NR 305 Assessment of the Neurological System DQ
NR 305 Assessment of the Neurological System DQ
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Randy Adams is a 38-year-old male patient of Dr. Joseph Reynolds who was admitted yesterday morning for 24-hour observation for mild concussion following a motor vehicle accident. Randy lost consciousness during the accident and was very confused when he arrived in the ER after EMS transport. He is an Iraq war veteran and he seemed to think after the accident that this all happened in Iraq. Dr. Reynolds is concerned that Randy has some residual problems from a couple of explosive incidents that occurred while he was in Iraq. The physician is unsure whether Randy’s current symptoms are from the car accident or from prior injuries so he has referred him for consultations to both a neurologist and to a behavioral health specialist.
Based on the above please discuss the following.
- Pathophysiology of concussive injuries and treatment
- Neurological assessment tools used in your current practice setting (if not presently working, please describe one used during prior employment or schooling)
- Current best practices associated with post-traumatic stress disorder (PTSD)
- Nursing interventions you would include in this patient’s plan of care
Open Resources for Nursing (Open RN)
Now that we have reviewed tests included in a neurological exam, let’s review components of a routine neurological assessment typically performed by registered nurses. The neurological assessment begins by collecting subjective data followed by a physical examination.
Subjective data collection guides the focus of the physical examination. Collect data from the patient using effective communication and pay particular attention to what the patient is reporting, including current symptoms and any history of neurological illness. Ask follow-up questions related to symptoms such as confusion, headache, vertigo, seizures, recent injury or fall, weakness, numbness, tingling, difficulty swallowing (called ) or speaking (called ), or lack of coordination of body movements.
See Table 6.10a for sample interview questions to use during the subjective assessment
Table 6.10a Interview Questions Related to Subjective Assessment of Neurological System
Interview Questions Follow-up Are you experiencing any current neurological concerns such as headache, dizziness, weakness, numbness, tingling, tremors, loss of balance, or decreased coordination?Have you experienced any difficulty swallowing or speaking?
Have you experienced any recent falls?
If the patient is seeking care for an acute neurological problem, use the PQRSTU method to further evaluate their chief complaint. The PQRSTU method is described in the “Health History” chapter.Note: If critical findings of an acute neurological event are actively occurring, such as signs of a stroke, obtain emergency assistance according to agency policy. Have you ever experienced a neurological condition such as a stroke, transient ischemic attack, seizures, or head injury? Describe the condition(s), date(s), and treatment(s). Are you currently taking any medications, herbs, or supplements for a neurological condition? Please describe.
Life Span Considerations
At birth, the neurologic system is not fully developed. The brain is still developing, and the newborn’s anterior fontanelle doesn’t close until approximately 18 months of age. The sensory and motor systems gradually develop in the first year of life. The newborn’s sensory system responds to stimuli by crying or moving body parts. Initial motor activity is primitive in the form of newborn reflexes. Additional information about newborn reflexes is provided in the “Assessing Reflexes” section. As the newborn develops, so do the motor and sensory integration. Specific questions to ask parents or caregivers of infants include the following:
- Have you noticed your infant sleeping excessively or having difficulty arousing?
- Has your infant had difficulty feeding, sucking, or swallowing?
Depending on the child’s age and developmental level, they may answer questions independently or the child’s parent/guardian may provide information. Specific questions for children include the following:
- Have you ever had a head injury or a concussion?
- Do you experience headaches? If so, how often?
- Have you had a seizure or convulsion?
- Have you noticed if your child has any problems with walking or balance?
- Have you noticed if your child experiences episodes of not being aware of their environment?
The aging adult experiences a general slowing in nerve conduction, resulting in a slowed motor and sensory interaction. Fine coordination, balance, and reflex activity may be impaired. There may also be a gradual decrease in cerebral blood flow and oxygen use that can cause dizziness and loss of balance. Examples of specific subjective questions for the older adult include the following:
Educate older adults to change positions slowly, especially when standing up from a lying or sitting position. Lightheadedness and loss of balance during these activities increase the risk for falls.
- Have you ever had a head injury or recent fall?
- Do you experience any shaking or tremors of your hands? If so, do they occur more with rest or activity?
- Have you had any weakness, numbness, or tingling in any of your extremities?
- Have you noticed a problem with balance or coordination?
- Do you ever feel lightheaded or dizzy? If so, does it occur with activity or change in position?
The physical examination of the neurological system includes assessment of both the central and peripheral nervous systems. A routine neurological exam usually starts by assessing the patient’s mental status followed by evaluation of sensory function and motor function. Comprehensive neurological exams may further evaluate cranial nerve function and deep tendon reflexes. The nurse must be knowledgeable of what is normal or expected for the patient’s age, development, and condition to analyze the meaning of the data that is being collected.
Nurses begin assessing a patient’s overall neurological status by observing their general appearance, posture, ability to walk, and personal hygiene in the first few minutes of nurse-patient interaction. For additional information about obtaining an overall impression of a patient’s status while performing an assessment, see the “General Survey” chapter.
Level of orientation is assessed and other standardized tools to evaluate a patient’s mental status may be used, such as the Glasgow Coma Scale (GCS), NIH Stroke Scale, or Mini-Mental State Exam (MMSE). Read more information about these tools under the “Assessing Mental Status” section earlier in this chapter.
The nurse also assesses a patient’s cerebellar function by observing their gait and balance. See the “Assessing Cerebellar Function” section earlier in chapter for more information.
Auscultation refers to the action of listening to sounds from the heart, lungs, or other organs with a stethoscope as a part of physical examination. Auscultation is not typically performed by registered nurses during a routine neurological assessment. However, advanced practice nurses and other health care providers may auscultate the carotid arteries for the presence of a swishing sound called a . Bruits suggest interference with cerebral blood flow that can cause neurological deficits.
Palpation during a physical examination typically refers to the use of touch to evaluate organs for size, location, or tenderness, but palpation during the neurologic physical exam involves using touch to assess sensory function and motor function. Refer to sections on “Assessing Sensory Function,” “Assessing Motor Function,” “Assessing Cranial Nerves,” and “Assessing Reflexes” earlier in this chapter for additional information on how to perform these tests.
See Table 6.10b for a summary of expected and unexpected findings when performing an adult neurological assessment.
Table 6.10b Expected Versus Unexpected Findings on Adult Neurological Assessment
Assessment Expected Findings Unexpected Findings (Document and notify provider if new finding*) Inspection Alert and oriented to person, place, and timeSymmetrical facial expressions
Clear and appropriate speech
Ability to follow instructions
PERRLA (Pupils are equal, round, and reactive to light and accommodation)
Cranial nerves all intact
Negative Romberg test
Sensory function present
Cortical functioning (indicated by stereognosis) intact
Coordinated gait with equal arm swing
Finger-to-nose, rapid alternating arm movements, and heel-to-shin performance intact
Negative pronator drift test
Motor strength in upper and lower extremities equal bilaterally
Deep tendon reflexes intact
Not alert and oriented to person, place, and/or timeAsymmetrical facial expressions
Inability to follow directions
Pupils unequal in size or reactivity
Deficits in one or more cranial nerve assessments
Positive Romberg test
Sensory function impaired in one or more areas
Stereognosis not intact
Shuffled or asymmetrical gait with unequal arm swing
Unable to complete finger-to-nose, alternating arm movement, or heel-to-shin tests
Positive pronator drift test
Unequal strength of upper and/or lower extremities
One or more deep tendon reflexes are not reactive
Critical findings to report immediately and/or obtain emergency assistance: Change in mental status, pupil responsiveness, facial drooping, slurred words or inability to speak, or sudden unilateral loss of motor strength