Neurological Assessment

High Desert State Prison

Medical Education - 2009

Acknowledgements: exerpted, in part, from “Neuro Assessment”

from Doctorsecrets.com and “Neurological Assessment”

by Sherry Burrell, RN, MSN and other sources

Review of Anatomy & Physiology• The function of the nervous system is to control all motor, sensory & autonomic functions of the body. Divided into:

Central Nervous System (CNS)• Consisting of the brain and spinal cord.

Peripheral Nervous System (PNS)• Cranial nerves (12) and spinal nerves (31)• Autonomic Nervous System

– Sympathetic Division: “fight or flight” response– Parasympathetic Division:

The Central Nervous System

CNS:The Brain

• The brain controls, initiates and integrates all body functions.– Composed of both gray matter and white matter.– Protective Mechanisms:

• Skull (cranium): Bony container surrounding the brain • Meninges: Three additional layers of protection

– Dura mater, arachnoid mater & pia mater

– Potential & Actual Spaces• Epidural Space • Subdural Space• Subarachnoid Space

Head Injuries

Head Injury

• Broad term to classify sudden trauma to head, which includes injuries sustained to the scalp, skull or brain.

• Most common causes:– MVA: motor vehicle collisions (50%)– Falls (21%)– Violence (12%)– Sports related-injuries (10%)

• The most serious type of head injury is traumatic brain injury (TBI)

Clear discharge from ear

Periorbitalbruising/swelling

Scalphematoma

Physical

TBI: Pathophysiology

Primary Injury – Initial damage to the brain that results from

the traumatic event.

• Secondary Injury– Additional damage to the brain tissue

occurring minutes to hours after the initial traumatic event.

– As a result of the cellular changes that occur with cerebral edema, ischemia and hemorrhage.

TBI: Clinical Manifestations

• Neurological Deficits • Altered Level of

Consciousness • Confusion• Pupillary

Abnormalities • Vital sign Changes• Altered Reflexes

– Gag– Corneal

• Headache• Dizziness• Impaired Hearing or

Vision• Sensory or Motor

Dysfunction• Seizures

ScalpInjury

Very vascular Can distract from more serious injuryWhat about brain and neck????Bleeding usually NOT enough to cause hypovolemic shock. Exceptions: Children, arterial

Cerebral Concussion

• Head injury with temporary loss of neurological function with no structural damage.– Cause: jarring of the brain results in temporary disruption of

synaptic activity; often occurs with acceleration-deceleration injuries.

• Clinical Manifestations:– Loss of consciousness; usually brief– Amnesia regarding events immediately prior to injury

• Postconcussion Syndrome– Usually occurs within 24 to 48 hours after injury and may

present up to several months later, but will subside in time. • S/Sx: HA, lethargy, irritability, memory deficits, dizziness &

insomnia

Cerebral Contusion

• Bruising of the brain tissue; actual structural damage visible on diagnostic testing (i.e. CT scan).– Often caused by deformation or acceleration-deceleration

injuries (often two focal areas of bruising)

• Clinical Manifestations– Loss of consciousness (more than brief)– Vary depending on the location & size of contusion

• Secondary injury is possible (i.e. hemorrhage or cerebral edema) the client must be monitored closely for increased ICP.

Intracranial Hemorrhage (ICH)

• Trauma can cause bleeding within the brain tissue or within the spaces surrounding the brain.– The result is hematomas or collections of blood within

cranial vault; most serious of brain injuries

• Classified according to location:– Epidural hematoma– Subdural hematoma– Intracerebral hematoma

Epidural Hematoma (EDH)

• Blood collects between the dura mater & the skull – Most often arise from arterial hemorrhage

• Cause usually is injury of middle meningeal artery; resulting in rapid accumulation of blood.

– Clinical Manifestations:• + LOC after initial trauma; usually at the location of injury• Lucid interval (30-50% experience) • Rapid deterioration in neurologic status; S/Sx of ↑ ICP

– Management • Medical emergency requiring immediate medical and

surgical intervention (i.e. craniotomy).

Subdural Hematoma (SDH)

• Blood collects between the dura mater & the arachnoid mater – Often originating from venous hemorrhage

• Cause is usually injury to bridging veins; venous blood tends to accumulate more slowly than arterial blood, therefore signs/symptoms of ↑ ICP tend not occur as quickly.

– Two Main Types of SDH• Acute (less than 48 hours after injury)

– Requires immediate medical and /or surgical intervention• Chronic (over 2 weeks after injury)

– Often forget actual injury; common in elderly– S/Sx of ↑ ICP fluctuate or “come and go”– Management: Burr hole clot evacuation or craniotomy

Intracerebral Hematoma (ICH)

• Blood collects within the brain tissue (parenchyma)– Bleeding causes displacement of brain tissue; even small bleeds

can cause significant neurological alterations. • Destroys brain tissue• Causes cerebral edema• Increases ICP

– S/Sx of ↑ ICP maybe be immediate or develop overtime– Management:

• Depends on location of the bleed and size of the bleed– Small ICH will be absorbed overtime– Surgical management only if anatomically appropriate; if not will

be managed medically.

Interacerebral Bleeding

ClosedHeadInjuries

Coup Contra Coup Brain Injury

Depressed SkullFracture

Open Head Injury

Risks: swelling, bleeding, neural damage, infection.rapid decompensation

Increased Intracranial Pressures

• Compensatory mechanisms will eventually be exhausted and clinical manifestations of increased ICP will occur.

• Causes of Increased ICP: – Traumatic Brain Injuries– Brain Tumors– Other Causes:

• Meningitis or Encephalitis

• Brain Abscesses

• Hydrocephalus

Clinical Manifestations:Stages of Increased ICP

• Stage I: (Full Compensatory) – Alert & Orientated – History of head injury– Vital signs / pupillary responses normal – May complain of a headache

• Stage II: (Partial Compensatory) – Mental Status Changes

• Confusion and restlessness

– Decreased Level of Consciousness • Lethargy

– Vital signs / pupillary responses normal

Clinical Manifestations:Stages of Increased ICP

• Stage III (Beginning Decompensation)

– Further decrease in level of consciousness• Obtunded → Stupor

– Cushing’s Triad: • Systolic HTN (widening pulse pressure)

• Bradypnea

• Bradycardia (bounding, slow pulse)

– Small pupils (< 3mm); sluggish responses to light

– Vomiting (maybe projectile)

Clinical Manifestations:Stages of Increased ICP

• Stage IV (Herniation)– Comatose– Pupillary dilation & fixation (ipsilateral → bilateral) – Abnormal Posturing:

• Decorticate → Decerebrate → Flaccidity

– Cushing’s Triad Progresses To:• Narrowing pulse pressure• Weak, thready pulse• Respirations: Cheyne-Stokes → Ataxic Respirations

• Stage V (Death)

Herniation & Brain Death

• Herniation– Result of excessive ICP downward

displacement of brain tissue resulting in the cessation of CBF.

– Leads to irreversible brain anoxia and brain death

• Brain Death– Complete, irreversible cessation of function of

the entire brain and brain stem.

Brain Tumors

• Space-occupying intracranial lesions – Benign or malignant.

• Clinical manifestations differ according to area of lesion and rate of growth

• Common Signs / Symptoms:– Alterations in consciousness– Neurologic deficits

• Motor & Visual Disturbances – Headaches– Seizures– Vomiting (maybe sudden and projectile)

PeripheralNervousSystem

Peripheral Nervous System (PNS)

• Spinal Nerves (31 pairs) – Mixed Nerve Fibers: Exiting the spinal cord to receive

information and to transmit information to the cord → brain.

• Posterior Root = Sensory

• Anterior Root = Motor

– Reflex Arc• Interneurons connecting sensory & motor fibers.

– Dermatomes • Sensory depiction of the corresponding spinal nerves

PNS: Cranial Nerves

• There are 12 pair of cranial nerves.

• Sensory: CN I, II & VIII

• Motor: CN III, IV,

VI, XI & XII

• Mixed: CN V, VII,

IX & X

Cranial Nerves• The neurological exam performs many tests at the head of the patient. These are to

test if Cranial Nerve function is intact. The exam tests the twelve Cranial Nerves:

• I    - Olfactory / Smell • II   - Optic / Vision • III  - Oculomotor / Eye Movement & Pupil Size • IV   - Trochlear / Eye Movement • V    - Trigeminal / Facial Sensation • VI   - Abducens / Eye Movement • VII  - Facial / Facial Motor - Expressions • VIII - Acoustic / Hearing - Balance • IX   - Glossopharyngeal / Swallowing • X    - Vagus / Swallowing - Heart Rate • XI   - Spinal Accessory / Shoulder & Neck Movement • XII  - Hypoglossal / Tongue Movement

Cranial Nerves

PNS InjuriesSpinal Injuries

PNSSpinalMap

Spinal Cord InjuryLocations

Spinal Nerves

Quad

Para

Always properly immobilize an actual

or suspected head or spinal injury!

Performing a Neurological Assessment

Neurological Assessment

• Health History • General Signs & Symptoms• Physical Examination Considerations

– Level of Consciousness – Motor Function– Pupillary Function / Eye Movements– Vital Signs

• Respiratory Patterns

• Laboratory & Diagnostic Testing

General Signs / Symptoms

• Memory Loss

• Disorientation

• Changes in level of consciousness

• Seizures

• Speech or Swallowing Difficulties

• Vision & Pupillary Changes

• Dizziness

• Headache / Pain

• Weakness

• Loss of Coordination

• Tremors

• Numbness / Tingling

• Paralysis

• Nausea / Vomiting

• Bowel or Bladder Difficulties

Physical Examination Considerations

• Level of Consciousness – Most important aspect of neurologic examination– Level of consciousness first to deteriorate; changes

often subtle, therefore requiring careful monitoring.

• Consciousness:– Composed of Two Components:

• Arousal (Alertness)• Awareness (Content)

– Assessment: Orientation vs. Disorientation » Person, Place & Time » Varying sequence of questions is important !!

Categories of Consciousness

• Alert: – Responds immediately to minimal external (visual, tactile or

auditory) stimuli.

• Lethargic: – A state of drowsiness; client needs increased external stimuli

to be awakened but, remains easily arousable; verbal, mental & motor responses are slow or sluggish.

• Obtunded: – Very drowsy, when not stimulated, but can follow simple

commands when stimulated (i.e. shaking or shouting) ; verbal responses include one or two words, but will drift back to sleep without stimulation.

Categories of Consciousness

• Stuporous: – Awakens only to vigorous and continuous noxious (painful) stimulation; minimal

spontaneous movement; motor responses to pain are appropriate but, verbal responses are minimal and incomprehensible (i.e. moaning).

• Comatose: – Vigorous external stimulation fails to produce any

verbal response; both arousal and awareness are lacking; no spontaneous movements but, motor responses to noxious stimuli maybe be purposeful (light coma) or

– non-purposeful or absent – (deep coma).

Assessing LOC

• Glasgow Coma Scale (GCS)– Three Categories:

• Eye opening• Best motor response• Best verbal response

– Scoring• Highest or best possible score 15 • A score of < 8 indicates coma • Lowest or worst possible score 3

Glasgow Coma Scale

Pupillary Examination

• The pupillary examination can be quickly and easily performed in the unconscious or minimally responsive patient when a TBI is suspected, and can provide valuable information about the degree of initial or progressing brain injury. Several types of TBI’s may cause pupillary changes, which indicate the need for rapid interventions to decrease ICP caused by cerebral bleeding and/or edema. Nurses are in a key position to detect early changes in a patient's condition and administer or advocate for immediate interventions.

Check pupil size in lighted room, and reactivity to light in a darkened room.

Unequal pupil size can be a sign of a serious brain injury.

Brain Injury with bleedingor swelling

Rapid interventionsare needed to preventdeath or permanent brain damage – TBI’scan progress rapidly!

Assessing the Cranial Nerves CN I Olfactory: smell; skip except in facial trauma

CN II Optic: vision; count fingers or movement in all quadrants and periphery in each eye; blink to threat in temporal and nasal quadrants if unable to participate

CN III Oculomotor: moves

eyes in all directions except

outward and down & in; opens

eyelid; constricts pupil

CN IV Trochlear:moves eyes

down and in…..

CN VI Abducens: moves eyes outward

EOM’s:

(extraoccular movement) assessment of eye

movement in all

directions ( III, IV VI)

CN V Trigeminal: 3 branches;

sensation to the face,

cornea and scalp;

opens jaw against resistance

CN VII Facial: moves the face; taste.

CN VII paralysis

CN VIII Acoustic: 2 branches, acoustic (hearing) and vestibular (balance)

CN IX Glossopharyngeal: moves the pharynx (swallow, speech & gag)

CN X Vagus: voice quality

CN XI Spinal Accessory: turns head and elevates

shoulders

CN XII Hypoglossal: moves

tongue

ShoulderShrug

Assessment Tip:Test CN IX, X, XII all at once: Test gag, swallow and speech together……………..

CN Tips: observe for nystagmus with EOM’s (2-3 beats normal with lateral gaze). diplopia (double vision): cover one eye, should clear if sixth nerve palsy (offer eye patch over good eye).

Motor ExaminationMotor Exam: use the motor grading scale to maintain objectivity and eliminate confusion 5/5: strong against resistance 4/5: weak against resistance 3/5: overcomes gravity; offers

no resistance 2/5: cannot overcome gravity;

moves with gravity eliminated 1/5: contracts muscle to stimulus

0/5: no muscle movement Assess hand grips for strength and equality.

Drift AssessmentDrift Assessment: test for motor weakness

Arm: hold arms out with palms up; eyes closed • Pronator drift: hands pronate (roll over); • Motor drift: arm “drifts” downward • Cerebellar drift: arm “drifts” back toward head or out to side

Leg: no need to close eyesmotor: leg “drifts”toward bed

Movement Assessment

Movements are purposeful or non-purposeful purposeful: picking at tubings or bed linens, scratching noselocalizing: moving toward or removing a painful stimulus; must cross the midline; occurs in the cortexwithdrawal: pulling away from pain; occurs in the hypothalamus

non-purposeful: do not cross the midlineabnormal flexion: (decorticate) rigidly flexed arms and wrists; fisted hands; occurs in upper brainstemabnormal extension: (decerebrate) rigidly, rotated inward extended arms with flexed wrists and fisted hands; occurs in midbrain or pons.

Decorticate

Decerebrate

Response to Painful Stimuli

Eliciting movements using central painTrapezius pinch: deep pressure to

trapezius muscle Supraorbital pressure: pressure under supraorbital ridge Sternal pressure: knuckle pressure

to sternum; do not rub! Peripheral Pain: nailbed pressure may elicit a spinal cord reflex which can be reproduced in a brain dead patient

TrapeziusPinch

Abmornal Reflexes

Abnormal Reflexes: Babinski: initial inflection of great toe in response stroking of sole; upgoing toe is abnormalGrasp: involuntary grasp in response to stimulation of palm; abnormal in an adult Doll’s eyes: impairment of eye movement to

opposite side when head is turned = damage to brainstem; no movement = loss of brainstem

Speech Patterns

Note: speech patterns, fluency, word usage ability to follow 1 or 2 step commands (must cross the midline) ability to name common objects and their use.

Aphasia: a disorder in processing Language: Apraxia of speech: disorder in programming of speech (dominant hemisphere) Dysarthria: disorder in mechanics of speech (cranial nerve weakness)

Hemispheres of the BrainLanguage & Speech: assessed together; located in the dominant hemisphere (left in most, including lefties). LEFT: written & spoken language, reasoning, number skills, scientific knowledge, right hand control.

RIGHT: insight,

3-D forms,

imagination,

music awareness,

Art awareness,

left hand control.

Left Right

Brain Teaser

BrainTeaser

Neuro Aessessment Quiz• 1. Peripheral Nervous System

(PNS) is made up of the following except::

a) Cranial nerves (12) b) Ventriclesc) Axons and Neuronsd) Spinal nerves (31)e) Cerrebellar nerves• 2. The Autonomic Nervous

System contains both the Sympathetic Division of nerves and the Parasympathetic Division of nerves. True or False________________.

• 3. Intracranial Hemorrhage can occur in the following places except:

a) Epidural spaceb) Subdural spacec) Subarachnoid spaced) Ethmoid space

• .4. A Coup Contracoup injury is defined as: When the head strikes a fixed object, the coup injury occurs at the site of impact and the contrecoup injury occurs at the opposite side. True or False____________________

• 5. The Facial nerve controls:a) Movement of the chin, tongue and

parotid glands.b) Movement of the tongue, soft

palete and eyebrows.c) Movement of the chin and cheeks

muscles.d) Movement of all the facial

expression muscles.• 6. Which nerve controls movement

on the neck and shoulders?a) Abducensb) Accousticc) Spinal Assesoryd) Occulomotor

• 7. A serious injury to the cervical spine and spinal cord most likely will result in the following condition:

a) Hemiplegiab) Quadraplegiac) Paraplegiad) Contralateral paralysis• 8. Any suspected head, neck or

spine injured victim should immediately be given spinal immobilization precautions, except:

a) When the victim complains of pain only upon turning his head to one side.

b) When the victim refuses to allow spinal immobilization even after listening carefully to multiple attempts to explain the dangers and risk involved.

c) When the victim is intoxicated on alcohol and cannot speak clearly.

d) When the victim was never unconscious and denies any pain.

• 9. When assessing a patient with altered LOC, you feel his state of awareness/arousal is best described as “Obtunded”, this means:

a) Very drowsy, when not stimulated, but can follow simple commands when stimulated (i.e. shaking or shouting); verbal responses include one or two words, but will drift back to sleep without stimulation.

b) A state of drowsiness; client needs increased external stimuli to be awakened but, remains easily arousable; verbal, mental & motor responses are slow or sluggish.

c) Awakens only to vigorous and continuous noxious (painful) stimulation; minimal spontaneous movement; motor responses to pain are appropriate but, verbal responses are minimal and incomprehensible (i.e. moaning).

d) Vigorous external stimulation fails to produce any verbal response; both arousal and awareness are lacking; no spontaneous movements but, motor responses to noxious stimuli maybe be purposeful

• 10. The Glasgow Coma scale tests for three kinds of responses, they are:

a) Eye Openingb) Motor Responsec) Verbal Responsed) Auditory Response• 11. The best and worst possible

score on the GCS is:a) 15 and 0b) 13 and 3c) 15 and 3d) 18 and 5• 12. When assessing pupillary

response, you are looking for the following conditions except:

a) Coordinated eye movement and bilateral blinking.

b) Reactivity to and accommodation to light.

c) Symmetry of pupils and accommodation to light.

d) Abnormal pupil shape.

• 13. A constricted “pin point” pupil indicates: (best answer)

a) Brain Stem herniationb) Cardiac Arrestc) Cerebral Infarction of the parietal lobed) Cerebral Infarction of the occipital lobee) A wide variety of conditions, some

being extremely life threatening. • 14. What Cranial nerve(s) controls the

movement of the eyes down and in?a) CN VI Abducensb) CN III Oculomotorc) CN IV Trochleard) CN II Optic• 15. The Motor strength scale goes

from 0/5 to 5/5, 0 being no strength at all and 5 being normal strength. A person with a motor strength of 4/5 would be:

a) overcomes gravity; offers no resistanceb) strong against resistancec) weak against resistanced) no muscle movement

• 16. Match the following postures with its definition:

• Decerebrate_____________• Decorticate______________

a) Abnormal flexion: rigidly flexed

arms and wrists; fisted hands; occurs in upper brainstem

b) Abnormal extension: rigidly, rotated inward, extended arms with flexed wrists and fisted hands; occurs in midbrain or pons.

• 17. The Babinski reflex is the initial inflection (extension) of great toe in response stroking of the sole of the foot, select the correct answer:

a) An upgoing great toe is abnormal.b) An upgoing great toe is normal.c) An upgoing great toe is abnornal

in adults.d) An upgoing great toe is normal in

infants.

• Answers• 1 e• 2 True• 3 d• 4 True• 5 d• 6 c• 7 b• 8 b• 9 a• 10 d• 11 c• 12 a• 13 e• 14 c• 15 c• 16 Decer = b. Decor = a• 17 c&d