ASSESSMENT OF THE NEUROLOGIC SYSTEM More than 10 minutes of oxygen deprivation-brain death

-assessment of the neurologic system is a challenge

because of the complexity of the nervous system. Mean arterial pressure at which autoregulation is effective
Neurologic assessment becomes multifaceted and lengthy. (70-105 mmHg)
-Upper limit is 150 mmHg
Perception-conscious recognition and interpretation
(awareness) of the sensory stimuli that serve as a basis for MAP= SBP + 2 (DBP)
understanding, learning and knowing or for the motivation 3
of a particular action or reaction Cerebral perfusion pressure needed to ensure blood flow to
the brain
Coordination-when action or reaction towards a stimulus is CPP= MAP-ICP
occurring in a purposeful, orderly fashion, appropriate -30 mmHg is incompatible with life
response to a stimulus
Cranium and Cerebral column
3 essential components of skull:
1. Brain tissue-78% Cranial meninges
2. Blood -12 % Dura mater
3. CSF-10% Arachnoid
Pia mater
Monro-Kellie Hypothesis
If volume added to the cranial vault equals the volume Falx cerebri-divides the
displaced from it, the total intracranial volume will not left from right
change hemispheres
Normal ICP: 60-150 mmH20 or 0-15 mmHg Subdural-more bleeding
Cerebral Blood Flow NEUROLOGIC ASSESSMENT
Amount of blood in milliliters passing through Comprehensive History Taking
100g of brain tissue in 1 minute 1. Biographical and demographic data- it includes personal
Global CBF-approximately 50 ml/min profile of the patient, source of history and the clients
Brain needs constant supply of oxygen and mental status
glucose (20% of bodys oxygen, 25% of bodys 2. Current health
glucose)
a. Chief complaint- obtains a detailed description of the Mental Status Examination
event that have led the client to seek care. Use open An indication of how patient is functioning as a whole and
ended question. how the patient is adapting to the environment
b. Symptom analysis- 1. General appearance-
3. Past health history 2. Intellectual capacity or performance- consists of fund
a. Childhood infectious disease and immunizations of knowledge and calculation activity
Rubella and rubeola 3. LOC-the most sensitive indicator of changes in the
Meningitis neurologic status
Herpes simplex virus -begin by observing spontaneous behavior
cytomegalovirus -visual cue
influenza -verbal cues
b. Major illnesses and hospitalizations -tactile
-Noxious agent- use of central stimulus rather than
Pernicious anemia
peripheral (nail bed pressure) because it may elicit a
Cancer reflex
DM a. sterna pressure
Infections b. supraorbital ridge pressure
Hypertension c. sternocleidomastoid muscle pinch
Liver and renal disease 4. Orientation- to time, place and event or situation
F & E imbalances 5. Memory- retrograde (long-term memory) and
Acid-Base Imbalances anterograde (recent memory or short-term)
Head trauma 6. Mood/affect
Seizures and stroke 7. Judgment/Insight- include reasoning, abstract
c. Medications- thinking, problem solving and the clients perception
CNS stimulants of the situation.
Sedatives and hypnotics 8. Language/communication
Antideppressives
MENTAL STATUS ASSESSMENT WITH ABNORMAL
Analgesics
FINDINGS
Anti hypertensive and stroke
d. Growth and development
Unilateral neglect (lack of caring of the other side of the
body); strokes involving middle cerebral artery.
 Poor hygiene and grooming: dementing disorders
Abnormal gait and posture: transient ischemic
attacks(TIAs) , strokes, and Parkinsons disease
Emotional swings, personality changes: strokes
Aphasia-defective or absent language function: TIAs,
strokes involving anterior/posterior artery; general term
for impairment of language
Dysphonia- change in tone of voice
Dysarthria- (different in speaking); is indistinctness of
words in word articulation resulting from interference
with the peripheral speech mechanisms (e.g. muscles of
the tongue, palate, pharynx, or lips) [Phipps, 1998, p.
1901]
Decreased level of consciousness
Confusion, Coma
COGNITIVE FUNCTION ASSESSMENT WITH
ABNORMAL FINDINGS
Disorientation to time and place: stroke of right cerebral
hemisphere
1. Memory deficits
2. Emotional defense
CRANIAL NERVE ASSESSMENTS
Cranial I (Olfactory): Anosmia
1. lesions of frontal lobes
2. impaired blood flow to middle cerebral artery.
Cranial II (Optic)
1. blindness in eye: strokes of internal carotid
artery, TIAs
2. Homonymous hemianopia - impaired vision or
blindness in one side of both eyes; blockage of
posterior cerebral artery.
3. Impaired vision: strokes of anterior cerebral
artery; brain tumors
Note:
Visual acuity-mediated by the cones of the
retina
Field of vision or peripheral vision-portion of
space in which objects are visible during the
fixation of vision in one direction. The
receptors for peripheral fields are the rod
neurons of the retina. (Phipps, 1998, p. 1906)
Cranial nerve III, IV, VI (Oculomotor, Trochlear,
Abducens)-motor nerves that arise from the brainstem
1. Nystagmus - involuntary eye movement;
strokes of anterior, inferior, superior, cerebellar
arteries
2. Constricted pupils: may signify impaired blood
flow to vertebralbasilar arteries.
3. Ptosis (eyelid falldown); dropping of the upper
eyelid over the globestrokes of posterior
inferior cerebellar artery; myasthenia gravis,
palsy of CN III
Cranial nerve V (Trigeminal)largest cranial nerve with
motor and sensory components: changes in facial sensations;
impaired blood flow to carotid artery
1. Decreased sensation of face and cornea on same side
of body; strokes of posterior inferior cerebral artery
2. Lip and mouth numbness
3. Loss of facial sensation: contraction of masseter and
temporal muscles, lesions CN V
4. Severe facial pain: trigeminal neuralgia (tic dorlourex)
Cranial VII (Facial nerve)mixed nerve concerned with
facial movement and sensation of taste
1. Loss of ability to taste
 2. Decreased movement of facial muscles
3. Inability to close eyes, flat nasolabial fold, paralysis
of lower face, inability to wrinkle the forehead
4. Eyelid weakness; paralysis of lower face; paralysis of
upper motor neuron
5. Pain, paralysis, sagging of facial muscles: affected
side in Bells palsy
Cranial VIII (Acoustic)composed of a cochlear division
related to hearing and a vestibular division related to
equilibrium (Phipps, 1998, p. 1909)
Decreased hearing or deafness: strokes of
vertebralbasilar arteries or tumors of CN VIII
Cranial IX(Glossopharyngeal) and cranial X (Vagus)chief
function of cranial nerve IX is sensory to the pharynx and
taste to the posterior third of tongue; cranial nerve X is the
chief motor nerve to the soft palatal, pharyngeal and
laryngeal muscles (Phipps, 1998, p. 1909)
1. Dysphagia (difficulty swallowing)
2. Unilateral loss of gag reflex
Cranial XI (Spinal accessory)motor nerve that supplies
the sternocleidomastoid muscle and upper part of trapezius
muscles
1. Muscle weakness
2. Cortralateral hemiparesis: strokes affecting middle
cerebral artery and internal artery
Cranial XII (Hypoglossal)
1. Atrophy, fasciculations (twitches): LMN disease
2. Tongue deviation toward involved side of the body
SENSORY FUNCTION ASSESSMENT WITH
ABNORMAL FINDINGS
Altered sensation occurs with variety of neurologic
pathology
Altered sense of position: lesions of posterior column of
spinal cord
Inability to discriminate fine touch: injury to posterior
columns
MOTOR FUNCTION ASSESSMENT WITH ABNORMAL
FINDINGS
Muscle atrophy: LMNs disease
Tremors (groups, large of muscle fibers)-Parkinsons disease
(tremors at rest), multiple sclerosis (tremors observed in
activity)
Fasciculations (single muscle fiber): disease or trauma to
LMN, side effects of medications, fever, sodium deficiency,
anemia
Flaccidity (decreased muscle tone): disease or trauma to
LMN and early stroke
Spasticity (increased muscle tone): disease of corticospinal
motor tract
Muscle rigidity: disease of EP motor tract
Cogwheel rigidity (muscular movement with small regular
jerky movement; parkinsons disease
Muscle weakness-in arms, legs, hands: TIAs
Hemiplegia-paralysis of half of body vertically
Flaccid paralysis: strokes of anterior spinal artery, multiple
sclerosis or myasthenia gravis
Total loss of motor function: below level of injury
Spasticity of muscle: incomplete cord injuries
CEREBELLAR FUNCTION ASSESSMENT WITH
ABNORMAL FINDINGS
Ataxia (lack of coordination and clumsiness of movement,
staggering, wide-based and unbalanced gait)
Steppage gait (client drags or lifts foot high, then slaps foot
onto floor; inability to walk on heels; disease of LMN
Sensory ataxia (client walks on heels before bringing down
toes and feet are held wide apart; gait worsens with eyes Positive Kernigs sign-excessive pain when examiner
closed attempts to straighten knees with client
Parkinsonian gait (stooped over position while walking with supine and knees and hips flexed
shuffling gait with arms held close to the side)
Rombergs test (Positive)- With feet approximated, the
patient stands with eyes open and then closed; if closing the
eyes increases the unsteadiness, a loss of proprioceptive
control is indicated

REFLEX Decorticate posturing (up)- decorticate response, mummy

Hyperactive: reflexes baby, flexor posturing- damage to mesencephalic region and
Decreased reflexes the corticospinal tract
Clonus of foot (Hyperactive, rhythmic dorsiflexion and
plantar flexion of foot)
Superficial reflexes (such as abdominal) and cremasteric
reflex
Positive Babinski reflex (dorsiflexion of big toe)
(plantiflexion- Normal)
Decerebrate posturing (down)- extensor posturing- the head
is arched back, the arms are extended by the sides, and the
legs are extended. Decerebrate posturing indicates brain
stem damage or rather damage below the level of the red
Special Neurologic Assessment nucleus (eg. mid-collicular lesion)
Brudzinskis sign (pain, resistance, flexion of hips and knees
#Altered Level of consciousness
when head flexed to chest with client supine)
1. Consciousness
Requires:
1. Arousal: alertness; dependent upon reticular
activating system (RAS); system of neurons in
thalamus and upper brain stem
 2. Cognition: complex process, involving all c. Orientation changes: losses orientation to time first,
mental activities; controlled by cerebral then place, person
hemispheres d. Continuous stimulation required to maintain
wakefulness
Process that affect LOC: e. Client has no response, even to painful stimulation
a. Increased ICP
b. Stroke, hematoma, intracranial hemorrhage Loss of Simultaneous Eye Movement
c. Tumors Loss of normal reflex functioning:
d. Infections 1. Dolls eye movement: eye movement in opposite
e. Demyelinating disorders direction of head rotation (normal function of brain
stem)
Systemic Conditions affecting LOC 2. Oculocephalic reflex: eye move upward with passive
Hypoglycemia flexion of neck; downward with passive neck
F/E imbalance extension (normal function)
Accumulated waste products from liver or renal 3. Oculovestibular response (cold caloric testing):
failure instillation of cold water in ear canal cause nystagmus
Drugs affecting CNS: alcohol, analgesics, (lateral tonic deviation of eyes) toward stimulus
anesthetics (normal function)
Seizure activity: exhausts energy metabolites
Level of Consciousness
Alert
Lethargic-very sleepy
Obtunded Glasgow Coma Scale
Stuporous 1 2 3 4 5 6
Coma Opens eyes
E Opens eyes in
Death ye
Does not in response
response to
Opens eyes
N/A N/A
open eyes to painful spontaneously
s voice
Client Assessment with Decreased LOC stimuli
V
a. Increased stimulation required to elicit response from Incomprehe Utters Oriented,
er Makes no Confused,
client ba sounds
nsible inappropriate
disoriented
converses N/A
b. More difficult to arouse; client agitated and confused sounds words normally
l
when awakened M Makes no Extension to Abnormal Flexion / Localizes Obeys
o
painful flexion to c. Movements are more generalized and less purposeful
stimuli painful stimuli Withdrawal to painful (withdrawal, grimacing)
t movements commands
(decerebrate (decorticate painful stimuli stimuli d. Reflexive motor responses
or
response) response)
e. Flaccid with little or no motor response

COMA

Use CPOMR to evaluate the lesion

Interpretation
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".
Generally, brain injury is classified as:
Severe, with GCS 8
Moderate, GCS 9 - 12
Minor, GCS 13.
Intubation and severe facial/eye swelling or damage makes
it impossible to test the verbal and eye responses. In these
circumstances, the score is given as 1 with a modifier
attached e.g. 'E1c' where 'c' = closed, or 'V1t' where t = tube.
A composite might be 'GCS 5tc'. This would mean, for
example, eyes closed because of swelling = 1, intubated = 1,
leaving a motor score of 3 for 'abnormal flexion'. Often the 1
is left out, so the scale reads Ec or Vt.
MOTOR FUNCTION ASSESSMENT
a. Client follows verbal commands
b. Pushes away purposely from noxious stimuli
C: Conscious
P: Pupil
O: Ocular movement
M: Motor response
R: Respiratory pattern
Irreversible coma - vegetative state
Permanent condition of complete unawareness of self and
environment, death of cerebral hemispheres with continued
function of brain stem and cerebellum
Client does not respond meaningfully to environment but
has sleep-wake cycles and retains ability to chew, swallow
and cough
Eyes may wander but cannot track objects
Minimally conscious state: client aware of environment, can
follow simple commands, indicates yes/no responses; make
meaningful movements (blink, smile)
Often results from severe head injury or global anoxia
Locked-in syndrome
1. Client is alert and fully aware of environment; intact
cognitive abilities but unable to communicate through
speech or movement because of blocked efferent
pathways from brain
 2. Motor paralysis but cranial nerves may be intact
allowing client to communicate through eye
movement and blinking
3. Occurs with hemorrhage or infarction of pons,
disorders of lower motor neurons or muscles
Brain Death
1. Cessation and irreversibility of all brain functions
2. General criteria:
a. Absent motor and reflex movements
b. Apnea
c. Fixed and dilated pupils
d. No ocular responses to head turning and caloric
stimulation
e. Flat EEG
Papilledema-due to the compression of optic disc
Respiratory changes-dependent on site of pressure
Motor changes-dependent on site of pressure;
usually starts contralaterally; then hemiplegia,
decortication or decerebation depending on
pressure on brain stem
Late signs: coma, apnea, unilateral pupil changes
ICP monitoring
Continuous intracranial pressure monitor is used for
continual assessment of ICP and to monitor effects of
medical therapy and nursing interventions

STROKE
ICP
Increased blood volume, increased brain volume, increased Right brain damage Left brain damage
CSF volume Paralyzed left Paralyzed right
Normal pressure: 5-15 mmHg, with pressure tranducer with side side
head elevated 30; 60-180 cmH20, water manometer with Spatial- Impaired
client lateral recumbent perceptual deficits speech/language
Tend to deny or Impaired right
Manifestations: minimize problems and left
Decreasing level of sensorium-most sensitive, Impaired discrimination
reliable and earliest indicator: due to cerebral judgment Aware of
hypoxia, interference with RAS function Impaired time deficits, depression,
Increasing BP, decreasing pulse concepts anxiety
Pupillary changes (a reflection of tissue shifts Short term span Impaired
Cushings triad-increasing systolic pressure, comprehension
widening pulse pressure and bradycardia (final Slow
compensatory mechanism to maintain CSF) performance,
 cautious above C4 respiration
C5 Neck, Arm, chest,
SPINAL CORD INJURY scapular all below
A. Early symptoms of spinal shock elevation chest
Absence of reflexes below level of lesion C6-C7 Neck, some Some arm,
Flaccid paralysis below level of injury chest fingers, some
Hypotonia results in bowel and bladder distention movement, chest
Inability to perspire in affected parts some arm movement all
Hypotension movement below chest
Thoracic Neck, arms Trunk, all
B. Later symptoms of spinal cord injury (full), some below chest
Reflex hyperexcitability chest
State of diminished reflex hyperexcitability below Lumbo- Neck, arms, Legs
site in all instances of cord damage following sacral chest, turnk
hyperreflexia
In total cord damage-loss of motor and sensory
function is permanent
Sacral region-atonic bladder and bowel with
impairment of sphincter control
Lumbar region- spastic bladder and loss of bladder
and anal sphincter control
Thoracic-trunk below the diaphragm
Cervical-from neck down, if above C4 respirations
and depressed
In partial cord damage, depends on the type of
neurons affected (spastic vs. flaccid)

MUSCLE FUNCTION AFTER SPINAL CORD INJURY

(((log-rolling)
Spinal Cord Muscle Muscle
Injury Functioning Function
remaining Loss
Cervical, None All including