SUBJECT: LP Focus A -- Assessment of Neurological Function

I. List the purpose for assessing neurological status.

A. There are actually several reasons for assessing the neurological

status of your patient.

1. To determine the presence or absence of neurological

dysfunction.
2. To establish a baseline.
3. To assess the effects of the neurological deficits in regards
to the patients:

a. Lifestyle
b. Independence in ADL
c. Ability to take responsibility for his life (decision
making, cognitive function, etc.)
d. Ability to cope psychologically & emotionally with
stress
(ALL of 3 above is referring to the idea that rehabilitation begins on
admission)

4. To establish a nursing diagnosis so that the remaining steps

of the nursing process can be carried out (Individualized Care
Plan)
5. Aides the physician in establishing a diagnosis

II. Describe the components of a neurological assessment in terms of: Level

of consciousness (Glasgow's Coma Scale); Pupils & Eye movement;
Sensory function; Motor function; Vital Signs

A. Components of Neurological Assessment - Neuro assessments are

conducted every 15 mins to 4 hrs, depending on condition of pt.

1. Level of consciousness
a. controlled by reticular activating system (RAS)

(1) a diffuse system of neurons extending from the

lower brain stem to the cerebral cortex
(2) the earliest indicator of neurological change,
probably because the RAS is most sensitive to
changes in blood supply (Oxygen & glucose)
b. No uniformly accepted terminology to describe levels of
consciousness - The nurse should describe the
behavior noted:

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 (1) Assess orientation to:

(a) Person (his identity)

(b) Place (present location)
(c) Time (general time of day, month, year)

(2) Assess ability to follow directions by his

response to simple commands

(3) No response to verbal, then:

(4) Assess painful stimuli

(a) press dull end of pencil against fingernail

bed
(b) press knuckle into sternum

page 1476 c. Glasgow's coma scale - An objective

measure to describe LOC. Based on the pt's response
in three areas:

(1) eye opening

4 spontaneously
3 on request
2 to pain stimuli
1 no opening

(2) best verbal response

5 Oriented to time, place, person

4 engages in conversation, confused in
content
3 words spoken but conversation not
sustained
2 groans evoked by pain
1 no response

(3) best motor response

6 obeys a command
5 localizes a painful stimulus
4 normal flexion either arm
3 abnormal flexion of arm
2 extends arm to painful stimulus

2
 1 no response

(The total GCS score is a sum of the numeric values assigned to each of the
three areas evaluated. The highest GCS score is 15 for a fully alert person, and
the lowest possible score is 3. A GCS score of 8 or less is generally indicative of
coma.)

2. Pupils & Eye Movement

a. size of pupils

(1) should be round & equal in size

(2) pupil normally 3.5 mm in diameter
(3) normal range (2 mm - 6 mm)

b. Reaction to light

(1) need dimly lit room

(2) pupils checked one at a time
(3) direct beam of light toward pupil of eye to be
tested
(4) normally pupil contracts briskly & dilates as
quickly on removing light - (Known as direct light
reflex)
(5) normally this reaction should also occur in the
other pupil although not as pronounced (Known
as consensual light reflex)
(6) brisk, sluggish, or nonreactive (fixed), direct light
response in both eyes should be equal
(7) abnormal response of the pupil is related to
interruption of the oculomotor nerve (cranial
nerve III)

c. Eye Movement

(1) Observe the eyes within their sockets as the pt.

looks straight ahead - do they protrude, or are
they sunken?
(2) Hold finger or object 12 inches from nose and
have pt. follow object with eyes as you move it

3. Sensory Function - usually assess once a day

Can assess while administering care

a. light touch

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 b. deep pressure
c. pain
d. temperature
*ask to close eyes, compare for both sides
*ask pt. to differentiate between cold & warm water during bath

4. Proprioception - The awareness of posture, movement and

changes in equilibrium and the knowledge of position, weight,
and resistance of objects in relation to the body. Test by
having patient close eyes while standing.

5. Motor Function

a. muscle size

(1) observe & measure same muscle on opposite

sides of body for symmetry
(2) abnormal findings:

(a) atrophy
(b) asymmetry

b. muscle tone

(1) guide muscle thru passive range of motion

(2) abnormal findings

(a) flaccidity
(b) spasticity
(c) rigidity

c. muscle strength

(1) observe muscle movement against gravity &

against active resistance
(2) abnormal findings

(a) weakness (paresis)

(b) paralysis
(c) involuntary movements

d. reflexes

(1) gag

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 (a) stroke one side of the mucous membrane
of the post pharynx at a time
(b) should gag

(2) swallow

(a) stroke one side of the uvula at a time

(b) uvula should rise & deviate to the
stimulated side

(3) corneal reflex

(a) lightly touch cornea with cotton

(b) immediate blink

(4) Babinski reflex

(a) use blunt object (key) to stroke

lateral side of sole of the foot
(b) normal - brisk flexion of the toes
(c) abnormal - extension of the great toe and
fanning of the other toes
(d) usually indicative of injury to the
corticospinal (pyramidal) tract; however,
this is not an infallible sign since it can be
elicited in the newborn infant, in
intoxicated adults and following a
generalized seizure.

6. Vital Signs - frequency depends on the pt's condition

a. temperature
(1) controlled by the hypothalamus
(2) could be subnormal or elevated
(3) take rectally in unconscious pt
(4) stay with the pt while the thermometer is in place
(5) always record the route used
(6) assess every 30 minutes until normal

b. pulse

(1) record rate, rhythm & quality (full, thready,

bounding)
(2) chart apical or radial

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 c. blood pressure

(1) onset of cerebral pressure on blood

pressure and pulse is variable
(2) with continued increase of pressure on the
brainstem, there will be an increase in systolic pressure
(3) Cushings triad - with even further pressure

(a) bradycardia (60 or below)

(b) bradypnea (often irregular)
(c) hypertension (140/90 or above) with a
widening pulse pressure
(d) above findings are related to pressure on
the medulla (a late clinical finding)

d. respirations

pg 1478 (1) record rate & pattern

(a) Cheyne-Stokes -- cycles of

hyperventilation and apnea
(b) Central neurogenic hyperventilation --
sustained, regular rapid and deep
breathing
(c) Apneustic -- prolonged inspiratory phase
or pauses alternating with expiratory
pauses
(d) Cluster -- clusters of breaths follow each
other with irregular pauses between
(e) Ataxic -- completely irregular with some
breaths deep and some shallow. Random,
irregular pauses, slow rate.