NEUROLOGICAL ASSESSEMENT

Whether it's a brief check of neurological status or a comprehensive neuro exam, your
assessment may uncover nervous system dysfunction before it's too late.

The neuro assessment is a key component in the care of the neurological patient. It can help you
detect the presence of neurological disease or injury and monitor its progression, determine the
type of care you'll provide, and gauge the patient's response to your interventions.

The initial assessment should be a comprehensive exam covering several critical areas: level of
consciousness and mentation, cranial nerves, movement, sensation, cerebellar function, and
reflexes. This initial exam will establish baseline data with which to compare subsequent
assessment findings.

Once a thorough exam is done on admission or at the beginning of each shift, subsequent
assessments should be problem-focused, zeroing in on the parts of the nervous system affected
by the patient's condition. The patient's diagnosis and the acuity of her condition will determine
how extensive your problem-focused assessments will be and how frequently you'll need to
conduct them.

The single most important assessment

Evaluation of level of consciousness (LOC) and mentation are the most important parts of the
neuro exam. A change in either is usually the first clue to a deteriorating condition.

The following terms are commonly used to describe a decreased LOC, so it helps to be familiar
with them:

Full consciousness. The patient is alert, attentive, and follows commands. If asleep, she
responds promptly to external stimulation and, once awake, remains attentive.1

Lethargy. The patient is drowsy but awakens—although not fully—to stimulation. She will
answer questions and follow commands, but will do so slowly and inattentively.1

Obtundation. The patient is difficult to arouse and needs constant stimulation in order to follow
a simple command. She may respond verbally with one or two words, but will drift back to sleep
between stimulation.

Stupor. The patient arouses to vigorous and continuous stimulation; typically, a painful stimulus
is required.1 She may moan briefly but does not follow commands. Her only response may be an
attempt to withdraw from or remove the painful stimulus.

Coma. The patient does not respond to continuous or painful stimulation. She does not move—
except, possibly, reflexively—and does not make any verbal sounds.
Since these and other terms used to categorize LOC are frequently used imprecisely, you'd be
wise to avoid using them in your documentation.1,2 Instead, describe how the patient responds to
a given stimulus. For example, write: "Mrs. Jones moans briefly when sternum is gently rubbed,
but does not follow commands." Bear in mind that recognizing and describing a change in LOC
is more important than appropriately naming it.3

When assessing LOC, there are several tools you can choose from. With stroke patients, for
instance, you may want to use the National Institutes of Health (NIH) Stroke Scale. (You can
obtain a copy at www.strokecenter.org/trials/scales/nihss.pdf.) Typically, though, it is the
Glasgow Coma Scale (GCS) that comes to mind when one is assessing LOC. It's especially
useful for evaluating patients during the acute stages of head injury.

A GCS score is based on three patient responses: eye opening, motor response, and verbal
response. The patient receives a score for her best response in each of these areas, and the three
scores are added together. The total score will range from 3 to 15; the higher the number, the
better. A score of 8 or lower usually indicates coma.

If the patient is alert or awake enough to answer questions, you'll also assess mentation.
Determine if she is oriented to person, place, and time by asking questions like: What is your
name? Where are you right now? Why are you here? What year is it? Who is the president?

A comprehensive evaluation of mentation will include tests of higher intellectual function, as

well. To test abstract reasoning, for example, you might ask the patient to interpret a well-known
proverb.

Pupils are another important component of the neuro exam. Assessing them is especially
important in a patient with impaired LOC. Like a change in LOC, a change in pupil size, shape,
or reactivity can indicate increasing intracranial pressure (ICP) from a mass or fluid. You'll
check pupils as part of the cranial nerve assessment, which is covered in the table at right.

Assessing for signs of motor dysfunction

A bedside neuro assessment almost always includes an evaluation of motor function. Since you'll
be assessing the ability to move on command, the patient must be awake, willing to cooperate,
and able to understand what you are asking her.

With the patient in bed, assess motor strength bilaterally: Have the patient flex and extend her
arm against your hand, squeeze your fingers, lift her leg while you press down on her thigh, hold
her leg straight and lift it against gravity, and flex and extend her foot against your hand. Grade
each extremity using a motor scale like the one below.

+5 - full ROM, full strength

+4 - full ROM, less than normal strength

+3 - can raise extremity but not against resistance

+2 - can move extremity but not lift it

+1 - slight movement

0 - no movement

As part of the motor assessment, also check for arm pronation or drift. Have the patient hold her
arms out in front of her with her palms facing the ceiling. If you observe pronation—a turning
inward—of the palm or the arm or the arm drifts downward, it means the limb is weak.

Assess motor response in an unconscious patient by applying a noxious stimulus and observing
the patient's response to it. Another approach is central stimulation, such as sternal pressure.
Central stimulation produces an overall body response and is more reliable than peripheral
stimulation for this purpose. The reason: In an unconscious patient, peripheral stimulation, such
as nail bed pressure, can elicit a reflex response, which is not a true indicator of motor activity.

If you use central stimulation, however, do so judiciously because deep sternal pressure can
easily bruise the soft tissue above the sternum.4 In our neuro intensive care unit (NICU), we
avoid sternal pressure. Instead, we squeeze the trapezius muscle because it's less traumatic.

Supraorbital pressure is another option for central stimulation. Don't, however, use it on patients
with facial fractures or vagal nerve sensitivity.

Evaluating sensation and cerebellar function

The sensory exam evaluates the patient's ability, or lack thereof, to perceive and identify specific
sensations with her eyes closed. Include it in your neuro assessment if there's a specific need, as
in spinal cord injury. The patient must be able to cooperate with the exam. She'll need to tell you
whether she feels the sensation and whether both sides of her body feel it equally.

Begin with the feet and move up the body to the face, comparing one side with the other. Assess
sensation to light touch using your fingertips or cotton.

Test superficial pain sensation with a clean, unused safety pin. Be sure not to break the skin, and
discard the pin appropriately after you've finished using it on the patient. If you prefer to use
something less invasive, snap a wooden, cotton-tipped swab in two and use one of the broken
ends; again, take care not to scratch or puncture the skin. Also, test sensation using a dull object.
The patient should be able to distinguish sharp from dull.

If you need to test temperature sensation, you can use a specimen tube of ice or cold water or the
chilled handle of a reflex hammer. To test vibratory sensation, use a tuning fork.

Test proprioception, or position sense, by moving the patient's toes and fingers up or down.
Grasp the digit by its sides and have the patient tell you which way it's pointing. Remember,
guessing will yield correct answers 50% of the time.
Move on to the cerebellar assessment, if indicated. It may not be necessary in a problem-focused
exam, and it can't be done if the patient can't or won't follow commands.

If the patient is in bed, you may not be expected to assess her balance and gait. In that case,
limiting testing to coordination is acceptable. Hold up your finger and have the patient quickly
and repeatedly move her finger back and forth from your finger to her nose. Then have her
alternately touch her nose with her right and left index fingers. Finally, have her repeat these
tasks with her eyes closed. The movements should be precise and smooth.

To assess the lower extremities, have the patient bend her leg and slide that heel along the
opposite shin, from the knee to the ankle. This movement, too, should be accurate, smooth, and
without tremors.2

If the patient is able to stand and she's not restricted to bed, you can assess her balance using the
Romberg test. Have her stand with her feet together, arms at her sides, and eyes open; she should
be able to stand upright with no swaying. If she can do that, have her close her eyes and stand the
same way. If she falls or breaks her stance after closing her eyes, the Romberg test is positive,
indicating proprioceptive or vestibular dysfunction.

Deep tendon, superficial, and brain stem reflexes

Reflex assessment encompasses deep tendon, superficial, and brain stem reflexes. Deep tendon
reflexes include the triceps, biceps, brachioradialis, patellar, and the Achilles tendon. The box at
left shows how to assess them. Although deep tendon reflexes aren't routinely assessed, they
should be tested in any patient with a spinal cord injury.

The plantar reflex is the only superficial reflex that's commonly assessed and should be tested in
comatose patients and in those with suspected injury to the lumbar 4 – 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 and 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.

The 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.

Assess brain stem reflexes in stuporous or comatose patients to determine if the brain stem is
intact. (You'll check for the protective reflexes—coughing, gagging, and the corneal response—
as part of the cranial nerve assessment.) To test the oculocephalic, or doll's eye, reflex, turn the
patient's head briskly from side to side; the eyes should move to the left while the head is turned
to the right, and vice versa. If this reflex is absent, there will be no eye movement.

To test the oculovestibular reflex, also known as the ice caloric or cold caloric reflex, a physician
will instill at least 20 ml of ice water into the patient's ear. In patients with an intact brain stem,
the eyes will move laterally toward the affected ear. In patients with severe brain stem injury, the
gaze will remain at midline.
What vital signs reveal about neuro status

Because the brain stem and vagus nerve (CN X) play an important role in vasomotor tone,
conditions affecting these areas can cause vital signs to change. A change in vital signs, however,
is not a reliable indicator of neurological deterioration, as they tend to change too late to prevent
irreversible brain damage.

ICP produces a specific set of changes known as Cushing's triad. Present in herniation
syndromes, Cushing's triad consists of: increasing systolic blood pressure with a widening pulse
pressure, bradycardia, and bradypnea.6

Cushing's triad is a late sign of increased ICP. Once this pattern of vital signs occurs, brain stem
herniation is already in progress and it may be too late to reverse it. To detect increasing ICP
before it reaches this point, be alert for earlier signs: a subtle change in LOC or pupils, for
example.

Accurate and consistent documentation helps ensure that subtle changes in neuro status are
caught early on. Whether the unit you're working on uses computerized charting, flow sheets, or
hand-written notes, it's essential that you compare your findings to those of previous exams.
Through comparison, you'll be able to spot changes and trends and, when necessary, intervene
quickly and appropriately.

Verbal communication is important, too. In many NICUs, including ours, a bedside neuro exam
is done as part of the change-of-shift report, so that the off-going and oncoming nurses can
assess the patient together. The off-going nurse can then verify that the patient's status is
unchanged, perhaps saving the patient an unnecessary CT scan.

The neurological exam can be complex, but it's essential to the diagnosis and treatment of a wide
variety of neurological conditions. With practice and repetition, you will hone this essential, life-
saving skill, and your patients are bound to benefit.

Quick facts

 No matter how brief or extensive your neuro assessments are, comparing your findings to
those of previous exams is essential.
 When assessing motor response, use sternal pressure judiciously. Deep sternal pressure
can cause bruising.
 In many NICUs, a bedside neuro exam is done as part of the change-of-shift report so
that both sets of nurses can assess the patient together.
Assessing the cranial nerves

There are 12 pairs of cranial nerves—some sensory, some motor, and some both. The table
below lists the functions of each nerve and explains how to test them.

Whether you assess all 12 will depend upon the patient's diagnosis. If a patient has an acoustic
neuroma, for example, you'll focus on the acoustic nerve (CN VIII) and the nearby facial nerve
(CN VII). Because many of the nerves can't be tested without the patient's cooperation, you won't
be able to do a complete assessment on a comatose patient.

Extraocular movements (EOMs) are controlled by cranial nerves III, IV, and VI, which you'll
test together. Other functions that are dependent on more than one cranial nerve are: pupillary
response (CN II and III); the corneal reflex (CN V and VII); and the gag reflex (CN IX and X).

Nerve Classificati Major Assessment

on functions

I Olfactory Sensory Smell Have patient

identify a
familiar scent
with eyes
closed
(usually
deferred).

II Optic Sensory Vision (acuity Have patient

and field of read from a
vision); pupil card or
reactivity to newspaper,
light and one eye at a
accommodati time. Test
on (afferent visual fields
impulse) by having
patient cover
one eye, focus
on your nose,
and identify
the number of
fingers you’re
holding up in
each of four
visual
quadrants.
III Oculomotor Motor Eyelid Check
elevation; pupillary
most EOMs; responses by
pupil size and shining a
reactivity bright light on
(efferent one pupil;
impulse) both pupils
should
constrict. Do
the same for
the other eye.
To check
accommodatio
n, move your
finger toward
the patient’s
nose; the
pupils should
constrict and
converge.
Check EOMs
by having
patient look
up, down,
laterally, and
diagonally.

IV Trochlear Motor EOM (turns Have patient

eye look down
downward and in.
and laterally)

V Trigeminal Both Chewing; Ask patient to

facial and hold the
mouth mouth open
sensation; while you try
corneal reflex to close it and
(sensory) to move the
jaw laterally
against your
hand. With
patient’s eyes
closed, touch
her face with
cotton and
have her
 identify the
area touched.
In comatose
patients, brush
the cornea
with a wisp of
cotton; the
patient should
blink.

VI Abducens Motor EOM (turns Have patient

eye laterally) move the eyes
from side to
side.

VII Facial Both Facial Ask patient to

expression; smile, raise
taste; corneal eyebrows, and
reflex keep eyes and
(motor); lips closed
eyelid and lip while you try
closure to open them.
Have patient
identify salt or
sugar placed
on the tongue
(usually
deferred).

VIII Acoustic Sensory Hearing; To test

equilibrium hearing, use
tuning fork or
rub your
fingers, place
a ticking
watch, or
whisper near
each ear.
Equilibrium
testing is
usually
deferred.

IX Both Gagging and Touch back of

Glossopharyng swallowing throat with
eal (sensory); sterile tongue
taste depressor or
 cotton-tipped
applicator.
Have patient
swallow.

X Vagus Both Gagging and Assess gag

swallowing and
(motor); swallowing
speech with CN IX.
(phonation) Assess vocal
quality.

XI Spinal Motor Shoulder Have patient

accessory movement; shrug
head rotation shoulders and
turn head
from side to
side (not
routinely
tested).

XII Motor Tongue Have patient

Hypoglossal movement; stick out
speech tongue and
(articulation) move it
internally
from cheek to
cheek. Assess
articulation.

Assessing deep tendon reflexes

Deep tendon reflexes are tested with a reflex hammer. Test each of the following, grading them
from 0 to 5+, with 0 being no reflex, 2+ being normal, and 5+ being hyperreflexia with clonus
(repeated rhythmic contractions):

Biceps. The patient's arm should be flexed slightly with the palm facing up. Hold the arm with
your thumb in the antecubital space over the biceps tendon. Strike your thumb with the hammer;
the arm should flex slightly.

Triceps. The 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. The 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.

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 the patient's foot in slight dorsiflexion, lightly strike the back of the ankle,
just above the heel; the foot should plantar flex.