ASSESSMENT OF NEUROLOGICAL SYSTEM
Purposes of neurological examination
· Identify a neurological database.
· Establish the presence of nervous system dysfunction.
· Compare current data with the previous data to determine the trends and need for change in interventions.
· Provide a data base for nursing diagnosis and plan of care.
· To identify the potential collaborative problems.
· Pen light
· Tongue Blade
· Sterile Needle
· Tuning Forks 200-400 Hz and 500 -100 Hz
· Familiar Objects- Coins, Keys, Paper Clip
· Cotton wisp
· Reflex Hammer
· Vials of aromatic substances – coffee, orange, peppermint extract oil or clove
· Vials of solution – glucose, salt, lemons or vinegar and quinine with applications
· Test Tubes of hot and cold water
Assessment of neurological system includes
§ Mental status including level of consciousness
§ The cranial nerves
§ Motor function
§ Sensory function
It reveals that the client’s general cerebral function. These function includes intellectual, emotional functions.
Major areas of mental status assessment – language, orientation, memory and attention span and calculation.
Mental status examination
1) Appearance attitude and behaviour
ü Appearance- Posture, clothing, grooming facial expression
ü Attitude- Cooperative/ Noncooperative, Hostile/ defensive, Interested/ disinterested
ü Behaviour and Motor activity- Slow / Excess motor activity, Tics, Mannerisms, waxy flexibility
ü Pressure, tone, volume of speech. Flow of speech, slurring speech, circumstantiality, tangentiality.
3) Mood and affect
ü Mood- sustained emotional state ( euthymic euphoric, angry, anxious or apathetic )
ü Affect – the external and dynamic manifestations of a person’s internal emotional state. ( Appropriate inappropriate, congruent/ incongruent )
4) Thought process
ü Thought broadcasting, Thought withdrawal. Do you feel like somebody inserting thoughts into your mind? Do you feel like somebody is taking away thoughts from your mind?
5) Attention span- Assessment: assess patient ability to repeat a series of 5 or 6 digits backwards and forwards.
6) Orientation: Assessment: assess the patient ability to correctly state his name, date including month, year and approximate time of day and the name of place where he is in.
· Immediate- Digit repetition. I will tell 5numbers you have to repeat it back. 10, 15,20,23,30.
· Recent- Ask questions about the past 24 hours. What you had for your lunch yesterday?
· Recent Past- When you got admitted here?
· Remote- Ask the patient his date of birth Date of marriage
8) Perceptional disturbances: Ask questions about to find out whether the patient is having illusions and hallucinations. When you are alone do you feel like any voices talking to you? Do you feel like seeing some persons or images?
9) Abstract thinking: Ask the similarities and difference between a set of objects Car/ Train. Table/ Chair
10) Judgment: Ask questions about to find out how the person responds to a situation appropriately. Ask the patient what should you do when u find a stamped addressed letter?
Mini mental status examination
· Orientation to time- what is the date
· Registration- say 3 words and ask to repeat
· Naming –what is this
· Reading-read and do what it says
Language:Any defects in or loss of the power to express by oneself, by speech, writing, or signs , or to comprehend to spoken or written language due to disease or injury of the cerebral cortex, is called APHASIA. It can be categorized as sensory and motor aphasia.
Sensory or receptive aphasia is the loss of ability to comprehend written or spoken words.
Two types of sensory aphasia;
· Auditory (acoustic) aphasia
· Visual aphasia.
Motor or expressive aphasia involves the loss of power to express oneself by writing, making signs or speaking. Any defects in or loss of the power to express oneself by speech, writing or signs or to comprehend spoken or written language due to disease or head injury. If the client displays difficulty in speaking.
Point to common objects, and ask the client to name them. Ask the client to read some words and to match the printed and written words with pictures. Ask the client to respond to simple verbal and written commands. E.g.; point to your toes or raise your left arm.
Orientation: client’s ability to recognize other persons, awareness of when and where they presently are time and place), who they, themselves, are self).
Memory: Nurse assess the client’s recall of information presented seconds previously (immediate recall). Events or information from earlier in the day or examination (recent memory). Knowledge recalled from months or years ago (remote or long term memory).
To assess the immediate recall ask the client to repeat a series of three digits E.g.; 7-4-3, spoken slowly. Gradually increase the number of digits: e.g.; 7-4-3-5-6-7-2 until the client fails to repeat the series correctly.
Recent memory: Ask the client to recent events of the day, such as how the client got to the clinic.
Remote memory: previous illness or surgery, birthday or anniversary.
Attention span and calculation: Client’s ability to focus on a mental task that is expected to be able to be performed by persons of normal intelligence Ask the client to count backward from 100. Test the ability to calculate by asking the client to subtract 7 or 3 progressively from 100. i.e.; 100, 93, 86, 79. Normally an adult can complete serial sevens test in about 90 seconds with three or few errors.
Level of consciousness: LOC can lie anywhere along a continuum from a state alertness to coma. A fully alert client responds to questions spontaneously. A comatose client may not respond to verbal stimuli.
• Patient is awake, responds immediately and appropriately to all verbal stimuli
• Patient is lethargic, drowsy and inattentive but arouses easily.
• Patient spends much of time sleeping.
• He arouses with great difficulty and cooperates minimally when stimulated.
• Patient has lost his ability to respond to verbal stimuli.
• When the patient is stimulated with pain non purposeful motor activity is seen.
• When the patient is stimulated there is no response to verbal or painful stimuli.
• No motor activity is seen.
Assessment of level of consciousness –Glasgow coma scale
Glasgow Coma Scale, a system for describing the degree of loss of consciousness in the severely ill. It is also used to predict the length and result of coma, mostly in patients with head injuries.
Glasgow coma scale. It tests in three major areas:
· Eye response
· Motor response
· Verbal response
An assessment of total 15 points indicates the client is alert and completely oriented. A comatose client scores 7 or less.
Glasgow Coma Scale or GCS, developed in Glasgow, Scotland in 1974 is widely used in the assessment of comatose patients.
The range of possible score is from 3-15.
· Score 15- Fully alert oriented person.
· Score 3- Deep coma
· Score 8 – Unconsciousness
GLASGOW COMA SCALE
¨ Eye opening
2. To Speech
3. To pain
¨ Verbal response
¨ Motor response
3.Withdraws from pain
A reflex is an automatic response of the body to a stimulus. It is not voluntarily learned or conscious. It is tested by using a percussion hammer. Biceps reflex, triceps reflex, brachioradialis reflex, patellar reflex, Achilles reflex and Plantar (Babinski reflex) are tested during physical examination.
Ask the history the following: Presence of pain in the head, back, or extremities, as well as onset and aggravating and alleviating factors, disorientation to time, place, or person, speech disorder, any history of loss of consciousness, fainting, convulsions, trauma, tingling, any history of loss of consciousness, limping, paralysis, loss of memory, mood swings, problems with smell, taste, touch or hearing.
Test reflexes using a percussion hammer, comparing one side of the body of another. The response as described as on a scale of 0 to + 4.
Reflexes: Superficial and Deep tendon Reflexes
Superficial Reflexes: With the patient supine, stroke each quadrant of the abdomen with the end of a reflex hammer or tongue blade edge.
· The upper abdominal reflexes are elicited by stroking downward and toward the umbilicus
· Lower abdominal reflexes are elicited by stroking downward away from the umbilicus toward each area of stimulation should be bilaterally equal.
Autonomic reflex,any of a large number of normal reflexes that regulate the functions of the body’s organs. Autonomic reflexes control activities as blood pressure, heart rate, intestinal activity, sweating, and urination.
Deep tendon reflex(DTR), myotatic reflex, and tendon reflex: A quick contraction of a muscle when its tendon is sharply tapped by a finger or rubber hammer. Absence of the reflex may be caused by damage to the muscle, the nerve, nerve roots, or the spinal cord. A violent reflex may be caused by disease of the nervous system or by overactive thyroid gland. Reinforcement is accomplished by asking the patient to clench their teeth, or if testing lower extremity reflexes, have the patient hook together their flexed fingers and pull apart. This is known as the Jendrassik maneuver
It is key to compare the strength of reflexes elicited with each other. A finding of 3+, brisk reflexes throughout all extremities is a much less significant finding than that of a person with all 2+, normal reflexes, and a 1+, diminished left ankle reflex suggesting a distinct lesion.
Biceps reflex: Have the patient sit up on the edge of the examination bench with one hand on top of the other, arms and legs relaxed. Instruct the patient to remain relaxed. The biceps reflex is elicited by placing the examiners thumb on the biceps tendon and striking the thumb with the reflex hammer and observing the arm movement. Repeat and compare with the other arm.
Triceps reflex: These reflex tests the spinal cord C-7, C-8. Flex the client’s arm at the elbow, and support it in the palm of your non dominant hand. Palpate the triceps tendon about 2 to 5 cm above the elbow. A blow with a hammer directly to the tendon. Normally slight extension of the elbow.
The brachioradialis reflex: striking the brachioradialis tendon directly with the hammer when the patient’s arm is resting. Strike the tendon roughly 3 inches above the wrist. Note the reflex supination. Repeat and compare to the other arm. The biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve roots.
Patellar reflex, Knee jerk or quadriceps reflex: It tests the spinal cord: L-2, L-3, and L-4. Ask the client to sit on the edge of the table. So that the legs hang freely. Locate the patellar tendon directly below the patella. With a knee hammer directly blow to the tendon. Normal extension of the legs as the Quadriceps muscle contracts.
Insult to the cerebellum may lead to pendular reflexes. Pendular reflexes are not brisk but involve less damping of the limb movement than is usually observed when a deep tendon reflex is elicited. Patients with cerebellar injury may have a knee jerk that swings forwards and backwards several times. A normal or brisk knee jerk would have little more than one swing forward and one back. Pendular reflexes are best observed when the patient’s lower legs are allowed to hang and swing freely off the end of an examining table.
Achilles reflex: It tests the spinal cord level S-1, S-2. Position same as patellar reflex. And slightly dorsiflex the client’s ankle by supporting the foot lightly in the hand. Directly percuss to the Achilles tendon just above the heel. Normal: plantar flexion of the foot. (Downward jerk movement)
Plantar reflex (Babinski reflex): It is absent in adults. Use a moderately sharp object, such as key. Stroke the lateral border of the sole of the client’s foot, starting at the heel, continuing to the ball of the foot, then proceeding the across the ball of the foot toward the big toe. Normally all five toes bend downward; this is –ve Babinski reflex. In an abnormal response the toes spread outward and the big toe moves upward.
The Hoffman response is elicited by holding the patient’s middle finger between the examiner’s thumb and index finger. Ask the patient to relax their fingers completely. Once the patient is relaxed, using your thumbnail press down on the patient’s fingernail and move downward until your nail “clicks” over the end of the patient’s nail. Normally, nothing occurs.
A positive Hoffman’s response is when the other fingers flex transiently after the “click”. Repeat this manuever multiple times on both hands. A positive Hoffman response is indicative of an upper motor neuron lesion affecting the upper extremity in question.
Finally, test clonus if any of the reflexes appeared hyperactive. Hold the relaxed lower leg in your hand, and sharply dorsiflex the foot and hold it dorsiflexed. Feel for oscillations between flexion and extension of the foot indicating clonus. Normally nothing is felt.
Grading of reflexes
0: no response
1+: sluggish or diminished
2+: active or expected response
3+: more brisk than expected, slightly hyperactive
4+: brisk and hyperactive with intermittent or transient clonus
Cranial nerve 1- olfactory nerve:
To assess the sense of smell instruct the patient to close the nose, Occlude one nostril. Identify the odour. Repeat using the opposite nostril. Use substances such as cloves, lemon, soap, ginger, garlic etc.
Cranial nerve 2 – optic nerve:
Controls visual activity and visual field. To assess the visual field. To assess the visual acuity. Fundoscopic examination
Cranial nerve iii, iv, vi – oculomotor, trochlear, abducens:
Oculomotor controls pupillary reaction. Oculomotor, trochlear and abducens controls the extra ocular movements
Assessing pupillary reaction: Instruct the client to fix his eye on an object. Shine a beam of flashlight directly into the each pupil. Note the size shape, and reaction of the pupils to the light
PERRLA – Pupils Equal Round Reactive to Light and Accommodation
Cranial nerve V – trigeminal nerve:
Has got both sensory and motor components. It controls jaw movements and facial sensation. Sensory Function. Ask the patient close the eyes. Touch various parts of the body using a wisp of cotton. Patient is asked to identify where the cotton is applied each time
Motor function: Tell the patient to clench the teeth while palpating the temporal & masseter muscles of the jaws with the hands.
Temperature sensation: Two test tubes, filled with hot and ice-cold water. Touch the skin and ask the patient to identify “hot” or “cold.”
Test the corneal reflex: Ask the patient to look up and away from you. Touch the cornea (not just the conjunctiva) lightly with a fine wisp of cotton. If the patient is apprehensive, however, first touching the conjunctiva may allay fear.
Cranial nerve vii – facial nerve
Ask the patient to: Raise both eyebrows, Frown, Smile, and Puff out both cheeks. Close both eyes tightly so that you cannot open them. Test muscular strength by trying to open them. Note any weakness or asymmetry.
Cranial nerve viii – auditory nerve
Controls hearing and sense of balance. Hearing: Use a ticking watch one or two inches from the patient and ask the patient whether he can hear the tickling
Weber test, Rinne test
Weber test– Test for lateralization. Place the base of the lightly vibrating tuning fork firmly on top of the patient’s head or on the mid forehead. Ask where the patient hears it. Normally the sound is heard in the midline or equally in both ears. In unilateral conductive hearing loss, sound is heard in (lateralized to) the impaired ear.
In unilateral sensor neural hearing loss, sound is heard in the good ear.
Rinne test– Compare air conduction (AC) and bone conduction (BC). Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level with the canal. When the patient can no longer hear the sound, quickly place the fork close to the ear canal and ascertain whether the sound can be heard again. Normally the sound is heard longer through air than through bone (AC > BC). In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC = AC or BC > AC).
Cranial nerve ix and x – glossopharyngeal and vagus: Controls swallowing, gag reflex, articulation and phonation. Instruct the patient to open his mouth & say ah. Normally the soft palate and uvula elevate in midline, if there is paralysis the uvula deviates to one side. To assess gag, Use the back of a tongue depressor, very gently stimulate the back of pharynx.
Glossopharyhgeal –taste sensation, give salt, sugar ask to identify taste by closing eyes
Cranial nerve XI- spinal accessory
Ask the patient to turn his or her head to each side against your hand. Observe the contraction of the opposite sternocleidomastoid and note the force of the movement against your hand.
Cranial nerve xii- hypoglossal
Cerebellar function –
a) Gait b) Co-ordination
a) Gait b) Co-ordination
Observe the barefooted patient walk around the examination room or down a halfway; first with the eyes open and then closed. Observe the expected gait sequence, noting simultaneous arm moments and upright posture. Note any shuffling, widely placed feet, toe walking, foot flop, leg lag, scissoring, and loss of arm swing, staggering or reeling. The gait should have a smooth, regular rhythm and symmetric stride length.
Superficial Touch: Touch the skin with your fingertip, Have the patient point to the area touched.
Superficial pain:Alternating the point and hub of a sterile needle, touch the patient’s skin is an unpredictable pattern. Ask the patient to identify the sensation as dull or sharp.
Vibrations: Place the stem of a vibrating tuning fork against several bony prominences.
Graphesthesia– with a blunt pen or an application stick, draw a letter or number on the palm of the patient’s hand. Ask the patient to identify the figure.
Point location – Touch an area on the patient’s skin and withdraw the stimulus. Ask the patient to point to the area touched.
Motor and balance tests generally are;
Romberg test and other gross motor function and balance tests are used.
Walking gait: ask the client to walk across the room and back, and assess the client’s gait.
Romberg test: Ask the client to stand with feet together and arms resting at the sides, first with eyes open, then closed. Stand close during this test prevent the client from falling
May sway slightly but is able to maintain upright posture and foot stance.
Standing on one foot with eyes closed:
Ask the client close the eyes and stand on one foot and then the other. Stand close to the client during this test.
Maintains stance for at least 5 seconds.
Ask the client to walk a straight line, placing the heel of one foot directly in front of the toes of the other foot.
Maintain heel- toe- walking along a straight line.
Toe or heel walking:
Ask the client to walk several steps on the toes and then on the heels.
Able to walk several steps on toes or heels.
Fine motor tests for the upper extremities
Finger- to- nose-test:
Ask the client to abduct and extend the arms at shoulder height and rapidly touch the nose alternately with one index finger and then the other. The client repeats the test with the eyes closed if the test is performed easily.
Repeatedly and rhythmically touches the nose.
Alternating supination and pronation of hands on knees:
Ask the client to pat both knees with the palms of both the and then with the alternatively at an ever increasing rate.
Can alternately supinate and pronate hands at rapid pace.
Finger to nose and to the nurse’s finger:
Ask the client to touch the nose and then your index finger, held at a distance at about 45 cm, at a rapid and increasing rate.
Performs with co- ordination and rapidity.
Fingers To Fingers
Ask the client to spread the arms broadly at shoulder height and then bring the fingers together at the midline, first with the eyes open and then closed, first slowly and then rapidly.
Fingers to Thumb (Same Hand)
Ask the client to touch each finger of one hand to the thumb of the same hand as rapidly as possible.
Fine motor tests for lower extremities;
Heel down opposite shin:
Ask the client to place the heel of one foot just below the opposite knee and run the heel down the shin to the foot. The client may also use a sitting position for this test.
Demonstrates bilateral equal co- ordination.
Toe or Bail of Foot to the Nurse’s Finger
Ask the client to touch your finger with the large toe of each foot.
Compare the light- touch sensation of symmetric areas of the body.
Ask the client to close the eyes and to respond by saying “yes” or no”. Whenever the client feels the cotton wisp touching the skin.
With a wisp of cotton, lightly touch one specific spot and then the same spot on the other side of the body.
Test areas on the forehead, cheek, abdomen, foot and lower leg. Ask the client to point to the spot where the touch was felt.
This demonstrates whether the client is able to determine tactile location, i.e.; can accurately perceive where the client was touched.
Light tickling or touch sensation.
Light tickling or touch sensation.
If areas of sensory dysfunction are found, determine the boundaries of sensation by testing responses about every 2.5 cm in the area. Make a sketch of the sensory loss area of recording purposes.
Ask the client to close the eyes and to say “sharp”, “dull”, or “don’t know” when the sharp or dull end of the broken tongue depressor is felt.
Alternately use the sharp and dull end of a sterile pin or needle to lightly prick designated anatomic areas at random, e.g.; hand, forearm, foot, lower leg and abdomen. Allow at least seconds between each test to prevent summation effects of stimuli. i.e.; several successive stimuli perceived as one stimulus.
Able to discriminate “sharp” and “dull” sensations.
Touch the skin areas with test tubes filled with hot or cold water.
Have the client respond by saying “hot”, “cold” or “don’t know”.
Able to discriminate between “hot” and “cold” sensations.
Position for kinesthetic sensation
Commonly the middle fingers and the large toes are tested for the kinesthetic sensation.
To test the fingers, support the client’s arm with one hand, and hold the client’s palm in the other.to test the toes place the client’s heels on the examining table.
Ask the client close the eyes. Grasp a middle finger or a big toe firmly between your thumb and index finger, and exert the same pressure on both sides of the finger or toe while moving it.
Move the finger or toe until it up, down, or straight out, and ask the client to identify the position.
Use a brisk up-and- down movements before bringing the finger or toe suddenly to rest in one of the three positions.
Can readily determine the position of fingers and toes.
For all tests, the client’s eyes need to be closed.
One-and- two- point- discrimination:
Alternately stimulate the skin with two pins simultaneously and then with one pin. Ask whether the client feels one or two pinpricks
Perception varies widely in adults over different parts of the body.
Stereognosis (ability to recognize objects by touching them)
Place familiar objects, such as key, pare, clip, or coin in the client’s hand, and ask the client to identify them.
If the client has motor impairment of the hand and is unable to manipulate an object, write a number on a client’s palm, using blunt instrument, and ask the client to identify it.
Recognizes common objects.
Able to identify numbers or letters written on palm.
Simultaneously stimulate two symmetric areas of the body, such as thighs, the cheeks, or the hands.
Both points of stimulus are felt.
Document the findings in nurse’s record using forms or checklists.