Neurological Assessment

Introduction

The neurological assessment is the core nursing database for identifying nursing diagnoses, collaborative problems, and planning care. Assessment and care of all the patients including pediatric and psychiatric patients with a neurological problem constitutes one of the biggest challenges for many critical care nurses.

Definition

Neurological examination is the comprehensive baseline assessment of the functioning of the nervous system and/or the presence of neurological disorders.

Purposes

• To establish a neurological database.
• To identify the presence of nervous system dysfunctions.
• To determine the effects of nervous system dysfunction on activities of daily living (ADLs) and independent function.
• To detect life-threatening situations.
• To compare current data to the previous assessment data to determine trends and need for change in interventions.
• To obtain a database on which nursing diagnoses and collaborative problems will be based.

Indications

• Screening performed as a preliminary step to detailed investigation of physical functioning.
• Simple neurological examination as part of a health checkup or wellness check.
• Comprehensive neurological examination to examine a complaint related to the neurological system.

Types

1. Screening neurological examination.
2. Extended neurological examination (follow leads from abnormal findings).
3. Problem-focused examination (confined to a particular neurological system or region).

Articles

Categories of Neurological Assessment

• Health history (subjective data).
• Physical examination (objective data).

Components of the Patient Health History

• History of Present Illness
• P: Precipitating events (e.g., travel, a fall, infection, prodromal symptoms, drug).
• Q: Quality of symptoms (a complete description of presenting symptoms).
• R: Relief of symptoms (alleviating or aggravating factors).
• S: Severity of symptoms (a description of how incapacitating the symptoms are and how they affect the person’s lifestyle).
• T: Timing (the duration of the symptoms including the initial onset and frequency).

Systems Review

• Head, eyes, ears, nose, throat (HEENT): Dizziness, headache, vision changes, sensitivity to light, auditory changes, tinnitus, sinus infection, difficulty in swallowing, hoarseness, slurred speech, sinusitis, and infection.
• Cardiovascular: Palpitations, history of coronary artery disease, vascular problems.
• Respiratory: History of chronic pulmonary disease, episodes of shortness of breath, recurrent infections.
• Gastrointestinal: Nausea, vomiting, diarrhea or constipation, weight loss, history of gastrointestinal problems.
• Genitourinary: Incontinence, impotence.
• Musculoskeletal: Weakness or paralysis, decreased range of motion, muscle stiffness or pain, spinal problems.
• Neurological: Syncope, confusion, difficulty with concentration, speech problems, paresthesia, tremors, gait disturbances.
• Psychiatric: History of psychiatric problems, mood swings, delusions, or hallucinations.

Pertinent Medical History

COLDSPA mnemonic guideline: This guideline is used to collect pertinent medical history.

C-Character

O-Onset

L-Location

D-Duration

S-Severity

P-Pattern

A-Associated factors/how it affects the patient.

• Family history: Stroke, diabetes mellitus, hypertension, seizure, headache, cancer.
• Medical history: Stroke, diabetes mellitus, hypertension, vascular diseases, cancer, seizures, infections, renal or hepatic disease, psychiatric or neurological disease, trauma (any type of head injury), etc.
• Surgical history: Neurological or HEENT surgery, etc.
• Social history: Use of alcohol, cigarettes or drugs; any recent stressful events experienced, etc.
• Medications: Antiepileptics, psychotropics, antihypertensives, anticoagulants, sedatives, oral contraceptives, etc.
• Occupational history: Lifting heavy weight, performing repetitive movements, exposure to lead, insecticides, pollutants, or other chemicals, etc.

Neurological Examination

Purpose

Standard neurological examination helps to determine the presence, location, and nature of disease of the nervous system.

The seven categories of neurological assessment (mnemonic-LMCMCSR) are as follows:

1. Level of consciousness (LOC)
2. Mental status examination (MSE)
3. Cranial nerve function
4. Motor function
5. Cerebellar function
6. Sensory function
7. Reflex function

Level of Consciousness

• Consciousness is the state of being aware of self, the environment, and responses to the environment.
• Unconsciousness is a state of complete or partial loss of response to sensory stimuli as a result of cerebral hypoxia.
• Coma is a pathological state of unconsciousness characterized by the following: an unarousable sleep-like state; the eyes remain closed at all times; no speech or sound is noted; and there is no spontaneous movement of the extremities.

Components of Consciousness

1. Arousal: The state of responsiveness to sensory stimulation.
2. Awareness of self and the environment with the ability to respond: The orientation to person, place, and time and imply interaction with and reaction to environmental stimuli.

1.Glasgow Coma Scale

Definition: The GCS is a practical standardized system for assessing the degree of consciousness and is the most widely recognized LOC assessment tool. It was developed by G. Teasdale and B. Jennett in Glasgow, Scotland, in 1974.

The GCS score is derived by assigning notation to the level in each of the three subcomponents of the GCS and summing the results of a patient’s assessment.

Indications:

• Monitoring changes in LOC in the first few days after acute head injury.
• In cases of seizures, brain tumors, and abscesses, cerebral infarcts, metabolic disorders, toxic conditions, and cranial infections.
• Unstable comatose patients.

Interpreting the GCS:

• The highest possible score is 15 and the lowest score is 3.
• A score of 13-15 implies fully alert, oriented person; <8: an unconscious person; <3: a person in coma.
• Head injury classification based on GCS:
• Severe head injury: GCS score of 8 or less.
• Moderate head injury: GCS score of 9-12.
• Mild head injury: GCS score of 13-15.

Pupil Reactivity Score

The Pupil Reactivity Score (PRS) summarizes information about the loss of pupil reactivity to light which can be an indicator of the brainstem function and is calculated as follows:

The Glasgow Coma Scale Pupils (GCS-P) score is calculated by subtracting the PRS from the GCS total score:
                GCS – P = GCS – PRS
This aids in assessing both the level of consciousness through GCS and brainstem function through PRS.

2.Mental Status Examination

Purpose

• It gives an indication of how the patient is adapting to the environment.
• It involves determination of complex and high-level cerebral functions.

Components of MSE

1. General appearance and behavior: This includes:
2. Motor system activity
3. Body posture
4. Dress and hygiene
5. Facial expressions
6. Speech
7. State of consciousness: The patient must be conscious before other functions can be determined. The nurse should note:
8. Orientation to time, place, person and situation.
9. Memory
10. Immediate recall: For example, what did you have for breakfast this morning?
11. Remote memory: For example, which is your birthplace? (Or) Where did you do your schooling?
12. General knowledge: For example, who were the last three prime ministers of our country?
13. Insight: For example, what does “look before leap” mean?
14. Judgment: For example, what would you do if you were to hear the siren of an ambulance from behind, while driving?
15. Problem solving: For example, if you have to share an apple among four persons, what would you do?
16. Calculation: For example, how much is 45 + 30?
17. Mood and affect: Observe for signs of anger, agitation, euphoria, or depression, and whether it is appropriate to the situation.
18. Thought content: Note presence of hallucinations, illusions, paranoia, or delusions.
19. Intellectual capacity: Note the level of intelligence, dementia, and retardation. For example, who is the current President of our country?

• Assessment of Cranial Nerve Function

The examining of each cranial nerve is a very important component of neurological examination.

• Motor Function

This includes assessment of the following:

• Size, tone, and power of the major muscle groups of the body.
• Balance and coordination.
• Muscle Size

Inspect symmetric muscles for both size and contour. Use tape measure to note difference if asymmetrical.

Abnormal findings:

• Atrophy: Loss of muscle mass.
• Hypotrophy: Decreased mass (muscle wasting).
• Hypertrophy: Increased mass.

• Muscle Tone

With the patient relaxed, passively move the limbs through their range of joint motion (ROJM).

Normal:

• Slight resistance to movement.

Abnormal:

• Hypotonia (flaccidity): Decrease or loss of muscle tone (lower motor neuron disease, spinal shock, and some cerebral lesions).
• Hypertonia
• Rigidity: Increased tone resistance to passive movement throughout movement (extrapyramidal lesions).

Types of rigidity are as follows:

• Cogwheel rigidity: A series of stepwise, regular, rachet-like, small jerks that occur on passive movement (Parkinson’s disease).
• Lead-pipe rigidity: Uniform resistance throughout passive movement (some forms of Parkinson’s disease).
• Paratonia or gegenhalten: Resistance increases throughout flexion and extension; becomes less prominent when the patient is distracted (bilateral frontal lobe lesions often related to stroke).
• Spasticity: Resistance to passive movements for portions of the movement; due to loss of suprasegmental influence on the tonic contractions of the muscles; usually greatest in the flexors of the upper extremity and the extensors of the lower extremity (upper motor neuron lesion).
• Clasp-knife spasticity: Resistance to passive movement with sudden giving away toward the completion of joint flexion or extension (upper motor neuron paralysis).

Muscle Strength

Muscle strength is evaluated by asking the patient to move a muscle actively against gravity and then with resistance provided by the examiner.

Abnormal findings:

• Symmetric weakness of the proximal muscles-myopathy.
• Weakness of distal muscles-polyneuropathy.
• Weakness on one side of the body-lesion in the opposite-side brain.
• Weakness on one or both sides of the body simultaneously-spinal cord lesion.

Involuntary movements:

Assess the rate (cycles per second), distribution (proximal muscles, distal muscles), and relationship to movement (increasing or decreasing with movement).

• Tics, tremors, myoclonus, and spasms.
• Athetosis (slow, writhing, involuntary movements of the extremities).
• Chorea (involuntary, purposeless, rapid motions).
  
• Cerebellar Function (Balance or Coordination)
  Balance (Position and Gait)
• Note the patient’s stature (posture while standing) and gait.
• Note the pace and rhythm of the gait and observe the arm swing.

• Position
• Normal: Patient is able to stand still and walk normally.
• Abnormal findings: Ataxia.
• Staggering gait (feet are placed wide apart and the steps are unsteady).

• Gait
  Tandem walking is tested: Instruct the patient to walk heel to toe along a line (tandem gait). Protect the patient from falls.
• Normal: Patient is able to walk in tandem.
• Abnormal gait changes:
• Spastic hemiparesis: It is found in unilateral upper motor neuron disease. One arm is flexed, immobile, and close to the side; the leg is in a circled position, outward and forward, often with dragging of the toe.
• Scissor gait: It is present with bilateral spastic paresis of the legs. Each leg advances slowly and the thighs appear to cross forward on each other at each step. The steps are short. It looks as if the patient is walking through water.
• Step-page gait: It is associated with footdrop, secondary to lower motor neuron disease. The feet are lifted high, with knees flexed, and then brought down with a slap on the floor. It looks as if the patient is walking upstairs.
• Sensory ataxia: It is associated with loss of position sense in the legs. The gait is unsteady and wide-based. The feet are lifted high and brought down with a slap. Patients watch the ground to guide their steps. They cannot stand steadily with feet together when the eyes are closed (positive Romberg test).
• Cerebellar ataxia: It is associated with disease of the cerebellum or associated tracts. The gait is staggering, unsteady, and widely based, with exaggerated difficulty on the turns. The patient cannot stand steadily with feet together, whether eyes are open or closed.
• Parkinsonian gait: It is associated with Parkinson’s disease. The posture is stooped, the hips and knees slightly flexed. Steps are short and often shuffling. Arm swings are decreased and the patient turns around stiffly-“all in one piece”.

Coordination

1. Upper extremity
2. Finger-to-nose test: Ask the patient to alternatively touch the nose with the index finger, and then touch the examiner’s finger. The examiner repositions the finger while the patient is touching the nose so that the patient must adjust to a new distance each time. Repeat with the other arm.
3. Instruct to rapidly pronate and supinate the hand in the other palm; repeat with other arm.
4. Instruct to rapidly tap his/her index finger on the thumb; then tap all four fingers, one at a time, against the thumb as rapidly as possible. Repeat with the other hand.

Normal: Smooth and on-the-mark, accurate movements.

Abnormal: Dysmetria-inability to control accurately the range of movement in muscle action with resultant overshooting of the mark, especially of hand movement (overshooting is also called past-point).

• Lower extremity
• Heel-to-shin test: Patient should place one heel on the opposite shin below the knee and move the heel down the shin to the ankle. Repeat for the other leg.
• While lying on the back or sitting, the patient is instructed to draw the number 8 with the foot in the air; repeat with the other foot.

Normal: Patient performs action without jerking or hesitation.

• Sensory System
• Superficial sensation: Superficial pain, light touch, and temperature.
• Deep sensation: Vibration, deep pressure pain, and proprioception.
• Discriminative sensation: Point and two-point discrimination, recognition of shape and form (stereognosis), texture discrimination, graphesthesia, and extension phenomenon.

General Guidelines

• Patient should always have the eyes closed to avoid visual clues.
• Examiner should avoid giving verbal cues such as, “Is this sharp?”
• Avoid rhythmic application of the stimulus.
• If sensory dysfunction of the skin is identified, the extent and boundaries of that dysfunction must be delineated.

Superficial Sensation

• Light touch (this should be tested first): The examiner uses a cotton wisp to gently stroke over each of the four extremities and asks the patient to indicate when the stimulus is felt by saying “touch.”
• Pain
• Pain is tested by touching the skin with the sharp end of a disposable pin. Intermittently it is alternated with a simple touch with the dull end of the pin to determine whether the patient can distinguish the two stimuli.
• Extinction/inhibition is assessed by simultaneously stimulating opposite sides of the body symmetrically with either a pain or a touch stimulus.
• Normal: Both stimuli are perceived.
• Parietal lobe lesion: Only one stimulus is perceived.
• Temperature (need not be done if pain sensation is intact): Place test tubes of warm and cold water to the skin and ask the patient to identify the stimuli with the eyes closed.

Deep Sensation

• Vibration sense: With the patient’s eyes closed, place a vibrating tuning fork to the fingernails and the bony prominences of the big toe and thumb. Ask if the vibration or buzz is felt, and then ask the patient to indicate when the vibration ceases.
• Normal: Correctly identifies sensation.
• Abnormal: Inability to sense vibrations; may be seen in posterior column disease or peripheral neuropathy.
• Deep pressure pain: The Achilles tendon, or gastrocnemius muscle, belly, and forearm muscles are squeezed. The patient should perceive this pressure, and it should feel the same on both sides of the body.
• Position sense (proprioception): The thumb and then the large toe are moved up or down. The patient should be able to identify “up” or “down” with his/her eyes closed.
• Normal: Correctly identifies directions of movements.
• Abnormal: Inability to identify the directions of the movements; may be seen in posterior column disease or peripheral neuropathy.

Discriminative Sensation

• Two-point discrimination: A sharp object is used to touch a part of the body simultaneously, to determine if one or two pricks can be felt.
• Normal: Minimal recognizable separation is 4-5 mm in the fingertips and greater in other parts.
• Abnormal: In diseases of the sensory cortex and peripheral nervous system.
• Point discrimination: The patient is asked to name the location at which he/she was touched with the wooden end of an applicator or the examiner’s hand.
• Stereognosis (discernment of the form and configuration of objects felt, or 3D discrimination): Place three small, familiar objects such as a coin, a key, and a pen, one at a time in the patient’s hand. Ask the patient to identify each with the eyes closed.
• Abnormal: Astereognosis (loss of 3D discrimination).
• Texture discrimination: The patient is asked to differentiate among various textures (e.g., silk, wool).
• Graphesthesia (ability to feel writing on the skin): Ask the patient to identify numbers/symbols traced on the palm of the hand with a dull-pointed object while the eyes are closed.
• Abnormal: Agraphesthesia (inability to feel writing on the skin).
• Extinction phenomenon (simultaneous stimulation) Touch the patient at the same location on two sides of the body at the same time; alternate with touching only on side and determine if the patient can tell the difference. Ask the patient to state whether one or two pricks are felt.
• Normal: Ability to sense touch on both sides of the body.
• Abnormal: Sensation of touch felt only on one side of the body.

• Reflex Function

Reflex is an automatic response to a simple stimulus which does not require mental processing.

• Normal reflexes

Types:

• Superficial/cutaneous reflexes.
• Deep tendon/muscle-stretch reflexes/myotactic.
• Abnormal reflexes 
• Babinski and clonus.

Grading of pathological reflexes:

               +: Presence of a pathological sign (abnormal).

               -: Absence of a pathological sign (normal).

Grading of Muscle Stretch Reflexes

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

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