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Presented by Tracey Anderson, MSN, CNRN, FNP-BC, ACNP-BC

Neurosurgery Nurse PractitionerSummit Spine & Neurosurgery

Understand components of neurological assessment

Differentiate diagnostic imaging and laboratory work up by disorder

Recognize need for specialist referral and pre-referral work up

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Onset Progression Previous similar events Aggravated/Relieved by… Others with similar symptoms General medical problems Recent surgeries/illnesses

Level of Consciousness Memory/Cognition Cranial Nerves Motor Exam Sensory Exam Vital Signs

Orientation Memory – Short Term Judgment Attention Span Concentration Memory – Long Term Current Events

Assesses frontal lobe

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Area How To HintsOrientation Person: First, Last

Place: Location, City, StateTime: Year, month, day of week, dateReason for visit?

Avoid yes/no questions and don’t give hints

MemoryShort Term

3 Items – repeat in 3-5 minutes

Always use same 3 things

Area How ToJudgment “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

Area How To HintsMemoryLong 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

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# Cranial Nerve FunctionI Olfactory Smell a distinguishable scent (coffee, smelly markers, etc)II Optic Have patient readIII Oculomotor Pupil response, move eyes upwardIV Trochlear Turn eye downward and medially (look to nose)V Trigeminal V1, V2, V3 distributions w/ light touch, pinprick only if abnormalVI Abducens Turn eye laterally (look towards ears)VII Facial Wrinkle forehead, raise eyebrows, closes eyes tightly, pucker,

show teeth, puff out cheeksVIII Vestibulocochlear Check hearing (rub fingers together near ears)IX Glossopharyngeal Uvula elevation; sounds: ka ka, ga gaX Vagus Cough

Bear downXI Spinal Accessory Turn chin against hand, elevate shouldersXII Hypoglossal Tongue sounds (la, la), stick out tongue

Cardinal Signs of Gaze – the easy way!

V1

V2

V3

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# Cranial Nerve FunctionI Olfactory Smell a distinguishable scent (coffee, smelly markers, etc)II Optic Have patient readIII Oculomotor Pupil response, move eyes upwardIV Trochlear Turn eye downward and medially (look to nose)V Trigeminal V1, V2, V3 distributions w/ light touch, pinprick only if abnormalVI Abducens Turn eye laterally (look towards ears)VII Facial Wrinkle forehead, raise eyebrows, closes eyes tightly, pucker,

show teeth, puff out cheeksVIII Vestibulocochlear Check hearing (rub fingers together near ears)IX Glossopharyngeal Uvula elevation; sounds: ka ka, ga gaX Vagus Cough

Bear downXI Spinal Accessory Turn chin against hand, elevate shouldersXII Hypoglossal Tongue sounds (la, la), stick out tongue

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

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”,”

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Divided into: Body positioning

Involuntary movements

Muscle tone

Muscle strength

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

The Precise Neurologic Exam retrieved from http://edinfo.med.nyu.edu/courseware/neurosurgery/motor.html on 2/19/2013

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

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

Indicates an upper motor neuron lesion May be first indicator of pending change

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.

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

Tests forearm flexors and the intrinsic hand muscles.

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

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

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

Tests iliopsoas muscles.

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

Tests adductors of medial thigh.

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

Tests gluteus maximus and gluteus minimus.

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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.

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

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

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

Tests anterior compartment of lower leg.

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

Tests posterior compartment of lower leg.

Move large toe towards head.

This tests the extensor halucis longus (EHL) muscle.

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

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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

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

Rapid Alternating Movements Finger to Nose Heel-Shin Balance Romberg

Gait

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Motor Dermatome distribution C4-S1

Sensory Dermatomes Light touch Superficial pain Temperature/Deep pain Vibration

Reflexes

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

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Level of Consciousness Glasgow Coma Score

▪ Motor▪ Verbal▪ Eyes

CNS II/III pupils (midbrain) V/VII corneals (pons) IX/X cough/gag

(medulla)

Developmental Progression / Delays Reaction to Strangers / Pain Sick vs. Not Sick Emergence of migraines in very young Input of parents

Great website: http://library.med.utah.edu/pedineurologicexam/html/introduction.html

Environment Opioids Fluid & Electrolyte Balance Infection Fatigue Pain

Neurologic Assessment of the Older Adult, AANN Clinical Practice Guideline Series 2009

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Differentials Decision on imaging and other work up Consult with a peer Decision to refer to specialist

Biggest risk is missing a diagnosis that is time sensitive – never hesitate to refer to ED!

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Loss of Consciousness / Unresponsiveness

Acute Vision Loss

Prolonged Seizure (Status Epilepticus)

Acute loss of extremity function (paralysis)

Chronic Back Pain without neurologic deficit Chronic headaches that have been evaluated for

cranial lesions Non-hemorrhagic metastatic lesions that are

asymptomatic Numbness Tingling Stable deficits that have been present for

weeks/months

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CT / CTA

MRI / MRA

Lumbar Puncture

Angiography

Non contrast – if looking for blood Contrast if looking for infection or tumor Looks best at: Blood Bone “Quick Look” – this is often your 1st test (STAT!)

Poor quality for: Brain tumors Brainstem lesions

Can also do CT Perfusion & CT Angio

Non contrast – if looking at brain structure Contrast if looking for infection, enhancement of

high grade tumor Looks best at: Pathologic brain lesions Early changes in brain tissue Brainstem lesions

Poor quality for: Blood Bone

Can also do MRA, DWI, PWI May be done on urgent basis – rarely first test

done

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Indicated for AMS with no clues from imaging / labs Assessment of CNS infections (all types) For help in diagnosis of SAH CNS malignancies Demyelinating diseases and Guillain-Barré syndrome

Typical lab panel includes: Gram stain and culture Cell count (tubes #1 and #4) Glucose & Protein Can also check cytology, oligoclonal bands, etc.

Contraindications: Known/suspected intracranial mass Non-communicating hydrocephalus Infection in area of tap (lumbar) Coagulopathy

Caution in: Suspected aneurysmal SAH Patients with complete spinal block

Elevated ICP and/or papilledema by themselves NOT an absolute contraindication but extremely risky and not recommended

Is usually done after CT or MRI reveals vascular lesion or suspicion for vascular lesion

Rarely first test Often done STAT in stroke and aneurysm

situations Most invasive of all diagnostic tests discussed

here today Can usually do with contrast allergy if

premedicated with solumedrol and diphenhydramine

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Looks at structure and patency of vasculature Looks best at: Brain vasculature Vascular malformations (Gold standard for aneurysm

assessment)

Lower quality for: Spine vasculature

May be preceded by CTA or MRA May be done on urgent basis – rarely first test

done

Has had intermittently for months Always when she has her menstrual cycle Relieved with ASA and rest and caffeine

Sudden onset severe HA at 10:25am Dizzy, very nauseated Relieved by nothing Family feels she’s confused now Not able to control her legs to walk

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Worsening HA over 4 hours Now with stiff neck Feels chilled and like he has flu Notices a rash on body

1 month progression of right sided weakness Having trouble periodically naming things Has had low level headache for several

months No weight loss Had an episode that was concerning for

seizure yesterday

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Neurologic Assessment of the Older Adult, A Guide for Nurses. AANN Clinical Practice Guideline Series. 2009.

The complete neurological examination: what every nurse practitioner should know. Murray TA, Kelly NR, Jenkins S. Adv Nurse Pract. 2002 Jul;10(7);24-8.

Haymore, J. A Neuron in a haystack. AACN Clinical issues (1079-0713), 15(4), 568.

Greenberg M. Handbook of Neurosurgery. 7th Edition.