The document discusses assessment of the neurological system in adults. It outlines important information to gather prior to assessment, such as the location and effect of any lesions. The assessment examines level of consciousness, cranial nerves, motor function, reflexes, and more. Tests include the Glascow Coma Scale and evaluating responses of the central nervous system, peripheral nervous system, and specific areas like the cerebral cortex. The goal is to identify any abnormal signs or symptoms and select proper interventions.
2. Assessment is one of the key factors that
provides the information a nurse needs to
provide good, quality health care.
Key Points: Purpose for Assessment,
Assessment Guidelines, Intervention
options, and Possible Outcomes
Advanced Assessment Practices Specified
to Neurological System on Adult
Population
3. Important information to know prior to
assessment
• Location, nature, and effect of the lesion or area of
the nervous system.
• After assessment the clinician will be able to
identify trouble areas affecting the nervous
system, abnormal signs and symptoms of the
patient, and be able to select proper interventions
4. Level of Consciousness
(LOC)
• Arousal Level
• Orientation
Glascow Coma Scale (GCS)
• Eye Response
• Verbal Response
• Motor Response
Cranial Nerves
• 12 pairs of Cranial Nerves
Motor Function
• Commands
• Body Movements
Reflexes
• Superficial Reflexes
• Pathologic
• Visceral
• Deep Tendon Reflexes
Autonomic Responses
• Sympathetic Nervous System
• Parasympathetic Nervous
System
Pain Stimuli
• Central
• Peripheral
Vital Signs
5. Central Nervous
System
• Cerebral Cortex
• Cerebellum
• Basal Ganglia
• Hypothalamus
• Thalamus
• Brain Stem
• Spinal Cord
Peripheral Nervous
System
• Reflex Arc
• Cranial Nerves
• Spinal Nerves
• Autonomic Nervous
System
6. Cerebral Cortex
• Responsible for highest functioning behaviors
Thought
Reasoning
Sensation
Voluntary Movement
• Divided into two hemispheres and four lobes
Left and Right hemisphere
95% of the population is Left Dominant
Four Lobes
Frontal: Behavior, Emotions, Intellectual Function
Temporal: Auditory, Taste, Smell
Parietal: Sensory
Occipital: Vision
7. Cerebellum
• Controls motor coordination of voluntary muscle
movements, muscle tone, and equilibrium
Basal Ganglia
• Controls automatic associated movements of the body
Hypothalamus
• Control over many vital functions: Temperature, heart
rate, and blood pressure control. Also regulates sleep
center, pituitary gland hormonal release, and
coordination of autonomic nervous system activity and
emotional status
8. Thalamus
• “Main Relay Station” for the nervous system;
Sensory pathways of the spinal cord and
brainstem form synapses; conduction of nerve
impulses to the appropriate areas.
9. Brain Stem
• Composed of: Midbrain, Pons, and Medulla
Midbrain: merges spinal cord transmissions to the thalamus
and hypothalamus; it contains many motor neurons and
tracts
Pons: enlarged area containing fiber tracts, ascending and
descending.
Medulla: continuation of spinal cord, contains fiber tracts that
control autonomic functions (i.e. respiration, heart rate, GI
function); also location pyramidal decussation: the crossing
of nerve fibers (Left to Right motor movement=Inverse
relations ship L and R hemisphere).
10. Spinal Cord
• Responsible for sending nerve impulses from
spinal nerves to the brain; allowing a link from the
brain to the body.
• Dermatome Chart: A chart that displays
correlations between certain areas of skin to
particular spinal cord segments. (see pg. 662)
11. Dermatome – a circumscribed skin area
that is supplied mainly from one spinal
cord segment through a particular spinal
nerve.
Dermatome assessment involves
sensation to particular parts of the body in
regards to spinal cord involvement. Usually
assessed when injury to spinal cord
occurs. Each level assessed can pinpoint
the level of injury.
12. 12 pairs of Cranial Nerves: Labeled I-XII (use of Roman
Numerals)
I – Olfactory Nerve
• Travels through the Cribiform plate
• Sensation Tested: Smell
II – Optic Nerve
• Travels through the optic canal
• Sensation Tested: Sight
III – Oculomotor
• Travels through the Superior Orbital Fissure
• Somatic Motor Tested: Movement of superior, medial, inferior
rectus and inferior oblique muscle attached to the eye
(Extraocular Movements: EOM’s)
• Visceral Motor Tested: Sphincter Pupillae (Dilation and
constriction of pupils to light
13. IV – Trochlear Nerve
• Travels through the Superior Orbital Fissure
• Somatic Motor Tested: Movement of superior oblique
muscle movement (EOM’s)
V – Trigeminal Nerve
• Composed of several nerves labeled V1, V2, and V3
• V1 travels through the superior orbital fissure
• V2 travels through the foramen rotundum
• V3 travels through the foramen ovale
• Somatic Motor Tested: Mastication (chewing), Tensor
Tympani (located in auditory canal: Dampens extra
sounds), and Tensor Palati (assists with chewing)
• Sensation Tested: Feeling to the Face
14. VI – Abducens Nerve
• Travels through the superior orbital fissure
• Somatic Motor Tested: Lateral Rectus (Lateral EOM’s)
VII – Facial Nerve
• Travels through the Internal Auditory Canal
• Somatic Sensory Tested: Posterior External Ear Canal
• Special Sensory Tested: Taste (involves 2/3 of the anterior
tongue)
• Somatic Motor Tested: Facial movement and expressions
• Visceral Motor Tested: Salivary Glands and Lacrimal
Glands
VIII – Vestibulocochlear Nerve
• Travels through the Internal Auditory Canal
• Special Sensory Tested: Auditory and Balance
15. IX – Glossopharyngeal Nerve
• Travels through the Jugular Foramen
• Somatic Sensory Tested: 1/3 of the posterior
tongue and Middle Ear
• Visceral Sensory Tested: Carotid body and sinus
• Special Sensory Tested: Taste (Posterior 1/3 of
the tongue
• Somatic Motor Tested: Stylopharyngeas (dilates
esophagus to facilitate swallowing large food
bolus)
• Visceral Motor Tested: Parotid Gland (salivation)
16. X – Vagus Nerve
• Travels through the Jugular Foramen
• Somatic Sensory Tested: External Ear
• Visceral Sensory Tested: Aortic Arch/Body
• Special Sensory Tested: Taste over the Epiglottis
• Somatic Motor Tested: Soft palate, pharynx, and
Larynx (vocalization and swallowing)
• Visceral Motor Tested: Bronchoconstriction,
Peristalsis, Bradycardia, and Vomitting
17. XI – Spinal Accessory Nerve
• Travels through the Jugular Foramen
• Somatic Motor Tested: Trapezius and
Sternocleidomastoid movement (shoulder shrug)
XII – Hypoglossal Nerve
• Travels through the Hypoglossal Canal
• Somatic Motor Tested: Tongue Movement
18. Tools Needed to perform assessment
• Pen light
• Cotton swabs with wooden handle
• Reflex Hammer
• Tuning Fork
Breakdown of Exam
• Mental Status (Level of Consciousness and Orientation)
• Cranial Nerves
• Motor (Fine Motor and Gross Motor movements)
• Coordination and Gait
• Reflexes
• Sensory (Dermatomes)
• Special Tests (snellen chart and tuning fork)
19. Level of Consciousness Terms
Full Level of Consciousness: Awake, Alert, and Attentive; if patient is
sleeping, easily awaken to minor external stimulus
Lethargy: Awake but Drowsy, not fully attentive, slow response
Obtunded: Not easily awaken, requires repeated stimulus to keep
attention, slow to answer questions, will drift to sleep frequently, difficulty
following simple commands
Stupor: Constant stimulus needed, usually painful stimuli needed, no
commands, no attention span, minimal response from patient
Coma: No response from patient on cognitive level, even with constant
painful stimuli, no motor movement unless spinal reflex; unable to
arouse patient
Glascow Coma Scale: Assessment tool that checks patient arousal,
orientation, and motor function
20. Arousal Level
• Arousal to stimuli or no stimuli
Opens eyes spontaneously (No stimulus needed)
Auditory Stimuli (voice)
Tactile Stimuli (gentle touch or shake)
Painful Stimuli (Peripheral or Central)
• Response to Stimuli
Purposeful (moves away from stimuli, location of stimuli)
Non-purposeful (Spontaneous movements disregard of stimuli or posturing:
Decerebration or Decortication)
Unresponsive (no response to any stimuli)
• Orientation
Ability to answer questions regarding memory
Name
Place (Location)
Time (time, day, month, or year)
Situation (why patient is needing exam)
Editor's Notes
Neuroscience of Nursing Ellen Barker, pg 53
Barker pg 54
Advanced Health Assessment, Jarvis Chapter 23, pg 660-662
Advanced Health Assessment, Jarvis pg 656
Advanced Health Assessment, Jarvis pg. 657
Advanced Health Assessment, Jarvis pg 657
Advanced Health Assessment, Jarvis pg 657 and pg 662
Cranial Nerves website
Cranial Nerve Website
Neurological Examination Website
Patty Noah, RN MSN CNRN, Neurological Assessment: Refresher, http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=120796, published online: September 1, 2004