Intensive Care Nursing/Neurological Assessment

Objectives

 * 1) Recognize signs of neurological compromise
 * 2) List different methods of measuring orientation
 * 3) Describe neurologic assessment findings
 * 4) Identify normal findings of the neurologic assessment

Neurological Assessment
A thorough methodical neurological assessment can be utilized to determine presence of neurological deficits. These items may be adapted to your setting and these items have been included based on studies determining what is essential.

History

Examiner should ask patient about any history of: stroke, syncope, narcolepsy, seizure, head or spinal injury (i.e. concussion, traumatic brain injury, ...), etc, as well as family history of neurological disorders. Histories are further interrogated regarding: onset, duration, course, associated symptoms. Positive responses are further interrogated regarding: onset, duration, course, precipitating/associated symptoms, and attempts to alleviate symptoms. Speech and hearing are assessed by observing patient follow directions and respond to questions.

Symptoms

Headache, neuropathic pain, blurry/alteration in vision, slurred speech, difficulty hearing, dizziness/vertigo, paresthesia, tremors, difficulty swallowing, memory difficulty, or seizures.

Vital Signs

Though vital sign changes may be a sign of late stage neurological changes, monitoring can assist with recognizing “normal” for individual.

Mental Status - Sometimes a change in mental status is the first clue to a neurological problem.

Level of Consciousness - Examiner should have patient state: name, current location, date, and reason for visit. Glasgow Coma Scale - System to determine level of responsiveness assessing eye opening, verbal response and motor response (15-highest to 3-lowest)  Some other methods of measuring mental status to determine orientation and/or alertness either through psychological or sedation related clinical evaluation tools: RASS, CAM-ICU, MMSE, MSE

Cranial Nerves

CN I - Olfactory - Smell test (noting common smells: i.e. coffee, soap, citrus, herbs, etc.)

CN II - Optic - Snellen chart, visual fields, Fundoscopy, color charts

CN III – Oculomotor - Examiner should assess 6 cardinal gazes in “H” pattern and pupillary constriction. The oculomotor nerve controls eye adduction, and upward/downward gaze (PERRLA).

CN IV - Trochlear - Examiner should assess 6 cardinal gazes in “H” pattern. The trochlear nerve controls downward and inward gazes.

CN V – Trigeminal - Examiner should have patient clench jaw while examiner checks for symmetry. Also facial sensation (forehead, cheek, jaw) and corneal reflex should examined

CN VI – Abducens - Examiner should assess 6 cardinal gazes in “H” pattern. The abducens controls eye abduction (can cause “double vision”).

CN VII – Facial - Examiner should have patient clench face, smile (with teeth), frown, puff cheeks, lift eyebrows, Front 2/3 of tongue’s taste sensors

CN VIII – Acoustic (vestibulocochlear) - Auditory tests (whisper, conversational level hearing, etc.)

CN IX – Glossopharyngeal - Examiner should have patient swallow, say “ahh” for uvula/soft palate upward movement, gag reflex. Back 1/3 of tongue’s taste sensors

CN X - Vagus/Vagal - Examiner should have patient say “ahh” for uvula/soft palate upward movement, gag reflex

CN XI - Spinal Accessory - Examiner should have patient shrug shoulders and turn head right/left (against resistance)

<li>CN XII – Hypoglossal - Examiner should have patient stick out tongue and move right/left

Fundoscopy

<li>Visualize optic disks and blood vessels

Sensory - Have patient close eyes and state when sensation is felt. Can also have patient state or point where sensation was felt

<li>Light Touch - Examiner should touch wisp of cotton swab to all extremities, checking dermatomes.

<li>Pain and Temperature - Examiner should touch a sharp/dull instrument (like a broken cotton swab or tongue depressor) to all extremities to elicit response.

<li>Vibration - Examiner should utilize tuning fork over bony prominences (i.e. fingers, toes). Have patient state when vibration stops.

<li>Proprioception - Examiner should hold sides of finger and move up or down, have patient state which direction their finger moved.

<li>Discrimination Sensations - Graphesthesia (Examiner should write a number on patient’s palm, have patient state what number it is), Stereognosis (have patient state what item is placed into their hand: coin, key, pen, …).

Reflexes - Utilizing reflex hammer, a key point is to have the individual relax the joint tested. It may be required to have them divert attention by closing eyes, clenching jaw, or tensing a different muscle group.

<li>Biceps - Examiner should place their thumb on the biceps tendon while supporting the patient’s arm, and strike their thumb with reflex hammer to elicit muscle reflex.

<li>Brachioradialis - Examiner should hold patient’s thumb suspending arm, striking 2-3cm proximal to radial styloid process. Forearm supination should be elicited.

<li>Triceps - Examiner should support upper arm by holding biceps, strike triceps tendon above elbow.

<li>Patellar/Quadriceps -Examiner should have patient seated with legs dangling, examiner should strike tendon below patella. Can also be done from a supine position by examiner supporting one leg with hand behind knee.

<li>Achilles - Have patient rotate hip externally and flex knee. With foot dorsiflexed, examiner should strike Achilles directly.

<li>Plantar - Examiner should scrape lateral aspect of foot and across ball of foot in “J” motion. Normal reflex in adults is a plantar flexion of toes. Normal reflex in children is a fanning of toes and dorsiflexion of great toe (“Babinski’s sign”).

Cerebellar

<li>Rapid Alternating Movements - Examiner should have patient in seated position: alternate patting palm of hands, and back of hands on knees repeatedly, then speeding up. OR tap thumb to each finger then reverse direction on same hand, then speed up tapping.

<li>Finger-nose - Examiner should have patient tap own nose, then tap examiner’s finger, and tap own nose again, examiner moves finger, and the patient touches examiner’s finger again.

<li>Heel-Shin - Examiner should have patient lay supine, run one heel distally from knee along shin of opposite leg, then alternate sides.

Strength/Tone - Checking for flaccidity, cogwheel rigidity, rigidity, spasticity, and tremors

<li>Upper Extremities - Check range of motion (ROM) in all joints as well as strength against resistance.

<li>Lower Extremities - Check ROM in all joints as well as strength against resistance.

Balance/Gait

<li>Romberg - Have patient stand with eyes closed, arms at sides, and feet together for about 20 seconds. Patient should be able to maintain posture. Examiner should stand nearby as patient may fall.

<li>Tandem Walk (heel-to-toe) - Have patient walk in normal gait about 5-10 paces away from examiner, then return towards examiner walking heel-to-toe.

<li>Walk on heels and toes - Have patient walk about 5-10 paces away from examiner on heels only, then return towards examiner walking on toes only.

Activities

 * 1) /Neurological Assessment Quiz/
 * 2) /Neurological Assessment Worksheet/

References: