79ffNeuro Assessment HDSP Final 10.09

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Neurological Assessment

High Desert State Prison

Medical Education - 2009

Acknowledgements: exerpted, in part, from ³Neuro Assessment´

from Doctorsecrets.com and ³Neurological Assessment´

by Sherry Burrell, RN, MSN and other sources



Review of Anatomy & Physiology

The function of the nervoussystem is to control all motor,

sensory & autonomic functions

of the body. Divided into:

Central Nervous System (CNS)

Consisting of the brain andspinal cord.

Peripheral Nervous System (PNS)

Cranial nerves (12) and spinal

nerves (31)

Autonomic Nervous System

± Sympathetic Division:

³fight or flight´ response

± Parasympathetic Division:





The CentralNervous System



CNS:The Brain

The brain controls, initiates and integrates allbody 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

Scalp

hematoma

Physical



TBI: Pathophysiology

Primary Injury

± Initial damage to the brain that results fromthe traumatic event.

Secondary Injury ± Additional damage to the brain tissue

occurring minutes to hours after the initialtraumatic event.

± As a result of the cellular changes that occur with cerebral edema, ischemia andhemorrhage.



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 neurologicalfunction with no structural damage.

± Cause: jarring of the brain results in temporary disruption of synaptic activity; often occurs with acceleration-decelerationinjuries.

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 maypresent 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 damagevisible 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 cerebraledema) 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 withincranial 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 & theskull ± Most often arise from arterial hemorrhage

Cause usually is injury of middle meningeal artery; resultingin rapid accumulation of blood.

± Clinical Manifestations: + LOC after initial trauma; usually at the location of injury

Lucid interval (30-50% experience)

R

apid deterioration in neurologic status; S/Sx of ICP ± Management

Medical emergency requiring immediate medical and surgicalintervention (i.e. craniotomy).



Subdural Hematoma (SDH)

Blood collects between the dura mater & thearachnoid mater ± Often originating from venous hemorrhage

Cause is usually injury to bridging veins; venous blood tends

to accumulate more slowly than arterial blood, thereforesigns/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 ³come 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



Closed

HeadInjuries



Coup ContraCoup BrainInjury





Depressed

SkullFracture

Open

HeadInjury

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





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)





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)



Peripheral

NervousSystem



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





PNS Injuries

Spinal Injuries



PNSSpinalMap



SpinalCordInjuryLocations



Spinal Nerves



Quad

Para







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





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 simplecommands when stimulated (i.e. shaking or shouting) ; verbalresponses include one or two words, but will drift back tosleep without stimulation.



Categories of Consciousness

Stuporous: ± Awakens only to vigorous and

continuous noxious (painful) stimulation; minimalspontaneous movement; motor responses to pain

are appropriate but, verbal responses are minimaland incomprehensible (i.e. moaning).

Comatose: ± Vigorous external stimulation fails to produce any

verbal response; both arousal and awareness arelacking; no spontaneous movements but, motor responses to noxious stimuli maybe bepurposeful (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 andeasily performed in the unconscious or minimallyresponsive patient when a TBI is suspected, andcan provide valuable information about thedegree of initial or progressing brain injury.Several types of TBI¶s may cause pupillarychanges, which indicate the need for rapidinterventions to decrease ICP caused by

cerebral bleeding and/or edema. Nurses are in akey position to detect early changes in apatient's condition and administer or advocatefor immediate interventions.



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



Unequalpupil sizecan be a signof a serious

brain injury.



Brain

Injury withbleedingor swelling

Rapid interventionsare needed to preventdeath or permanentbrain damage ² 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 toparticipate



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 Examination

Motor Exam: use the motor grading scale to maintain

objectivity and

eliminate confusion

5/5: strong against resistance

4/5: weak against resistance3/5: 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 Assessment

Drift Assessment: test for motor weakness

Arm: hold arms out with palms up; eyes closed

Pronator drift: hands pronate (roll over);

Motor drift: arm ³drifts´ downward

Cerebellar drift: arm ³drifts´ back

toward head or out to side

Leg: no need to close eyes

motor: leg ³drifts´toward bed



Movement Assessment

Movements are purposeful or non-purposefulpurposeful: picking at tubings or bed linens, scratching nose

localizing: moving toward or removing a painful stimulus; must cross themidline; occurs in the cortex

withdrawal: pulling away from pain; occurs in the hypothalamusnon-purposeful: do not cross the midline

abnormal flexion: (decorticate)

rigidly flexed arms and wrists; fisted

hands; occurs in upper brainstem

abnormal 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 totrapezius muscle

Supraorbital pressure: pressureunder supraorbital ridgeSternal pressure: knuckle pressure

to sternum; do not rub!

Peripheral Pain: nailbed pressuremay elicit a spinal cord reflex which

can be reproduced in a brain dead patient

TrapeziusPinch





Speech Patterns

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

Aphasia: a disorder in processingLanguage:

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

Brain

Teaser

N A t Q i



Neuro Aessessment Quiz 1. Peripheral Nervous System

(PNS) is made up of the followingexcept::

a) Cranial nerves (12)

b) Ventricles

c) Axons and Neurons

d) Spinal nerves (31)

e) Cerrebellar nerves

2. The Autonomic NervousSystem contains both theSympathetic Division of nervesand the Parasympathetic Divisionof nerves. True or False________________.

3. Intracranial Hemorrhage canoccur in the following places

except:a) Epidural space

b) Subdural space

c) Subarachnoid space

d) Ethmoid space

.4. A Coup Contracoup injury isdefined as: When the head strikesa fixed object, the coup injury

occurs at the site of impact andthe contrecoup injury occurs at theopposite side. True or False____________________

5. The Facial nerve controls:

a) Movement of the chin, tongue andparotid glands.

b) Movement of the tongue, softpalete and eyebrows.

c) Movement of the chin and cheeksmuscles.

d) Movement of all the facialexpression muscles.

6. Which nerve controlsmovement on the neck andshoulders?

a) Abducens

b) Accoustic

c) Spinal Assesory

d) Occulomotor



7. A serious injury to the cervicalspine and spinal cord most likelywill result in the followingcondition:

a) Hemiplegiab) Quadraplegia

c) Paraplegia

d) Contralateral paralysis

8. Any suspected head, neck or spine injured victim shouldimmediately be given spinal

immobilization precautions,except:

a) When the victim complains of painonly upon turning his head to oneside.

b) When the victim refuses to allowspinal immobilization even after

listening carefully to multipleattempts to explain the dangersand risk involved.

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

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

9. When assessing a patient withaltered LOC, you feel his state of awareness/arousal is best describedas ³Obtunded´, this means:

a) Very drowsy, when not stimulated, butcan follow simple commands whenstimulated (i.e. shaking or shouting);verbal responses include one or twowords, but will drift back to sleepwithout stimulation.

b) A state of drowsiness; client needsincreased external stimuli to be

awakened but, remains easilyarousable; verbal, mental & motor responses are slow or sluggish.

c) Awakens only to vigorous andcontinuous noxious (painful)stimulation; minimal spontaneousmovement; motor responses to pain

are appropriate but, verbal responsesare minimal and incomprehensible (i.e.moaning).

d) Vigorous external stimulation fails toproduce any verbal response; botharousal and awareness are lacking; nospontaneous movements but, motor responses to noxious stimuli maybe bepurposeful



10. The Glasgow Coma scaletests for three kinds of responses,they are:

a) Eye Opening

b) Motor Responsec) Verbal Response

d) Auditory Response

11. The best and worst possiblescore on the GCS is:

a) 15 and 0

b) 13 and 3

c) 15 and 3

d) 18 and 5

12. When assessing pupillaryresponse, you are looking for thefollowing conditions except:

a) Coordinated eye movement and

bilateral blinking.b) Reactivity to and accommodation

to light.

c) Symmetry of pupils andaccommodation to light.

d) Abnormal pupil shape.

13. A constricted ³pin point´ pupilindicates: (best answer)

a) Brain Stem herniation

b) Cardiac Arrest

c) Cerebral Infarction of the parietal lobed) Cerebral Infarction of the occipital lobe

e) A wide variety of conditions, somebeing extremely life threatening.

14. What Cranial nerve(s) controls themovement of the eyes down and in?

a) CN VI Abducens

b) CN III Oculomotor

c) CN IV Trochlear

d) CN II Optic

15. The Motor strength scale goesfrom 0/5 to 5/5, 0 being no strength atall and 5 being normal strength. A

person with a motor strength of 4/5would be:

a) overcomes gravity; offers noresistance

b) strong against resistance

c) weak against resistance

d) no muscle movement

16 M t h th f ll i t



16. Match the following postureswith its definition:

Decerebrate_____________

Decorticate______________

a) Abnormal flexion: rigidly flexedarms and wrists; fisted hands;occurs in upper brainstem

b) Abnormal extension: rigidly,rotated inward, extended armswith flexed wrists and fisted

hands; occurs in midbrain or pons. 17. The Babinski reflex is theinitial inflection (extension) of great toe in response stroking of the sole of the foot, select thecorrect answer:

a) An upgoing great toe is abnormal.

b) An upgoing great toe is normal.c) An upgoing great toe is abnornalin adults.

d) An upgoing great toe is normal ininfants.

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

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79ffNeuro Assessment HDSP Final 10.09