Health assessment on the neurological system examination

1. PREPARED BY:
USHA RANI KANDULA,
ASSISTANT PROFESSOR,
DEPARTMENT OF ADULT HEALTH NURSING,
ARSI UNIVERSITY, ASELLA, ETHIOPIA,
EAST AFRICA.

2.  The neurological system controls or affects the
function of all body systems and allows
interaction with the external world.

3.  Its work is carried out through the transmission
of chemical and electrical signals between the
brain and the rest of the body.

4. The basic functions of the nervous system are
 cognition,
 emotion,
 memory,
 sensation and perception,
 and regulation of homeostasis.

5.  A comprehensive neurological assessment takes
hours to complete and is usually reserved for
clients with symptoms of neurological problems.

6.  As a staff nurse in general practice,
 you usually perform only portions of a
neurological exam.

7.  In the next few sections,
 we look at the components of a focused
neurological exam.

8.  When interpreting a neurological exam,
 consider the following developmental changes
and modifications:

9.  Infants Reflexes present at birth include
 rooting,
 sucking,
 palmar grasp,
 tonic neck reflex (fencing),
 and Moro.

10.  These reflexes disappear during infancy.
 With neurological injury, as may occur with
stroke or trauma, these reflexes may return,
indicating severe neurological problems.

11.  Because language skills and motor development
are age-dependent, the Denver Developmental
Screening Test (Denver II, 1990) is used as a
neurological screen for young children.

12.  The Denver II examines motor, language, and
coordination skills.

13.  It requires specialized training to administer and
evaluate.

14.  For toddlers and older children, you can usually
perform a comprehensive neurological exam
with ageappropriate modifications.

15.  For example, when testing for smell, use
materials that a young child knows, such as
bananas or apples.

16.  With advanced age, changes commonly observed
are slower reaction time, a decreased ability for
rapid problem-solving, and slower voluntary
movement.
 The number of functioning neurons decreases.

17.  However, intelligence, memory, and
discrimination do not change with normal aging.

18. Neurological deficits in older adults are usually the
result of adverse effects of
 medications or medication interactions,
 nutritional deficits,
 dehydration,

19.  cardiovascular changes that alter cerebral blood
flow,
 diabetes,
 degenerative neurological conditions.
 --e.g., Parkinson’s disease or Alzheimer’s
disease), alcohol or drug use, depression, or
abuse.

20.  Cerebral function refers to the client’s
intellectual and behavioral functioning.

21.  It includes --
 level of consciousness,
 orientation,
 mental status and
 cognitive function, and
 communication.

22.  Decreased level of consciousness is often the
first sign of neurological deterioration.
 Level of consciousness (LOC) includes arousal
and orientation.

23.  Arousal may range from alert to deeply
comatose.

24.  Arousal is classified based on the type of stimuli
(auditory, tactile, or painful) required to produce
a response from the client.

25.  An alert client responds to auditory stimuli
(e.g., verbal communication or noise).

26.  Key Point: Remember, if your client does not
speak your language he may not respond to
questions or commands.

27.  If the client does not respond to auditory stimuli,
try tactile stimuli.
 Begin with gentle touch to awaken the client
and capture attention.

28.  Be aware that many clients who have hearing
deficits lip-read to compensate.

29.  If you catch the client’s attention by touching
her hand, she may be able to respond to the
combined auditory and visual stimuli.

30.  If still no response is obtained, use painful
stimuli (e.g., squeezing the trapezius muscle).
 Clients who respond to painful stimuli withdraw
when pressure is applied.

31.  Document LOC by describing the client’s
response or by using the Glasgow Coma Scale
(GCS) to grade eye, motor, and verbal responses.

33.  The GCS evaluates eye opening, motor
responses, and verbal responses.

34.  Its limitations are that it relies heavily on vision
and verbal interaction, and does not evaluate
brainstem reflexes.

35.  A systematic review of evidence suggests that
best practice should include use of the GCS plus
other evaluation of brainstem reflexes, eye
examination, vital signs, and respiratory
assessment.

36.  A newer tool, the Full Outline of Un
Responsiveness (FOUR), provides additional
information beyond that of the GCS.

37.  If you are not using the GCS, use the following
terms to describe LOC.
 ■ Alert. Follows commands in a timely fashion.
 ■ Lethargic. Appears drowsy, easily drifts off to
sleep.

38.  ■ Stuporous. Requires vigorous stimulation
before responding.

39.  Comatose. Does not respond to verbal or painful
stimuli.

40.  Although those terms are widely used, a
thorough description is preferable. Look at the
following two chart entries:
 Example 1. Pt lethargic.

41.  Example 2. Pt responds to repeated tactile and
verbal
 stimulation. Quickly drifts off to sleep if
stimulation is discontinued.

42.  As you can see, the second charting entry
provides significantly more information than the
first.

43.  Orientation refers to the client’s awareness of
time, place, and person.

44.  Time orientation includes awareness of the year,
date, and time of day.

45.  Older adults who become disoriented to time
usually think it is an earlier date.

46.  If a client offers a bizarre time or futuristic date,
consider psychiatric concerns as the cause of
disorientation.

47.  Hospitalized patients are subjected to lights and
noise around the clock; are roused in the middle
of the night for medications or time-sensitive
treatments;

48.  and are given anesthesia and pain medications
that alter their sense of awareness, so they
easily become disoriented to time.

49.  Orientation to place involves awareness of
surroundings.
 The patient should know that he is, for example,
in the hospital and not in church.

50.  Patients who have been moved
(e.g., from the emergency department to a ward
bed) may not recall their room number but are
easily reoriented.

51.  Orientation to person involves recognition of
familiar persons and self-identity.

52.  The client should be able to state her name or
identify people in photographs at the bedside.

53.  Because a client may meet many health
professionals during a hospitalization,
 she may not be able to recall your name unless
you have had repeated encounters with her.

54.  Mental status and cognitive function include
behavior, appearance, response to stimuli,
speech, memory, communication, and judgment.

55.  By this point in the exam, you would have
already interviewed the client and talked with
him while performing the exam,

56.  so you would have a good deal of information
about his mental status and cognitive function.

57.  You would have already assessed posture, gait,
motor movements, dress, and hygiene through
the general survey and the musculoskeletal
exam;

58.  and you would be aware of the client’s mood
based on his tone of voice, actions, and
statements.

59.  Many clinicians choose to screen for mental
status and cognitive function by asking questions
of the client as they assess other body systems.

60.  This type of informal assessment helps relax the
client.

61.  If you choose this method, observe for clarity of
thought, appropriate content, concentration,
memory, and ability to perform abstract
reasoning.

62.  Normal findings include the ability to express
and explain realistic thoughts with clear speech;
speak with a smooth, natural pattern; follow
multistep directions; listen; answer questions;
and recall significant past events.

63.  Cranial nerve assessment is a key component of
the neurological exam.
 The cranial nerves control a variety of sensory
and motor functions .

64.  Deep tendon reflexes (DTRs) are automatic
responses that do not require conscious thought
from the brain.

65.  A reflex produces a rapid, involuntary response
that occurs at the level of the spinal cord.
 Because the brain is not involved, muscle
response is instantaneous.

66.  Intact sensory and motor systems are required
for a normal reflex response.
 Each DTR corresponds to a certain level of the
cord and is graded on a 0 to 4+ scale.

67.  You can elicit superficial reflexes by swiftly and
lightly stroking a body part (e.g., with the reflex
hammer).

68.  Superficial reflexes are graded as positive or
negative.

71.  To assess sensory function, ask the client to keep
his eyes closed as you apply various stimuli.

72.  Ask him to indicate when he feels a sensation.
 Vary your location and approach so that you test
sensation, not pattern recognition.

73.  If you notice an area of altered sensation,
systematically assess the area to define the
border of the change.

74.  If the client has known or suspected deficits, you
should test at numerous other sites.
 For techniques for assessing reflexes and sensory
function,

75.  The neurological system coordinates the function
of the skeleton and muscles.

76.  Motor pathways transmit information between
the brain and muscles and the muscles control
movement of the skeleton.

77.  The cerebellum helps coordinate muscle
movement, regulate muscle tone, and maintain
posture and equilibrium.

78.  The cerebellum is also largely responsible for
proprioception, or body positioning.

79.  Disorders of motor and cerebellar function result
in pain or problems with movement, gait, or
posture.

80.  Thus, when you assess the musculoskeletal
system, you also assess the motor functions of
the neurological system.