Neurological Assessment

Hi, and welcome to this video review of the neurological assessment!

No matter what setting you work in, it is likely that you will need to perform some degree of neurologic assessment at some point. Just a small change in neurologic status can indicate a neurologic injury, and early intervention can prevent permanent damage.

Subjective and Objective Data

There are two main parts to be collected in the neurological assessment: subjective data (the patient’s health history) and objective data (the physical examination).

The history and exam should be done in an orderly, symmetrical fashion to be certain that all areas are assessed. To detect abnormalities, each side of the body should be compared with the other side.

Let’s first look at assessing the health history.

When assessing the nervous system of the adult patient, ask the following questions:

• Have you ever had any type of head injury, with or without loss of consciousness?
• Have you ever had meningitis, encephalitis, injury to the spinal cord, seizures, or a stroke?
• Any family history of Alzheimer’s disease, stroke, epilepsy, brain cancer, or Huntington’s chorea?
• Do you experience headaches?
• Do you experience dizziness, lightheadedness, or problems with balance or coordination?
• Do you experience numbness or tingling?
• Have you noticed a decrease in your ability to smell or taste?
• Do you have ringing in your ears or hearing loss?
• Have you noticed any change in your vision?
• Do you have difficulty speaking, forming words, or understanding when people talk to you?
• Do you have difficulty swallowing?
• Do you have excessive stress or any mental health disorders?
• Are you exposed to any environmental or occupational hazards?

If the patient verbalizes any neuro concerns in the history assessment, a complete baseline neurological exam should be completed. If there is no suspicion of neuro disorders, then it may not be necessary to perform an entire neuro exam.

Neurologic Assessment

A thorough neurologic examination involves assessing mental status, cranial nerves, motor and cerebellar system, sensory function, reflexes, pupillary response, and vital signs. Unless you’re working on a neuro unit, you typically won’t need to perform all of these assessments. This review will focus on mental status, pupillary response, motor function, and reflexes.

Mental Status

Let’s start with mental status.

Evaluating a patient’s mental status includes level of consciousness (LOC), orientation, and memory. It is very important to test LOC, because it is the first thing to change when there is neurologic injury.

To assess LOC, be familiar with the Glasgow Coma Scale, which scores: the patient’s response to eye-opening, motor response, and verbal response. Begin by speaking the patient’s name, then saying it louder, and if still no response, gently shake the patient. If still no response, use painful stimulation for 15 to 30 seconds, such as squeezing and twisting the trapezius muscle or doing a sternal rub.

A reaction from one of these painful stimuli means it’s coming from the brain. If the patient only reacts to the painful stimuli with one side of the body, the nonreactive side can be assessed by pressing a pencil into the cuticle of a finger. The response will either be purposeful (patient pulling away from the pain), nonpurposeful (patient moves, but not in a meaningful way), or no response at all.

These tests will assist in scoring the patient’s response on the Glasgow Coma Scale.

Assessing the patient’s orientation involves asking detailed questions about his name, where he is, and the date. Memory is assessed based on immediate memory, short-term memory, and remote memory. Remote memory can be tested by asking about wedding dates or a news event. Short-term memory can be assessed by asking what he had for breakfast or a recent news event. Immediate memory involves asking the patient to remember 3 unrelated words and having him repeat them back to you. As you’re assessing orientation, also take note of the patient’s speech.

Pupillary Response

Assessment of the pupils involves looking at the size, shape, and symmetry of both pupils, noting the size in mm before shining a light on them. Normal pupils should both be the same size, about 2 to 6mm and round. Use a small flashlight to shine on one pupil at a time, coming from the outer edge of the eye, going towards the nose, and both pupils should constrict equally and briskly. Note the size in mm after constriction and how long it takes each eye to constrict.

Motor Function

Evaluating motor function involves assessing the strength and tone of muscles, looking at both sides of the body simultaneously. Take note of any asymmetry or atrophy on one side, which often indicates weakness. When assessing the upper extremities, have the patient raise his arms parallel to the floor or bed, and have him resist when you push them down. Do the same for the lower extremities, having him raise his legs and resist when you push them down.

Also have the patient grasp your fingers in his fist, assessing the equality of strength; then ask him to let go, and if he can’t let go on command, a neurologic injury is indicated. The pronator drift test involves having the patient stand with arms extended, palms up, in front of him, with eyes closed. Observe arms to see if one sways from its original position, which is a subtle indication of weakness.

When testing muscle strength, abnormalities in muscle tone will become more evident, such as limited range of motion, pain, or flaccidity, rigidity, or spasticity.

Reflexes

Now let’s take a look at reflexes. Reflexes are involuntary actions in response to a stimulus sent to the central nervous system. Variations in reflexes are often a first sign of neurological dysfunction. Deep tendon reflexes are reflexes elicited in response to stimuli to tendons. A soft rubber hammer is used to tap on the muscle tendon, and the normal response is for the muscle fibers to contract. Abnormal responses may indicate injury to the nervous system pathways that produce the deep tendon reflex. Influential factors include age, thyroid dysfunction, electrolyte abnormalities, and anxiety level of the patient.

There are five reflexes to check, including the biceps, triceps, brachioradialis, patellar, and achilles. When using a reflex hammer, the limbs should be in a relaxed and symmetric position, and a moderate tap is used to strike the tendon. If you’re having trouble eliciting a response, make sure you swing the reflex hammer briskly, removing it immediately after tapping the tendon. You also want to be sure you are hitting the specific tendon, and if you’re having trouble finding it, have the patient flex their muscle so you can feel the tendon, which will feel like a thick cord.

When reflexes are very brisk, clonus is sometimes seen, which is a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch. Deep tendon reflexes are rated on a scale of 0 to 5+, with 0 being an absent reflex, 1+ is diminished (may be normal), 2+ is normal, 3+ is brisker than normal (not necessarily pathologic), 4+ is hyperactive (considered clonus and often pathologic), and 5+ is sustained clonus.

Review Questions

Now let’s look at some review questions about the neurological assessment.

1. A thorough neurological exam should include assessment of the following:

1. Mental status, pupillary response, motor function, and reflexes
2. Level of consciousness, orientation, memory, deep tendon reflexes, and pupillary response
3. Mental status, cranial nerves, motor and cerebellar system, sensory function, reflexes, pupillary response, and vital signs
4. Glasgow coma scale, memory, and muscle strength and tone

 
2. A labor and delivery nurse is checking the deep tendon reflexes of a patient that is getting a magnesium sulfate drip. The patient’s DTRs are diminished, which the nurse knows is normal due to the effects of the drug she is receiving. What score would the nurse chart for this assessment?

1. 0
2. 1+
3. 2+
4. 3+

 
Thank you for watching this video review on the neurological assessment! I hope it was helpful.