1. Nursing Interventions in Performing a Neurological Exam
Connie Barbour, MSN, RN
Nursing Interventions in Performing a Neurological Exam

2. Objectives
1. Identify normal and abnormal findings in the neurological system. 2. Inspect and palpate the neurological system for variations of normal. 3. Identify cranial nerves and their interpretation. 4. Demonstrate various methods of evaluating sensory function. 5. Evaluate motor function and muscle tone in clients. 6. Evaluate reflexes and be able to interpret findings.

3. Review of Anatomy & Physiology
Cerebrum – sensory/motor function
Frontal Lobe – voluntary motor activities, smell, memory, judgment, affect, personality
Parietal Lobe - speech, high level sensory function
Occipital Lobe – vision, memory

4. Review of Anatomy & Physiology Cont.
Thalamus – Relays sensory input of taste, vision, and hearing to the cerebral cortex
Hypothalamus - Regulates temp., sleep, food & water consumption; ADH, TSH & growth hormone secretion
Brain Stem – origin of cranial nerves (pons, medulla oblongata, and midbrain)
Cerebellum – balance, voluntary movement and posture

5. General Goals of Assessment
Assessment of expected normal values
Establish baseline assessment
Early identification of abnormal finding

6. Preparation Setting up the room Setting up equipment
Well lit environment
Comfortable environment
Provide privacy/draping
Setting up equipment
Use of cue card
Set up equipment in order of use
Ensure equipment is in working order
Penlight

7. Principles of Organization
Non-invasive to invasive
Head to toe
Front to back
Side to side
When you touch the feet always wash your hands before continuing on.

8. Important Points Safety of Client Need for Universal Precautions
Be aware of how culture may influence exam
Gerontological adjustments
How might you need to adjust your exam for the following:
Child
Teenager
Older adult

9. Introduction Introduce self by Name & School
Call Client by respectful name
Explain purpose of exam
Make a statement about concerns/questions
Ask questions about client’s history of complaints > COLDSPA

10. COLDSPA Character Onset Location Duration Severity Pattern
Associated Factors
Character – Describe the s/s, (feeling, appearance, sound, smell , or taste)
Onset – When did it begin
Location – Where is it, does it radiate, Does it occur anywhere else,
Duration – How long does it last, Does it recur
Severity – How bad is it, how much does it bother you, Use 0-10 pain scale
Pattern – What makes it better or worse
Associated factors – What other s/s occur with it

11. Examination General Survey Central Nervous System
Cerebrum
Cerebellum
Peripheral Nervous System
Cranial Nerves

12. Subjective Data Health History History of Present Illness (HPI)
Use COLDSPA
Past Health History
Surgery, trauma, illness
Family History
Some disease processes may be familial or genetic
Lifestyle and health practices
Diet, environmental exposures, work

13. Additional Questions? difficulty swallowing
difficulty with head and neck
gait and balance
pain in lower back
muscle weakness or unusual muscle activity

14. Objective Data / Assessment
Peripheral Nervous System
Cranial Nerves (12)
Spinal Nerves (31)
Autonomic Nervous System
Sympathetic nervous system
“fight or flight”
Parasympathetic Nervous System
Rest and restore

15. Assessment
LOC & Use of Glasgow Coma Scale
(p.86, Table 4-2)
Eye Opening Response
Verbal Response
Integral Motor Response
Annotated mini-mental state examination
(p82, figure 4-5)
Note general appearance, affect, speech content, memory, logic, & speech patterns during the history & physical exam
LOC – level of consciousness

16. GLASCOW
COMA
SCALE
Caution! Grasp (“squeeze my hand” when you provide palmar stimulation) is a primitive reflex…release is not!
Possible score A GCS of 7 or less is indicative of a coma.

17. Terms to Define Level of Consciousness
Lethargy – drowsy, listless
Obtunded – decreased level of consciousness, but responds to stimulation
Stupor – senses are dulled to environment, senses dulled to all but deep painful stimulation
Coma – a deep state of unconsciousness marked by the absence of spontaneous eye movement, no response to painful stimuli, no vocalization
Obtunded – Possibly from a head trauma
Stupor- a state of mental numbness, like what happens when someone is in shock, difficult to rouse

18. Mini Mental State Exam Thought Processes Long Term Memory
Short Term Memory
Reality Orientation
Abstract Thinking, Judgement, Naming, Reading, Registration/Recall (House…Car…Lake…), Time, mothers’ maiden name, in 5 min/10min.
The Mini-Mental State Examination (MMSE) is a widely used, well-validated screening tool for
evaluation of cognitive impairment. It briefly measures orientation to time and place, immediate
recall, short-term verbal memory, calculation, language, and construct ability. Each area tested has a
designated point value, with the maximum possible score on the MMSE being 30/30

19. Charting Example
Alert & Oriented X 3. Affect appropriate. Responds easily to questions. Able to follow directions. Speech clear without slur or stutter. Short & Long Term memory intact.
When documenting your assessment it is better to describe the client’s response than to label his or her behavior.

20. Cranial Nerves 1. Olfactory (sensory) 2. Optic (sensory)
1. Olfactory (sensory)
2. Optic (sensory)
3. Oculomotor (motor)
4. Troclear (motor)
5. Trigeminal (sensory/motor)
6. Abducens (motor)
7. Facial (sensory/motor)
8. Vestibulocochlear/Acoustic (sensory)
9. Glossopharangeal (sensory/motor)
10. Vagus (sensory/motor)
11. Spinal accessory (motor)
12. Hypoglossal (motor)
Know this for test - Page 706, table 22-2
Mnemonics (pg 705): On Old Olympus’ Towering Tops A Finn and German Viewed Some (All) Hops
Cranial nerves are peripheral nerves that originate from the brain.

21. Cranial Nerve Article
Cranial Nerve Article with face diagram

22. Cranial Nerve (I) Olfactory
Sensory
Carries smell impulses from nasal mucous membrane to brain
Have patient clear nose, close eyes & occlude one nostril
Have patient ID aroma: vanilla, coffee or soap
Repeat with other nostril

23. Cranial Nerve (II) Optic
Sensory
controls central and peripheral vision
Assessed distant vision by using Snellen chart to determine visual acuity
Normal = 20/20
Color Vision
Near Vision tested by having patient reading written material
Normal – distance of inches

24. Cranial Nerve II Optic Abnormal
Amblyopia “lazy eye”
Myopia “near sighted”
Presbyopia – normal changes with age
Hyperopia “far-sighted”
Confrontation – to assess peripheral vision/visual fields
Confrontation - The confrontation eye test is a technique used to assess the eyes for peripheral vision. It can help a physician detect the presence of eye diseases caused conditions such as stroke, hypertension, glaucoma and other diseases. Cover your right eye the pt covers their left eye. Bring you finger into the field of view. Both of you should see it at the same time. Then cover you left eye and they cover their right eye. Again both of you should see your finger at the same time.
Homonymous hemianopsia is a eye disease caused by stroke where there is a loss in peripheral vision.
See Mosby’s pg 271
(Macular degeneration causes a blind spot in your central vision

25. Cranial Nerve (III) Oculomotor
Motor – tests also assess CN IV & VI
(trochlear & abducens)!
Contracts eye lid, eye muscles & “pupil”
Assess: absence of ptosis, pupillary response
Convergence
Accommodation – PERRLA is the documentation for a normal response in 2 tests. Distant to Near vision, and Indirect pupillary light reflex
[Corneal Light Reflex -In a person with normal ocular alignment the light lands on the center of both corneas
Ptosis – eye lid dropping
Convergence eye test – with both eyes a pt focuses on a penlight while it is slowly brought from a distance to their nose. They should let you know if they see double.
Accommodation – Test 1- focusing on a near object and then an object far away, 2-3 times Test 2 – Indirect pupillary light reflex ( Hand on nose and shine light on one eye, both pupils should constrict.
Indirect pupillary light reflex = consensual pupillary light reflex the other un-stimulated eye constrict at the same time as the stimulated eye
P- Pupils
E – Equal
R – Round
R – Reactive to
L – Light and
A – Accomidation
These are the six cardinal fields of gaze positions:
up/right
up/left
right
left
down/right
down/left

26. Pupillary Responses Size of 2-6 mm = normal (ave 3.5 mm)
infancy quite small
childhood and early adult largest
25% of people have a slight difference in size
Also refer to slide 29

27. Cranial Nerve III, IV & VI
6 Cardinal Fields of Gaze, Extraocular movement

28. Cardinal Fields of Gaze cont..
Cranial Nerves (III), (IV) & (VI)
Normal Finding – able to follow pointer without moving head
Abnormal Finding – Unable to follow pointer, or nystagmus
“Around the clock”
Nystagmus - Involuntary eye movements that occur from side to side, up and down, or in a circular pattern. As a result, both eyes are unable to hold steady on objects being viewed.

29. Cranial Nerve (V) Trigeminal
Sensory & Motor
Carries sensory impulses of pain, touch, and temperature from the face to the brain.
Influences clenching and lateral jaw movements (chewing and biting)
Assess: corneal reflex, clench teeth & move jaw (TMJ)

30. Corneal Reflex
Corneal reflex
Should blink immediately

31. Trigeminal Cranial Nerve Assessment (Temporal & Masseter muscles palpated with jaws clenched)
ASSESSMENT OF CN-5 TRIGEMINAL
The trigeminal nerve is the fifth cranial nerve, and it detects sensory stimulation over most of the face. It also has a motor function, supplying muscles that enable jaw movement. This nerve is tested by evaluating the patient's ability to sense touch over the forehead, cheek and jaw, as well as her ability to move and clench the jaw.
Tell the patient you are going to test the ability to feel touch or pain on the face. The eyes should be shut. Take a piece of cotton or the ball of your finger. Lightly touch both sides of the face.
Ask the patient to clench his or her jaws. Palpate the masseter and temporal muscles for asymmetry of volume and for tone
Ask the patient to move the jaw from side to side against the resistance of your palm. The paralyzed side will not move laterally.

32. Cranial Nerve (VII) Facial
Motor/Sensory
Innervates facial muscles (expressions)
Smile, frown, puffs cheeks, close eyes, show teeth
Contains senses for taste in the anterior 2/3 of tongue, stimulates secretions and tears
Assess symmetry of face, taste
Bell’s Palsy
Bell’s Palsy – Half the face will droop
Cranial nerve VII - intrinsic factor – B12 absorption

33. Facial CN (VII) Assessment
ASSESSMENT CN FACIAL
Assess:
Smile
Frown
Puff out cheeks
Wrinkle forehead
Show teeth

34. Cranial Nerve (VIII) Acoustic
Also called vestibulocochlear
Sensory
Hearing & balance
Assess by performing hearing tests
Whisper (p Mosby)
Weber (p Mosby) – lateralization of hearing
Rinne (p Mosby) – Air to Bone conduction
AC 2 x BC

35. Cranial Nerve (IX) Glossopharyngeal
Sensory
Contains sensory fibers for taste on posterior 1/3 of tongue
Sensors for gag reflex
Promotes swallowing movements
Contains secretory fibers for parotid glands
ASSESSED TOGETHER WITH CN X (VAGUS)

36. Cranial Nerve (X) Vagus
Sensory/Motor
(S) Carries sensations from throat, larynx, heart , lungs, bronchi, GI tract, and abdominal viscera
(M) Promotes swallowing, talking and production of digestive juices
ASSESS TOGETHER WITH CN IX
Have patient say “ah”
(soft palate & uvula should elevate to midline)
Patient able to talk without hoarseness
Able to swallow
Elicit “gag reflex”

37. Cranial Nerve (XI) Spinal Accessory
Motor
Innervates neck muscles
Movement of shoulders, head rotation, and some larynx movement
Assess:
Having patient shrug shoulders against resistance
Turn head against resistance
You are actually assessing muscle strength at the same time which is part of the head and neck assessment

38. Cranial Nerve (XII) Hypoglossal
Motor
Innervates tongue to assist with movement of food and talking
Assess:
stick out tongue midline
move side to side

39. Sensory Function Superficial sensation Deep sensation
Touch (cotton)
Pain (pin)
(Heat/Cold = omitted if pain intact)
Deep sensation
Vibration
Position (proprioception)
Discriminative sensation
2-point discrimination (1point-2point)
Stereognosis (familiar object)
Graphesthesia (draw number)

40. Cerebellum Assess balance and coordination by: Pronator drift
Gait
Walk the Line (Heel to toe), then heels, then toes.
Romberg test
Arms by side, standing – will have very little movement even with closed eyes for 20 seconds
Pronator drift
Standing with eyes closed—hold arms out in front of you with palms up. Then tap the palms of the hands . If OK, Pt will hold balance. If not OK pt will be unable to hold their balance.
Tandem balance
1 foot without losing balance (5 seconds) then hop x1
Finger to nose
Rapid alternating movement/Finger-thumb
See slide 4

41. Motor Function
Injury to almost any part of the nervous system affects the patients ability to move in some way.
Changes give clues as to possible damage location.
System Assessment for
Tone
Strength

42. Examples of some coordination tests
ASSESSMENT OF MOTOR SYSTEM

43. Muscle Tone Feel for muscle resistance
increased (hyper > spasticity or rigidity) or
decreased (hypo > flaccidity)
Note whether upper or lower neurons
Chapter 22, page 728

44. Muscle strength
Range 0 none/paralysis 1+ no movement/flicker of contraction felt 2+ full passive ROM only, severe weakness 3+ full ROM against gravity only, can’t overcome resistance, moderately weak 4+ slight weakness, full ROM against gravity & some resistance 5+ normal/full ROM against gravity & resistance

45. Muscle Strength (neck & shoulder already assessed with CN XI)
biceps (flexion)
triceps (extension)
hand grip
quads - thigh lift
shin kick (leg extension)
plantar flexion & dorsiflexion (ankles)

46. Reflexes
Grading 0 no response 1+ diminished/sluggish/minimal 2+ average/expected/active/(normal) 3+ more brisk than expected or average 4+ very brisk and hyperactive with clonus

47. Reflex Assessment EXAMPLES OF MAJOR DEEP TENDON REFLEXES TRICEPS
Spinal nerve assessment:
C6,7&8; C5&6; L2,3&4; S1&2
Quickly tests the integrity of the spinal cord.
TRICEPS
BICEPS
PATELLAR
ACHILLES

48. BRACHIORADIALIS

49. Babinski reflex POSITIVE RESPONSE
Dorsiflexion of great toe with fanning of remaining toes
The presence of this sign is normal in children
under 2 years old
If positive in an adult it is a sign of damage to the
central nervous system
Babinski (positive plantar reflex with dorsiflexion)