ASSESSMENT OF THE NERVOUS SYSTEM

OBJECTIVES

After completion of this session the students should be able :

To learn a basic Nervous System Examination To differentiate between normal and abnormal responses related to the neurologic system To apply findings to common clinical presentations To document findings in a structured, systematic way

Outlines
Introduction Review

of anatomy and physiology Nursing assessment

Introduction

The nervous system consists of the central nervous system (CNS), the peripheral nervous system, and the autonomic nervous system. Together these three components integrate all physical, emotional, and intellectual activities. The CNS includes the brain and spinal cord. These two structures collect and interpret voluntary and involuntary sensory and motor signals.

Introduction

The peripheral nervous system consists of the 12 pairs of cranial nerves and peripheral nerves. Most peripheral nerves contain both motor and sensory fibers.

Purposes of Neurologic Assessment

To collect baseline data to aid in establishing the etiology, diagnosis and prognosis To evaluate the present state of psychological functioning to evaluate changes in individuals emotional, intellectual, motor, and perceptual responses To determine the guidelines of treatment plan To ascertain if some seemingly psychopathological response, is in fact a disorder of the sensory organ (i.e., a deaf person appearing hostile)

Three important questions govern :the neurologic examination

1) 2) 3)

Is the metal status intact? Are right-sided and left-sided findings symmetric? If the findings are asymmetric or otherwise abnormal, does the causative lesion lie in the CNS or the peripheral nervous system?

Components of a Neurologic Assessment

INTERVIEW. 1 : The patient/family interview will allow the nurse to gather data: both subjective and objective about the patient's previous/present health state provide information to patient/family clarify information make appropriate referrals develop a good working relationship with both the patient and the family initiate the development of a written plan of care which is patient specific

Components of a Neurological Assessment

Mental Status. 1 Cerebellar Functions. 2 Cranial Nerve Testing. 3 Sensory. 4 Motor Function. 5 Reflexes. 6

Tools

The following tools will be used during :the neurological exam

Gloves Reflex hammer (tomahawk ) model Penlight Tongue blade Safety pin Cotton swab Ophthalmoscope Eye chart Tuning fork Coffee

I. The Mental Status

Appearance and behavior Speech and Language Moods and Thought perception Cognitive Functions

General appearance, manner and attitude

A simple means of gathering a great deal of information about the patient's neurological system is to observe the patient walking, talking, seeing, and hearing. Watching the patient enter the room is also important in giving the examiner information.

General appearance, manner and attitude

As the patient enters the room, check the following: Posture and motor behavior, purposeful movements and gestures Dress, grooming, and personal hygiene. Facial expression. Speech manner, mood, and relation to persons and things around him

Level of consciousness
The single most valuable indicator of neurological function is the individual's level of consciousness. You can legally describe the patient's condition in the nursing notes by saying, "appears to be" alert or lethargic or so forth. Alert. The patient is awake and verbally and motorally responsive. Confused. The patient may de disoriented to time, place and person and has poor judgment and may not think clearly. Lethargic. The patient is sleepy or drowsy and will awaken and respond appropriately to command.

Level of consciousness

Obtundation. The patient is difficult to arouse and needs constant stimulation to follow commands. He may respond with a few words but will drift back to sleep when the stimulus is removed Stupor. The patient becomes unconscious spontaneously and is very hard to awaken. Semi coma. The patient is not awake but will respond purposefully to deep pain. Coma. The patient is completely unresponsive. Consciousness is the most sensitive indicator of*** ** neurological change

GLASGOW COMA SCALE useful for fewmonitoring changes during the first unstabledays after acute injury or in .comatose clients

Assessment of Unconscious Client

SCALE is divided into three (3) subscales Eye Opening Verbal Response Motor Response

GLASGOW COMA SCALE

4 3 2 1

Best Eye Response

Spontaneously On command To Pain No response

Best Verbal Response 5 Alert & Oriented

4 3 2 1 Confused Inappropriate Incomprehensive No Response

Best Motor Response

6 5 4 3 2 1 Follows Direction Localizes Pain Withdraws from Pain Abnormal Flexions Abnormal Extensions NO Response

) The Glasgow coma scale (GCS

EYE OPENING (Max score 4) 4 Spontaneous eye opening. 3 Eye opening in response to speech - that is, any speech or shout. 2 Eye opening in response to pain. 1 No eye opening. TOTAL SCORE ...... / 15 RECORD YOUR FINDINGS You may record you findings on a specific CNS chart. Otherwise record in the following fashion:

) The Glasgow coma scale (GCS

ASSESS GRADES OF BEST VERBAL RESPONSE (Max score 5) 5 Oriented - patient knows who & where they are, and why, and the year, season & month. 4 Confused conversation - patient responds in conversational manner, with some disorientation and confusion. 3 Inappropriate speech - random or exclamatory speech, no conversational exchange. 2 Incomprehensible speech - no words uttered, only moaning. 1 No verbal response.

) The Glasgow coma scale (GCS

ASSESS GRADES OF BEST MOTOR RESPONSE (Max score 6) 6 Carrying out request ('obeying command') 5 Localizing response to pain. 4 Withdrawal to pain - pulls limb away from painful stimulus. 3 Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs 2 Extensor posturing to pain - stimulus causes limb extension 1 No response to pain.

Speech and Language

Note the quality, rate, loudness, clarity, and fluency of speech. If indicated, test for aphasia

TESTING FOR APHASIA

TEST Word Comprehension FINDINGS Ask client to follow a one-stage command, such as Point to your nose. Try a two-stage command: Point to your mount then your knee Ask client to repeat a phrase of one syllabus words ( the most difficult repetition task) NOTE: No ifs, ands or buts. Ask client to name he parts of the watch. Asks client to read a paragraph aloud. Ask client to write a sentence

Repetition

Naming Reading comprehension Writing

Thought and Perception

Assess coherency, logic and relevanceWhere were you born?; What kind of work do you do? Ask about the patients spirits, if indicated, assess for suicide tendencies and depression. Assess perception and reaction- How do you yourself now that you are in the hospital?

Affect/Mood

During the physical part of the examination, note the patient's mood and emotional expressions which you can observe by his verbal and nonverbal behavior. Notice if he has mood swings or behaves as though he is anxious or depressed. Notice whether or not the patient's feelings are appropriate for the situation. Disturbances in mood, affect, and feelings may be indicated by a patient who exhibits unresponsiveness, hopelessness, agitation, euphoria, irritability, or wide mood swings.

Cognitive Functions

Assess reality orientation: time, place and person- orderly progression of thoughts based in reality.

Cognitive Functions
Attention Digit span- ability to repeat a series of numbers forward and then backward Spelling backward- five letter word such as W-O-R-L-D

Calculations in basic mathematics

Serial

7s ability to subtract 7 repeatedly, starting with 100 Ask the patient to do some simple arithmetic problems without using paper and pencil. For example, ask him to add 7s or to subtract 3s backwards. It should take the patient of average intelligence about one minute to complete the calculations with few errors.

(Memory (recent and remote

Recent

Memory (e.g. events of the day Remote memory e.g., birthdays, anniversaries, social security number, schools attended New learning ability (recall) ability to listen and respond with understanding or knowledge; ask the client to repeat a phrase, or three of four words

Higher Cognitive Functions (Knowledge (normal intellect

Information and vocabulary Calculating abilities Abstract thinking Constructional abilities

Ask the patient to name five large cities, major rivers, etc. Another way to test this area is to ask the patient to tell you the meaning of proverb, or metaphor. For example, explain: Too many cooks spoil the soup. A penny saved is a penny earned. A stitch in time saves nine

II. The Cerebellar Functions

These include tests for balance and coordination. The cerebellum controls the skeletal muscles and coordinates voluntary muscular movement. Ask the patient to walk back and forth across the room. Observe for equality of arm swing , balance and rapidity and ease of turning.

Cerebellar Functions
Finger to finger test: have the patient touch. 1 their index finger to your index finger (repeat ). several times Finger to nose test: perform with eyes open. 2 .and then eyes closed Tandem walking: heel to toe on a straight line. 3 Romberg test. 4

The Romberg Test

Instruct the patient to stand with his feet together and his arms at his side. Have the patient do this with his eyes open and then with his eyes closed. (Stand close to the patient to keep him upright if he starts to sway.( Expect the patient to sway slightly but not fall. This is a test of balance. If the patient begins to sway, have them open their eyes. If swaying continues, the test is positive or suggestive of problem of cerebellum

Positioning
Usually

tested only on the great toes but it can be tested on the fingers too. Ask the patient to shut his eyes. Grasp the side of the toe between index finger and thumb. This prevents movement from being felt as pressure up or down. Move the digit up or down and ask the patient to tell you the direction of movement

Rapid alternating movements test

Seat the patient. Instruct him to pat his knees with his hands, palms down then palms up. Have him alternate palms down and palms up rapidly. Watch the patient to notice if his movements are stiff, slow, nonrhythmic, or jerky. The movements should be smooth and rhythmic as he does the task faster.

III. The Cranial Nerves

Evaluating the cranial nerves is an important part of the neurological examination. Taste and smell are usually not checked unless a problem is suspected in those areas.

Cranial Nerve I, The Olfactory Nerve

The olfactory nerve is not commonly tested during a screening physical exam but can be performed if damage secondary to trauma or intracranial mass is suspected. Each nostril should first be evaluated for potency by compressing one nostril and having the patient breath through the opposite. Each nostril should then be tested separately with a volatile, non-irritating substance such as cloves, coffee or vanilla. The patient should close his eyes, occlude one nostril and identify the substance placed under the open nostril.

Pupils:

To examine cranial nerves II , III and midbrain connections

PUPILLARY ASSESSMENT When assessing pupils (eyes) it is important to assess the : following size shape reactivity to light comparison of one pupil to the other

Pupils: Reaction to Light

To examine cranial nerves II , III and midbrain connections

Have the patient look at a distant object Look at size, shape and symmetry of pupils. Shine a light into each eye and observe constriction of pupil. Flash a light on one pupil and watch it contract briskly. Flash the light again and watch the opposite pupil constrict (consensual reflex Repeat this procedure on the opposite eye. Normal: Pupil size is 3-5 mm in diameter. They react briskly to light. Both pupils constrict consensually.

Pupils: Size

To examine cranial nerves II , III and midbrain connections

: Pupils can be described according to their size (in mm) or by description . Pinpoint: Seen with opiate overdose and pontine hemorrhage . Small: Normal if the person is in a bright room May be seen with Horner's syndrome, pontine hemorrhage, ophthalmic drops, . metabolic coma etc . Midposition: Seen normally . If pupils are midposition and nonreactive the cause is midbrain damage . Large: Seen normally when the room is dark . May be seen with some drugs and some orbital injuries . Dilated: Always an abnormal finding Bilateral, fixed and dilated pupils are seen in the terminal stage of severe anoxia. ischemia or at death Anti-cholinergic drugs can dilate pupils

Vision: Visual Acuity

To examine cranial nerve II and ocular function Position yourself in front of the patient. Test the patient's visual acuity, each eye separately covering one at a time. Snellen's chart is used by Ophthalmologists. Visual acuity is recorded as a fraction. The numerator indicates the distance (in feet) from the chart which the subject can read the line. The denominator indicates the distance at which a normal eye can read the line. Normal vision is 20/20. A pocket screener is used at the bedside. Hold the pocket screener at a distance of 12-14 inches. At this distance the letters are equivalent to those on Snellen's chart.

Vision field

By confrontation

Position yourself in front of the patient. The nose normally cuts off the medial field of vision. Hence, compare the patient's right eye to your left eye and vice versa. Instruct the patient to look straight at you and not to move their eyes. Compare your field of vision with the subject's. Bring your finger from the right field of vision until it is recognized. Test one quadrant at a time. Wiggle your fingers to see whether the patient can recognize the movement. Some like to have the patient count fingers, i.e., 1, 2 or 5. Test all four quadrants in a similar fashion. When abnormality is detected , would require automated methods of testing in the lab

Extraocular Muscles To examine cranial nerves III, IV and VI

Inspect the eyes. Look for symmetry of eyelids. Note the alignment of the eyes at rest. Ductions: Movement of one eye at a time Versions: Both eye movement Have the patient follow an object into each of the nine cardinal fields of gaze. Note that both eyes move together into each field. Eye movements should be smooth and without jerking. Eyelids should be gently lifted up by the examiner's fingers when testing downward gaze. Jerky, oscillatory eye movements (nystagmus) may be abnormal, especially if sustained or asymmetrical.

CN V: Trigeminal
Corneal reflex: patient looks up and away. Touch cotton wool to other side. Look for blink in both eyes, ask if can sense it. Repeat other side [tests V sensory, VII motor]. Facial sensation: sterile sharp item on forehead, cheek, jaw. Repeat with dull object. Ask to report sharp or dull. If abnormal, then temperature [heated/ water-cooled tuning fork], light touch [cotton]. Motor: pt opens mouth, clenches teeth (pterygoids). Palpate temporal, masseter muscles as they clench.

Motor Function: Facial Muscles To test cranial nerve VII

Inspect the face. Look for asymmetry at rest, during conversation and when testing various muscles. Ask the patient to wrinkle his forehead or raise his eyebrows, enabling you to test the upper face (frontalis) Next, have the patient tightly close his eyes. Test the strength of the orbicularis oculi by gently trying to pry open the patient's upper eyelid. Instruct him to puff out both cheeks. Check tension by tapping his cheeks with your fingers. Have the patient smile broadly and show his teeth, testing the lower face. Normal: No facial asymmetry. Wrinkling of the forehead and smiling are equal and symmetrical

CNVIII: Hearing

With eyes closed, the patient should be instructed to acknowledge hearing the gentle rubbing of the examiner's fingers approximately 3-4 inches away from his right and left ear. A watch, which the examiner can hear at a specific distance from his ear, is placed next to the patient's ear. Ask him to note when the watch sound disappears. Note that the examiner has to have normal hearing to do this exam (in at least one ear( Normal: In a quiet room, the patient should be able to hear the physician's fingers rubbed lightly together 3-4 inches from his ear.

CN IX and X

These tests will evaluate certain structures in the mouth. The nurse ask the patient to say "aah" and can detect abnormal positioning of certain structures such as the palatel-uvula. The examiner will also assess the sensation capabilities of the pharynx, by stimulating the area with a wooden tongue depressor, causing a gag reflex.

CNXI

Inspect Trapezius and Sternocleidomastoid muscles

Note muscle size (bulk). Look for asymmetry, atrophy and fasciculation.

Determine muscle power by gently trying to overpower contraction of each group of muscles.

Have patient shrug shoulder against resistance and evaluate strength of Trapezius muscle. Have patient turn head to one side against resistance and evaluate strength and observe contracting sternomastoid muscle

CNXII
This

nerve tests the bulk and power of the tongue. The examiner looks for tongue protrusion and/or abnormal movements

IV. Sensory Function

Testing for sensory function is the most difficult and the least reliable part of the examination. Perform two tests. (1) Test for pain. Perform this test using pin pricks in the arms and legs. Ask the patient to say "sharp" or "dull" after each stimulus and to reply immediately. This is a test of the patient's response to superficial pain. Usually, a sterile needle with a sharp point and dull hub on the other end is the instrument used. In a nonpredictable pattern, touch the patient's skin with one or the other end of the needle.

Test for touch

Touch the skin with a cotton ball using light strokes. Do not press down on the skin or touch areas of the skin that have hair. Instruct the patient to point to the area you have touched or tell you when he feels the sensation of being touched. (Obviously, he will not be watching you touch his skin.(

Test for Temperature

Testing for temperature sensation is often overlooked but it can be important. Tubes of hot and cold water may be used but an easier and more practical approach is often to touch the patient with a tuning fork as the metal feels cold. First touch the patient where sensation is thought to be normal and say, "Does that feel cold?" Then, when testing the limb, check that the patient is feeling the fork as cold and not just as pressure

V. The Motor System

When assessing motor function, from a neurological perspective, the assessment should focus on arm and : leg movement. You should consider the following muscle size. 1 muscle tone. 2 muscle strength. 3 involuntary movements. 4 posture, gait. 5

Motor System
Inspection Start by looking at the patient. Do muscles look wasted? Is there asymmetry? If the nurse strike the affected muscle with a jerk hammer, it may induce fasciculation.

Motor Functions Assessment

Term Common Meaning Strong Weak Unable to lift Withdraws Reflex Decorticate Normal Strength Not as strong as expected, moves against resistance but weak. Cant bring limb off the bed, cant move against gravity Pulls back from pain source Involves contraction of muscle in response to pain To painful stimuli: flexes arms, wrists with adduction of the upper extremities & extension, internal rotation & plantar flexion of Lower extremities To painful Stimuli : extends, abducts and hyperpronates arms & stiffly extends legs & plantar flexes feet. No response to pain, no muscle tone Incoordination of voluntary muscle groups.

Decerebrate

Flaccid Ataxia

Motor Functions Assessment

Range of Motion
Flexion. 1 Extension. 2 Abduction. 3 Adduction. 4 )Rotation ( Internal & External. 5
+4 +3 +2 +1 +0

Grading Reflexes
Hyperacative Brisker than average Average, NORMAL Diminished, low N No Response

Note : Findings are recorded as a fraction with 5 ( highest possible Score) as the denomination Ex: Normal ----------------- 5/5

Motor Functions Assessment

Grade Strength Full ROM against gravity and resistance; normal 5 muscle strength Full ROM against gravity and a moderate amount of 4 resistance; slight weakness Full ROM against gravity only, moderate muscle 3 weakness Full range of motion when gravity is eliminated, severe 2 weakness A weak muscle contraction is palpated, but no 1 movement is noted, very severe weakness Complete paralysis Note : Findings are recorded as a 0
Score) as fraction with 5 ( highest possible the denomination Ex: Normal ----------------- 5/5

Motor System
In a conscious patient, the single best test to quickly identify motor weakness is the drift test. Have the patient hold their arms outward at 90 degrees from the body. With palms up, have the patient close their eyes and hold the arms for a couple of minutes. Drifting will occur if one side is weak.

Abnormal posturing
Decorticate posturing
Legs and feet extendedwith planter flexion and arms rotatedand flexed on chest

Decerebrate posturing
Arms stiffly extended and hands turned outward and flexed,leg also extended with planter flexion
Decorticate posture may progress to decerebrate posture, or the two may alternate. The posturing may occur on one or both sides of the body.

VI. The Reflexes

A reflex is defined as an immediate and involuntary response to a stimulus.

Superficial reflexes. Stroke the skin with a hard object such as an applicator stick. What is felt is a superficial reflex 5 Ps Pain Pallor Pulses Paresthesia Paralysis

Biceps--deep tendon reflex

1- Have the patient's elbow at about a 90 angle of flexion with the arm slightly bent down as shown in figure 2-6. 2- Grasp the elbow with your left hand so the fingers are behind the elbow and your abductee thumb presses the biceps brachial tendon. 3- Strike your thumb a series of blows with the rubber hammer, varying your thumb pressure with each blow until the most satisfactory response is obtained. 4- Normal reflex is elbow flexion (bending(

Triceps--deep tendon reflex

Triceps reflex

Grasp the patient's wrist with your left hand and pull his arm across his chest so the elbow is flexed about 90 and the forearm is partially bent down. Tap the triceps brachial tendon directly above the olecranon process. The normal response is elbow extension.

Triceps jerk with one arm flexed

Triceps jerk with arms folded

Plantar (Babinski) reflex

Lightly stimulate the outer margin of the sole of the foot to get this reflex. Perform the reflex check in this manner:

Grasp the ankle with your left hand. Use a blunt point and moderate pressure and stroke the sole of the foot near its lateral border. Stroke from the heel toward the ball of the foot where the course should curve across the ball of the foot to the medial side, following the bases of the toes. A normal reflex is for the patient to have plantar flexion of all his toes.

Patellar reflex )(kneejerk

Test the reflex in this manner
1 -Have the patient sit on a table or high bed to allow his legs to swing freely. 2 -Tap the patellar tendon directly with a rubber hammer. 3 -Normally, the knee extends. 4 -Conduct the reflex check as shown in this figure if the patient must be lying down. Put your hand under the popliteal fossa and lift the patient's knee from the table or bed. Tap the patellar tendon directly.

)Achilles reflex (ankle jerk

Tap the Achilles tendon and the foot should extend from the contraction of the gastrocnemius and soleus muscles responding to that tap. Perform the reflex test in this manner:

Have the patient sit on a table or bed so that his legs dangle. With your left hand, grasp the patient's foot and pull it in dorsiflexion (upward). Find the degree of stretching upward of the Achilles tendon that produces the optimal response. Tap the tendon directly. Normal response is contraction of the gastrocnemius and plantar flexion of the foot.

Deep tendon reflexes should be graded on a scale of 0-4

as

follows: = 0 absent despite reinforcement = 1 present only with reinforcement = 2 normal = 3 increased but normal = 4 markedly hyperactive, with clonus

Others: Vital Signs

Changes in vital signs are not consistent early warning signals. Both respiratory and cardiac centres are located in the brainstem. Therefore, compression of the brainstem will cause changes in vital signs. This is usually a late sign and impending herniation/death will occur if the problem is not resolved. Do not forget to compare findings to previous assessment

Other s: CONVULSION SCORING CHART .((Rhea et al

Factors Occurrence Duration Severity Frequency Ventilation 0 None in 24 hours fleeting Mild twitching More than 60 minutes apart adquate 1 2 Occur only in Occur stimulation spontaneously Last between 10-60 Longer than sec. 1minute Moderate clonus Severe shaking 60-10 minutes Less than 10 apart minutes apart impaired Impaired to the point of cyanosis

*Score is done every 4 hours Interpretation: Score above 7 increase the dose of anticonvulsant Score of 5-7 may be transitional. If it tends to increase from 5-7 during a 24-hour period, convulsion potential is still high, but if reversed, patient is stable and improving Score 2-4 are important to observe the trends, but there is less urgency. A stable score in this range by the late 2nd or 3rd week, recovery is expected

In Summary

ASSESSMENT OF THE :NEUROLOGICAL SYSTEM

Establishing Nursing Data Base a. Demographic Profile b. Chief complains c. Present Illness c.1: Assess the circumstances of injury and admission c.2: Assess Chief Complaint A any associated Sx with cc )P - what provokes ( make worst) or (Makes better Q - Quality of Pain R - Region and Radiation S - Severity of pain 1-10 T - Timing ( when did it start & stop, intermittent or constant duration d. Past and Family History

ASSESSMENT OF THE :NEUROLOGICAL SYSTEM

Review of System. 2 Comprehensive Physical Assessment including Vital signs. 3 Comprehensive Neuro Assessment. 4
Important Questions govern the Neurological Examination 3

?Is mental status intact. 1 ?Are Right sided & left sided findings symmetric. 2 If findings are asymmetric or otherwise abnormal, does the causative. 3 ?lesion lie in the CNS or the Peripheral Nervous System

Components of a Neurological Assessment

Mental Status. 1 Cerebellar Functions. 2 Cranial Nerve Testing. 3 Sensory. 4 Motor Function. 5 Reflexes. 6