Care of the client with 1

Neurological problems
Part 1 -- Assessment
Presented by: Professor Fordham, MSN

NUR224

Revised 03/28/17
Lets review the Assessment 2
of the Nervous System
Health history
Initial interview
Present illness
Chief complaint
Past Medical History
History of falls
History of trauma
Current Medication --prescribed and over the
counter
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Common Symptoms for 3
Neurological Disorders

Common symptoms
Pain
Seizures
Dizziness and vertigo
Visual disturbances
Abnormal sensation
Muscle weakness

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Lets now review neurological 4
physical assessment

Neurologic examination is a systematic process

that includes:
Clinical tests
Observations
Assessments

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Assessing Level of Consciousness 5

Alert and oriented

Responds to verbal stimulus
Unresponsive
Responds to pain

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Lets review neurological 6

physical assessment

Neurological assessment is divided into five

components:
Consciousness and cognition
Cranial nerves
Motor system
Sensory system
Reflexes

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Assessing Consciousness and 7

Cognition

Cerebral abnormalities may cause disturbances

in:
mental status
intellectual functioning
thought content
emotional status

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Assessing Consciousness and 8
Cognition

Should be assessed upon initial contact with

your client and continuously monitored for
changes throughout your contact with the
client
The nurse should record and report specific
observations regarding and changes over time
Alterations should be described in specific and
nonjudgmental terms

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Assessing Consciousness and 9
Cognition
cont
Mental status
Does the client appear to be aware of and interact
with surroundings?
What is the clients appearance and behavior?
Note dress, grooming, and personal hygiene
What is the clients posture, gestures, movements and
facial expression

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 10
Assessing Consciousness and Cognition cont

Intellectual function
Average intelligence quotient (IQ)
Can repeat 7 digits without faltering
Can repeat 5 digits backwards
Test for abstract reasoning
Higher level of intellectual function
Do you know what is meant by A stitch in time save nine?

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Assessing Consciousness and Cognition 11
cont

Intellectual function (may have frontal cortex)

Questions designed to assess this capacity might include:
How are a mouse and a dog or pen and pencil alike?

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 Assessing Consciousness and 12
Cognition cont
Thought Content
Are the clients thoughts spontaneous, natural, clear, relevant,
and coherent?
Emotional Status
Mood
Depressed
Agitated
Euphoric
Anxious

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Assessing Consciousness and Cognition cont 13

Language ability
Can the client understand spoken and written language?
Is the client experiencing aphasia?

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 14
Assessing Consciousness and Cognition cont

Impact on Lifestyle
Nurse assesses the impact of any impairment on lifestyle
Level of consciousness (LOC)
Consciousness is the clients wakefulness and ability to
respond to the environment
LOC is most sensitive indicator of neurologic function
Observe alertness and ability to follow commands

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What are the components of the 15

Peripheral Nervous System

The cranial nerves

The spinal nerves

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 Peripheral Nervous System 16

The autonomic nervous system

Sympathetic
fight or flight response
Main neurotransmitter is norepinephrine (noradrenaline)
Sympathetic discharge releases adrenalin (epinephrine)
Parasympathetic
Controls most visceral functions
Primary neurotransmitter is acetylcholine

See table 65-3 ANS page 1917

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 17

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 18

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Cranial Nerves 19

12 pairs of cranial nerves

Cranial nerves are numbered in the order in
which they arise from the brain

See page 1915 Table 65-2

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 20

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Some Equipment Used in Cranial 21

Nerve Assessment

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 Cranial Nerve I 22

Olfactory (I)
May be assessed by evaluating the clients sense of smell
Sensory, smell
Have the client close the eyes and occlude one nostril with finger
Ask the client to smell and identify odors such as coffee, tea,
cloves, toothpaste, orange, and peppermint with each nostril and
eyes closed
Normal Response
Client is able to identify smell with each nostril separately and with
eyes closed unless such condition like a cold is present

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 23

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 Cranial Nerve II 24

Optic (II)
Sensory
Vision
Assess visual acuity with a Snellen chart
Check color vision by asking the client to name the colors of several nearby
objects
Check visual fields
Examiner slowly moves his or her finger from the periphery toward the center
until the client states it can be seen
Significant findings include:
Visual field defects
Decreased visual acuity or blindness
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 25

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 Cranial Nerve III 26

Oculomotor (III)
Test eye movement toward the nose
Inspect for conjugate movements and nystagmus
Evaluate pupil size
Test for pupillary reactivity to light
Inspect ability to open eyelids

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 Cranial Nerve 27

Oculomotor cont
Significance:
Dysconjugate gaze
eyes not both fixated on the same point
Gaze weakness or paralysis
Double vision
Dilated pupils
With or without impaired pupillary reaction to light
Inability to open the affected eyelid

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 Cranial Nerve IV 28

Trochlear (IV) Motor

Facial sensation, corneal reflex, mastication
Test for upward eye movement
Inspect for conjugate movements and nystagmus
Significance findings include:
Dysconjugate gaze
Gaze weakness or paralysis
Double vision

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 Cranial Nerve V 29

Trigeminal (V)
Have client close the eyes
Touch cotton to forehead, cheeks, and jaw
Sensitivity to superficial pain is tested in these same three
areas by using sharp and dull ends of a broken tongue blade
Alternate between sharp and dull with each movement
If responses are incorrect, test for temperature sensation

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 Cranial Nerve 30

Trigeminal cont
While the client looks up, light touch a wisp of cotton against
the temporal surface of each cornea
A blink and tearing are normal responses
Have the client clench and move the jaw from side to side.
Palpate the masseter and temporal muscles, noting strength
and equality

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 Cranial Nerve 31

Significant findings include:

Impaired or absent corneal reflex, facial numbness, and jaw
weakness

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 Cranial Nerve VI 32

Abducens (VI)
Muscles that move the eye
Test for lateral eye movement
Inspect for conjugate movement
Significant finding includes:
Dysconjugate gaze, gaze weakness or paralysis and double vision

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Cranial Nerve VII 33
Facial (VII)
Symmetry of facial expression and muscle movement in
upper and lower face, salivation, tearing, taste,
sensation in the ear
Observe for symmetry while client performs facial
movements:
smiles, whistles, elevates eyebrows, frowns, tightly closes
eyelids against resistance

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Cranial Nerves 34

Facial
Sensory and motor
Innervates facial movement
Test taste perception on the anterior two thirds of
the tongue
Have the client show the teeth
Attempt to close the clients eyes against
resistance, and ask the client to puff out the cheeks

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Cranial Nerves 35

Facial
Place sugar, salt, or vinegar on the front of the
tongue, with an applicator, and have the client
identify these substances by their tastes
Significance:
Facial weakness
Inability to completely close the eyelid
Impaired taste

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Cranial Nerves VIII 36

Acoustic (VIII)
Hearing and equilibrium
Sensory
The ability to hear tests the cochlear portion
The sense of equilibrium tests the vestibular portion

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Cranial Nerves 37

Acoustic Nerve:
Check the clients ability to hear a watch ticking or
a whisper
Observe the clients balance, and observe for
swaying when walking or standing
Significance:
Decreased hearing or deafness and impaired
balance

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Cranial Nerves IX 38

Glossopharyngeal (IX)
Assess clients ability to swallow and discriminate
between sugar and salt on posterior tongue
Sensory and motor
Significant findings include:
Difficulty swallowing (dysphagia)
Impaired taste

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Cranial Nerve X 39

Vagus (X)
Muscles of pharynx, larynx, and soft palate, sensation in
external ear, pharynx, thoracic and abdominal viscera
Parasympathetic innervation of thoracic and abdominal
organs

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 40

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 Cranial Nerves 41

Vagus (X)
Sensory and motor
Test assess swallowing and phonation, sensation to the
exterior ears posterior wall, and sensation behind the ear
Test assesses sensation to the thoracic and abdominal
viscera

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Cranial Nerves 42

Vagus (X)
Significant findings:
Weak or absent gag reflex
Difficulty swallowing, aspiration, hoarseness, and slurred
speech (dysarthria)

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 43

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Cranial Nerves XI 44

Spinal accessory (XI)

Motor
Test assesses uvula and soft palate movement and
sternocleidomastoid and trapezius muscles
Test assesses upper portion of the trapezius muscle, which governs
shoulder movement and neck rotation
Palpate and inspect the sternocleidomastoid muscle as the client
pushes the chin against the examiners hand
Palpate and inspect the trapezius muscle as the clients shrugs the
shoulders against the examiners resistance

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Cranial Nerves 45

Spinal Accessory (XI)

Significant findings:
weak or absent shoulder shrug and inability to turn the head
to the side

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Cranial Nerve XII 46

Hypoglossal (XII)
Movement of tongue
Motor
Test assesses tongue movements involved in
swallowing and speech
Observe the tongue for asymmetry, atrophy,
deviation to one side, and fasciculations

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 Cranial Nerve 47

Hypoglossal
Ask the client to push the tongue against a tongue depressor and
then have the client move the tongue rapidly in and out and
from side to side
Ask the client to say light, tight, and dynamite and
observe whether the sounds of the letters l, t, d, and n are clear
and distinct

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 Cranial Nerve 48
Hypoglossal
Significant:
Difficulty swallowing and slurred speech

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 Spinal Nerves 49

Spinal cord is composed of 31 pairs of spinal nerves

8 cervical
5 lumbar
5 sacral
1 coccygeal

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 50

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Motor- How would you as the nurse
assess motor function?
51

Muscle Strength and Coordination

Observe the gait
Look for even stance and posture, involuntary tics, and
gross deformities of musculature
Inspect the muscles for atrophy, mostly looking at large
muscle groups
Perform passive range of motion for assessment of
muscle tone and bulk
Observe for spasms or flaccidity

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 Motor Function 52

Some of the assessment that the RN can perform:

Ability to flex or extend extremities
Some examples:
Turn palms down and attempt to break fists
Elbows at side, apply resistance and instruct to allow you to
press out and up
Shoulders: flexion, extension, adduction and abduction against
resistance
Feet: dorsiflexion and plantar flexion

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 Motor Function 53

Important to assess and compare bilaterally

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 Test for Balance and 54

Coordination

Romberg:
Client is standing with hands to the side and eyes closed, observe
the balance does the client sway
Positive sign is loss of balance that is increased by closing eyes
Negative (normal) sign is observing minimal swaying and effort to
maintain balance while standing with eyes closed

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 Sensory Function 55

Assessing Proprioception (sense touch without looking)

Touch
Assess for the ability to sense a range of touch thats broad through
narrow
Use a thumbtack or pin for the small diameter
Vibration
Tuning fork may be used
With clients eyes closed, strike a tunning fork and place on the
clients leg
Ask if and where the vibration can be felt

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 Sensory Testing 56

Perform all sensory tests with eyes closed

May test with sharp and dull with broken Q-tip. Its
important to assess distal extremities in patients with
diabetes in order to collect data on peripheral neuropathy

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 Reflexes: 57

What are reflexes?

Involuntary contractions of muscles or muscle groups in
response to a stimulus
Reflexes are classified as:
Deep tendon
Superficial
Pathologic
Testing reflexes enables the examiner to assess involuntary
reflex

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 Reflexes 58

Deep Tendon Reflexes

Strike tendon by itself or with tendon pressing on it
Biceps tendon: Relax arm and press on biceps.
Triceps: Hold the upper arm with your hands and strike
where the triceps tendon inserts

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Reflexes 59

Patellar: Aim for the depression where the

patellar tendon runs. Let the weight of the
hammer go down. Knee should jerk
Achilles reflex: Aim hammer on Achilles tendon
on the posterior aspects of ankle to see the
foot jerk
See page 1926 Figure 65-13
See page 1927 Chart 65-4

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Gerontologic Considerations 60

Normal aging process, the nervous system undergoes

many changes and is more vulnerable to illness
Age-related changes in the nervous system vary in
degree and must be distinguished from those due to
disease

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Gerontologic Considerations 61
Motor Alterations
Reduced nerve input into muscle contributes to an
overall reduction in muscle bulk, with atrophy most
easily noted in the hands
Changes in motor function often result in decreased
strength and agility, with increased reaction time
Gait is often slowed and wide based
These changes can create difficulties in maintaining
balance, predisposing the older person to falls

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 Gerontologic Considerations 62

Sensory Alterations
Tactile sensation is dulled in the older adult due to a
decrease in the number of sensory receptors
There may be difficulty in identifying objects by touch, due
to fewer tactile cues are received from the bottom of the
feet and the person may become confused about body
position and location
Sensitivity in glare, Decreased peripheral vision, and
constricted visual field occur due to degeneration of visual
pathways, resulting in disorientation, especially at night when
there is little or no light in the room.

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Gerontologic Consideration 63

Older adult takes longer to recover visual sensitivity when

moving from a light to dark area, nightlights and safe
arrangements of furniture
Loss of hearing can contribute to confusion, anxiety,
disorientation, misinterpretation of the environment, feelings
of inadequacy , misinterpretation of the environment ,
feelings of inadequacy and social isolation
Also affected is sense of taste and smell
Important for the client to have smoke and CO2 detectors

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Gerontologic Considerations 64

Temperature Regulation and Pain Perception

Older adult may feel cold more readily than heat and may
require extra covering when in bed
Room temperature somewhat higher than usual may be
desirable
Reaction to painful stimuli may be decreased with age

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Gerontologic Consideration 65

Mental Status
Decreases with age
Memory, language, and judgement capacities remain intact
Change in mental status should never be assumed to be a
normal part of aging
What is delirium?
Transient mental confusion, usually with delusions and
hallucinations can be seen client with underlying CNS damage

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Lets review pupillary assessment 66

P: Pupils
E: Equal
R: Round
R: Reactive to
L: Light bilaterally
A: Accommodate
PERRLA: Pupils Equal, Round, Reactive to Light
(bilaterally) and Accommodate
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Assessing the Pupils 67
Size, Shape, Response

Pupillary size: Pinpoint, small, large, dilated

Pupillary shape: Irregular, keyhole, or ovoid
Pupillary response: Brisk, sluggish,
nonreactive, fixed, unequal or dilated
Normal findings: Equality of the pupillary
response, size, and shape

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PEARRL 68

Pupils are both present? What is their general condition?

Equal are both pupils the same size? Unequal pupils can
indicate a head injury causing pressure on the optic nerve.
R --Round
R Regular in size
L react to light both eyes should be assessed twice for
reaction to light -- right eye then left eye -- assessing for
sympathetic eye movement (both eyes doing the same thing
at the same time

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 Lets Review the Glasgow Coma Scale 69

An tool that assesses neurological function on a 15-point

scale
Evaluates the patients arousal and awareness
Elements of the Glasgow Coma Scale
Eye opening: best eye-opening response
Verbal response: best verbal response
Motor response: best motor response
Painful stimuli is used to evaluate eye opening, verbal and motor
response

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Glasgow Coma Scale 70

Eye Opening (Arousal)

Score 4: eyes open spontaneously
Score 3: eyes open to speech
Score 2: eyes open in response to pain only
Score 1: eyes do not open to verbal or painful
stimuli
A C is assigned if the patient cannot open
eyes due to ptosis, bandage, or inflammation
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Glasgow Coma Scale 71

Verbal Response (Awareness)

Score 5: oriented
Score 4: confused
Score 3: inappropriate words
Score 2: incomprehensible sounds
Score 1: no response
A D is assigned if the patient has issues such as
dysphagia that are inhibiting speech
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 72

Glasgow Coma Scale

Motor Response
Score 6: responds to request and can make at least 2 different
movement
Score 5: localizes to central pain
Score 4: withdraws from pain
Score 3: flexion to pain or localization decorticate posturing
Decorticate posturing
Score 2: extension to pain, or a semi-purposeful (withdrawal)
Decerebrate posturing
Score 1: no response to painful stimuli

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Glasgow Coma Scale 73

Score Total
Score 15: maximum score possible
Score 8: indicative of severe brain insult
Score 3: lowest possible score

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Your client is scheduled for several 74
diagnostic test today and tomorrow. The
PCP has ordered:

Cerebral angiography
CT scan of the brain
Myelography
Lumbar puncture
MRI
Electroencephalography

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 75

Lets discuss what are the RNs responsibility in

caring for the client pre and post diagnostic
procedure?
What client education is indicated?

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Sample Questions 76

1. The nurse is assessing cranial function and

ask the client to cover one nostril at a time
to see if the client can smell coffee, alcohol
and mint. The client is unable to smell any
of the odors. The nurse is aware that the
client has a dysfunction of which cranial
nerve?
a. CN I c. CN III
b. CN II d. CN IV
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 77

2. To assess the functioning of the trigeminal

and facial nerves (CNs V and VII), the nurse
should
a. Shine a light into the clients pupil
b. Check for unilateral eyelid drooping
c. Touch a cotton wisp strand to the cornea
d. Have the client read a magazine or book

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 78

3. The nurse is assessing the pupils of a client

who has had a head injury. What does the
nurse recognize as a parasympathetic effect?
A. Dilated pupils
B. Constricted pupils
C. One pupil is dilated and the opposite pupil
is normal
D. Roth spots

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 79

4. A nurse assesses the clients level of

consciousness using the Glasgow Coma Scale.
What score indicates severe impairment of
neurologic function?
a. 3
b. 6
c. 9
d. 12

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References 80

Smeltzer, S and Bare, B., Hinkle, J.I. (2010).

Brunner and Suddarths Textbook of Medical-
Surgical Nursing. 12th edition. Philadelphia:
Lippincott, Williams and Wilkins.

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