Neurological Assessment for nursing students ppt

"With ordinary talent and extraordinary
perseverance, all things are attainable."
- Thomas E. Buxton
"Achievement is connected
with action, not in genes..…!”
- Conrad Hilton

PREPAIRED BY
Prof. Mrs. Blessy Thomas
Medical Surgical Nursing
(Neuroscience Nursing )

DEFINITION
Neurological assessment is a system
process that includes a variety of clinical test,
observation and assessment designed to
evaluate a complex system.

NEUROLOGICAL ASSESSMENT
 Neurological assessment of the patient with a stroke is
critical to prevent re-injury of brain tissue or to preserve
tissue that is viable.
 This assessment begins the moment a nurse encounters a
patient.
 First, the nurse watches the patient for the least amount of
stimulus that is required to arouse the patient.
 The patient should be spoken to before he or she is
touched.

CONTINUED……..
 Then, the nurse should assess the level of consciousness,
quick neuro exam, and basic motor function.
 Depending on the setting, the neurological examination
may be performed once an hour in the intensive care
setting, once every two hours in a transitional care unit, or
once every four hours on the general floor.
 The most important point is to remember that a
neurological emergency can occur rapidly.
 Every contact with a patient whether for an official stroke
examination or not, should have the patient's neurological
status in mind (AANN, 2004).

Equipment and Techniques
 Equipment
 Penlight
 Tongue blade
 Tuning fork
 Familiar objects (coin,
key, paper clip)
 Cotton wisp
 Reflex hammer
 Aromatic substances
 Pin
 Equipment
 Flavored substances
 Test tubes of hot and
cold water
 Snellen chart
 Two point
discriminator
 Techniques
 Inspection
 Palpation

Review of Related History
 Current Problems
 Seizures/convulsions
 Character
 Aura?
 LOC
 Frequency
 Associated
manifestations
 Timing
 Duration
 Time of day
 Activities
 Medications
 Current Problems
 Pain
 Gait coordination
 Weakness or paresthesia
 Paresthesia: unusual
sensation such as
numbness, tingling, or
burning
 Changes in mental status
 Changes in the 5 senses

 Past Medical History
 Trauma
 CVA
 Meningitis, encephalitis
 Deformities
 Hypertension
 Neurologic disorder
 Brain surgery

 Family History
 Hereditary disorders
 Huntington’s chorea
 Muscular dystrophy
 Neurofibromatosis
 Alcoholism
 Mental Retardation
 Epilepsy or other
seizure disorder
 Family History
 Alzheimer disease
 Learning disorders
 Weakness or gait
disorders
 Thyroid disease
 Diabetes
 Hypertension

 Personal and Social History
 Environmental or occupational hazards
 Hand, eye, foot dominance
 ADL
 Sleeping patterns
 Use of alcohol and tobacco
 Use of mood-altering drugs
 Anxiety

MINI NEUROLOGICAL ASSESSMENT
FOR PATIENT WITH STROKE
 Check for the level of consciousness
 Check blood pressure of the patient
 Call the patient by his/her name, see for response
 Ask the patient to close his/ her eyes and lift both
the upper limbs
 Ask the patient to lift his or her legs one bye one
NOTE: If the patient is not able to lift the left side
right side of the brain is affected in the same way
to the opposite side also

Complete Neurological Assessment
5 Components
 Cerebral Function
 Cranial Nerve Function: I-XII
 Cerebellar and Motor Function
 Sensory System
 Reflexes

Neuro Check
 Level of consciousness (LOC)
 Pupil response and size
 Verbal responsiveness
 Extremity strength and movement
 Vital signs

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

Neurological Assessment for nursing students ppt

CEREBRAL FUNCTION
 Level of consciousness:
 Level of arousal: Sub cortical
 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

Cerebral Function:
Verbal Responsiveness and Speech
 Dysarthria: difficulty with mechanics of speech
 Aphasia:
 TEMPORAL-receptive
 Inability to understand or process speech
Wernicke’s
 Auditory: spoken word
 Visual: written word
 FRONTAL-expressive
 Inability to form or use language Broca’s
Area
 Spoken OR written or BOTH
 GLOBAL: both receptive and expressive

Glascow Coma Scale
 Score BEST
response in each
category
 Highest score = 15
(normal)
 Lowest score = 3
(deep coma)
 Eye Opening
Spontaneous 4
To Voice 3
To Pain 2
None 1
 Best Verbal
Oriented 5
Confused 4
Inappropriate Words 3
Incomprehensible Sounds 2
None 1
 Best Motor
Obeys Commands 6
Localizes Pain 5
Withdraws to Pain 4
Flexion to Pain (decorticate) 3
Extension to Pain (decerebrate)
2
None 1

CRANIAL NERVE
 Ⅰ Olfactory nerve
 Ⅱ Optic nerve
 Ⅲ Occulomotor nerve
 Ⅳ Trochlear nerve
 Ⅴ Trigeminal nerve
 Ⅵ Abducent nerve
 Ⅶ Facial nerve
 Ⅷ Vestibulocochlear nerve
 Ⅸ Glossopharyngeal nerve
 Ⅹ Vagus nerve
 Ⅺ Accessory nerve
 Ⅻ Hypoglossal nerve

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

ASSESSMENT
 Ask the patient to close the eyes
 And also close one nostril with finger
 Ask the patient to smell

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

Pupil Size
 Normal range: 2 - 6 mm
 Drugs: pinpoint pupils
 Increased intracranial pressure: pupils begin to
dilate
 Dilated and fixed, poor prognosis

Pupils and Vision
 Pupil evaluation is a
necessary neurological
assessment parameter.
 Normal pupil sizes ranges
from 2-6mm. It is easy to
see if abnormal size: <1
or >6 mm.
 Pupil size and reactivity
can be evaluated in
ambient room lighting.

Use a flashlight for more brisk response if vision
or neurological abnormality is suspected.
Note: Abnormal pupil function seldom occurs
alone in patients who appear to be interacting
normally.

ASSESSMENT
 Visual acuity by using
snellen chart
OR
 Show finger in front of the
patient and ask the patient to
tell the number of fingers

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

ASSESSMENT
 Check the pupillary response : look at the
diameter of your partner's eyes in dim light
and also in bright light.
 Check for differences in the sizes of the right
and left pupils

CN III, CN IV, CN VI
 Oculomotor, trochlear, abducens nerves
(motor)
 Assess EOM’s
 Assesses midbrain and pons

ASSESSMENT
 . Hold up a finger in front of your partner.
 Tell your partner to hold his or her head still
and to follow your finger, then move your
finger up and down, right and left.
 Do your partner's eyes follow your fingers?

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

ASSESSMENT
 To test the motor part of the nerve, tell your partner
to close his or her jaws as if he or she was biting
down on a piece of gum.
 To test the sensory part of the trigeminal nerve,
lightly touch various parts of your partner's face
with piece of cotton or a blunt object.

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

ASSESSMENT
 The motor part of the facial nerve can be tested by
asking your partner to smile or frown or make
funny faces.
 The sensory part of the facial nerve is responsible
for taste on the front part of the tongue.
 Keep a few drops of sweet or salty water on this
part of the tongue and see if your partner can taste
it.

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)

ASSESSMENT
 Have your partner close his or her eyes and
determine the distance at which he or she can hear
the ticking of a clock or stopwatch.

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

ASSESSMENT
 Have your patient drink some water and observe
the swallowing reflex.
 You could try a few drops of salty (or sugar)
water on this part of the tongue and see if your
patient can taste it.

CN XI: Spinal Accessory Nerve
 Motor
 Shrug shoulders trapezius
 Turn head sternocleidomastoid

ASSESSMNT
 To test the strength of the muscles used in head
movement, put you hands on the sides of your
partner's head.
 Tell your partner to move his or her head from
side to side.
 Apply only light pressure when the head is
moved.

CN XII: Hypoglossal Nerve
 Motor
 Tongue movements, strength
 Speech sounds: d, l, n, t

ASSESSMENT
Have your patient stick out his or her
tongue and move it side to side.

Proprioception/Cerebellar
Function
 Proprioception
 The sensation of position and muscular
activity originating from within the body
which provides awareness of posture,
movement, and changes in equilibrium
 Test
 Coordination and Fine Motor Skills
 Balance

Proprioception/Cerebellar Function
 Rapid rhythmic alternating movements
 Have seated person alternately pronate and
supinate hands, patting knees, and gradually
increasing speed
 Have person touch thumb to each finger on the
same hand sequentially from index to little finger
and back, gradually increasing speed
 person should be able to do these movements
smoothly, maintaining rhythm, with increasing
speed
 Observe for slow, stiff, non-rhythmic, or jerky
movements

 Accuracy of movement
 Finger-to-finger test with person’s eyes open
 Movements should be rapid, smooth, and accurate
 Consistent past pointing may indicate cerebellar
impairment
 Finger to nose test with person’s eyes closed
 Movement should be smooth, accurate, and rapid
 Heel-to-shin with person supine, sitting, or standing
 Should move heel from knee up and down the shin in a
straight line, without irregular deviations to the side

Continued.
 Finger to finger test
 Finger to nose

 Balance: Equilibrium
 Ability to balance on one foot with eyes closed for
at least 5 seconds
 Ability to stand in place on one foot for at least 5
seconds

 Balance: Equilibrium
 Romberg test
 Have person stand with arms at side and feet together
 Have person perform initially with eyes open and then
with eyes closed
 Stand close to prevent falls
 person should maintain position with eyes open or
closed for 20 seconds with only minimal swaying
 If the Romberg is positive (i.e. there is significant
swaying or the person has to take a step to
maintain/regain balance) DO NOT DO OTHER TESTS
OF BALANCE

Contd…..
 Romberg
 Stand feet together
arms at side
 Eyes open
 Eyes closed 20-30
seconds
 Slight sway is
normal

 Balance: Gait
 Heel-toe walking will exaggerate any
unexpected finding in gait evaluation

Contd…….
 Heel to toe walking

Contd……
 Have the patient walk across
the room under observation.
 Next ask the patient to walk
heel to toe across the room,
 Then on their toes only,
 finally on their heels only.

Gait Disturbances
A. Spastic Hemiparesis
B. Spastic Paresis
(Scissors Gait)
C. Foot Drop
D. Sensory Ataxia
(+ Romberg’s eyes
closed)
E. Cerebellar Ataxia
(+ Romberg’s eyes
open or closed)
F. Parkinsonian

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

Sensory Function
 Primary Sensory Functions
 Always with the person’s eyes closed
 Sites
 Vision, hearing, smell, taste and facial sensations
 Part of CN Assessment
 Hands
 Lower arms
 Abdomen
 Feet
 Lower legs

Sensory Function
 Superficial touch
 Use a cotton wisp
 Have the person point to the area touched
 Superficial pain
 Sharp and dull sensations
 Allow 2 seconds between each stimulus
 Temperature and deep pressure
 ONLY TESTED when superficial pain sensation is
not intact

Sensory Function
 Vibration
 Place stem of tuning fork against bony prominences
 Begin distally
 Sites
 Sternum
 Finger – wrist – elbow - shoulder
 Toes – ankle – shin
 Position of joints (great toes, one finger on each
hand)
 Up
 Down

Sensory Function
 Cortical Sensory Functions
 Always with the person’s eyes closed
 Stereognosis
 Ability to identify a familiar object by touch and
manipulation
 Tactile agnosia: inability to recognize objects
 Graphesthesia
 With a blunt pen, draw a letter or number on the palm
 Should be readily recognized

Sensory Function
 Point location
 Touch an area of the body and ask the person to point
to where you have touched
 This is being tested the same time as superficial touch
 Extinction phenomenon
 Simultaneously touch one or both sides of the body
 Ask the person to point to where you have touched

Sensory Function
 Two-point discrimination
 Use two pointed objects, alternate touching skin with
one or two points
 Find the distance at which the person can no longer
discriminate 2 points
 Fingertips 2 - 8 mm
 Toes 3 - 8 mm
 Palms 8-12 mm
 Forearms 40 mm
 Upper arms and thighs 75 mm

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

(protective reflexes)
 Corneal Reflex
 Test using a clean cotton
wisp, lightly touch the
outer corner of each eye
on the sclera
 Normal: (+) elicits a blink
 Abnormal: (-) no blink
 Eye protection
 Lubrication

(protective reflexes)
 Gag reflex
 Test: gently touch
posterior pharynx
with cotton
applicator
 Normal: (+)
elevation of the
uvula (gag)
 Abnormal: (-) No
gag
 NPO

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

Deep Tendon Reflexes
 Have person relaxed
 Position limb with slight tension on the tendon to
be tapped
 Grading
 0 No response
 1+ Sluggish or diminished
 2+ Active or expected response
 3+ More brisk than expected
 4+ Hyperactive with or without clonus

BICEPS
 Antecubital fossa
 With the arm gently flexed at the elbow, find the
biceps tendon with your thumb.
 Strike your own thumb with the hammer
 Response – contraction of biceps muscle causing
flexion of the elbow

TRICEPS
 Back of elbow
 With the elbow in flexion, tap the triceps tendon, just
proximal to the elbow, with a reflex hammer.
 The arm could also be abducted at the shoulder for this
maneuver
 Response – contraction of the triceps muscle with
extension of elbow

Brachioradialis
 1-2 inches above the wrist
 Support the relaxed arm either on the lap or semipronated
on your forearm
 Strike above the styloid process a few centimeters above
the wrist on the thumb side
 Response – flexion and supination of the forearm

PATELLAR
 “Knee jerk”
 Slightly lift up the leg under the knee, and tap the
patellar tendon with a reflex hammer
 If performed in a sitting position, have the legs dangle
over the edge of the chair or table
 Response – contraction of the quadriceps muscle
with extension of lower leg

Deep Tendon Reflexes
Assessing Spinal Cord Level
 Biceps
C5 - C6
 Brachioradialis
C5 - C6
 Triceps
C7 - C8
 Abdominal
T8, T9, T10
 Patellar (knee-jerk)
L2, L3, L4
 Achilles
S1, S2

ACHILLES
 At level of ankle
 Slightly externally rotate at the hip
 Gently dorsiflex the foot
 Tap the Achilles tendon with a reflex
hammer
 Response – contraction of the
gastrocnemius muscle with plantar flexion
of foot

Plantar Reflex:
Babinski 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

CONCLUSION
 Nurses are the caregivers that have the most
contact with the patient and have the ability to
notice subtle changes quickly. This quick
assessment and report to the physician can
make a difference in the outcome of the
patient. Because "time is brain", nursing
professionals must be knowledgeable about
stroke care standards to manage these patients
quickly and appropriately.

Neurological Assessment for nursing students ppt

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