Cerebrovascular Accident (CVA) case studySTUDENT NAME : Abdulaziz
ID NUMBER:………………………………..
Definition of CVA:
A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of brain function
resulting from a disruption of the blood supply to a part of the brain.
•
Cerebrovascular accident or stroke is the primary cerebrovascular disorder in the United States.
•
A cerebrovascular accident is a sudden loss of brain functioning resulting from a disruption of the blood
supply to a part of the brain.
•
It is a functional abnormality of the central nervous system.
•
The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of
movement, thought, memory, speech, or sensation.
❖ Summary of the case study
Mr. Almutairi, male, 61 years old, working in food trade business, overweight (95 kg.), was brought to the
emergency room with has a history of hypertension for five years ago. He complained that he felt like he
cannot speak properly and started feeling numbness on his face, and he cannot see objects beyond his
periphery. He could not move his right arm and leg. His son reported that his does not take any maintenance
medications and smokes three packs of cigarettes every day. He was diagnosed with ischemic stroke (CVA)
by the attending physician in ER.
Vital signs:
PB: 193/105 P: 78 /min
RR: 18 /min
TEMP: 36.8
Main complaint:
The patient cannot speak properly and started feeling numbness on his face, he cannot see objects beyond his
periphery, and he could not move his right arm and leg.
Risk Factors
The nonmodifiable and modifiable risk factors of Cerebrovascular accident for this case include:
Nonmodifiable
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Advanced age (61 years)
•
Gender (Male)
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Race (Middle eastern)
Modifiable
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Hypertension
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Hyperlipidaemia
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Obesity
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Smoking
Causes
The patient stroke maybe caused by the following:
•
Large artery thrombosis. Large artery thromboses are caused by atherosclerotic plaques in the large
blood vessels of the brain.
•
Small penetrating artery thrombosis. Small penetrating artery thrombosis affects one or more vessels
and is the most common type of ischemic stroke.
Signs and symptoms
General signs and symptoms the patient exhibited include:
•
Numbness or weakness of the face. Without adequate perfusion, oxygen is also low, and facial tissues
could not function properly without them.
•
Change in mental status. Due to decreased oxygen, the patient experiences confusion.
•
Trouble speaking. Cells cease to function because of inadequate perfusion.
•
Visual disturbances. The eyes also need enough oxygen for optimal functioning.
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Hemiparesis. There is a weakness of the face, arm, and leg on the same side due to a lesion in the
opposite hemisphere.
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Ataxia. Staggering, unsteady gait and inability to keep feet together.
•
Dysarthria. This is the difficulty in forming words.
•
Paresthesia. There is numbness and tingling of extremities and difficulty with proprioception.
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Expressive aphasia. The patient is unable to form words that is understandable yet can speak in singleword responses.
Motor Loss
•
•
Hemiplegia, hemiparesis
Flaccid paralysis and loss of or decrease in the deep tendon reflexes.
Communication Loss
•
•
Dysarthria (difficulty speaking)
Apraxia (inability to perform a previously learned action)
Perceptual Disturbances and Sensory Loss
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Sensory losses: slight impairment of touch or more severe with loss of proprioception; difficulty in
interrupting visual, tactile, and auditory stimuli
Diagnostic Findings
•
CT scans demonstrate ischemia in the left side of the brain.
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MRI shows the areas of ischemia.
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Laboratory studies include:
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PT 11.8; INR 0.95
Blood Sugar: 98 mg/dl; BUN: 20; Creatinine: 1.19
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Serum Electrolyte: (Na: 138.6; K: 3.09; Cl: 103)
CBC: (Hct: 41.8; Plt: 125, 000; WBC: 10, 400)
Lipid Profile: (Chol: 206; Trigly: 77; HDL: 48; LDL: 106)
This patient may also need the following diagnostic test to be done include:
•
Cerebral angiography. Helps determine specific cause of stroke, e.g., hemorrhage or obstructed artery,
pinpoints site of occlusion or rupture. Digital subtraction angiography evaluates patency of cerebral
vessels, identifies their position in head and neck, and detects/evaluates lesions and vascular abnormalities.
•
EEG. Identifies problems based on reduced electrical activity in specific areas of infarction; and can
differentiate seizure activity from CVA damage.
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ECG and echocardiography. To rule out cardiac origin as source of embolus (20% of strokes are the
result of blood or vegetative emboli associated with valvular disease, dysrhythmias, or endocarditis).
Nursing Management
After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits.
Nursing Assessment
During the acute phase, a neurologic flow sheet is maintained to provide data about the following important
measures of the patient’s clinical status:
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Change in level of consciousness or responsiveness.
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Presence or absence of voluntary or involuntary movements of extremities.
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Stiffness or flaccidity of the neck.
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Eye opening, comparative size of pupils, and pupillary reaction to light.
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Colour of the face and extremities; temperature and moisture of the skin.
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Ability to speak.
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Presence of bleeding.
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Maintenance of blood pressure.
During the post-acute phase, assess the following functions:
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Mental status (memory, attention span, perception, orientation, affect, speech/language).
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Sensation and perception (usually the patient has decreased awareness of pain and temperature).
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Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration status,
skin integrity, activity tolerance, and bowel and bladder function.
•
Continue focusing nursing assessment on impairment of function in patient’s daily activities.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses for a patient with stroke may include the
following:
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Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain
injury.
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Acute pain related to hemiplegia and disuse.
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Deficient self-care related to stroke sequelae.
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Disturbed sensory perception related to altered sensory reception, transmission, and/or integration.
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Disturbed thought processes related to brain damage.
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Impaired verbal communication related to brain damage.
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Risk for impaired skin integrity related to hemiparesis or hemiplegia and decreased mobility.
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Interrupted family processes related to catastrophic illness and caregiving burdens.
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Sexual dysfunction related to neurologic deficits or fear of failure.
Nursing Care Planning & Goals
The major nursing care planning goals for the patient and family may include:
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Improve mobility.
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Achievement of self-care.
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Relief of sensory and perceptual deprivation.
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Prevention of aspiration.
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Continence of bowel and bladder.
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Improved thought processes.
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Achieving a form of communication.
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Maintaining skin integrity.
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Restore family functioning.
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Improve sexual function.
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Absence of complications.
Nursing Interventions
Nursing care has a significant impact on the patient’s recovery. Here are some nursing interventions done for
this patient:
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Positioning. Position to prevent contractures, relieve pressure, attain good body alignment, and prevent
compressive neuropathies.
•
Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.
•
Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed in the axilla.
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Prevent oedema. Elevate affected arm to prevent edema and fibrosis.
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Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
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Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the patient to
thrombosis and pulmonary embolus.
•
Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing and
begin walking as soon as standing balance is achieved.
•
Personal hygiene. Encourage personal hygiene activities as soon as the patient can sit up.
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Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual
perception is intact.
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Referred to a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in
teaching alternate swallowing techniques.
•
Voiding pattern. Analyse voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
•
Be consistent in patient’s activities. Be consistent in the schedule, routines, and repetitions; a written
schedule, checklists, and audiotapes may help with memory and concentration, and a communication
board may be used.
•
Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent
body parts.
Improving Mobility and Preventing Deformities
•
Position to prevent contractures; use measures to relieve pressure, assist in maintaining good body
alignment, and prevent compressive neuropathies.
•
Apply a splint at night to prevent flexion of affected extremity.
•
Prevent adduction of the affected shoulder with a pillow placed in the axilla.
•
Elevate affected arm to prevent oedema and fibrosis.
•
Position fingers so that they are barely flexed, place hand in slight supination. If upper extremity spasticity
is noted, do not use a hand roll; dorsal wrist splint may be used.
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Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day.
Establishing an Exercise Program
•
Provide full range of motion four or five times a day to maintain joint mobility, regain motor control,
prevent contractures in the paralysed extremity, prevent further deterioration of the neuromuscular system,
and enhance circulation. If tightness occurs in any area, perform a range of motion exercises more
frequently.
•
Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and
pulmonary embolus.
•
Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (e.g.,
shortness of breath, chest pain, cyanosis, and increasing pulse rate).
•
Supervise and support the patient during exercises; plan frequent short periods of exercise, no longer
periods; encourage the patient to exercise unaffected side at intervals throughout the day.
Preparing for Ambulation
•
Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is gone,
when indicated).
•
Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt table if
needed).
•
Begin walking as soon as standing balance is achieved (use parallel bars and have a wheelchair available in
anticipation of possible dizziness).
•
Keep training periods for ambulation short and frequent.
Preventing Shoulder Pain
•
Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder.
•
Use proper patient movement and positioning (e.g., flaccid arm on a table or pillows when patient is
seated, use of sling when ambulating).
•
Range of motion exercises are beneficial but avoid over strenuous arm movements.
•
Elevate arm and hand to prevent dependent oedema of the hand; administer analgesic agents as indicated.
Enhancing Self Care
•
Encourage personal hygiene activities as soon as the patient can sit up; select suitable self-care activities
that can be carried out with one hand.
•
Help patient to set realistic goals; add a new task daily.
•
As a first step, encourage patient to carry out all self-care activities on the unaffected side.
•
Make sure patient does not neglect affected side; provide assistive devices as indicated.
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Improve morale by making sure patient is fully dressed during ambulatory activities.
•
Assist with dressing activities (e.g., clothing with Velcro closures; put garment on the affected side first);
keep environment uncluttered and organized.
•
Provide emotional support and encouragement to prevent fatigue and discouragement.
Managing Sensory-Perceptual Difficulties
•
Approach patient with a decreased field of vision on the side where visual perception is intact; place all
visual stimuli on this side.
•
Teach patient to turn and look in the direction of the defective visual field to compensate for the loss; make
eye contact with patient and draw attention to affected side.
•
Increase natural or artificial lighting in the room; provide eyeglasses to improve vision.
•
Remind patient with hemianopsia of the other side of the body; place extremities so that patient can see
them.
Assisting with Nutrition
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Observe patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, food
retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
•
Consult with speech therapist to evaluate gag reflexes; assist in teaching alternate swallowing techniques,
advise patient to take smaller boluses of food, and inform patient of foods that are easier to swallow;
provide thicker liquids or pureed diet as indicated.
•
Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated.
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Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check tube
position before feeding, administer feeding slowly, and ensure that cuff of tracheostomy tube is inflated (if
applicable); monitor and report excessive retained or residual feeding.
Attaining Bowel and Bladder Control
•
Perform intermittent sterile catheterization during the period of loss of sphincter control.
•
Analyse voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
•
Assist the male patient to an upright posture for voiding.
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Provide high fiber diet and adequate fluid intake (2 to 3 L/day), unless contraindicated.
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Establish a regular time (after breakfast) for toileting.
Improving Thought Processes
•
Reinforce structured training program using cognitive, perceptual retraining, visual imagery, reality
orientation, and cueing procedures to compensate for losses.
•
Support patient: Observe performance and progress, give positive feedback, convey an attitude of
confidence and hopefulness; provide other interventions as used for improving cognitive function after a
head injury.
Improving Communication
•
Reinforce the individually tailored program.
•
Jointly establish goals, with the patient taking an active part.
•
Make the atmosphere conducive to communication, remaining sensitive to patient’s reactions and needs
and responding to them in an appropriate manner; treat the patient as an adult.
•
Provide strong emotional support and understanding to allay anxiety; avoid completing patient’s sentences.
•
Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes may
help with memory and concentration; a communication board may be used.
•
Maintain patient’s attention when talking with the patient, speak slowly, and give one instruction at a time;
allow the patient time to process.
•
Talk to aphasic patients when providing care activities to provide social contact.
Maintaining Skin Integrity
•
Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.
•
Employ pressure relieving devices; continue regular turning and positioning (every 2 hours minimally);
minimize shear and friction when positioning.
•
Keep skin clean and dry, gently massage the healthy dry skin and maintain adequate nutrition.
Improving Family Coping
•
Provide counselling and support to the family.
•
Involve others in patient’s care; teach stress management techniques and maintenance of personal health
for family coping.
•
Give family information about the expected outcome of the stroke, and counsel them to avoid doing things
for the patient that he or she can do.
•
Develop attainable goals for the patient at home by involving the total health care team, patient, and
family.
•
Encourage everyone to approach the patient with a supportive and optimistic attitude, focusing on abilities
that remain; explain to the family that emotional lability usually improves with time.
Helping the Patient Cope with Sexual Dysfunction
•
Perform in depth assessment to determine sexual history before and after the stroke.
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Interventions for patient and partner focus on providing relevant information, education, reassurance,
adjustment
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of medications, counselling regarding coping skills, suggestions for alternative sexual positions, and a
means of sexual expression and satisfaction.
Teaching points
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Teach patient to resume as much self-care as possible; provide assistive devices as indicated.
•
Have occupational therapist make a home assessment and recommendations to help the patient become
more independent.
•
Coordinate care provided by numerous health care professionals; help family plan aspects of care.
•
Advise family that patient may tire easily, become irritable and upset by small events, and show less
interest in daily events.
•
Make a referral for home speech therapy. Encourage family involvement. Provide family with practical
instructions to help patient between speech therapy sessions.
•
Discuss patient’s depression with the physician for possible antidepressant therapy.
•
Encourage patient to attend community-based stroke clubs to give a feeling of belonging and fellowship to
others.
•
Encourage patient to continue with hobbies, recreational and leisure interests, and contact with friends to
prevent social isolation.
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Encourage family to support patient and give positive reinforcement.
•
Remind spouse and family to attend to personal health and wellbeing.
Evaluation
Expected patient outcomes may include the following:
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Improved mobility.
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Self-care achieved.
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Relief of sensory and perceptual deprivation.
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Prevention of aspiration.
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Continence of bowel and bladder.
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Improved thought processes.
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Achieved a form of communication.
•
Maintained skin integrity.
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Restored family functioning.
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Improved sexual function.
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Absence of complications.
Discharge and Home Care Guidelines
Patient and family education is a fundamental component of rehabilitation.
•
Consult an occupational therapist. An occupational therapist may be helpful in assessing the home
environment and recommending modifications to help the patient become more independent.
•
Physical therapy. A program of physical therapy may be beneficial, whether it takes place in the home or
in an outpatient program.
•
Antidepressant therapy. Depression is a common and serious problem in the patient who has had a
stroke.
•
Support groups. Community-based stroke support groups may allow the patient and the family to learn
from others with similar problems and to share their experiences.
•
Assess caregivers. Nurses should assess caregivers for signs of depression, as depression is also common
among caregivers of stroke survivors.
Documentation Guidelines
The focus of documentation should involve:
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Individual findings including level of function and ability to participate in specific or desired activities.
•
Needed resources and adaptive devices.
•
Results of laboratory tests, diagnostic studies, and mental status or cognitive evaluation.
•
SO/family support and participation.
•
Plan of care and those involved in planning.
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Teaching plan.
•
Response to interventions, teaching, and actions performed.
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Attainment or progress toward desired outcomes.
•
Modifications to plan of care.
Prevention methods of CVA
•
Healthy lifestyle. Leading a healthy lifestyle which includes stop smoking, maintaining a healthy weight,
following a healthy diet, and daily exercise can reduce the risk of having another attack of stroke by about
one half.
•
DASH diet. The DASH (Dietary Approaches to Stop Hypertension) diet is high in fruits and vegetables,
moderate in low-fat dairy products, and low in animal protein and can lower the risk of stroke.
•
Stroke risk screenings. Stroke risk screenings are an ideal opportunity to lower stroke risk by identifying
people or groups of people who are at high risk for stroke.
•
Education. The patient and his family must be educated about recognition and prevention of another
attack of stroke.
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Low-dose aspirin. Research findings suggest that low-dose aspirin may lower the risk of stroke.
Neurological system assessment SHEET
A focused neurological assessment of your patient can make a difference between life and death, permanent
disability, or complete recovery. It is a key standard of care for all patient. The purpose of a neurological assessment
is to detect neurological disease or injury in your patient, monitor its progression to determine the type of care you’ll
provide, and gauge the patient’s response to your interventions (Noah, 2004). Performing a neurological assessment
early is important in establishing a baseline for later comparison (Anness & Tirone, 2009). The initial evaluation is
usually a comprehensive examination covering several critical areas of assessment, including level of consciousness
(LOC), orientation, speech, facial symmetry, motor and sensory function and reflex activity. Assessment of cranial
nerve function, cerebellar function and reflex activity are covered in a comprehensive neurological assessment. The
neurological exam should be incorporated into the rest of your physical exam.
❖ History
Specific emphasis should be placed on the following:
❖ Presenting complaint
➢ Ask about the symptoms:
• What are they?
• Which part of the body do they affect? Are they localized or more widespread?
• When did they start?
• How long do they last for?
• Were they sudden, rapid, or gradual in onset? Is there a history of trauma?
• Are the symptoms static or deteriorating, or are there exacerbations and remissions? For
example, worsening of symptoms with hot environments – e.g., sauna, hot bath, or hot weather
in demyelinating disorders (called Uhthoff’s sign).
• Does anything trigger the symptoms – e.g., exercise, sleep, posture, or external stimuli such as
light or smell?
➢ Ask about any associated symptoms (other features of neurological disease):
• Headache.
• Numbness, pins, and needles, cold or warmth.
• Weakness, unsteadiness, stiffness, or clumsiness.
• Nausea or vomiting.
• Visual disturbance.
• Altered consciousness.
• Psychological changes – e.g., agitation, tearfulness, depression or elation, sleep disturbance.
• For children, ask about performance at school.
➢ Try to understand how the symptoms may affect the patient’s life – ask about activities of daily living.
❖ Past medical history
➢ Some neurological problems can present years after a causative event.
➢ Enquire about other medical problems, past and present. These may give clues to the diagnosis. For
example:
• A person in atrial fibrillation may be producing multiple tiny emboli.
• There may be vascular problems or recurrent miscarriage to suggest antiphospholipid
syndrome.
• There may be diabetes mellitus.
➢ Ask about pregnancy, delivery, and neonatal health.
➢ Ask about any infections, convulsions or injuries in infancy, childhood, or adult life. Particularly ask
about head or spinal injury, meningitis, or encephalitis.
❖ Systematic enquiry
➢ The systematic enquiry is particularly important here. For example:
• Loss of weight and appetite may suggest malignancy, and this may be a paraneoplastic syndrome.
• Gain in weight may have precipitated diabetes mellitus.
•
Polyuria may suggest diabetes mellitus. Difficulty with micturition or constipation may be part of the
neurological problem but was not volunteered in the general history. In men, enquire about erectile
dysfunction.
❖ Social history
➢ Note smoking and drinking habits. Alcohol is a significant neurotoxin, both centrally and peripherally.
➢ Ask about drugs, including prescribed, over the counter and illicit (such as cocaine usage that can be
linked to cardiovascular problems). This includes complementary and alternative medicines.
➢ Ask about occupation and what it involves. There may be exposure to toxins. Is repetitive strain
injury likely? Is there prolonged visual work which may predispose to tension-type headache or
migraine? The job may involve driving but the patient has admitted to convulsions. He/she may work
at heights or in a dangerous environment.
➢ Ask about marital status. Has there been recent bereavement or divorce which may have affected
symptoms?
➢ Ask about sexual orientation and consider the likelihood of sexually transmitted infection – eg,
syphilis, HIV.
❖ Family history
➢ Consider if there may be a genetic basis or predisposition. For example:
• A cousin with Duchenne muscular dystrophy or Becker’s muscular dystrophy would be
important for a boy who cannot run like his peers.
• Huntington’s chorea is unusual in that it is a familial disease that does not present until well
into adult life.
• A family history of, for example, type 2 diabetes mellitus, cerebral aneurysm, neuropathies,
epilepsy, migraine, or vascular disease may be important.
❖ Results of Specific Investigations (X-rays, CT Scans, Blood Tests)
❖ The Physical Examination of the neurological system
This is comperhinsive Guide to the Neurological Examination and we will need the following Equipment to preform
it:
12345-
Reflex hammer.
128-Hz tuning fork.
Ophthalmoscope.
Pocket eye chart (for near vision testing)
Cotton swabs, tongue blades, and safety pins.
❖ I. Mental Status.
A. Level of consciousness.
1. Note if awake and alert.
2. If not, describe what level of stimulation is needed to arouse and keep patient awake. E.g., “opens eyes to
noxious stimuli; falls back asleep if not continuously stimulated.”
B. Attentiveness.
1. Patient is attentive if able to attend to you and the examination without getting easily distracted.
2. Have patient spell WORLD backwards or count backwards or say the months of the year backwards.
C. Orientation.
1. Ask patient full name, location, and full date.
2. Patient is “oriented x 3” if all 3 are entirely correct.
3. If not oriented x 3, write out patient’s responses. Do not say “oriented x 2 (or 1)”.
D. Speech and language.
Listen to patient’s verbal output: motor ability to produce words, quantity of spontaneous speech, rate of speech
production, sentence structure, accuracy/appropriateness of words used, and ability to repeat a sentence, follow
commands, and come up with the right words for things. This include:
1. Fluency is normal if patient speaks in complete sentences without hesitancy between words.
2. Comprehension is normal if patient is able to answer your questions appropriately and follow exam
instructions:
a. “Do what I say: Look to the door and then look to the window.”
b. If not done perfectly, give simpler command: “Show me your thumb.”
3. Repetition.
“Repeat after me: I went to the store and forgot my wallet.”
4. Naming.
a. Point to objects around room, asking what they are: watch, pen, telephone.
b. If done well, ask more difficult ones: (watch) band, (pen) cap, (telephone) receiver.
5. Reading.
Have patient read and follow a written command: Close Your Eyes.
6. Writing.
Have patient write a complete sentence of their choosing.
E. Memory.
1. Registration: “Repeat these words after me: apple, table, penny.” Do not proceed to memory testing until
patient says them all correctly.
2. Immediate Recall: 1-3 minutes later, “What were those 3 words I asked you to remember?”
3. Recent memory: “What did you have for breakfast this morning?”
4. Remote memory: “Where did you grow up/go to school? When was your wedding/child born/military service?”
F. Higher intellectual function.
1. General knowledge: “Who is the U.S. president/Missouri governor? What is the capital of Illinois?”
2. Abstraction: “What does ‘People in glass houses shouldn’t throw stones’ mean?”
3. Judgment: “What would you do if you found a sealed, stamped, addressed envelope lying on the ground?”
4. Insight: “Why did your daughter bring you to the hospital?”
5. Reasoning: “How do a lie and a mistake differ?”
❖ II. Cranial Nerves.
➢ A. CN I Olfactory.
1. Have patient close eyes.
2. Occlude one nostril and test other using nonirritating substances (e.g., vanilla, cloves, coffee). Avoid those that
stimulate trigeminal nerve endings or taste buds (e.g., peppermint, menthol, ammonia, alcohol swabs).
3. Compare 2 sides.
➢ B. CN II Optic.
1. Visual acuity.
•
•
•
•
Hold Snellen chart at comfortable reading distance (about 14 inches).
Cover 1 eye and have patient read chart.
For each eye, record smallest line patient can read.
Glasses should be left on (looking for optic nerve lesion, not refractive error).
2. Visual fields.
•
•
•
•
•
•
Stand directly in front of patient and have patient look you in both eyes.
Hold your hands midway between you and the patient far enough laterally that you can barely see them out
of the corner of your eyes.
Wiggle a finger on one hand.
Ask patient to indicate on which side the finger is moving.
Repeat in upper and lower temporal quadrants.
If abnormality is suspected or is found on screening test above, test all 4 quadrants of each eye individually:
i. Have patient close one eye; you should close your own eye that is opposite the patient’s closed eye,
since you will be serving as the normal control.
ii. Move a finger or penlight into the periphery of each visual quadrant (upper and lower temporal and
nasal), asking patient to indicate when movement is detected. It should be seen by you and patient at
the same time.
3. Fundoscopy.
•
•
•
•
•
Have patient focus on distant wall.
Be sure your head is not obstructing patient’s view of that target.
View optic disc using ophthalmoscope.
Note disc color and presence of venous pulsations, papilledema (disc hyperemia, blurred
margins, absent venous pulsation), or hemorrhages.
4. Pupillary function (CN II and CN III).
a. Test pupillary reaction to light.
i.
ii.
iii.
iv.
v.
Dim room lights as necessary.
Ask patient to look into distance to avoid effect of accommodation.
Shine bright light obliquely into each pupil.
Look for both direct (same eye) and consensual (other eye) constriction.
Record pupil size in mm (normal is about 2-5 mm) and any asymmetry or irregularity.
b. If light reflex is abnormal, test pupillary reaction to accommodation.
i.
ii.
iii.
Hold finger 10 cm from patient’s nose.
Have patient alternate looking into distance and at finger.
Observe pupillary response.
➢ C. CN III, IV, VI Oculomotor, Trochlear, Abducens.
1. Visual inspection.
i.
Look at ocular alignment at rest (primary gaze). Does the reflection of light hit at same location in each
eye? Is one eye deviated in, down and out, or up?
Observe for ptosis (lid droopiness).
ii.
2. Six cardinal directions of gaze.
i.
ii.
iii.
Stand 3-6 feet in front of patient.
Ask patient to follow your finger with the eyes without moving the head. Place your hand on top of head
to keep it still if necessary.
Move your finger in the six cardinal directions and observe whether movements are full in each eye.
3. Convergence.
i.
ii.
Ask patient to follow your finger with the eyes without moving the head. Hold lids up if necessary.
Move your finger toward bridge of patient’s nose and observe eye movements.
4. Smooth pursuits (smooth following movements).
– Steadily move your finger horizontally and then vertically as in testing individual extraocular muscles, but
this time, look at smoothness of following movements.
5. Saccades (discrete, rapid movements from one object to another).
i.
ii.
iii.
Hold up your hands in front of patient (with each hand held a few inches lateral to the eye).
Have patient alternate looking from one hand to the other.
Observe accuracy with which eyes reach target. Do they consistently undershoot or overshoot the target?
Is there oscillation before hitting the target?
6. Nystagmus.
i.
ii.
iii.
Observe for involuntary horizontal, vertical, or rotary oscillation of the eyeballs at primary gaze (looking
straight ahead) and on sustained horizontal and vertical gaze.
If present, note direction of movement and whether movement persists or fatigues.
A few beats of nystagmus at extremes of gaze is a normal finding).
7. Pupillary light response. (see CN II)
➢ D. CN V Trigeminal.
1. Facial sensation.
a. Explain to patient what you intend to do.
b. Use sharp end of a broken cotton swab or a pin to test pain sensation on forehead, cheek, and jaw of each
side of face.
c. Ask patient to tell you whether it feels about the same on both sides.
d. If not, map out where abnormality is to see if it conforms to distribution of trigeminal
nerve. Specifically, march stimulus from forehead back past hairline, from cheek to
tragus of the ear, and from jaw to neck. (V1 extends far back to the top of the skull—it
does not end at the hairline. V3 ends just above the jaw line inferiorly and just before
the ear laterally.)
2. Corneal reflex (CN V and CN VII).
a. Lightly touch peripheral aspect of cornea from the side with fine wisp of cotton.
b. Look for normal blink reaction of both eyes.
c. Repeat on other side.
d. If response is less than brisk, touch cornea more centrally.
3. Temporalis and masseter strength.
a. Ask patient to open mouth and clench teeth.
b. Palpate temporalis and masseter muscles.
➢ E. CN VII Facial.
1. Observe for any facial asymmetry at rest in forehead wrinkles, palpebral fissure width, nasolabial folds, or corner
of mouth.
2. Ask patient to do the following and note any lag, weakness, or asymmetry:
a. Smile.
b. Puff out cheeks.
c. Close both lips and resist your attempt to open them.
d. Close both eyes and resist your attempt to open them.
e. Raise eyebrows.
3. Corneal reflex (see CN V).
➢ F. CN VIII Acoustic.
1. Screen hearing.
a. Face patient and hold out your arms with your fingers near each ear.
b. Rub your fingers together on one side.
c. Ask patient to tell you when and on which side the rubbing is.
d. Increase intensity as needed.
e. Note any asymmetry.
➢ G. CN IX & X Glossopharyngeal & Vagus.
1. Listen to patient’s voice. Note any hoarseness, nasal, or breathy quality.
2. Ask patient to say “Ah” and watch movement of soft palate and pharynx. (Do not pay attention to uvula, which can
deviate to one side or another in the normal person.). Note any asymmetry of palate elevation.
3. Ask patient to swallow and to cough.
4. In the unconscious or uncooperative patient, test gag reflex.
a. Stimulate back of throat with a cotton swab on each side.
b. Look for gagging after each stimulus.
➢ H. CN XI Spinal Accessory.
1. Trapezius.
a. From behind patient, look for atrophy or asymmetry of trapezii.
b. Ask patient to shrug shoulders against resistance and note strength.
c. Ask patient to push head back against resistance and note strength.
2. Sternocleidomastoid.
a. Place hand on lower face and ask patient to turn head towards that side against resistance.
b. Observe contraction of opposite sternocleidomastoid.
➢ I. CN XII Hypoglossal.
1. Note tongue position at rest in the mouth and on protrusion. Does tongue deviate in either position?
2. Ask patient to stick out tongue and move it from side to side. Note strength and rapidity of movements.
3. Have patient push tongue into each cheek while you push from the outside. Note strength.
❖ III. Motor System.
A. Visual inspection.
1. Note muscle bulk. Look for generalized or focal muscle wasting or hypertrophy.
2. Look for extraneous movements, e.g., tremor (At rest? With action?), fasciculation (muscle twitching).
3. Note speed of movement, e.g., slow to initiate (bradykinesia).
B. Tone (muscle tension at rest).
1. Ask patient to relax.
2. Flex and extend patient’s wrists, elbows, ankles, and knees.
3. Look for resistance that is decreased (hypotonia) or increased (throughout range of motion=rigidity; springlike=spasticity).
C. Strength and Endurance.
1. Isolate muscle you are testing so patient can’t use strong muscles that have similar function to compensate
for weak one being tested.
2. Fix proximal joint when testing distally. E.g., if testing pronation, fix the humerus, so patient can’t use
shoulder to compensate for weak pronation.
3. Give yourself the advantage. E.g., when testing deltoid, press on outstretched hand rather than on elbow.
4. Have patient walk on heels and toes and do deep knee bend or get out of chair without using arms.
5. Test at least the following muscles on both sides:
a. Deltoid: abduction (elevation) of upper arm (C5-6; axillary nerve).
b. Biceps: flexion of forearm at elbow (C5-6; musculocutaneous nerve).
c. Triceps: extension of forearm at elbow (C6-8; radial nerve).
d. Extensor carpi radialis: dorsiflexion of hand at wrist (C5-6; radial nerve).
e. Abductor pollicis brevis: palmar abduction of thumb with thumb at right angle to palm (C8-T1;
median nerve).
f. Interossei: finger abduction (dorsal) and adduction (palmar) (C8-T1; ulnar nerve).
g. Iliopsoas: hip flexion (L1-3; femoral nerve).
h. Quadriceps: knee extension (L2-4; femoral nerve).
i. Hamstrings: knee flexion (L5-S2; sciatic nerve).
j. Tibialis anterior: foot dorsiflexion (L4-5; deep peroneal nerve).
k. Gastrocnemius/soleus: foot plantar flexion (S1-2; tibial nerve).
6. Assign score of 0-5 for each muscle based on Medical Research Council scale.
7. Note if strength fatigues after sustained muscle contraction.
❖ IV. Reflexes.
A. Muscle stretch reflexes.
1. Position limb and place muscle in slight tension.
2. Quickly tap the tendon/periosteum to which muscle is attached.
3. Observe vigor and briskness of response and compare side-to-side.
4. If reflexes are diminished or absent, try reinforcing the reflex by distraction or via isometric contraction of
other muscles (clenched teeth).
5. Test at least the following reflexes: (spinal nerve root in bold is the predominant contributor).
a. Biceps (C5, C6; musculocutaneous nerve).
i. Patient’s arm should be partially flexed at the elbow with palm down.
ii. Place your thumb or finger firmly on biceps tendon.
iii. Strike your finger with reflex hammer.
iv. You should feel the response even if you can’t see it.
b. Triceps (C6, C7; radial nerve) .
i. If patient is seated: support upper arm and let forearm hang free.
ii. If patient is lying down, flex arm at elbow and hold it close to chest.
iii. Strike the triceps tendon above the elbow.
c. Knee (L2, L3, L4; femoral nerve).
i. Have patient sit or lie down with knee flexed.
ii. Strike patellar tendon just below patella.
iii. Note contraction of the quadriceps and extension of the knee.
d. Ankle (S1, S2; tibial nerve).
i. Dorsiflex foot at ankle.
ii. Strike Achilles tendon.
iii. Watch and feel for plantar flexion at the ankle.
6. Test for clonus (rhythmic oscillations of flexion/extension) at the ankle.
i. Support knee in a partly flexed position.
ii. With patient relaxed, quickly dorsiflex foot.
iii. Observe for rhythmic oscillations.
7. Assign grade on scale of 0-4.
B. Plantar response (L4-S2, especially S1; tibial nerve).
1. Using the end of a reflex hammer, a broken tongue blade, or a key, stroke lateral aspect of the sole of each foot
from heel to toes, then drag the stimulus across the foot just beneath the toes.
2. Note movement of toes.
3. If no response, increase pressure of stroking.
4. If patient ticklish or withdrawing whole foot, either have patient stroke own foot or apply stimulus along lateral
aspect of foot only.
5. Flexion of all toes (downgoing toe) is a normal response. Extension of the great toe (upgoing toe; positive
Babinski) with fanning of the other toes is abnormal.
❖ V. Sensory System.
A. General points.
1. Explain each test before you do it.
2. Unless otherwise specified, the patient’s eyes should be closed during testing.
3. Test all 4 extremities.
4. Compare side to side and ask if the two sides are about the same. Avoid leading questions like “Is this sharp?”
5. Compare distal and proximal areas of the extremities.
6. When you detect an area of sensory loss, map out its boundaries in detail.
B. Vibration.
1. Use a 128-Hz (low-pitched) tuning fork.
2. Lightly strike tines against your hand and place stem of the fork over most distal joint of patient’s great toe.
3. Ask whether patient feels anything and what the sensation is.
4. If vibration is felt, ask when it goes away. Count number of seconds.
5. Repeat on other side, being sure to strike the fork with about equal force, and compare duration vibration is felt.
6. If vibration sense is impaired, move proximally one joint at a time until it is felt.
7. Test the fingers in a similar fashion.
C. Joint position sense.
1. Grasp patient’s great toe on sides of distal phalanx and hold it away from other toes to avoid friction.
2. Demonstrate to patient what “up” and “down” feel like and tell patient you will move the toe in one of these two
directions only.
3. Move toe a few degrees and ask patient to identify direction in which toe was moved.
4. If position sense is impaired, increase stimulus intensity (move toe a greater distance); if still impaired, test at
more proximal joint (ankle–>knee–>hip).
5. Test fingers in a similar fashion.
D. Pain.
1. Use a safety pin or sharp end of a broken cotton swab.
2. Test for a distal gradient of sensory loss in leg by applying stimulus at toes and marching your way up to knee.
a. Ask patient if the sensation is “about the same” or if it changes as you move up the leg.
3. Test for sensory loss in most commonly affected nerve and nerve root distributions.
a. Test the following areas:
i. Palmar aspect of index finger (median nerve).
ii. Palmar aspect of 5th finger (ulnar nerve).
iii. Web space between thumb and index finger on dorsal surface of hand (radial
nerve).
iv. Web space between great toe and 2nd toe on dorsal surface of foot (L5).
v. Lateral surface of foot (S1).
b. Apply stimulus to one and then another of these locations in the upper or lower extremity, asking patient
if the two areas are “about the same.”
4. In the patient complaining of sensory symptoms, move stimulus from abnormal area to normal area, asking
patient to report when stimulus begins to feel stronger. Another technique is to apply stimulus to an uninvolved
part of the body and say, “If this sharpness/coolness is worth $1, how much is this worth?” and then apply
stimulus to the involved part.
E. Temperature.
1. Testing of temperature is usually reserved for the patient in whom testing of pain sensation is abnormal.
2. Press a cold tuning fork against the skin to make sure there is temperature loss in same distribution as pain
loss.
F. Light touch.
1. Touch the skin lightly with your fingers.
2. Ask patient to respond whenever a touch is felt (e.g., “left arm”).
3. Test face, arms, and legs in random order.
G. Double simultaneous stimulation (test for extinction/tactile neglect).
1. Can be performed only when light touch is intact.
2. Touch both sides of patient’s face or body simultaneously.
3. Ask patient to indicate whether touch is felt on the left, right, or both.
H. Graphesthesia (integrative sensation).
1. Can be performed only when light touch is intact.
2. Using a pen cap, paper clip, or your finger, draw a number in patient’s palm or, for more sensitivity, on index
finger.
3. Ask patient to identify the number.
I. Stereognosis (integrative sensation).
1. Can be performed only when light touch and position sense are intact.
2. Place a familiar object (e.g., coin, paper clip, key) in patient’s hand.
3. Ask patient to move it around using fingers and to identify it.
J. Romberg.
1. Have patient stand with feet together and eyes open.
2. Have patient close eyes.
3. Hold your arms out to steady/catch patient if necessary.
4. Watch for development of swaying or falling when eyes are closed (“positive Romberg”)—indicates either
impaired proprioception or vestibular dysfunction.
❖ VI. Coordination.
A. Truncal stability.
1. Observe patient sitting on a chair or side of bed with hands in lap. (Make sure if sitting on side of bed that bed
is reclined flat.)
2. Note any leaning towards one side or falling backwards.
B. Fine finger movements (finger tapping).
1. Have patient tap distal joint of thumb with tip of index finger as fast as possible.
2. Observe rhythm, speed, and precision of movements.
3. Repeat on other side.
C. Toe tapping.
1. Have patient tap your hand with ball of each foot as fast as possible.
2. Observe rhythm, speed, and precision of movements.
3. Repeat on other side.
D. Finger-nose-finger.
1. Have patient alternately touch your outstretched finger and own nose.
2. Be sure your finger is far enough away that patient’s arm must fully extend to reach it.
3. Observe speed, and precision of movements. Note any oscillation, especially one that worsens as patient’s
finger nears the target. Note if patient consistently passes (overshoots), fails to reach (undershoots), or is off to
left or right of target.
4. Repeat on other side.
E. Heel-knee-shin.
1. Patient should be lying down on exam table/bed. Place heel of one foot just below knee of the other leg.
2. Have patient run that heel up and down shin of other leg.
3. Observe speed, and precision of movements. Note any wavering.
4. Repeat on other side.
F. Rapid Alternating Movements.
1. Have patient alternately tap dorsal and plantar surface of one hand onto other hand, the thigh, or the bed (as
fast as possible).
2. Observe rhythm, speed, and precision of movements.
❖ VII. Station and Gait.
A. Observe the patient do the following:
1. Rise from a seated position.
2. Walk across room, turn, and come back.
3. Walk on toes.
4. Walk on heels.
5. Walk heel to toe (tandem gait) in a straight line. (Many otherwise normal elderly people cannot perform this
task.)
B. Be prepared to catch the patient if necessary. If there is any doubt in your mind as to whether the patient may fall,
get assistance (nurse, patient care technician, resident) before testing gait. Do not use this doubt as a reason not to
test gait, however.
C. Pay attention to the following:
1. Posture of body and extremities (e.g., leaning or pulling towards one side or backwards, twisting or holding
back one arm).
2. Length, speed, and rhythm of steps.
3. Base of gait (how far apart are the legs).
4. Arm swing (is it reduced unilaterally or bilaterally).
5. Steadiness.
6. Turning (steadiness of turns and number of steps required to complete the turn).
❖ VIII. Meningeal Signs.
A. Ask patient to flex and extend neck.
B. Passively flex and extend patient’s neck.
C. Observe for palpable stiffness on either active or passive movement.
There are many different assessment tools for neurological function, however, the most widely known and used tool
is the Glasgow Coma Scale (GCS).
❖ The patient is assessed and scored in three areas:
1- Eye opening
2- Verbal response
3- Motor response.
❖ The highest possible score is a 15, which reflects an individual who is fully alert, aware, and orientated,
whereas the lowest possible score is a 3 and reflects an unconscious individual.
•
References
Anness, E. & Tirone,K. (2009). Evaluating the neurologic status of unconscious patients. American Nurse
Today, 4(4). Retrieved from http://www.americannursetoday.com/article.aspx?id=2548&fid=2446
Noah, P. (2004). Neurological assessment: A refresher. Modern Medicine. Retrieved from
http://www.modernmedicine.com/news/neurological-assessment-refresher
Rowlett, R 2001, Glasgow Coma Scale, University of North Carolina, viewed 27 March 2018,
http://www.unc.edu/~rowlett/units/scales/glasgow.htm
Teasdale, G 2015, Glasgow Coma Scale: Do it this way, GCS, viewed 27 March 2018,
http://www.glasgowcomascale.org/
Neurological
assessment
Assessment: The Neurologic Examination
History taken
Key points in a neurological history
Assessment: The Neurologic Examination
History taken
Key points in present complains
Assessment: The Neurologic Examination
History taken
Subjective Data— Health History
❑ Headache
❑ Head injury
❑ Dizziness/vertigo
❑ Seizures
❑ Tremors
❑ Weakness
Assessment: The Neurologic Examination
History taken
Key points time of course
Assessment: The Neurologic Examination
History taken
Key points neurology system review
Assessment: The Neurologic Examination
History taken
▪ Past medical history (PMH)
▪ Family history
▪ Personal & social history
▪ Drugs, allergies
Physical Examination
Six Subsets of the Neuro Exam
Mental Status
Cranial nerves
Motor and Coordination
Muscle
Sensory
Physical Examination
Mental Status
Level of Alertness
Subjective view of Examiner
Definition of Consciousness
Terminology for Depressed Level of Consciousness
Concept of Coma
Delirium
Degree of Orientation
Physical Examination
Mental Status
Concentration
Serial 7’s or 3’s
“WORLD” backwards
Months of the Year Backwards
Try to quantify degree of impairment
Physical Examination
Mental Status
Memory
Immediate Recall
A task of concentration
Short-Term Memory
“3/3 objects after 5 minutes”
Long-Term Memory
Last thing to go
Physical Examination
Mental Status
Language
Aphasia vs Dysarthria
Receptive Language
Command Following
Expressive Language
Fluency
Word Finding
Repetition
Screens for Receptive, Expressive, and Conductive
Aphasias
Physical Examination
Mental Status
• Calculations, R-L confusion, finger agnosia,
agraphia
Gerstmann’s Syndrome (Dominant Parietal Lobe)
Hemineglect
Non-Dominant Parietal Lobe
• Delusional Thinking, Abstract Reasoning, Mood,
Judgement, Fund of Knowledge, etc
Important for Psychiatry
Does not localize well to one region of the cortex
Neurocognitive Testing required to get at more specific deficits
Physical Examination
Mental Status
LOC Terminology
Full consciousness- Patient is alert, attentive, and follows commands. If asleep,
responds promptly to external stimulation and, once awake, remains attentive.
Lethargic- Patient is drowsy but awakens—although not fully—to stimulation. Will
answer questions and follow commands, but slowly and inattentively.
Obtunded- Patient is difficult to arouse and needs constant stimulation in order to
follow a simple command. May respond verbally with one or two words, but will drift
back to sleep between stimulation.
Stuporous- Patient arouses to vigorous and continuous stimulation; typically, a painful
stimulus is required. May moan briefly but does not follow commands. Only response
may be an attempt to withdraw from or remove the painful stimulus.
Comatose- Patient does not respond to continuous or painful stimulation. Does not
move—except, possibly, reflexively—and does not make any verbal sounds.
Physical Examination
Mental Status
LOC Assessment Tools
Typically, it is the Glasgow Coma Scale (GCS) that is used to
assess LOC.
Physical Examination
Mental Status
LOC Assessment Tools
Physical Examination
Cranial Nerves
Physical Examination
Cranial Nerves
12 cranial nerves = sensory and motor function
Midbrain (CN III, IV)
Pons (CN VIII)
Medulla (CN IX to XII)
Ipsilateral findings except on CN V
Acoustic problem (CN VII, VIII)
Pupillary response (CN II, III)
Corneal reflex (CN V, VII)
Gag reflex (CN IX, X)
Physical Examination
Cranial Nerves Olfactory Nerve
Distinguish Coffee
from Cinnamon
Smelling
Salts
irritate
nasal
mucosa and test V2
Trigemminal Sense
Disorders of Smell
result from closed
head injuries
Physical Examination Optic Nerve
Cranial nerve II
Cranial Nerves
Visual Acuity
Visual Fields
Afferent input to Pupillary Light
Reflex
APD
Look
at
the
Nerve
(Fundoscopic Exam)
“VA equals 20/20 OU at near”
“PEERLA”
Physical Examination
Cranial Nerves
Optic Nerve
Cranial nerve II
Visual Acuity
Visual Fields
Afferent input to Pupillary Light Reflex
APD
Look at the Nerve (Fundoscopic Exam)
“VA equals 20/20 OU at near”
“PEERLA”
Abducens Nerve
Cn VI
Trochlear Nerve
c.n. IV
Physical Examination
Cranial Nerves
Normal pupils are equal in size and
shape and are situated in center of
iris
•Pupillary size varies with intensity
of ambient light, but at average
intensity is 3-4 mm
–Miosis 5 mm
–Anisocoria = pupillary asymmetry
Physical Examination
Cranial Nerves
Cranial Nerves III, IV, VI
Extra-Ocular Muscles
Efferent limb of pupillary light reflex (III)
Edinger-Westphal nucleus in tegmentum of
midbrain
Ptosis
Oculomotor Nerve Palsy
Part of Horner’s Syndrome
Cardinal Directions of Gaze
Efferent output for Oculocephalic Reflex
Look for Nystagmus
“EOMI without nystagmus”
Physical Examination
Cranial Nerves
Cranial Nerves III, IV, VI
Physical Examination
Cranial Nerves
Trigeminal Nerve
c.n. V
Motor Component
Opthalmic (V1), Maxillary (V2),
and Mandibular (V3)
Distributions
All modes of Primary Sensation
Modalities can be tested
Afferent input for the Corneal
Blink Reflex
“Facial sensation intact in all
distributions”
Physical Examination
Cranial Nerves
Trigeminal Nerve
c.n. V
Physical Examination
Cranial Nerves
Motor innervation to facial muscles
UMN versus LMN Facial Weakness
Efferent output to Corneal Blink
Reflex
Other Functions
Parasympathetic input to
lacrimal, sublingual, and
submandibular glands, taste to
anterior 2/3 of tongue, general
sensation to concha of earlobe
and small part of scalp, motor
input to stapedius muscle
“Facial motor intact”
Facial Nerve
c.n. VII
Physical Examination
Vestibulocochlear Nerve
Cranial Nerves
c.n. VIII
Hearing and Balance
Patients will complain of
tinnitis, hearing loss,
and/or vertigo
Weber and Renee Test
Differentiates Conductive
vs Sensorineural hearing
loss
Afferent input to the
Oculocephalic Reflex
Doll’s Eye Maneuver
Cold Calorics
Not “COWS”
“Hearing grossly intact
AU”
Distinguishing the type of deafness.The Rinne test A +
B.The Weber test C.
Physical Examination Glossopharyngeal
Cranial Nerves
and Vagus Nerves
c.n.’s IX and X
Afferent (IX) and Efferent
(X) components for the
Gag Reflex
Vagus Nerve also does all
parasympathetics
from
the neck down until the
mid-transverse colon
Physical Examination
Cranial Nerves
Spinal Accessory
Nerve
c.n. XI
Examining the accessory nerve.
Testing the sternomastoid and the
trapezius.
Physical Examination
Hypoglossal Nerve
Cranial Nerves
c.n. XII
Protrudes the
tongue to the
opposite side
Tongue in cheek
(strength)
Hemi-atrophy and
fasiculations (LMN)
The Neurological Examination
Motor Examination
Compare left to right, proximal to distal, arms
to legs
–Bulk (muscle mass)
–Tone (muscle tension at rest)
–Strength
–Reflex
–Balance and coordination
– Sensation
The Neurological Examination
Motor Examination
–Bulk (muscle mass)
Compare size and contours of muscle ( flat, concave?
Unilateral or bilateral, proximal or distal). Look for:
• Atrophy: abnormally small muscle with wasted appearance.
–Happen in disuse, injury to lower motor neuron disease such as
polio.
•Hypertrophy: increased size and strength occur with isometric
exercise
-Look at the thinner and hypothenar muscle ( convex and full)
-Look at the space between metacarpals ( full, slightly depressed)
The Neurological Examination
Motor Examination
Tone is the normal degree of tension (contraction) in voluntary
relaxed muscle
Tone is the resistance appreciated when
moving a limb
passively
“Normal Tone”
Hypotonia
“Central Hypotonia”
“Peripheral Hypotonia”
Increased Tone
Spasticity (Corticospinal Tract)
Rigidity (Basal Ganglia, Parkinson’s Disease)
Dystonia (Basal Ganglia)
The Neurological Examination
Motor Examination
The Neurological Examination
Motor Examination
Strength
Medical Research Council Scale
5/5 = Full Strength
4/5 = Weakness with Resistance
3/5 = Can Overcome Gravity Only
2/5 = Can Move Limb without Gravity
1/5 = Can Activate Muscle without
Limb
0/5 = Cannot Activate Muscle
Moving
The Neurological Examination
Motor Examination
Upper Limb Strength
The Neurological Examination
Motor Examination
Lower limb Strength
The Neurological Examination
Motor Examination
Reflexes
The Neurological Examination
Motor Examination
Deep tendon reflexes includeTriceps
Biceps
Brachioradialis
Patellar
Achilles tendon
Not routinely assessed
Should be tested in any patient with a spinal cord injury
Tested with reflex hammer.
Graded from 0-5+
0- no reflex
2+- normal
5+ hyperreflexia with clonus (repeated rhythmic contractions)
The Neurological Examination
Motor Examination
Biceps- Patient’s arm should be flexed slightly with the palm
facing up. Hold arm with your thumb in the antecubital space
over the biceps tendon. Strike your thumb with the hammer;
the arm should flex slightly.
Triceps- Patient’s arm should be flexed 90 degrees. Support
the arm and strike it just above the elbow, between the
epicondyles; the arm should extend at the elbow.
Brachioradialis- Patient’s arm should be flexed slightly
and resting on the lap with the palm facing down. Strike the
outer forearm about two inches above the wrist; the palm
should turn upward as the forearm rotates laterally.
The Neurological Examination
Motor Examination
Patellar- With the patient’s legs dangling (if possible), place
your hand on one thigh and strike the leg just below the kneecap;
the leg should extend at the knee.
Achilles tendon- With patient’s foot in slight dorsiflexion,
lightly strike the back of the ankle, just above the heel; the foot
should plantar flex.
The Neurological Examination
Motor Examination
Assessing Superficial Reflexes
• Plantar reflex is the only superficial reflex that’s commonly
assessed and should be tested in comatose patients, and those
with suspected injury to lumbar 5-5 or sacral 1-2 areas of the
spinal cord.
• Stimulate the sole of the foot with a tongue blade or the handle of a
reflex hammer.
• Begin at the heel & move up the foot, in a continuous motion,
along the outer aspect of the sole and then across the ball to the
base of the big toe. 7
• Normal response is plantar flexion (curling under) of the toes.
• Extension of the big toe (Babinski’s sign) is abnormal, except in children
younger than 2 years.
The Neurological Examination
Motor Examination
Assessing Superficial Reflexes
• Plantar reflex is the only superficial reflex that’s commonly
assessed and should be tested in comatose patients, and those
with suspected injury to lumbar 5-5 or sacral 1-2 areas of the
spinal cord.
• Stimulate the sole of the foot with a tongue blade or the handle of a
reflex hammer.
• Begin at the heel & move up the foot, in a continuous motion,
along the outer aspect of the sole and then across the ball to the
base of the big toe. 7
• Normal response is plantar flexion (curling under) of the toes.
• Extension of the big toe (Babinski’s sign) is abnormal, except in children
younger than 2 years.
The Neurological Examination
Motor Examination
Assessing brain stem Reflexes
Gag reflex (CN IX, X)
Its absence may increase risk for aspiration
Cough reflex (CN X)
Pupillary reflex (CN II, III)
PERRLA
Pupils equal round reactive to light and accommodation
Anisocoria
Myosis = pontine hemorrhage, narcotics
Mydriasis = brain injury, anticholinergics
Mid-position fixed pupils = severe cerebral damage
Corneal reflex (CN V, VII)
The Neurological Examination
Motor Examination
Assessing brain stem Reflexes
Pupillary reflex (CN II, III)
The Neurological Examination
Motor Examination
Vital signs and neurological system
Brainstem = breathing
Lesions from cerebrum to cervical cord cause
changes of breathing patterns
Cheyne-Stokes respiration
Intracranial cause, hypoxemia, cardiac
failure
Ataxic breathing: marker of brainstem
dysfunction
Increased ICP = Cushing’s triad
Hypertension, widening pulse pressure,
bradycardia, bradypnea
The Neurological Examination
Motor Examination
Muscle coordination
The finger nose test
The heel chin test
The Neurological Examination
Motor Examination
Muscle coordination
–Stance (posture):
•Romberg test: test of position sense, patient stand feet together,
eyes closed, for 20-30 sec. dose patient able to maintain upright
position
–Positive: when lose balance, sways, widens base of feet to avoid
falling
The Neurological Examination
Motor Examination
Muscle coordination
•Pronator drift test:
–stand for 20-30 sec, arms up, palms up, eyes closed;
–then instruct the patient to keep arms up, tap the arms briskly
downward, the patient should be able to keep arms up back
smoothly.
–Abnormal finding: downward drift of arm with flexion of elbow
and fingers; or pronation of one arm (Corticospinal tract lesion).
The Neurological Examination
Motor Examination
Assessing sensation
Primary Sensory Modalities
Light Touch (Multiple Pathways)
Pain/Temperature Sensation (Spinothalamic Tract)
Vibration/Position Sensation (Posterior Columns)
Cortical Sensory Modalities
Stereognosis
Graphesthesia
Two-Point Discrimination
Double Simultaneous Extinction
The Neurological Examination
Motor Examination
Assessing sensation
• Pain and Temperature
• Pinprick (One pin per patient!)
• Sensation of Cold
• Look for Sensory Nerve or
•
Dermatomal Distribution
• Vibration Sensation
• C-128 Hz Tuning Fork (check great toe)
• Joint Position Sensation
• Check great toe
• Romberg Sign
• Higher Cortical
Sensory Function
• Graphesthesia
• Stereognosis
• Two-Point
Discrimination
The Neurological Examination
Motor Examination
Assessing sensation
• Pain and Temperature
• Vibration Sensation
The Neurological Examination
Diagnostic studies
❑ COMPUTED TOMOGRAPHY SCANNING
❑ POSITRON EMISSION TOMOGRAPHY
❑ SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY
❑ MAGNETIC RESONANCE IMAGING
❑ CEREBRAL ANGIOGRAPHY
❑ NONINVASIVE CAROTID FLOW STUDIES
❑ MYELOGRAPHY
❑ TRANSCRANIAL DOPPLER
❑ ELECTROENCEPHALOGRAPHY
❑ ELECTROMYOGRAPHY
❑ NERVE CONDUCTION STUDIES
The Neurological Examination
Diagnostic studies
❑LUMBAR PUNCTURE AND EXAMINATION
❑OF CEREBROSPINAL FLUID
❑Post–Lumbar Puncture Headache
❑Queckenstedt’s Test
❑Cerebrospinal Fluid Analysis
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