Assessment of Neurologic Function

Dr. Lubna Dwerij

Anatomic and Physiologic Overview

 The nervous system consists of two major parts:

 The central nervous system (CNS), including the brain and
spinal cord.
 The peripheral nervous system, which includes the cranial
nerves, spinal nerves, and autonomic nervous system.
 The function of the nervous system is to control motor,
sensory, autonomic, cognitive, and behavioral activities.
Anatomic and Physiologic Overview

 The brain itself contains more than 100 billion cells that:
 Link the motor and sensory pathways.
 Monitor the body’s processes,
 Respond to the internal and external environment,
 Maintain homeostasis
 Direct all psychological, biologic, and physical activity
through complex chemical and electrical messages
Anatomic and Physiologic Overview
 Cells of the Nervous System
 The basic functional unit of the brain is the
neuron.
 The dendrites are branch-type structures for
receiving electrochemical messages.
 The axon is a long projection that carries
electrical impulses away from the cell body.
 Some neurons have a myelinated sheath that
increases speed of conduction.
 Nerve cell bodies occurring in clusters are called
ganglia or nuclei. A cluster of cell bodies with the
same function is called a center (eg, the
respiratory center).
Neurotransmitters
 Neurotransmitters communicate messages from one
neuron to another or from a neuron to a specific target
tissue.
 A neurotransmitter potentiates, terminates, or modulates
a specific action, and it can either excite or inhibit
activity of the target cell.
 Many neurologic disorders are due, at least in part, to an
imbalance in neurotransmitters.
 For example, Parkinson’s disease develops from decreased
availability of dopamine, while acetylcholine binding to
muscle cells is impaired in myasthenia gravis
Assessment of the Nervous System
 Health History
 An important aspect of the neurologic assessment is the
history of the present illness.
 The initial interview provides an excellent opportunity to
systematically explore the patient’s current condition and
related events while simultaneously observing overall
appearance, mental status, posture, movement, and
affect.
 Neurologic disease may be stable or progressive,
characterized by symptom-free periods as well as
fluctuations in symptoms.
Assessment of the Nervous System
 The health history therefore includes details about the
onset, character, severity, location, duration, and
frequency of symptoms and signs;
 Associated complaints; precipitating, aggravating, and
relieving factors;
 Progression, remission, and exacerbation; and the
presence or absence of similar symptoms among family
members.
Common Symptoms
 The symptoms of neurologic disorders are as varied as the
disease processes themselves.
 Symptoms may be subtle or intense, fluctuating or
permanent, inconvenient or devastating.
Common Symptoms - Pain
 Pain is considered an unpleasant sensory perception and
emotional experience associated with actual or potential
tissue damage or described in terms of such damage.
 Pain is therefore considered multidimensional and entirely
subjective.
 In neurologic disease, acute pain may be associated with
brain hemorrhage, spinal disk disease, or trigeminal
neuralgia.
 In contrast, chronic or persistent pain extends for long
periods of time and may represent a broader pathology.
 This type of pain can occur with many degenerative and
chronic neurologic conditions (eg, multiple sclerosis).
Common Symptoms - Seizures
 Seizures are the result of abnormal paroxysmal discharges
in the cerebral cortex, which then manifest as an
alteration in sensation, behavior, movement, perception,
or consciousness.
 The alteration may be short, such as in a blank stare that
lasts only a second, or of longer duration, such as a tonic–
clonic grand mal seizure that can last several minutes.
 The seizure activity reflects the area of the brain affected.
 Seizures can occur as isolated events, such as when
induced by a high fever, alcohol or drug withdrawal, or
hypoglycemia.
 A seizure may also be the first obvious sign of a brain lesion
Common Symptoms - Dizziness and Vertigo
 Dizziness is an abnormal sensation of imbalance or
movement.
 It is fairly common in the elderly and one of the most
common complaints encountered by health professionals.
 Dizziness can have a variety of causes, including viral
syndromes, hot weather, roller coaster rides, and middle
ear infections.
 One difficulty confronting health care providers when
assessing dizziness is the vague and varied terms patients
use to describe the sensation.
Common Symptoms - Dizziness and Vertigo
 About 50% of all patients with dizziness have vertigo,
which is defined as an illusion of movement, usually
rotation
 Vertigo is usually a manifestation of vestibular
dysfunction.
 It can be so severe as to result in spatial disorientation,
lightheadedness, loss of equilibrium, and nausea and
vomiting.
Common Symptoms – Visual
Disturbances
 Visual defects that cause people to seek health care can
range from the decreased visual acuity associated with
aging to sudden blindness caused by glaucoma.
 Lesions of the eye itself (eg, cataract), lesions along the
pathway (eg, tumor), or lesions in the visual cortex (eg,
stroke) interfere with normal visual acuity.
 Abnormalities of eye movement (as in the nystagmus
associated with multiple sclerosis) can also compromise
vision by causing diplopia or double vision.
Common Symptoms-Muscle Weakness
 Muscle weakness is a common manifestation of neurologic
disease.
 Weakness can be sudden and permanent, as in stroke, or
progressive, as in neuromuscular diseases such as
amyotrophic lateral sclerosis.
 Any muscle group can be affected
Common Symptoms- Abnormal Sensation
 Abnormal sensation is a neurologic manifestation of both
central and peripheral nervous system disease.
 Altered sensation can affect small or large areas of the
body. It is frequently associated with weakness or pain and
is potentially disabling.
 Lack of sensation places a person at risk for falls and
injury.
Past Health, Family, and Social History
 The nurse may inquire about any family history of genetic
diseases.
 The nurse should be aware of any history of trauma or
falls that may have involved the head or spinal cord.
 Questions regarding the use of alcohol, medications, and
illicit drugs are also relevant.
 The history-taking portion of the neurologic assessment is
critical and, in many cases of neurologic disease, leads to
an accurate diagnosis.
Past Health, Family,
and Social History
Physical Assessment

 The neurologic examination is a systematic process that

includes a variety of clinical tests, observations, and
assessments designed to evaluate the neurologic status of
a complex system.
 The brain and spinal cord cannot be examined as directly
as other systems of the body. Thus, much of the
neurologic examination is an indirect evaluation that
assesses the function of the specific body part or parts
controlled by the nervous system.
Physical Assessment
 A neurologic assessment is divided into five components:
 Consciousness and cognition.
 Cranial nerves.
 Motor system.
 Sensory system.
 Reflexes.
Physical Assessment
 Assessing Consciousness and Cognition
 Cerebral abnormalities may cause disturbances in:
 Mental status.
 Intellectual functioning.
 Thought content.
 Emotional status.
 There may also be alterations in language abilities, as well
as lifestyle.
Physical Assessment
 Mental Status
 An assessment of mental status begins by observing the
patient’s appearance and behavior, noting dress,
grooming, and personal hygiene.
 Posture, gestures, movements, and facial expressions
often provide important information about the patient.
 Does the patient appear to be aware of and interact with
the surroundings?
 Assessing orientation to time, place, and person assists in
evaluating mental status.
Physical Assessment
 Intellectual Function
 A person with an average IQ can repeat seven digits without
faltering and can recite five digits backward.
 The capacity to interpret well-known proverbs tests abstract
reasoning, which is a higher intellectual function.
 Questions designed to assess intellectual abilty in patient
with damaged frontal cortex might include
 The ability to recognize similarities: for example, how are a
mouse and dog or pen and pencil alike?
 Can the patient make judgments about situations: for
example, if the patient arrived home without a house key,
what alternatives are there?
Physical Assessment
 Language Ability
 The person with normal neurologic function can
understand and communicate in spoken and written
language.
 Does the patient answer questions appropriately? Can he
or she read a sentence from a newspaper and explain its
meaning? Can the patient write his or her name?
 A deficiency in language function is called aphasia.
Physical Assessment
Physical Assessment
 Level of Consciousness
 Consciousness is the patient’s wakefulness and ability to
respond to the environment.
 Level of consciousness is the most sensitive indicator of
neurologic function.
 To assess level of consciousness, the examiner observes
for alertness and ability to follow commands.
 If the patient is not alert or able to follow commands, the
examiner observes for eye opening; verbal response and
motor response to stimuli.
 Noxious stimuli should be used first, then painful stimuli if
no response is observed.
Glasgow coma scale
 The Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a
person's level of consciousness after a brain injury.

 https://www.youtube.com/watch?v=v6qpEQxJQO4
Glasgow coma scale

 Individual elements as well as the sum of the score are

important. Hence, the score is expressed in the form "GCS
9 = E2 V4 M3 at 07:35". Patients with scores of 3-8 are
usually considered to be in a coma. Generally, brain injury
is classified as:
 Severe, GCS < 8–9
 Moderate, GCS 8 or 9–12 (controversial)
 Minor, GCS ≥ 13.
Physical Assessment
 Level of Consciousness
 In the patient with decreased level of consciousness,
motor and cranial nerve function become the priority
assessments, as abnormalities can indicate the area of
involvement in the absence of responsiveness.
Physical Assessment
 Examining the Cranial Nerves
 Cranial nerves are assessed when level of consciousness is
decreased, with brain stem pathology, or in the presence
of peripheral nervous system disease.
 Examining the Motor System
 Motor Ability
 Muscle Strength
 Balance and Coordination
Physical Assessment

 Examining the Reflexes

Diagnostic Evaluation
 Computed Tomography Scanning
 The images provide cross-sectional views of the brain,
distinguishing differences in tissue densities of the skull,
cortex, subcortical structures, and ventricles.
 An intravenous (IV) contrast agent may be used to
highlight differences further.
 The image is displayed on an oscilloscope or TV monitor
and is photographed and stored digitally.
 The brightness of each slice of the brain in the final image
is proportional to the degree to which it absorbs x-rays.
 CT scanning is usually performed first without contrast
material and then with IV contrast, if needed.
Diagnostic Evaluation
 Computed Tomography Scanning
 The patient must lie with the head held perfectly still
without talking or moving the face, because head motion
distorts the image.
Diagnostic Evaluation
 Computed Tomography Scanning
 CT has a high degree of sensitivity for detecting lesions.
 Abnormalities detected on brain CT include tumor or other
masses, infarction, hemorrhage, displacement of the
ventricles, and cortical atrophy.
 Whole-body CT scanners allow cross sections of the spinal
cord to be visualized.
Diagnostic Evaluation
 Nursing Interventions
 Preparation includes teaching the patient about the need
to lie quietly throughout the procedure.
 Sedation can be used if agitation, restlessness, or
confusion interferes with a successful study.
 If a contrast agent is used, the patient must be assessed
before the CT scan for an iodine/shellfish allergy.
 Renal function must also be evaluated, as the contrast
material is cleared through the kidneys.
Diagnostic Evaluation
 Nursing Interventions
 A suitable IV line for contrast injection and a period of
fasting (usually 4 hours) are required prior to the study.
 Patients who receive an IV contrast agent are monitored
during and after the procedure for allergic reactions and
changes in kidney function
Diagnostic Evaluation
 Magnetic Resonance Imaging
 An MRI scan can be performed with or without a contrast
agent and can identify a cerebral abnormality earlier and
more clearly than other diagnostic tests.
 It is particularly useful in the diagnosis of brain tumor,
stroke, and multiple sclerosis, and does not involve
ionizing radiation.
 A complete MRI scan may take an hour or longer to
complete, so use in emergency situations is limited.
 Newer MRI applications allow imaging of brain blood flow
and metabolism via special imaging techniques added to
the MRI.
Diagnostic Evaluation
 Both MRI and CT images are used as tools to plan and
direct surgical intervention.
 For patient safety, the nurse must make sure that no
patient care equipment (eg, portable oxygen tanks) that
contains metal or metal parts enters the room where the
MRI is located.
 For the MRI, the patient lies with the head in a frame on a
flat platform that is moved into a tube housing the
magnet.
 The tube is narrow; persons with a wide girth may not fit
into the scanner
Diagnostic Evaluation
 The scanning process is painless, but the patient hears
loud thumping of the magnetic coils as the magnetic field
is being pulsed.
 Patients may experience claustrophobia while inside the
narrow tube; sedation may be prescribed in these
circumstances.
 The patient may be taught to use relaxation techniques
while in the scanner.
 The patient is informed that he or she will be able to talk
to the staff during the scan through a microphone inside
the scanner
Assignment
 Discuss the procedure and nursing care for the following diagnostic
evaluation (Medical surgical, pages 1852, 1853, 1854, 1855)
 Cerebral Angiography
 Myelography
 Electroencephalography
 Lumbar Puncture and Examination of Cerebrospinal Fluid
Reference
 Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's textbook of
medical-surgical nursing (Edition 13.). Wolters Kluwer Health/Lippincott
Williams & Wilkins.