Neurological Assessment (TEST 3) – Flashcards
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Why is a neurological assessment important?
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***An Intact, appropriately functioning nervous system is critical for all human endeavors, exerts unconscious control over basic body functions, such as respirations, temp, and movement coordination, and enables very complex interactions with people and the environment
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What are the goals of a neurological assessment?
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Detection of change in neuro status, particularly acute and life-threatening alterations Localize pathology Make a medical diagnosis
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Why do nurses perform neurological assessments?
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Actual and potential health problems r/t neuro dysfunction and the patient's response to the problems
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Any SIGNIFICANT CHANGES in Neurological Status include?
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Acute change in mental status Change in LOC not explained by known cause (sedative, etc.) Seizure activity Flexor or Extensor posturing, either spontaneous or in response to noxious stimuli Change in size and decreased reactivity to light in one or both pupils. Normal 2-6mm Onset of eye deviation
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What are some other SIGNIFICANT CHANGES?
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Progressing weakness or paralysis Changes in ability to identify sensation Significant changes in vital signs
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What is included in the Abbreviated Acute Assessment?
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Rapid assessment of LOC Use of Glasgow coma scale as indicated (GCS) Pupillary reaction Gross assessment of motor strength Gross assessment of sensation Vital signs
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Glasgow coma scale
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GCS
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What to ask in a neurologic health history?
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Headaches Head injury Dizziness/vertigo, seizures, tremors Weakness, coordination and gait, numbness or tingling Difficulty swallowing, speaking: expression or comprehension of speech/language Difficulty with concentration, memory, attention span Alteration in any of the senses Past history of stroke , spinal injury, meningitis, congenitial defect, alcoholism Environmental hazards: insecticides, organic solvents, lead, illegal drugs.
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What are the history variations in infants and children?
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Prenatal History, Birth History, Respiratory Status at birth, Neonatal health, (Balance, seizures, developmental milestones, learning problems), Exposure to lead, Family History of Seizures and Muscular Dystrophy
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Mother's health, medications taken, infections, exposure to rubella, CMV, toxemia, bleeding, history of trauma or stress, HTN, drug or alcohol use
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Prenatal Hx
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Apgar scores, gestational age, birth weight, presentation, use of instruments, prolonged or precipitous labor, fetal distress
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Birth Hx
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Supplemental oxygen, resuscitation, ventilation, cyanosis, continuous apnea
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Respiratory status at birth
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infections, seizures, irritability, sucking & swallowing (poorly coordinated?)
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Neonatal Health
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What are the history variations in an Aging Adult?
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Inability to perform ADLs Social withdrawal Pattern of increased stumbling or falling, change in gait Dizziness Memory changes, confusion Tremors Vision or hearing changes LOC Fecal or urinary incontinence Transient neurologic deficits (possibly TIAs)
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How to Document Physical Appearance and Behavior
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Posture & Body movements Voluntary, deliberate, coordinated, smooth, even Dress, grooming and hygiene LOC Facial expression Symmetrical Speech Normal tone with moderate pace Mood and affect
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How to Test Cognitive Abilities and Mentation
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Orientation Attention span Recent memory/Remote memory New learning ----4 unrelated words test (Fun, carrot, ankle, loyalty) ----Recall at 5, 10, 30 minute intervals Aphasia ----Word comprehension, reading, writing
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Can copy simple drawings of objects
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Spatial Perception
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Proverb interpretation/Abstract reasoning Calculation
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Higher intellectual functions
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Assess long-term goals Unrealistic or impulse decisions
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Judgement
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How to document Thought Processes and Perceptions
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Thought processes Logical, illogical, unrealistic Thought content Consistent and logical Perceptions Aware of reality, illusions, hallucinations Suicidal Ideations
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Neuro exam should be done when the infant is in a?
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quiet, alert state
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What to observe in infants?
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Observe spontaneous activity for symmetry and smoothness of movement
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How to test sensory integrity in infants?
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All limbs to painful stimuli
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How to test deep tendon reflexes in infants?
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Babinski reflex---normal until 16 to 24 months
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What are the history variations in Children?
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Denver II Developmental test, measures fine & gross motor, language and personal-social skills Observe play for gait and fine motor coordination Deep tendon reflexes Behavioral checklist Mood, play, school, friends & family relations Cognitive Psychological development Coping with environment Neurological soft signs
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***Controversial b/c do not always indicate pathology. ***They are nonfocal, functional neurological findings that often provide subtle clues to an underlying CNS deficit or a neurological maturation delay. Children with multiple soft signs often have learning disabilities ***Soft signs include but are not limited to: Short attention span Poor coordination of position Hypopactivity/Hyperactivity Impulsiveness Labile emotions Distractibility No demonstration of handedness Language and articulation problems
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Neurological Soft Signs
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What are the history variations during Pregnancy?
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***Exam same as adult ***Deep tendon reflexes Baseline evaluation should be done at initial prenatal visit Preclampsia - exaggerated deep tendon reflexes
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What are the history variations in the Elderly?
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Always assess sensory function first Allow more time for maneuvers of coordination and movement Diminished sense of smell and taste
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Shuffle (flexion hip/knees)
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Gait (in Elderly)
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What may be diminished in the Elderly?
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Tactile, vibratory and position sensation
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Less brisk or absent
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Deep tendon reflexes (in Elderly)
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LOC: Glascow Coma Scale
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Assessing Behavior (in Elderly)
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Glascow Coma Scale (in Elderly)
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Used for older adults at risk for falls
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Tinetti Balance and Gait Assessment Tool
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Orientation New learning: avg 2 of 4 words after 5 minutes. Will improve with verbal cues.
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Cognitive Funtion (in Elderly)
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verbal test to screen for dementia, name 10 items in four categories-fruits, animals, colors, towns Max score = 40, dementia <15
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Set Test (in Elderly)
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Most widely used scoring system for quantifying LOC Simple, high degree of interobserver reliability, correlates well with outcome following severe brain injury Numeric score reflects the sum of: E - _____________ opening response V - ________________ response M - __________________ response
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Glascow Coma Scale (emphasized) E-EYE V-VERBAL M-MOTOR
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Total possible score = 15. Document as 15/15 Score of 15 = FULLY ALERT STATE. Scores less than 7 reflect coma May alternately document each category as: E4 V5 M6 Particularly useful when limitations are present Patient that is intubated Spinal cord injury Severe orbital trauma
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Glascow Documentation
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Limited utility in children, especially under 36 months
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Pediatric Glascow
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Olfactory -Smell
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Cranial Nerve I
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Optic -Visual acuity, visual fields -Examine ocular fundus for color, size, and shape of optic disk
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Cranial Nerve II
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Oculomotor -Pupillary reaction -Eyelid elevation -Most EOM - 6 cardinal gazes
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Cranial Nerve III
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Trochlear -Downward and inward eye movement
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Cranial Nerve IV
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Trigeminal -Jaw movement -Sensation to eyes, corneal reflex -Sensation of touch, pain, and temperature to face
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Cranial Nerve V
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Abducens -Lateral Eye Movement
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Cranial Nerve VI
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Facial -Facial movement -Taste---anterior 2/3 of tongue
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Cranial Nerve VII
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Acoustic -Hearing and Equilibrium
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Cranial Nerve VIII
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Glossopharyngeal -Voluntary muscles for swallowing and phonation -Sensation of nasopharynx, gag reflex -Taste posterior 1/3 of tongue -Secretion of salivary glands -Carotid reflex
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Cranial Nerve IX
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Vagus Voluntary muscles of phonation and swallowing Sensation behind ear and part of ear canal Secretion of digestive enzymes, peristalsis, and carotid reflex Involuntary action of heart, lungs and digestive tract
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Cranial Nerve X
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Spinal Accessory -Sternomastoid and trapezius muscles, size and strength -Turn head, shrug shoulders
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Cranial Nerve XI
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Hypoglossal -Tongue movement, lingual sounds -Have pt. say "light, tight, dynamite"
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Cranial Nerve XII
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Inspect and palpate muscles (when inspecting motor system)
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Size, strength, tone, ROM, involuntary movements (tic, tremor)
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Cerebellar function (when inspecting motor system)
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---Balance tests Observe gait Romberg test (stand with eyes closed) Shallow knee bend or hop in place ---Coordination and skilled movements Rapid alternating movements (RAM) Thumb to each finger Finger to finger Finger to nose Heel to shin
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Testing Sensory System
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Compare sensations on symmetric parts of the body Decreased sensation to sensitive areas (map borders) Spinothalamic tract (eyes closed) ---Pain ---Temperature ---Light touch
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Move Extremities
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Testing Position (Kinesthesia)
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Fine Touch
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Testing Tactile discrimination
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Eyes closed id objects held
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Testing Stereognosis
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Id traced number in palm
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Testing Graphesthesia
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Ability to distinguish two simultaneous pin pricks (will not do) **More sensitive on fingertips, less on upper arms, thighs, and back
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Testing Two-Point Discrimination
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Simultaneously touch both sides of the body
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Testing Extinction
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Point where touched
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Testing Point Location
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How to document Deep Tendon Reflexes
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4+ - Very brisk 3+ - Brisker than average 2+ - Normal 1+ - Diminished 0 - Absent
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Where to test reflexes
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Biceps Triceps Brachioradialis Quadriceps Archilles Plantar (Babinski's) Positive Babinski's = fanning of toes
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Infant Motor System variations
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Motor system Smooth and symmetrical movements Denver II for gross and fine motor coordination Muscle tone
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Testing for Muscle Tone in Infants (birth to 12 months)
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Extremities are symmetrically folded inward, hips slightly abducted, fists are tightly flexed. Breech babies, do not have flexion in lower extremities, frog position Landau reflex-raises head and arches back
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Variations in Infants
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Sensory system Hypoesthesia, respond by crying or withdrawal Reflexes Rooting - 3-4 months Sucking - 10-12 mths Palmar grasp - 3-4 mths Plantar grasp - 8-10 mths Babinski's (positive Babinski's until age 2) Tonic neck (fencing position) occurs from 2-6 mths Moro reflex - startle reflex Placing reflex - hold under arms, top of foot touches underside of table, baby flexes hip and knee, then extends hip, to place foot on table - 4 days p birth Stepping reflex - disappears before voluntary walking
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Alert Lethargic Obtunded Stupor (Semi-coma) Coma
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LOC Terminology
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Drowsy state, may have decreased cough or gag reflex
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Obtunded
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a state of near-unconsciousness or insensibility.
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Stupor
