1

Neurologic Assessment

Because Every Patient has a Brain…

Tracey Anderson, MSN, CNRN, FNP-BC, ACNP-BC Neurosurgery Nurse Practitioner

Colorado Health Medical Group – Brain & Spine

Disclosures

Codman Neuro: Clinical Faculty for Advanced Practice Provider Course

A Quick Anatomy Review…

2

Meninges “Potential space” between all layers

Subdural – usually Venous

Epidural – usually Arterial

Subarachnoid – usually Arterial

Frontal Lobes

Frontal Lobe Characteristics

• Your “mother”

• “how to behave”

• Initiates activity

• Location of motor function

• Lies in the anterior fossa of the skull

3

Anterior Frontal Lobe

• Abstract thinking

• Inhibition / Tact

• Emotion

• Insight

• Judgment

• Short Term Memory

• Ethics

Functional Layout of Motor Strip

Temporal Lobes

4

Temporal Lobe Characteristics

• Auditory input

• 2 auditory centers

– Primary • specific tones, loudness, and qualities of sound

– Secondary • interprets the meaning of the spoken word and music

(Wernicke’s)

• Only in Dominant hemisphere (left side in 90-95% of population)

• Long term memory is located in medial temporal lobe

Parietal Lobes

5

Parietal Lobe Characteristics

• Sensory interpretation

• Proprioception & Neglect

• Visual-spatial information

• Spatial orientation

Functional Layout of Sensory Strip

Occipital Lobes

6

Occipital Lobe Functions

• Primary visual cortex – direct visual signals from the macula area of the

retina

– Interpretation and discrimination of visual input

• Secondary visual cortex – interprets the meaning of the written word

– Peripheral vision, double, and blurred vision difficulties often result from damage to this lobe

• “End” point for the Optic Tract

Correlating Assessment to Anatomy

• Know normal

• Understand duplicity/redundancy

• Correlate to vascular supply

• Anticipate potential deficits plan for care

7

Assessment: Key to Neuro Patients

• 60 Second Assessment

• Same assessment EVERY time!

• Shift to shift assessment

• Recording & describing assessment

• Monitoring trends

• Scoring systems: Many including Glasgow, Barthel, NIHSS, etc.

Common Mistakes

• Inadequate baseline

• Inadequate stimulation

• Failure to recognize subtle changes

• Failure to recognize significance of changes

• Failure to escalate issue up chain of command

Basics of Assessment

• Shift to Shift assessment

• Subtle changes key!

• Escalate stimulus – harder, louder, longer

• Pain response – central or peripheral

• Types of stimuli

– Trapezius squeeze

– Sternal rub (caution in trauma)

– Supraorbital pressure

8

Assessment Parameters

• Level of Consciousness

• Motor Response

• Cranial Nerve exam

• Vital Signs

Level of Consciousness

• Earliest and Most Sensitive indicator of change

• Arousal (wakefulness)

• Awareness (ability to interact/interpret environment) – Orientation: person, place, time, situation (x4)

– Attention Span

– Language

– Memory (short term)

Motor Exam

• Normal vs. Abnormal movement

• Highest Level = following commands

• Localization or purposeful movements

• Flexion or withdrawal to central pain

• Posturing or abnormal movement

– Decorticate

– Decerebrate

9

Motor Strength

• Different than response, only tested with “normal” movement

• 5/5 = normal against gravity & resistance

• 4/5 = full ROM against moderate resistance and gravity

• 3/5 = full ROM against gravity only

• 2/5 = extremity moves but not against gravity

• 1/5 = muscle contracts, extremity doesn’t move

• 0/5 = no visible/palpable contraction/movement

Pupil Response

• Assess size, equality, reaction

• Bilateral pinpoint – think Pons, narcotics

• Bilateral dilated – think hypoxia, atropine, ICP

• Hippus

*Reactivity of pupils is either present or absent – no value in “brisk” “sluggish”

Assessment: LOC

• Orientation

• Memory – Short Term

• Judgment

• Attention Span

• Concentration

• Memory – Long Term

• Current Events

Assesses frontal lobe

10

Assessment: LOC Area How To Hints

Orientation

Person: First, Last

Place: Location, City,

State

Time: Year, month, day

of week, date

Reason for hospitalization?

Avoid yes/no

questions

and don’t

give hints

Memory

Short Term

3 Items – repeat in 3-5

minutes

Always use

same 3

things

Assessment: LOC

Area How To

Judgment “What would you do if you were in

a crowded theater and saw a

fire?”

Attention Span

&

Concentration

Note if you must frequently regain

their attention

Assessment: LOC

Area How To Hints

Memory

Long Term

Who is current president

and who were the last 3

before him?

Know them

yourself!

Current

Events

Ask what significant

event/holiday has

recently happened

11

Assessment: Language

• Expression

– Initiation, articulation, pronunciation, rate and rhythm, inflection/affect, word substitutions, confabulation and perseveration

• Repetition

– “You Can’t Teach an Old Dog New Tricks”

• Comprehension

– Ask them to complete multi-step tasks

– Avoid visual cues

Lesions

Upper Motor Neuron

• Weakness

• Spasticity

• Hyperreflexia

• Primitive Reflexes

– Grasp

– Suck

– Snout

• Babinski reflex

Lower Motor Neuron

• Weakness

• Hypotonia

• Hyporeflexia

• Atrophy

• Fasciculations

Motor System Examination

Divided into:

• Body positioning

• Involuntary movements

• Muscle tone

• Muscle strength

12

Upper Extremity: Biceps

• The biceps muscle is innervated by the C5 and C6 nerve roots via the musculocutaneous nerve.

The Precise Neurologic Exam retrieved from

http://informatics.med.nyu.edu/modules/pub/neurosurgery/motor.html on

3/15/2016

Upper Extremity: Triceps

• The triceps muscle is innervated by the C6 and C7 nerve roots via the radial nerve.

Upper Extremity: Deltoid

• The deltoid muscle is innervated by the C5 nerve root via the axillary nerve.

13

Pronator Drift

• Indicates an upper motor neuron lesion

• May be first indicator of pending change

Upper Extremity: Wrist Extension

• The wrist extensors are innervated by C6 and C7 nerve roots via the radial nerve.

• The radial nerve is the "great extensor" of the arm: it innervates all the extensor muscles in the upper and lower arm.

Upper Extremity: Finger Flexion

• Finger flexion is innervated by the C8 nerve root via the median nerve.

• Tests forearm flexors and the intrinsic hand muscles.

14

Upper Extremity: Finger Abduction

• Finger abduction or "fanning" is innervated by the T1 nerve root via the ulnar nerve.

Upper Extremity: Thumb Opposition

• Thumb opposition is innervated by the C8 and T1 nerve roots via the median nerve.

Lower Extremity: Hip Flexion

• Hip flexion is innervated by the L2 and L3 nerve roots via the femoral nerve.

• Tests iliopsoas muscles.

15

Lower Extremity: Hip Adduction

• Adduction of the hip is mediated by the L2, L3 and L4 nerve roots.

• Tests adductors of medial thigh.

Lower Extremity: Hip Abduction

• Abduction of the hip is mediated by the L4, L5 and S1 nerve roots.

• Tests gluteus maximus and gluteus minimus.

Lower Extremity: Hip Extension

• Abduction of the hip is mediated by the L4, L5 and S1 nerve roots.

• Tests gluteus maximus when they press down on hand placed under thigh.

16

Lower Extremity: Knee Extension

• Knee extension by the quadriceps muscle is innervated by the L3 and L4 nerve roots via the femoral nerve.

Lower Extremity: Knee Flexion

• The hamstrings are innervated by the L5 and S1 nerve roots via the sciatic nerve.

Lower Extremity: Ankle Dorsiflexion

• Ankle dorsiflexion is innervated by the L4 and L5 nerve roots via the peroneal nerve.

• Tests anterior compartment of lower leg.

17

Lower Extremity: Ankle Plantar Flexion

• Ankle plantar flexion is innervated by the S1 and S2 nerve roots via the tibial nerve.

• Tests posterior compartment of lower leg.

Lower Extremity: EHL

• Move large toe towards head.

• This tests the extensor halucis longus (EHL) muscle.

• The EHL is almost completely innervated by the L5 nerve root.

Motor Assessment: Babinski

18

Sensory Assessment

• Stereognosis – size & shape

• Graphesthesia - feel

• Discrimination – right vs. left

• Calculation

– Serial 7’s: Subtract 7 from 100 serially

– What is 6 x 7

– How many quarters in $1.75

Assessment: Coordination

• Rapid Alternating Movements

• Finger to Nose

• Heel-Shin

• Balance

– Romberg

• Gait

Cranial Nerves

19

# Cranial Nerve Function

I Olfactory Smell a distinguishable scent (coffee, smelly markers, etc.)

II Optic Have patient read

III Oculomotor Pupil response, move eyes upward

IV Trochlear Turn eye downward and medially (look to nose)

V Trigeminal V1, V2, V3 distributions w/ light touch, pinprick only if abnormal

VI Abducens Turn eye laterally (look towards ears)

VII Facial Wrinkle forehead, raise eyebrows, closes eyes tightly, pucker,

show teeth, puff out cheeks

VIII Vestibulocochlear Check hearing (rub fingers together near ears)

IX Glossopharyngeal Uvula elevation; sounds: ka ka, ga ga

X Vagus Cough

Bear down

XI Spinal Accessory Turn chin against hand, elevate shoulders

XII Hypoglossal Tongue sounds (la, la), stick out tongue

Cranial Nerve Exam

Cardinal Signs of Gaze – the easy way!

V1

V2

V3

20

# Cranial Nerve Function

I Olfactory Smell a distinguishable scent (coffee, smelly markers, etc.)

II Optic Have patient read

III Oculomotor Pupil response, move eyes upward

IV Trochlear Turn eye downward and medially (look to nose)

V Trigeminal V1, V2, V3 distributions w/ light touch, pinprick only if abnormal

VI Abducens Turn eye laterally (look towards ears)

VII Facial Wrinkle forehead, raise eyebrows, closes eyes tightly, pucker,

show teeth, puff out cheeks

VIII Vestibulocochlear Check hearing (rub fingers together near ears)

IX Glossopharyngeal Uvula elevation; sounds: ka ka, ga ga

X Vagus Cough

Bear down

XI Spinal Accessory Turn chin against hand, elevate shoulders

XII Hypoglossal Tongue sounds (la, la), stick out tongue

Cranial Nerve Exam

Facing Cranial Nerve Assessment, Barbara Bolek, American Nurse Today, November 2006.

Cranial Nerve Function Summary

• I: Smell

• II: Pupils, acuity, fields

• III: Pupils, lids, EOMs

• III/IV/VI: EOMs

• V: Facial sensation, corneals

• VI: EOMs (lateral gaze)

• VII: Facial symmetry, close lid

• VIII: Hearing

• IX & X: Cough & Gag

• XI: Shoulder shrug

• XII: Tongue

21

Sorting Out Brain vs. Spine Problem

Assessment of the Spine

• Motor

– Dermatome distribution C4-S1

• Sensory

– Dermatomes

– Superficial pain

– Temperature/Deep pain

– Vibration

• Reflexes

Reflex Grading Scale

Grade

Description

0 Absent

1+ or + Hypoactive

2+ or ++ “Normal”

3+ or +++ Brisk/Hyperactive

4+ or ++++ Non-sustained clonus

5+ or +++++ Sustained clonus

Retrieved 3/15/2016 from http://stanfordmedicine25.stanford.edu/the25/tendon.html

22

Assessment Parameters Perform rapid assessment & compare to baseline:

•Motor Exam

•Sensory Exam

•Rectal Tone

•Reflexes

Assessment must incorporate dermatomes!

Pathologic Signs

• Hoffman sign

• Clonus

• Anal Wink

• Radiculopathy – dysfunction of a nerve root due to

isolated points of pressure w/ signs and symptoms including: pain, sensory disturbance, weakness, hypoactive reflexes

• Myelopathy – gradual loss of nerve function caused by

disorders of the spine

23

Red flags!

– History of IV drug use or malignancy

– Marked focal pain to palpation

– Progressive Neurologic Deficit

– Foot drop

– Cauda Equina syndrome

Where Mistakes are Made

• Inadequate baseline data

• Incorrect interpretation of findings

• Incomplete work up

• Failure to escalate up chain of command

• Failure to look at “big picture”

The Unconscious Patient

• Level of Consciousness – Glasgow Coma Score

• Motor

• Verbal

• Eyes

• CNS – II/III pupils (midbrain)

– V/VII corneals (pons)

– IX/X cough/gag (medulla)

24

Glasgow Coma Score

Eyes Open spontaneously 4 Open to verbal command 3 Open to pain

2 No response

1 Best Motor Response Obeys commands 6 Localizes pain 5 Flexion-Withdrawal 4 Flexion-Abnormal 3 Extension

2 No response

1

Best Verbal Response Oriented and converses 5 Disoriented and converses 4 Inappropriate words

3 Incomprehensible Sounds 2 No response

1 Glasgow Coma Scale Total 3 -15

Description of Full Outline of Unresponsiveness

Iyer V N et al. Mayo Clin Proc. 2009;84:694-701

© 2009 Mayo Foundation for Medical Education and Research

Full Outline of UnResponsiveness (FOUR score)

• Eye Response – 4: tracking/blinking to command

– 3: open not tracking

– 1: open to pain

– 0: remain closed to pain

• Motor Response – 4: thumbs up/fist/peace

– 3: localizing

– 2: flexion

– 1: extension

– 0: no response

• Brainstem Reflexes – 4: pupil/corneal present

– 3: one pupil wide/fixed

– 2: pupil or corneal absent

– 1: pupil and corneal absent

– 0: absent pupil, corneal and cough

• Respiratory Pattern – 4: not intubated

– 3: not intubated, Cheyne-Stokes

– 2: not intubated, irregular breathing

– 1: breathes above ventilator rate

– 0: breathes at ventilator rate or apnea

25

Brain Death • Loss of all brain & brainstem function

• Spinal reflexes may persist (but you cannot elicit repeat response)

• Testing varies by institution

• Gold standard: Cerebral blood flow

• Bedside Exam: Cranial nerve exam (including doll’s eyes and cold caloric testing), apnea test, deep pain stimuli

Questions?

Tracey.Anderson2@uchealth.org