facial injuries
• Performed one nostril at a time
• Able to correctly identify smells

10
Cranial Nerve II

• Optic nerve (sensory)
• Visual acuity, visual fields, ophthalmic exam of
  retinal structures
• Area and extent of visual field loss depends on
  location of problem

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Visual Field Defects
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Cranial Nerve III

• Oculomotor nerve (motor)
• Elevation of eyelid
• Muscles of eye
• (with IV and VI)
• Assess pupil size, shape, response to light and
  accommodation? parasympathetic inervation
• Assesses midbrain
• Normal response PERRLA- pupils equal round
  reactive to light and accommodation
• How do you test for accommodation?
• If PERRL, usually no need to test

13
CN III, CN IV, CN VI

• Oculomotor, trochlear, abducens nerves (motor)
• Assess EOMs
• Assesses midbrain and pons

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CN V Trigeminal Nerve (sensory and motor)

• Sensory three branches
• Opthalmic, Maxillary, Mandibular
• Motor
• Muscles of mastication
• Palpate temporal and masseter muscles
• Open mouth? symmetry
• Corneal reflex
• ? Contact wearers

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CN VII Facial Nerve (sensory and motor)

• Sensory taste to anterior 2/3 of tongue
• Motor Facial expression and secretion of saliva
• Wrinkle forehead, raise and lower eyebrows, smile
  and show teeth, puff cheeks, close eyes
• Observe for symmetry
• UMN problems vs. facial nerve paralysis

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CN VIII Acoustic Nerve (sensory)

• Vestibulocochlear nerve
• Hearing (cochlear) and balance (vestibular)
• Testing Tuning Fork Weber and Rinne tests
• Weber tuning fork to center of forehead
• NORMAL hear equally in both ears
• RINNE tuning fork to mastoid process then
  auditory canal
• NORMAL hear air conduction 2X as long as bone
  (Rinne positive)

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CN IX and CN X

• Glossopharyngeal and Vagus
• Sensory and motor
• Assess together
• Taste posterior 1/3 of tongue
• Swallowing, gag reflex
• Movement of pharynx (ahhhhh)
• Assesses medulla

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CN XI Spinal Accessory Nerve

• Motor
• Shrug shoulders? trapezius
• Turn head? sternocleidomastoid

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CN XII Hypoglossal Nerve

• Motor
• Tongue movements, strength
• Speech sounds d, l, n, t

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Motor Assessment

• Assess muscle strength, tone, size
• Observe for decreased fine motor movements
• Finger grasp, arm strength
• Compare side to side
• Can indicate UMN problems
• Degenerative cerebral disease, trauma or ischemia
  
• Can indicate LMN disease
• Problems within spinal cord cord compression or
  injury

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Cerebellar Function

• Balance
• Tandem, heel-toe walking
• Romberg test (feet together, eyes closed)
• Coordination
• Rapid alternating movements
• Finger to nose to finger test
• Heel down shin

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Cerebellar Function Abnormal Findings

• Ataxia incoordination of voluntary muscle action
• Dysdiadochokinesia inability to do rapid
  alternating movement
• Dysmetria past pointing
• Positive Rombergs sign
• Pt sways badly or loses balance? positive Romberg
  sign
• If cerebellar, pt sways with eyes open or closed
• If proprioceptive ( posterior columns) patient OK
  with eyes open

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Gait Disturbances

• Spastic Hemiparesis
• Spastic Paresis
• (Scissors Gait)
• Foot Drop
• Sensory Ataxia
• ( Rombergs eyes closed)
• Cerebellar Ataxia
• ( Rombergs eyes open or closed)
• F. Parkinsonian

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Deep Tendon Reflexes Assessing Spinal Cord Level

• Biceps C5C6
• Brachioradialis C5C6
• Triceps C7C8
• Abdominal T8T9T10
• Patellar (knee-jerk) L2L3L4
• Achilles S1S2

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Grading Reflexes

• Grade 0-4
• 0 ? reflex absent
• 2 ? normal
• 4 ? CLONUS ? UMN disease
• Compare side to side
• Many variations
• Patient must be relaxed

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Superficial Reflexes

• Graded as PRESENT or ABSENT
• Corneal Reflex (CN V)
• Present ? Brisk blink
• Loss in stroke, coma, CONTACT WEARERS
• EYE PROTECTION
• Gag Reflex (CN X)
• Present ? Elevation of uvula bilaterally
• Loss in stroke
• ASPIRATION PRECAUTIONS

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Plantar ReflexBabinski Response

• Stroke lateral aspect of sole of foot
• NORMAL response ? plantar FLEXION
• BABINSKI response ? pathological in adult
• POSITIVE BABINSKI Dorsiflexion of great toe with
  fanning of other toes
• Indicates upper motor neuron disease

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Grasp Reflex Significance

• COMA Stimulation of palm of hand
• POSITIVE Pt will grasp firmly
• Will not let go to command
• Indicates frontal lobe damage, thalamic
  degeneration, cerebral atrophy

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Sensory Function

• Assessing dorsal columns or parietal lobe
• Light touch, position sense, vibration
• Stereognosis able to identify object placed in
  hand
• Graphesthesia
• Extinction touch one or both sides of body
• Two point discrimination
• Spinothalamic tracts and parietal lobe
• Pain and temperature
• Sharp or dull

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Gerontologic Considerations

• Smeltzer Bare p 1841
• Structural changes
• Decreased conduction
• Muscle atrophy
• Diminished reflexes
• Sensory alterations
• Mental status changes
• BUT.CANNOT ATTRIBUTE NEUROLOGIC CHANGES TO AGE
  WITHOUT THOROUGH ASSESSMENT!!!!

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Anatomical Planes
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Skull and Spinal X-rays

• C-spine films routinely ordered in multiple
  trauma to rule out cervical fracture
• X-rays used to evaluate skull, spinal
  abnormalities, pituitary tumor
• Frequently ordered to evaluate low back pain

33
Computerized Tomography

• Cross sectional images brain and spine using
  radiation and computer
• More specific views of bone and tissue than
  X-rays
• Useful in detecting tumors, hemorrhages,
  hematomas, ventricular enlargement
• May be used with IV contrast enhancement

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CT Patient Preparation

• Pt must be as motionless as possible
• Confused combative client/ pediatric
  considerations
• If contrast used
• ?? allergies to shellfish
• NPO for 4 hours prior to test
• IV started in radiology (if not already in place)
• Should remove wigs, hairpins, clips and jewelry?
  interfere with image seen
• Test should take 30-60 minutes
• Post-test resume diet and encourage fluids if IV
  contrast used

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PET Scan

• Images of actual organ functioning
• Inhaled or injected radioactive substance
• Shows metabolic changes
• Alzheimers
• Brain tumors
• O2 uptake after stroke

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MRI Nursing Considerations

• Use of electromagnet and radio waves
• Check patient history!!
• PATIENTS WHO CANNOT HAVE MRI
• Pacemakers
• Metal implants, plates, screws, or clips (old
  aneurysm surgeries!)
• IUDs, metal heart valves
• SAFETY
• IV pumps, portable oxygen tanks cannot be in scan
  area
• Patient Preparations and teaching
• No metals jewelry, credit cards, eyemakeup
• Process takes 45 minutes to 1 hour ? pt. must
  lie still
• MRI machine makes loud beating noise
• Closed MRI tight space problems with
  claustophobia?
• May need Valium pre-test/ some cannot tolerate

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Cerebral Angiography

• Injection of contrast medium into cerebral
  circulation
• Useful in detecting cause of stroke, headaches,
  seizures
• Femoral access most commonly used vessel
• Risk stroke

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Cerebral Angiography Procedure Patient
Preparation

• Injection of contrast medium into cerebral
  circulation
• Useful in detecting cause of stroke, headaches,
  seizures
• NPO solids 6-10 hours
• Clear liquids/ water encouraged 24 hours prior
• Assess PT/ PTT
• Stop anticoagulants prior to test (usually)
• Contrast dye precautions/ informed consent
• Patient AWAKE slight sedation
• Femoral puncture ? mark peripheral pulses
• Burning or flushing with contrast injection
  expected
• Procedure will take 1-2 hours
• http//www.heartcenteronline.com/myheartdr/common/
  artprn_rev.cfm?filenameARTID560

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MR Angiography (MRA)

• Utilization of MR technology to view vasculature
• Same restrictions as MRI
• May use contrast material (gadolinium) but is not
  iodine based

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Myelogram

• Injection of contrast medium into subarachnoid
  space? x-ray visualization
• Useful for visualizing obstructions within spinal
  canal
• Dye bathes nerve roots? any compressin of nerve
  roots visualized
• Helpful in diagnoses of herniated discs and
  spinal cord tumor

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Patient Preparation

• Inpatient procedure/ 23 HR
• Consent form
• NPO 4-8 hours prior
• Probably mild sedation given IV started
• Lumbar puncture in radiology? CSF aspirated
• Either water based (Amipaque) or oil based
  (Pantopaque) dye used
• Hold phenothiazines (Phenergan), TCAs, SSRIs 48
  hours
• Lower seizure threshhold
• X-ray table tilted
• CT performed at end

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Post-procedure Care

• Amipaque not aspirated? absorbed by body
• HOB 30-60 degrees for 24 hours
• Pantopaque aspirated at end of visualization
• Patient flat for 24 hours (rarely used)
• Quiet activity, little stimulation
• Push fluids, monitor I and O, BUN, Creatinine
• BP, RR, pulse temperature monitored
• May experience nausea, headache? should diminish
  ? no Phenergan or Compazine!
• No neck stiffness or confusion should occur

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EEG

• Amplifies and
• records electrical
• activity in brain
• Uses
• Detecting areas of abnormal or absent brain
  activity
• Brain tumors, hematomas, seizure activity
• Determination of brain death in comatose patient

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EEG PreparationUse of Evoked Potentials

• Preparation
• Avoidance of caffeine prior to exam
• No gels, sprays in hair
• Must be quiet and still as possible
• Evoked Potentials
• Auditory, sensory, visual record brain activity
  in response to stimuli
• Diagnostic for various disorders

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Electromyography (EMG) and Nerve Conduction
Velocities (NCV)

• EMG Needle electrodes inserted into skeletal
  muscles? patient relaxes and contracts various
  muscles and action potential recorded
• NCV Nerve stimulated with electrical impulse
• Useful in studying patients with cervical or
  lumbar disc disease, myasthenia gravis, muscular
  dystrophy (LMN diseases)
• Patient should be taught to expect some mild
  discomfort

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Lumbar Puncture

• Insertion of needle into subarachnoid space
  between L2 and S1
• Withdrawal of small amount CSF for diagnostic
  evaluation
• Measurement of CSF pressure
• Should not be performed if evidence of greatly
  increased CSF pressure (papilledema)

47
Lumbar Puncture

• Patient preparation
• No diet or fluid restrictions
• Empty bowel and bladder before
• Careful instructions regarding cooperation during
  test
• Signed consent required
• Positioning
• Chart 60-4 p 1847

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Lumbar Puncture

• CSF in three labeled tubes
• Protein and glucose
• Culture
• Blood cell counts
• Post-procedure care
• Prone with pillow under abdomen for 1 hr
• Flat in bed 6-24 hours (30 degrees)
• Increased fluid intake
• Observe site for swelling, leakage
• Observe for post spinal headache

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Post-Lumbar Puncture Headache

• Most common complication
• CSF leaks from needle track ? depleted
• Increases when patient upright
• AVOID use small gauge needle/ keep prone after
• Treatment bedrest, analgesics, hydration
• Persistent Blood patch

50
CSF Fluid Analysis

• Pressure Normal 70-180 mmH2O
  (5-15mmHg)
• Increased SAH, brain tumor, viral meningitis
• Appearance clear and colorless
• Bloody SAH or traumatic tap (will clear)
• Cloudy infection
• Orange or yellow RBC breakdown, elevated protein

51
CSF Fluid Analysis

• Cell Count 0-5 monos and no RBCs
• Elevated monos? infection, abcess, tumor,
  infarction, chronic illness (MS)
• RBCs? SAH or traumatic tap
• Protein 15-45 mg/dl
• Lower than plasma because of BBB
• Elevated infection, tumor, MS, degenerative
  brain disease
• Glucose 50-75 mg/dl
• Elevated DM or diabetic coma
• Decreased acute bacterial meningitis, tumor