Week 5 (Class 2) - Neurological Assessment

Question 1

The Central Nervous System consists of?

What is it responsible for?

Answer 1

The Brain and Spinal Cord

• Cerebrum (2 hemispheres; (L) analytical and (R) creative) - largest part that controls 80%
• Cerebral cortex (frontal, parietal, temporal, occipital, Wenicke’s area, Broca’s area) - thinking and processing; movement; language
• Basal ganglia
• Thalamus
• Hypothalamus
• Cerebellum - movement and coordination, balance
• Amygdala - emotions
• Forebrain - body temp, reproductive function, eating, sleeping, emotion
• Midbrain - Motor movement (eye), auditory, visual processing
• Brainstem (pons, medulla) - basic functions; breathing, HR, BP
• Spinal cord

Control and coordination of body

Question 2

What does the frontal lobe control?

Answer 2

Motor function for the contralateral side

Question 3

What does the PNS consist of?

Answer 3

Cranial, spinal and peripheral nerves

- Connect CNS to rest of body

Question 4

PNS:

1. Cranial Nerves
   - How many pairs?
   - Order?
   - Types
   - Myelination?
   - Example?
   - Aging adults

Answer 4

12 pairs that enter and exit (no spinal cord involvement)

Order:
I and II from the cerebral hemisphere

III and IV from the midbrain

V, VI, VII, VIII from the pons

IX, X, XI, XII from the medulla

Types:

• Sensory
• Motor
• Mixed (Sensory and motor)

Myelination starts after birth = why they have unsophisticated movements
- Core outwards; fine motor skill of arms and legs comes along later once myelinated

Ex. MS

• Chews up myelin on nerves
• Results in jerky, uncoordinated movements

Aging adults
- 80y brain is decreased in weight by 15%

Question 5

What is the Mnemonic to remembering the cranial nerves (PNS)?

Answer 5

On / Some = Olfactory / Sensory
Old / Say = Optic / Sensory
Olympus / Marry = Oculomotor / Motor
Towering / Money = Trochlear / Motor
Top / But = Trigeminal / Both
A / My = Abducens / Motor
Fin / Brother = Facial / Both
And / Says = Auditory / Sensory
German / Big = Glossopharyngeal / Both
Viewed / Brains = Vagus / Both
Some / Matter = Spinal accessory / Motor
Hops / More = Hypogloassal / Motor

Question 6

PNS:

2. Spinal Nerves
   - How many?
   - Categories?
   - Afferent/Efferent
   - Nerve?

Answer 6

31 spinal nerves

• 8 cervical
• 12 thoracic
• 5 lumbar
• 5 sacral
• 1 coccygeal

Afferent = Arrive - Input coming in

Efferent = Exit - Message away out to body

Nerve: Where the fibers come together

Question 7

What is a dermatome?

Answer 7

area of skin supplied by one particular spinal nerve

Question 8

PNS:

2. Spinal Nerves
   - Name what each nerve innervates
   - C1-C3
   - C1
   - C4-C6
   - C7-T1
   - T1-T6
   - T6-T12
   - T12-L4
   - L4-S4

Answer 8

C1-C3: innervate movement in and above the neck including the larynx;
C1 has no dermatome/sensory responsibilities, mostly motor
C4-C6: innervate the neck and shoulder and diaphragm (C3-C5 for breathing independently)
C7 – T1: innervate arms, fingers, hand grasp (think self-care, transfers with arms)
T1-T6: provide trunk stability for balance when sitting (thinking getting patients up and out of bed), innervate intercostal muscles for respirations
T6-T12: innvervate intercostals and abdominal muscles for respirations and transfer strength
T12-L4: innervate muscles of the abdomen, and upper leg (quads and hip abductors)
L4-S4: innervate hip abductors and extensors (hamstrings), muscles of knee, ankles, and feet, and the perineum for leg strength and bowel and bladder control

Question 9

PNS:

3. Autonomic Nervous System
   - What is it?
   - Sympathetic?
   - Parasympathetic?
   - What is a reflex?

Answer 9

Autonomic Nervous system: Maintains involuntary functions of cardiac and smooth muscle of the viscera and glands

The autonomic nervous system is divided into these two types

a) Sympathetic
- ‘Fight or Flight’ produces body-to-action during periods of physiologic and psychologic stress neurotransmitter of significance here: epinephrine (adrenaline)

b) Parasympathetic
- ‘Rest & Digest’ functions in a complementary and counterbalancing manner to conserve body resources and day-to-day functions (e.g., rest, digest) neurotransmitter

Reflexes: involuntary responses

Question 10

What are a few neurological disease entities you can think of?

Answer 10

1. Degenerative – aging: cognitive disorders (memory), Alzheimer’s, autoimmune/progressive such as MS, Parkinson’s
2. Genetic – Spina bifida, MD, ALS
3. Injury – Traumatic Brain Injury (TBI), concussions (this is a hot topic)
   falls, MVA
4. Cardiovascular - stroke – risk ↑ with ↑BP, age, DM, smoking, obesity & CVD which are widely experienced by population
   - Headaches
   - Vertigo
   - Brain tumours
   - Epilepsy
   - Neuropathy/peripheral neuropathy as seem in DM

Question 11

What are health promotion / injury prevention for neuro?

Answer 11

Ex. Stroke prevention

• Smoking
• Smoking and oral contraception
• FAST to recognize strokes

Ex. Injury Prevention
- Balance and falls

Ex. Prevention of Meningeal Infections
- Vaccinations

Ex. Reduction for risk - Seizures

• Meds
• Sudden changes to meds
• Sleep deprivation
• Other illness
• Stress

Ex. Folic Acid
- Women of child bearing years should take a multivitamin

Question 12

What subjective data would be required in a health history pertaining to a neurological assessment?

Answer 12

• Presenting with headaches
• Presenting with facial drooping
• Presenting with head injury from a fall
• Presenting with dizziness
• Presenting with limb weakness
• Presenting with difficulty speaking
• Ex. Seizures, tremors, incoordination, numbness/tingling, pain, difficulty swallowing/speaking

Question 13

Do you want a whole history during a health history pertaining to a neurological assessment?

• Environmental/Occupational Hazards?
• Current Health Status?
• Past Medical History?

Answer 13

YES

You want a whole history, family history if relevant, but significant history might include:
- History of stroke “CVA” (cerebrovascular accident), spinal cord injury, meningitis or encephalitis, congenital defect, or alcoholism (Korsakoff syndrome caused by severe thiamine deficiency which is often due to chronic alcohol misuse).

YES

Environmental/Occupational Hazards:
- Are you exposed to any environmental/occupational hazards: insecticides, organic solvents, lead, toxic inhalants, etc.?

YES

Current Health Status: (include all medications, dose, and frequency)

YES

Past Medical and Surgical

• History
• Family History
• Social Habits

Question 14

What objective data might be needed in a neurological assessment?

Answer 14

Equipment you (might) need:

• Penlight with pupil scale*
• Everyday objects*
• Tongue blade
• Cotton ball
• Pin
• Tuning fork (128 or 256 Hz)
• Percussion hammer

Question 15

What are the 8 components of a neurological assessment?

Answer 15

1. Vital Signs*
   - Tells us about intracranial pressure (ICP)
2. Level of Consciousness (LOC) using GCS*
   - Glascow Coma Scale has 3 parts to measure the level of consciousness
3. Cranial Nerves 1 – 12 (concentrate on 3, 7, 9, 12)*
4. Speech*
5. Strength testing*
6. Cerebellar function
7. Sensation testing
8. Reflexes** (advanced)

Question 16

What should you watch out for during a neurological assessment?

Answer 16

Vital Signs

• Decreasing pulse
• Decreasing respirations
• Decreasing oxygen saturation level
• Increasing BP
• Widening pulse pressure (This is the difference between systolic & diastolic values - This happens with increased intracranial pressure (ICP))
• Cushing’s Triad (symptom of increased ICP): Bradycardia, Hypertension with widening pulse pressure, Bradypnea/irregular respirations

Question 17

What is LOC?

• How is it measured?
• 3 components?
• Score range?

Answer 17

LOC = Level of Consciousness
- Measured by the Glascow Coma Scale (GCS)

3 components:

• Eye opening
• Verbal response
• Motor response

Score range:

• 3-15
• Severe, with GCS ≤ 8 cannot protect their airway
• Moderate, GCS 9 - 12
• Minor, GCS 13-14
• Perfect score 15

Question 18

What are the 3 dimensions of best verbal response (orientation)?
- What must be considered?

Answer 18

1. Person
2. Place
3. Time

*To be considered oriented, all 3 must be correct

Question 19

What is the sequence for eye opening?

- How long do you apply stimulus?

Answer 19

1. Speak
2. Shout
3. Shake
4. Pain

You want to allow the stimulus a good 15-30 SEC MIN/MAX before deciding they have “no response.” No response is a weighty finding. You want to be sure.

Question 20

What if there is no eye opening?

• Round 1?
• No response?
• Eye Orbit?
• Rationale?

Answer 20

Then the first round pain stimulus is peripheral in the form of pressure on the nail bed with something like a pencil
- Grab a pen or a pencil, hold it across your nail bed perpendicular to your finger, and firmly press.

If no response, move to something central such as the trapezius squeeze.

• You grasp the trapezius muscle, give a squeeze and a twist.
• Moving more centrally is a more powerful stimulus for the brain, so you might get a response centrally but nothing peripherally.

Alternatively, you can take your thumb and apply pressure to the orbit of the patient’s eye. Try this on yourself too. It hurts.

The reason you’re doing this is to coax a response out of the patient’s brain by doing something that the brain should perceive as unpleasant or irritating

• The more severe the impairment, the less reaction you’ll get from the patient
• At a certain point, the patient’s brain will react in ‘reflexive’ ways to pain and discomfort that are demonstrative of a desperate brain under too much stress to cope.

Question 21

What has fallen out of favour for eye opening? Why?

Answer 21

The sternal rub has fallen out of favour as a method for eliciting a response to pain

• You’ll still read about it in places, and you’ll still see clinicians doing it on occasion, usually because they have always done it and don’t want to try something new.
• The sternal rub is a central pain stimulus that involves forming a fist with your hand and then firmly rubbing your knuckles up and down the patient’s sternum
• In the stress of the moment and desperation to see some sort of response from the patient, clinicians end up rubbing so hard for so long that they rub layers of the patient’s skin off and cause a great deal of superficial damage
• Since we have better methods that do the same thing without all the damage, the sternal rub is now considered abuse and should be replaced with one of the other central stimulation methods

Question 22

What is the best motor response (LOC)?
- What does it reflect?

What do you ask?
- What if they do not obey?

Answer 22

Patient’s ability to receive the simple command, and produce the action
- Ability reflects LOC, not motor impairment (though motor impairment may interfere, more on that later)

Ask the PT to follow 3 simple motor commands

• If unable to obey commands, may observe some spontaneous movement, localization = remove discomfort
• If unable to obey commands, no movement, normal flexion = attempt to move away from discomfort

Question 23

What is decerebrate and decorticate postures?

- What can cause this?

Answer 23

These postures are so specific, and always alarming to see - When you observe these postures, you understand that the patient’s brain is in severe distress

Decerebrate

• Results from damage to upper brain stem
• Arms are adducted and extended with the wrists pronated and fingers flexed
• Legs stiffly extended with plantar flexion of feet

Decorticate

• Results from damage to one or both corticospinal tracts
• Arms adducted and flexed with wrists and fingers flexed on chest
• Legs stiffly extended and internally rotated with plantar flexion of feet

Causes:

• Your exam
• These patients may be unresponsive/in coma and this posture is this is the only observable movement

Question 24

What are 4 aspects of a CN II optic (incoming light) and CN III oculomotor (muscle control) pupillary assessment?

Answer 24

1. Pupil Size, equality, & shape:
   - Measure pupil size in mm using measuring guide. Both pupils should be the same size & shape.
2. Direct light reflex:
   - Pupil should constrict briskly & immediately in response to the light source.
3. Consensual light reflex:
   - Pupils should constrict when light source is aimed at the opposite pupil
4. Accommodation:
   - Hold finger/penlight 12 inches from client’s face, and bring it toward their nose
   - Both pupils should constrict equally and turn inward (converge) simultaneously.

Question 25

What is the name for pupils that are different size on the (L) vs. (R)?

Answer 25

Anisocoria

• Common in general population
• Problems that can cause pupils to differ in size include things like bleeding in the brain, increased ICP, pressure on/inflammation of the optic nerve, tumour, concussion, stroke, others…

Question 26

What does PERLA stand for? Can it be used in documentation?

Answer 26

If documenting this assessment in a SOAP (which you may or may not need to do) it is acceptable to document ‘PERRLA’ as a stand alone statement in the O data.

Pupils Equal Round Reactive to light & Accommodation.

• You don’t write ‘PERRLA is normal.’ or ‘PERLLA is within expected ranges.’
• It is acceptable to use this acronym, and it is a complete statement on its own.

Question 27

What do you look for in a neurological assessment - facial weakness?

Answer 27

MOTOR AND SENSORY - CN VII (Facial Nerve)

• Function: Facial expression

Tests for Motor:

• Raise eyebrows
• Frown
• Eye “clenching”
• Show teeth
• Smile
• Puff out cheeks
• Sticking out the tongue is another movement we ask clients to perform, can highlight dysfunction
• Sticking out the tongue belongs to CN XII (hypoglossal)

Question 28

What do you look for when assessing the CN IX and X nerves (i.e. glossopharyngeal and vagus)?

Answer 28

Motor and sensory

Function: Swallowing and taste

Test for Motor:

• “Ahhh” - uvula and palate rise
• Gag reflex
• SLP for swallowing assessment

Question 29

How do you assess ones speech?

- What is aphasia?

Answer 29

Aphasia is an impairment of language, affecting comprehension or production of speech.
- Aphasia is always due to injury to the brain

Question 30

What is receptive aphasia?

- Wenickes?

Answer 30

Receptive Aphasia:
- Poor comprehension, speech is fine, impaired meaning

“Wenicke’s Aphasia” - is a type of aphasia in which people are unable to understand language in its written or spoken form, and even though they can speak with normal grammar, syntax, rate, and intonation, they cannot express themselves meaningfully using language.
- People with Wernicke’s aphasia are typically unaware of how they are speaking and do not realize it may lack meaning. Having a deficit and not knowing it exists or denying it exists is called anosognosia. People with Wernicke’s Aphasia typically remain unaware of even their most profound language deficits.

Question 31

What is expressive aphasia?

• Brocas
• How does it differ from dysarthria and apraxia?

Answer 31

Expressive Aphasia:

• “Broca’s Aphasia”
• Characterized by the loss of the ability to produce language (spoken or written).

Expressive aphasia differs from dysarthria, which is typified by a patient’s inability to properly move the muscles of the tongue and mouth to produce speech.

Expressive aphasia also differs from apraxia of speech which is a motor disorder characterized by an inability to create and sequence motor plans for speech.
- Comprehension is typically only mildly to moderately impaired in expressive aphasia.

Question 32

How do you test for receptive deficit? Why?

Answer 32

1. Point to the ceiling
2. Close your eyes
3. Can you answer this question: Does a stone sink in water?

This part of the assessment of speech is testing whether the client understands you. The third question is assessing for abstract thought, a more sophisticated cognitive task.
- Receptive deficit is assessed before expressive deficit.

Question 33

How do you test for expressive deficit? Why?

What should you be with these types of patients?

Answer 33

Using three different objects ask:

• What is this? What does it do?
• Ex. Pen, watch, key.

You can vary the objects and the language, these are just the default suggestions on the form, and items a nurse typically has in their pocket.

• If you do choose different items, they must be items that a patient should reasonably be expected to know
• For example, don’t show the patient a piece of medical equipment and then fault them for not knowing what it is or what it does

BE PATIENT

• This can be a frustrating experience for patients if they are having trouble with speech
• Be very patient, and give the patient plenty of time.
• Try to remain neutral when your patient responds… Saying “good! That’s right, Bill” might seem like you’re encouraging him, but what happens when you get to the part that he has trouble with and you don’t say anything like you said before?
• It can be distressing for patients to think that they’re “getting it wrong.” - Being supportive needs to take different forms than verbal praise during the formal assessment.

Question 34

What if patients ask questions during the neurological exam?

Answer 34

If patients ask questions during the exam, and you’re not sure how to answer or you notice that something is abnormal, you don’t have to keep it from them.
- Just consider the context, and also consider that one assessment is just that—it is one snapshot in time that isn’t always so meaningful or informative until there is lots of data to assemble into a bigger picture.

Question 35

How do you assess a patient for pronator drift?

- What does it test for?

Answer 35

1. Sit patient up in bed/chair
2. Close eyes
3. Hold arms straight out in front, palms up, shoulder height
4. Hold position for 20 seconds
5. If present, arm on one side will be weak and therefore fall and drift across body
6. Hand will pronate (palm will go from face up to face down)
   - Reflecting a contra-lateralpyramidal tractlesion
   - A lesion in thecerebellumproduces a drift upwards.

Tests for upper motor neuron disease

Question 36

What is not part of a focused or rapid neurological assessment but you may observe or read about?

Answer 36

Gait Assessment
- Involves observing the patient as they walk, and taking note of any abnormalities, including problems with balance and coordination

Tandem Gait:

• Is a method of walking where the toes of the back foot touch the heel of the front foot at each step
• Used as a test to help diagnose ataxia (ataxia is combination of symptoms caused by cerebellar damage).

Romberg Test

• The Romberg test is a test of proprioception, related to cerebelar function
• This test is performed by asking the patient to stand, feet together with eyes open, then with eyes closed.
• The patient with significant proprioceptive loss will be able to stand still with eyes open because vision will compensate for the loss of position sense, but will sway or fall with their eyes closed because they are unable to keep their balance

Question 37

How can you test a PT ability to organize and complete movements that require coordination on the part of the brain?

What are the rules?

Answer 37

1. Rapid alternating movements
2. Finger-to-finger test
3. Finger-to-nose test
4. Heel-to-shin test

There’s no rules around what and how many of these activities the patient should be ask to perform
- The clinician assesses each component of the neuro exam until they are confident in what they do or don’t observe

Question 38

What is the Babinski Reflex?

When is it normal?

When is it abnormal?

Answer 38

Occurs after the sole of the foot has been firmly stroked from heel up to toes

• The big toe then moves upward or toward the top surface of the foot
• The other toes fan out

This reflex is normal in children up to 2 years old and disappears as the child gets older.

When the Babinski reflex is present in a child older than 2 years or in an adult, it is often a sign of a brain or nervous system disorder

Question 39

What muscles are commonly tested during a gross extremity assessment (i.e. strength)?

What do you ask the PT to do?

Answer 39

Upper:

• Biceps
• Triceps
• Deltoid

Lower:

• Hamstrings
• Quads

Ask patient to lift each limb off the bed/exam table to see how they manage against gravity

• Then see how the patient manages against resistance by instructing them to counter your pressure (ie. you push they resist by pulling)
• Do this bilaterally to compare

Question 40

Why do we ask PT about their bowls on neurological record?

What are we trying to prevent? Why?

Answer 40

The reason we ask the neuro patients (most of them, anyway) about their last BM/the reason we keep track of the patient’s BMs is because of the relationship between constipation, and ICP.

We track the client’s bowel habits in order to prevent constipation

• When patients are constipated, they tend to strain when trying to move their bowels
• Straining (like, Valsalva maneuver, ‘bearing down) causes ICP to rise
• For the majority of patients, that’s no big deal. But for patients who already have elevated ICP, OR are at risk for elevated ICP, OR for whom any increase in ICP could destabilize their condition (for example, because they have recently had some bleeding into their brain that has stopped for the time being), constipation is a big potential problem.

If patients are in the hospital, we keep track on our records

• If they are seeking care and don’t remember, a lot of times they will be given stool softeners or laxatives as a precaution against constipation
• This would be a possible nursing intervention in the hospital too.

Question 41

In Summary…

Answer 41

The central nervous system is made up of the brain and spinal cord; responsible for control and coordination of the body

The peripheral nervous system has 31 spinal nerves; connects the CNS to the body

The autonomic nervous system is divided into the sympathetic (fight or flight) and the parasympathetic (rest & digest)

Assessing the neurological system involves vital signs, LOC, speech, and muscle strength

Pupillary reflexes reflect the function of the optic and oculomotor cranial nerves

Rising ICP causes heart rate and resps to slow down, BP to increase, and pulse pressure to widen

Consistency in assessment is important to track progress or deterioration over time

Comprehensive neuro assessment is a more advanced process, generalist nurses perform more focused and sometimes urgent/rapid assessments of neurological function

Health promotion involves modifying risk by supporting healthy lifestyle habits

Preventative strategies around injury prevention and early identification and intervention for neurological illness

Question 42

Relevance?

Answer 42

You don’t have to work on a neuro floor to encounter a patient experiencing a neuro problem

When urgent neurological signs and symptoms are discovered, time is of the essence-the earlier the intervention, the better the outcome

Early intervention depends on swift recognition and assessment by the nurse

Nurses are well positioned to notice changes, even very small ones, in the patient’s condition. If those first, subtle signs are noticed, the patient has a better chance of surviving the event

Some neurological conditions are not urgent, but do play a big role in the lives of patients in terms of their functional ability, independence, and quality of life

Regardless of where a nurse works, patients come to us for care with preexisting conditions that are an important part of their context for receiving treatment and care

Understanding the chronic nature of some neurological disorders, and some of the residual effects patients are left with after a neurological event, help nurses to individualize whatever services and care they provide thereby upholding their commitment to providing patient focused care

Question 43

Terminology, Concepts, and Acronyms?

Answer 43

• CNS vs PNS
• TBI
• CVA
• LOC
• Cushing’s triad
• ICP
• GCS
• Decorticate
• Decerebrate
• PERRLA
• Direct/consensual light reflex
• Anisocoria
• Aphasia
• Pronator drift
• Romberg’s sign
• Babinski sign
• Contralateral