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Neuro Assessment — Transcript

by Gina Kemper · 8,577 words · 1,544 segments · language en · Watch on YouTube

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0:01Hi class. Welcome to the last lecture of
0:04health assessment. So today we're going
0:06to talk about um the neurologic
0:08assessment which is arguably one of the
0:11most important assessments we'll perform
0:13because it evaluates the function of
0:15both the central and peripheral nervous
0:17systems and even subtle neurologic
0:20changes can indicate a rapidly
0:22developing emergency. So recognizing
0:25abnormal findings early is really
0:27essential. Now the nervous system
0:30controls virtually every body system. So
0:32during this assessment we are evaluating
0:34the patients ability to think,
0:36communicate, move, feel sensations,
0:39maintain balance and respond
0:40appropriately to their environment. And
0:42one one of the biggest concepts to
0:44remember is that neurologic assessments
0:46establish a baseline. So once you know
0:49what is normal for your patient, you can
0:51quickly recognize deterioration during
0:53subsequent assessments.
0:56So unlike a complete neurologic exam
0:58performed by a neurologist, um bedside
1:01nurses will typically perform a focused
1:03neurologic assessment that emphasizes
1:05early recognition of change. So
1:08depending on the patient's condition, we
1:10may um assess them very briefly
1:13neurologically.
1:14um doing neuro checks every few hours
1:17after a stroke or doing a more
1:20comprehensive
1:22um neurologic assessment during a
1:24routine physical.
1:29Here are those learning objectives
1:30today.
1:34So before we perform our neurologic
1:36assessment, it's helpful to review the
1:37major structures of the central nervous
1:39system or the CNS. So the CNS consists
1:42of the brain and spinal cord and it's
1:44responsible for receiving, processing
1:46and responding to information.
1:49Then we have the neurons which are the
1:50basic functional unit of the nervous
1:52system. And each neuron has a cell body
1:55which contains the nucleus. There are
1:58dendrites which receive information from
2:00other cells and finally the axon which
2:02carries signals away from the cell. So
2:05neurons communicate through electrical
2:07and chemical signals to control body
2:09functions.
2:11Then we have the cerebrum which is the
2:13largest part of the brain and it's
2:14responsible for conscious thought,
2:16sensation, movement, memory and
2:18language. We have the frontal lobe which
2:21controls voluntary movement,
2:22personality, judgment and speech
2:25production also known as Broca's area.
2:28Then we have the parietal lobe which
2:30processes touch, pain, temperature and
2:32spatial awareness. the temporal lobe
2:35which is involved in hearing and memory
2:38and also language comprehension which is
2:40known as worn area and then finally the
2:44occipital lobe which is responsible for
2:46vision
2:47and we have deeper structures of the
2:49brain including the basil ganglia which
2:51helps regulate smooth coordinated
2:53movement the phalamus which acts as a
2:56relay station for sensory information
2:59the hypothalamus which regulates body
3:01temperature hunger thirst hormones and
3:03autonomic nervous system, the lybic
3:06system which plays a major role in
3:08emotions, motivation and memory and then
3:11we also have the brain stem which
3:13connects connects the brain to the
3:14spinal cord and controls many vital
3:17functions necessary for life. The
3:19midbrain this helps with eye movements
3:21and reflexes. The pawns helps regulate
3:25breathing and sleep and serves as
3:27communication pathway. The medulla which
3:30controls heart rate, blood pressure and
3:32respiration. the reticular formation
3:34which helps regulate alertness,
3:36consciousness and the sleep wake cycle.
3:40Cerebellum which coordinates balance,
3:42posture, muscle tone and smooth
3:45purposeful movements.
3:48And so damage to the cerebellum often
3:50results in poor coordination and
3:52unsidiate.
3:54And then we also have protective
3:56structures. So the brain is protected by
3:58several structures including the skull
4:00which provides physical protection. Then
4:03the meninges which are three layers of
4:05connective tissue that surround the
4:06brain and spinal cord and the ventricles
4:09which produce and circulate cerebral
4:11spinal fluid and cerebral spinal fluid
4:13cushions the brain and spinal cord and
4:15helps remove waste and provides
4:17nutrients.
4:19So this should essentially be a review
4:21from anatomy and physiology.
4:25So now that we've discussed the central
4:27nervous system, let's look at the
4:29peripheral nervous system or the PNS.
4:31And while the central nervous system
4:32serves as the body's control center, the
4:34peripheral nervous system acts as the
4:36communication network that connects the
4:38brain and spinal cord to every other
4:40part of the body. So think of this as if
4:42the brain is the hospital administrator
4:45making decisions. The peripheral nervous
4:47system um are the phone lines carrying
4:50messages to and from every department.
4:53So the peripheral nervous system allows
4:55the brain to receive sensory information
4:57from the environment and send motor
4:59commands to muscles and organs.
5:02So we have the spinal cord which is the
5:04major communication pathway between the
5:06brain and the body and it begins at the
5:08base of the brain stem and it extends
5:10through the vertebral column to
5:12approximately the level of the first or
5:14second lumbar vertebrae.
5:17So the spinal cord performs two major
5:19functions. It carries sensory
5:21information from the body to the brain
5:24and it carries motor commands from the
5:26brain to the muscles. It also serves as
5:28a center for many reflexes that occur
5:31without conscious thought. For example,
5:33if you accidentally touch a hot stove,
5:36sensory nerves immediately transmit the
5:38pain signal to the spinal cord and
5:40before your brain even processes what
5:42happened, the spinal cord initiates a
5:44reflex that causes you to pull your hand
5:46away. So this rapid response actually
5:48helps prevent further injury. And so
5:51damage to the spinal cord can interrupt
5:53communication between the brain and the
5:55body. The level of injury really
5:57determines what functions are affected.
5:59For example, a cervical spinal cord
6:02injury may impair movement and sensation
6:04in all four extremities. Whereas a
6:06lumbar injury affects um only the lower
6:09extremities.
6:11Then we have the cranial nerves. The
6:13peripheral nervous system also includes
6:15the 12 pairs of cranial nerves. And
6:18unlike spinal nerves, cranial nerves
6:20emerge directly from the brain or brain
6:22stem rather than the spinal cord. So
6:25each cranial nerve has a specific
6:27function. Some are responsible for
6:29sensation. Some control muscle movement
6:31and others perform both sensory and
6:33motor function functions.
6:40Um, as bedside nurses, we typically
6:42perform a focused cranial nerve
6:44assessment um, rather than testing all
6:4712 nerves in every patient. So, we
6:50routinely assess pupils, facial
6:52symmetry, speech, swallowing, tongue
6:54movement, and shoulder strength because
6:56these are going to provide valuable
6:57information about neurologic function,
6:59and they're particularly important in
7:01patients with suspected stroke. So later
7:04in today's lecture, we'll discuss um
7:05some practical ways to assess each
7:07cranial nerve and identify findings that
7:10should raise concern.
7:13Then we have spinal nerves. The
7:15peripheral nervous system also contains
7:1731 pairs of spinal nerves which branch
7:20branch off the spinal cord and
7:22interervate the entire body. And so
7:24these nerves are considered mixed nerves
7:27meaning they contain both sensory fibers
7:29which bring information to the central
7:31nervous system and motor fibers which
7:33carry commands from the central nervous
7:35system to muscles. So the spinal nerves
7:38are divided into regions. We have eight
7:40cervical, 12 thoracic, five lumbar and
7:44five sacral and one cox coxal nerve. Um,
7:48so notice that there's eight cervical
7:50nerves but only seven cervical
7:53vertebrae. Um, this is actually a really
7:55common enclelex question because the
7:57cervical nerves exit above their
7:59corresponding vertebrae with the
8:01exception of the eighth cervical nerve.
8:04So each spinal nerve supplies a specific
8:07area of skin called a dermatome and
8:11specific groups of muscles called myo.
8:14So understanding dermatomes helps
8:16clinicians localize neurologic injury.
8:19For example, if a patient reports
8:21numbness along the thumb and lateral
8:23forearm, this may suggest involvement of
8:26the C6 nerve root.
8:29So many neurologic disorders involve the
8:32peripheral nervous system rather than
8:33the brain itself. Um things like
8:36peripheral neuropathy commonly seen in
8:38patients with diabetes results in
8:40numbness, tingling, burning pain and
8:43decreased protective sensation in the
8:44feet. Gileiam beret syndrome. This is an
8:48autoimmune disorder that causes rapidly
8:50ascending muscle weakness and it can
8:52progress to respiratory failure. Bell's
8:55palsy. This affects the facial nerve and
8:57results in unilateral facial weakness.
9:00ridiculopathy which is often caused by a
9:02herniated disc compressing a spinal
9:04nerve which leads to pain, numbness or
9:07weakness along that affected dermatome.
9:10So recognizing whether symptoms
9:12originate from the central nervous
9:13system or the peripheral nervous system
9:15is going to help guide further
9:16assessment and treatment.
9:22The autonomic nervous system or the ANS
9:25it regulates involuntary body functions
9:27meaning functions that occur without any
9:30conscious thought. So unlike the somatic
9:32nervous system which controls voluntary
9:34skeletal muscle movement, the autonomic
9:36nervous system controls cardiac muscle,
9:38smooth muscle, glands, blood vessels,
9:42internal organs. Um it's constantly
9:45working to maintain homeostasis. So it's
9:48adjusting body functions based on the
9:49body's needs.
9:52Things like heart rate, blood pressure,
9:54respiratory rate, blood uh digestion,
9:57pupilary size.
10:00There are two divisions of the autonomic
10:02nervous system um that work together to
10:05maintain balance. So we have the
10:07sympathetic nervous system which
10:09prepares the body to respond to stress
10:11or danger. And you'll often hear this
10:13called the fight orflight response.
10:17And then we also have the
10:20parasympathetic nervous system which has
10:22the opposite effect. It promotes the
10:24body's rest and digest activities. So
10:26when you're sitting down after dinner
10:28watching television, that's when your
10:30par sympathetic nervous system is
10:33working its hardest.
10:40Let's see.
10:43Then the autonomic nervous system
10:45communicates using chemical messengers
10:48called neurotransmitters.
10:50Um the two major neurotransmitters
10:52you're you'll encounter epinephrine and
10:54norepinephrine. These are primarily
10:57active um activate the sympathetic
11:00nervous system. So increasing heart
11:01rate, blood pressure, cardiac
11:03contractility, respiratory rate, blood
11:06glucose. And you'll hear these discussed
11:08frequently in pharmarmacology because
11:10many medications either mimic or block
11:12those effects.
11:15Acetylcholine. This is the primary
11:17neurotransmitter of the parasympathetic
11:19nervous system. It slows the heart,
11:20stimulates digestion, promotes glandular
11:24secretions and supports nor normal
11:26resting body functions.
11:30Reflexes. Now let's shift to that. Um,
11:33reflexes are another important component
11:36of the neurologic assessment. A reflex
11:38is an automatic involuntary response to
11:40a stimulus and they occur very quickly
11:43because they do not require conscious
11:45thought. They allow the body to protect
11:47itself from injury and maintain posture
11:49and muscle tone.
11:52Uh, reflex arc. So, every reflex follows
11:54the same basic pathway called the reflex
11:56arc. There are five components. A
11:59receptor
12:00detects the stimulus.
12:03A sensory neuron carries the signal to
12:05the spinal cord. The spinal cord
12:07processes the information. A motor
12:09neuron carries the response away. An
12:11aector muscle or gland produces the
12:14response. So notice that the brain does
12:15not have to initiate the movement. The
12:18brain becomes aware of the stimulus
12:19after the reflex has already occurred.
12:22And this explains again why you withdraw
12:24your hand from a hot stove before even
12:25consciously realizing it. There are
12:28several categories of reflexes. So we
12:31have deep tendon reflexes and these are
12:33the reflexes most commonly assessed
12:36during a neurologic exam including the
12:39biceps, triceps, brachioraiialis,
12:41patellar, achilles. And these help
12:45evaluate the integrity of the peripheral
12:47nerves, spinal cord and upper motor
12:49neuron pathways.
12:52Then we have superficial reflexes which
12:54occur when the skin is stimulated. Um
12:57examples include plantar reflex,
12:59abdominal reflex. So one important
13:03example is the babin babinsky reflex. Um
13:06in adults stroking the sole of the foot
13:08could cause the toes to curl downward.
13:11An upward movement of the great toe with
13:13a fanning of the other toes. That's
13:15called a positive Babinsky sign and it
13:17may indicate upper motor neuron lesion.
13:21But in infants this response is
13:23considered normal because the nervous
13:25system is still developing.
13:27Then we have visceral reflexes
13:31um which regulate internal organ
13:33function. So pupilary constriction in
13:37response to light, bladder emptying,
13:39blood pressure regulation, GI motility.
13:43Many of these occur automatically
13:44through the autonomic nervous system.
13:46And then finally, neonatal reflexes. So
13:48infants are born with several primitive
13:51reflexes that will disappear as the
13:54nervous system matures. So things like
13:55the moral reflex, which is the sucking,
13:58rooting, um palmer grasp, stepping
14:02reflex. Um so any persistence of these
14:05reflexes beyond the expected
14:07developmental age can actually indicate
14:09neurologic dysfunction.
14:15Back to older adults. So one of the most
14:17important things to understand is the
14:19difference between normal neurologic
14:20aging and abnormal neurologic changes.
14:23So many of our patients especially in
14:25med surge are older adults. So while
14:28some neurologic changes are expected
14:30with aging, others should never be
14:31dismissed as just getting older. So our
14:34goal is to recognize what is considered
14:36a normal age- related change and
14:38identify findings that require further
14:40evaluation,
14:44things like structural brain changes. So
14:46as people age, the brain underos gradual
14:49structural changes and one of the most
14:51common changes is the loss of neurons
14:53and a decrease in the number of synaptic
14:56connections between nerve cells. So
14:58although the brain can compensate for
15:00many of these changes, communication
15:02between neurons becomes slightly less
15:04efficient and blood flow through the
15:06brain also decreases modestly with age
15:10and nerve impulse conduction slows. So,
15:13these normal physiologic changes may
15:15contribute to slower processing speed,
15:18but they don't um significantly impair a
15:20healthy older adult's ability to
15:22function independently. It's important
15:25to remember that healthy aging is not
15:28it's not resulting in sudden confusion,
15:31significant memory loss, or loss of
15:33independence. Those are abnormal.
15:37Reduction in brain volume. So beginning
15:40around middle adulthood there is a
15:42gradual decrease in overall brain volume
15:44particularly in the frontal cortex and
15:46hippocampus the frontal lobe is
15:49responsible again for executive
15:51functioning planning and
15:52decision-making. So while the
15:54hippocampus plays a critical role in
15:56learning and memory so although brain
15:59volume decreases with age many older
16:01adults continue to have excellent
16:03cognitive function
16:06reduction in cognitive abilities. Many
16:09older adults notice subtle changes in
16:11cognition. Um, normal age- related
16:13cognition changes include slower
16:16processing of new information, taking
16:18longer to recall names or words, mild
16:22decreases in multitasking ability,
16:25longer reaction times, and needing
16:27additional time to learn new technology
16:29or unfamiliar tasks. But long-term
16:32memory, v vocabulary, and accumulated
16:35knowledge, those are generally
16:36preserved.
16:44One of the most common mistakes in
16:46healthcare is assuming that confusion is
16:48a normal part of aging, which it is not.
16:50Um, acute confusion is more likely to
16:53represent delirium, which may be caused
16:56by infection, dehydration, medications,
16:59metabolic disturbances, or hypoxia. And
17:02that requires prompt assessment.
17:06increased risk for poor balance,
17:08postural hypotension, falls and injury.
17:11So, neurologic aging also affects
17:13balance and mobility. And several
17:15factors contribute to this fall risk
17:18including slower nerve conduction,
17:20decreased muscle strength, reduced
17:23proprioception, changes in vision,
17:26vestibular dysfunction, delayed reaction
17:29times.
17:31So that's going to contribute to poor
17:33balance, postural hypotension, falls,
17:35and injury.
17:38Always assessing for that
17:41reduced light touch and pain sensation.
17:44So normal aging also affects sensory
17:46perception. Um older adults often
17:48experience decreased sensitivity to
17:50light touch, pain, temperature,
17:52vibration, and position sense. And
17:55because sensation is diminished,
17:57injuries may go unnoticed. So, for
18:00example, an older adult with diabetes um
18:03and peripheral neuropathy may not
18:06realize they have developed a foot ulcer
18:08until becomes infected. Um likewise,
18:12burns from heating pads or hot bath
18:14water. They may occur because
18:16temperature sensation is impaired. So,
18:18always comparing sensation bilaterally
18:20considering that the patient has reduced
18:22sensation may also increase their risk
18:25for injury.
18:27and then increased size of the
18:28ventricles. As brain tissue gradually
18:31decreases, the fluid fil ventricles
18:33within the brain naturally enlarge. Um
18:36this enlargement is considered a normal
18:38finding and healthy aging and it
18:40reflects the loss of surrounding brain
18:42tissue. However, significant ventricular
18:45enlargement may also occur in conditions
18:48such as normal pressure hydrophilis
18:51which can present with um gate
18:54disturbance, urinary incontinence,
18:56cognitive impairment. So unlike many
18:58dementias, normal pressure hydrophilis
19:01is sometimes reversible with treatment
19:03making early recognition of that
19:05important.
19:10Um, as nurses, it's important to
19:12recognize that neurologic diseases do
19:14not affect all populations equally.
19:17However, it's equally important to
19:18understand why these disparities exist.
19:21So, differences in neurologic outcomes
19:23are often influenced by a combination of
19:25factors including genetics, prevalence
19:27of chronic diseases such as hypertension
19:30and diabetes, socioeconomic factors,
19:33access to preventative health care,
19:36environmental exposures, health
19:38literacy, and structural barriers to
19:40care. So recognizing these disparities
19:42has going to help us provide equitable
19:43care while avoiding assumptions or
19:46stereotypes about individual patients.
19:49And so I have some information on more
19:53cultural variations and health
19:54disparities in this slide.
19:59One of the most important
20:00responsibilities is recognizing again
20:02when neurologic findings represent an
20:04emergency. So many neurologic conditions
20:07develop gradually whereas others can
20:09deteriorate within minutes. Because the
20:11brain is highly dependent on oxygen and
20:13blood flow, delayed recognition can
20:15result in permanent neurologic damage.
20:17So this slide is highlighting just
20:19assessment findings that should
20:20immediately capture your attention and
20:24provide um prompt rapid intervention.
20:27Um a helpful phrase to remember is any
20:30sudden neurologic change is an emergency
20:33until proven otherwise.
20:35So, significant changes in neurologic
20:37status. So, when performing a neurologic
20:39assessment, always compare your findings
20:41to the patient's baseline and ask
20:43yourself, is this new? Has this changed
20:46since my last assessment? Is it getting
20:48worse? Um, trending assessment findings
20:51over time rather than relaying on a
20:53relying on a single assessment is really
20:56important.
20:58any acute change in mental status. This
21:00is one of the earliest signs of
21:02neurologic deterioration.
21:04Um any sudden change in mental status
21:07like new confusion, disorientation,
21:10agitation, difficulty following
21:12commands, sudden lethargy, new memory
21:16impairment, and personality changes. So,
21:19a patient who was alert and oriented
21:20this morning but is now confused should
21:22never be dismissed as just tired or
21:26they're just, you know,
21:29off. I don't know. Just do something
21:31about that. Um because potential causes
21:34could include stroke, hypoglycemia,
21:37hypoxia, infection or sepsis, medication
21:41effects, electrolyte abnormalities,
21:44increased intercraanial pressure. um
21:47always assessing airway breathing,
21:50vital signs, blood glucose, oxygen
21:52saturation,
21:54and the time that the symptoms began.
21:58Any unexplained changes in level of
21:59consciousness. This is going to be the
22:02most sensitive indicator of neurologic
22:04function. So patients progressing from
22:07alert to lethargic or uptunded
22:10um to comeosseure
22:19activity. So any new seizure activity
22:21requires prompt assessment during a
22:24seizure. Our priorities are going to
22:25include protecting the patient from
22:27injury, maintaining airway, timing the
22:30seizure, observing the characteristics
22:32of the seizure. Um, we're avoiding any
22:34restraint. We're never placing anything
22:36in the patient's mouth. And after the
22:39seizure ends, we're assessing the
22:40neurologic status, airway, oxygenation,
22:43and possible causes.
22:46Another finding requiring immediate
22:48attention is abnormal posturing, which
22:50often indicates severe brain injury.
22:52There are two classic postures.
22:54decorticate posturing which is flexion
22:57of the arms towards the chest
23:00like they're grabbing the spinal cord
23:03with extension of the legs. This
23:05suggests injury above the brain stem.
23:08And then we have disserate posturing
23:10which is extension and internal rotation
23:12of the arms with plantar flexion. It
23:15suggests more severe damage involving
23:17the brain stem. It's generally
23:18associated with a poorer prognosis. But
23:21both findings require immediate provider
23:23notification and rapid evaluation.
23:27Changes in pupil size or reactivity. So
23:29the pupils provide valuable information
23:31about that brain stem function. Right?
23:33So normal pupils are equal round
23:35reactive to light and accommodating. So
23:38concerning findings would include
23:39unequal pupils, dilated, pinpoint,
23:42sluggish reaction, non-reactive. So
23:46these findings may indicate increased
23:47endocranial pressure, brain herniation,
23:50intercraanial ble bleeding, cranial
23:53nerve three compression, sometimes
23:55medication side effects or drug
23:57intoxication.
23:58Remember we're comparing both pupils and
24:00documenting
24:04progressing weakness or paralysis. Any
24:06new weakness, especially if if wow, I
24:09can't speak. If it develops suddenly,
24:11requires immediate assessment. asking
24:14our patients to smile, raise both arms,
24:17squeeze our hands, push and pull with
24:19their feet, comparing both sides. Um
24:21because any utilateral weakness can
24:24suggest stroke, intercraanial
24:26hemorrhage, brain tumor or spinal cord
24:29injury
24:32and then changes in sensation. Um
24:35sensory deficits may include numbness,
24:37tingling, loss of light, touch, loss of
24:40pain sensation, inability to identify
24:43limb position, sudden unilateral sensor
24:46sensory loss often accompanies a stroke.
24:49So um whereas progressive bilateral
24:53numbness or ascending weakness, we it
24:55may suggest disorder such as that
24:57Gileiam beret syndrome.
25:00But again, always comparing sensation on
25:02both sides of the body.
25:04And then any significant changes in
25:06vital signs. Um neurologic emergencies
25:08often produce changes in vital signs. Um
25:12sometimes hypertension with a widening
25:14pulse pressure, brada cardia, irregular
25:17respiration. So together um it might
25:21indicate incraanial pressure, possible
25:24brain herniation.
25:26Um sometimes other concerning findings
25:28include severe hypertension during an
25:30acute stroke and on the opposite
25:32hypotension which reduces cerebral
25:35profusion.
25:36Sometimes fever can increase uh cerebral
25:39metabolic demand and cause seizures. Um
25:43so interpreting vital signs
25:47in many clinical situations you won't
25:49have time to perform a complete neuro
25:51exam. So if a patient suddenly develops
25:54neurologic symptoms, your priority is
25:56going to perform a focused neurological
25:59assessment. So to quickly determine
26:02whether the patient is deteriorating or
26:04whether immediate intervention is
26:05needed. Um so this abbreviated
26:08assessment is commonly performed in
26:10emergency departments, um ICUs, stroke
26:13units, postoperative settings, and
26:15whenever a patient experiences an acute
26:18change in neurologic status. So, think
26:20of this as your rapid neuroche. It
26:22should only take a few minutes, but it
26:24provides a lot of great information
26:25about brain function. And the first and
26:28most um important assessment is the
26:30patient's level of consciousness because
26:32this is one of the earliest indicators
26:34of neurologic deterioration. So, begin
26:36by asking yourself, is this patient
26:39awake? Do they respond appropriately?
26:41Can they follow commands? Has their
26:44level of consciousness changed since the
26:46last admission um or assessment?
26:49Um for patients with altered
26:52consciousness, we commonly use the
26:54Glasco coma scale or GCS to provide an
26:57objective measurement. Um so the GCS
27:00evaluates three components. Eye opening,
27:02which is four points. And we observe how
27:04the patient opens their eyes. If they
27:06open them spontaneously, that's a four.
27:09If they open their eyes to verbal
27:11command, that's a three. If they open
27:13their eyes only to painful stimuli,
27:15that's a two. And then no eye opening is
27:17a one. Um and then we look at verbal
27:23response assessing orientation and
27:25communication which is five points. Um
27:28so the higher the score the better
27:30outcome. Um the lower the score the
27:32worse the outcome for the Glasco coma
27:35scale. Um so take a look at the Glasco
27:40coma scale um for what it measures and
27:42how many points are allocated for each
27:51and then we assess pupils. So remember
27:54the acronym PRAA pupils equal round
27:57reactive to light um and accommodation.
28:02We're assessing the size, equality,
28:04shape, direct light response.
28:07Um any concerning findings would be
28:09fixed pupils, sluggish response, unequal
28:12pupils, dilated or pinpoint.
28:17And then we look at extremity strength.
28:19So, motor strength is one of the fastest
28:20ways to screen for stroke or spinal cord
28:23injury. We want to ask our patient to
28:24raise both arms, hold them out in front,
28:27squeeze both of your hands, do the push
28:29and pull with both feet, comparing the
28:31right and left sides. And we're looking
28:33for any weakness, a drift, paralysis, or
28:36asymmetry, like one-sided weakness.
28:39That's always concerning for a stroke.
28:41Then, we're looking at facial asymmetry,
28:43um, which provides, um, us information
28:46about cranial nerve 7 function.
28:49um for possible stroke. So, we're asking
28:51our patients to smile, show their teeth,
28:53puff out their cheeks, raise both
28:55eyebrows, close their eyes tightly, and
28:56we're observing for facial droop, any
28:59flattening of the nasal labial fold,
29:01unequal eyebrow movement, and difficulty
29:04closing one eye.
29:07sensation. Um, if the patient's awake
29:09and able to communicate, we're assessing
29:11sensation by lightly touching both side
29:14both sides of the body and asking if it
29:16feels the same on both sides. So, the
29:18arms, the legs, and the face. Um,
29:22patients may report numbness, tingling,
29:24burning, or decreased sensation. We're
29:26always comparing um side to side.
29:31If consciousness is impaired,
29:34um,
29:36additional brain stem reflexes may be
29:38assessed. And these are going to help us
29:40again determine whether important brain
29:42stem struct structures are still
29:44functioning.
29:49And then finally, vital signs.
29:52Um, always look looking at vital signs
29:55um for abnormalities.
29:59So before we begin the physical exam,
30:01it's important to obtain a thorough
30:03health history as you know by now. Um so
30:06our subjective assessment is going to
30:07help us identify patients who may be at
30:10increased risk for neurologic disorders
30:11and it provides us valuable context for
30:14interpreting our physical assessment
30:15findings. Um so many neurologic
30:18conditions develop gradually and subtle
30:21symptoms reported by the patient may be
30:23early indicators that something is
30:24wrong. Um so asking focus questions
30:27allows us to establish a baseline. Also
30:30identify risk factors and guide our
30:31objective assessment.
30:33Um so first thing is assessment of risk
30:35factors. A health history should focus
30:37on identifying any factors that increase
30:40the patients risk for neurologic disease
30:42while also exploring any current
30:44neurologic symptoms. Um common symptoms
30:46that you might want to ask about
30:48headaches, dizziness or vertigo, syncopy
30:52or fainting, weakness, numbness or
30:54tingling, tremors, difficulty walking,
30:57any memory changes, speech difficulties,
31:01any vision changes or seizures. Um and
31:04so we want to know the onset, duration,
31:06severity, frequency, and progression of
31:08the symptoms which are going to provide
31:10us important clues to the underlying
31:12cause.
31:14um biographical or you know general
31:17demographic information. So age is one
31:20of the strongest risk factors for many
31:22ne neurologic disorders. Um stroke risk
31:25increases with age. Parkinson's disease
31:28typically develops after age 60 along
31:31with Alzheimer's disease which becomes
31:33more common in older adults. Um whereas
31:36some disorders like multiple sclerosis,
31:38this often presents in younger adults
31:40between the age of 20 and 40.
31:44Occupation may also provide important
31:46information. So patients who work in
31:48construction or manufacturing,
31:50agriculture, military settings may have
31:52a history of repetitive head trauma,
31:54chemical exposures, toxin exposure. So,
31:58we want to ask um about that as well as
32:00any participation in contact sports um
32:03or activities with a history of repeated
32:05concussions,
32:07past medical history. Um many chronic
32:11medical conditions significantly
32:13increase the risk of neurologic disease.
32:15Um some important conditions to ask
32:17about include hypertension, diabetes,
32:21hyper lipidmia, atrial fibrillation,
32:24coronary artery disease, any previous
32:27stroke or TIA which is transient
32:30eskeemic attack. Um seizure disorders,
32:33migraines, multiple sclerosis,
32:36Parkinson's disease, dementia, traumatic
32:38brain injury or spinal cord injury. We
32:41also want to ask about previous
32:42surgeries involving the brain, spine or
32:45corateed arteries.
32:49Lifestyle and personal habits um
32:52definitely have a significant impact on
32:53neurologic health. So we want to ask
32:55about things like smoking which we know
32:57accelerates atherosclerosis and can
33:00substantially increase the risk of
33:02stroke, alcohol use because excessive
33:05alcohol consumption can contribute to
33:07peripheral neuropathy, cognitive
33:09impairment, falls, nutritional
33:12deficiencies and withdrawal seizures. um
33:15recreational drug use. So substances
33:17like cocaine, methamphetamines,
33:20and opioids can increase the risk of
33:22stroke, seizures, altered mental status,
33:24and you know, of course, overdose. Um
33:27physical activity. So regular exercise
33:29reduces the risk of stroke and supports
33:31cognitive health. So education on that
33:33is important as well as diet. um because
33:37poor nutrition and vitamin deficiencies,
33:39particularly vitamin B12 deficiency, can
33:42contribute to neuropathy and cognitive
33:44changes. And then sleep, asking about
33:47quality of sleep. Um untreated sleep
33:49apnnea can increase the risk of
33:51hypertension, stroke, and cognitive
33:53impairment.
33:55Then moving on to medications, we're
33:57always performing a thorough medication
33:59review. Um, many medications can affect
34:02neurologic function. Things like
34:04sedatives, bzzoioipines,
34:06opioids, anti-convulsants,
34:09anti-dopressants, anti-csychotics,
34:12muscle relaxants. So, we want to ask
34:14about any prescription medications,
34:16over-the-counter medications, herbal
34:18supplements, and recent medication
34:20changes.
34:25Family history. Some neurologic
34:27disorders have a strong genetic
34:28component. So we want to ask whether
34:30close relatives have been diagnosed with
34:32stroke, aneurysms, Alzheimer's disease,
34:35Parkinson's, Huntingtons, multiple
34:38sclerosis, epilepsy, migraine headaches,
34:41peripheral neuropathies, things like
34:42that. Um although the family history
34:45does not guarantee that the patient will
34:46develop a condition, it may increase
34:48their overall risk and then influence
34:50screening recommendations for that
34:52person.
34:57And again, as nurses, our role extends
34:59beyond assessment. We're also educators.
35:02And so, every patient encounter is an
35:04opportunity to promote neurologic health
35:06and prevent injury and help patients
35:08manage chronic neurologic disorders. Um,
35:11many neuro diseases cannot be completely
35:14prevented, but we can often reduce risk,
35:16delay progression, or improve quality of
35:18life through patient education.
35:21So, as you know, the teaching you
35:23provide should always be individualized.
35:25based on the patients age, risk factors,
35:27their health literacy, diagnosis, and
35:30support systems. Um, so stroke
35:32prevention, which is stroke, is one of
35:34the leading causes of long-term
35:36disability, but many strokes are
35:38preventable by addressing modifiable
35:40risk factors. Um, so education should
35:42focus on controlling the conditions that
35:44contribute to stroke. things like
35:46maintaining um a normal blood pressure,
35:48managing diabetes, lowering cholesterol,
35:51treating atrial fibrillation, quitting
35:54smoking, limiting alcohol in intake, and
35:57exercising rec uh regularly as well as
36:00eating a heart-healthy diet that's low
36:02in saturated fat and sodium.
36:07Um recognizing a stroke, this is equally
36:10important part of stroke prevention. Um
36:12so teaching the families the be fast
36:16acronym. B for balance um so any sudden
36:19loss of balance or coordination. E is
36:22for eyes so sudden loss of vision or
36:24double vision. F is for face which is
36:27facial drooping. A arms so weakness or
36:30numbness in one arm. S for speech so
36:33slurred speech or difficulty speaking.
36:35And then T for time which call 911
36:38immediately and emphas emphasize to the
36:40patient that stroke treatments are
36:42highly time dependent. Uh so never drive
36:45themselves to the hospital. Never wait
36:47to see if symptoms improve.
36:52Injury prevention. So protecting the
36:54brain and spinal cord from injury. It's
36:56another important aspect of neurologic
36:57health. So strategies um appropriate for
37:00the patients age and lifestyle. So
37:02always wearing a seat belt while in a
37:04vehicle, wearing helmets during
37:06bicycling, skiing, snowboarding, things
37:08like horseback riding or motorcycles, uh
37:11contact sports. So um that's important
37:14for um head protection. And then
37:18preventing falls, removing any trip
37:21hazards, using handrails, improving the
37:24lighting, and wearing supportive
37:26footwear. Remember to avoid alcohol or
37:29drug use before driving or operating
37:31machinery. Using assistive devices such
37:34as canes or walkers when needed. And
37:37then for older adults, just, you know,
37:39important fall prevention education is
37:42particularly important because even
37:44seemingly minor falls can result in
37:46traumatic brain injury or subdural
37:48hematomas, especially our patients on
37:51blood thinners.
37:54Chronic neurologic conditions. So many
37:56disorders listed here are chronic
37:58progressive diseases that require
38:00long-term management rather than cure.
38:03So helping patients understand their
38:04diagnosis, manage symptoms, and maintain
38:07the highest possible level of
38:09independence for those.
38:14So when we're collecting a neurologic
38:16health history, it's important to ask
38:18about common symptoms that may indicate
38:20dysfunction of the brain, spinal cord,
38:22peripheral nerves, or cranial nerves.
38:24And these symptoms often help guide the
38:26rest of our assessment and help us
38:27determine whether the problem is acute,
38:30chronic, localized, or generalized. Um,
38:33so as you ask about each symptom,
38:35remember the old carts framework.
38:42So common symptoms like headache or
38:44other pain. Headache is one of the most
38:46common neurologic complaints, but not
38:48all headaches are the same. Um, so we're
38:50asking where the pain is located, when
38:52did it start, was the onset sudden or
38:55gradual, how would you describe the
38:57pain, is your usual, is this your usual
39:00headache? Have you experienced headaches
39:02like this before? Um, what other
39:04symptoms have occurred with the
39:06headaches? Um, so many headaches are
39:09primary headaches such as tension
39:11headaches or migraines. But certain
39:13headaches characteristics should
39:15immediately raise concern like a patient
39:17saying this is the worst headache of my
39:18life or like a sudden thunderclap
39:21headache. Those require more immediate
39:22evaluation because they may indicate
39:25subaractid hemorrhage. Um,
39:29any headaches accompanied by fever, neck
39:31stiffness, altered mental status, we're
39:33thinking about u menitis.
39:36um
39:38localized weakness. We're asking our
39:41patients whether weakness affects one
39:43arm, one leg, one side of the face or
39:45one side of the body. Um there are many
39:48you know probing questions that we can
39:50ask our patients about that along with
39:53generalized weakness which involves the
39:55entire body rather than one specific
39:57area. Sometimes possible causes of this
40:00could be infection, dehydration,
40:02electrolyte imbalances, anemia, you
40:05know, a number of things. Um, but also
40:08some neurologic disorders such as
40:10Gileiam Beret syndrome also begin with
40:13generalized weakness that progresses
40:15over time. So, you know, we are diving
40:19in and asking more specific questions
40:21about all of these common symptoms.
40:29Um, and these are just additional
40:31neurologic symptoms that should be
40:32explored during the health history. Many
40:34of these involve higher cortical
40:37function or the cranial nerves and can
40:39help localize where neurologic problems
40:41may be occurring. So, collecting
40:43subjective data on all of these things,
40:46you know, asking our probing questions.
40:52And now that we've completed the health
40:54history, we'll move on to the objective
40:55assessment or the physical exam of the
40:57neurologic system. So, one thing um
41:00students often notice is that neuro
41:02assessments can seem intimidating
41:05because there are many components. Um
41:07but the key is really to just be
41:08systematic and perform the assessment in
41:10the same order every time. Unlike some
41:13body systems where the assessment is
41:15relatively straightforward, the neuro
41:17assessment evaluates several different
41:18functions simultaneously. So things like
41:21mental status, cranial nerve function,
41:23motor function, sensory function,
41:25coordination, balance, and reflexes. Um,
41:28and each part provides information about
41:30a different area of the nervous system,
41:32which helps us identify where a
41:34neurologic problem may be occurring. So
41:37fortunately, you don't need a lot of a
41:38specialized equipment to perform a neuro
41:40assessment. things like a pen light or
41:42flashlight, great tool, use very
41:45frequently to assess pupilary size. Um,
41:48even direct or consensual light reflexes
41:51like accommodation if appropriate. Um,
41:55and remember when we're assessing
41:57pupils, so we want to remember to
41:58document the size, equality, shape,
42:01reactivity to light,
42:05tongue blade. This is useful when
42:07assessing the mouth and certain cranial
42:08nerves that can be used to inspect the
42:10oral cavity. Um, observe pallet
42:13elevation. Assess cranial nerve 10, the
42:16vagus, which helps us evaluate
42:18swallowing. So, observing the gag reflex
42:20when appropriate. Remember that the gag
42:23reflex is not routinely tested on every
42:25patient because it can be uncomfortable
42:27and may increase aspiration risk.
42:31Cotton swab. This is commonly used for
42:33sensory testing. allows us to assess
42:35light touch sensation, facial sensation,
42:37coral reflex when indicated, um
42:40protective sensation in selected
42:42patients. Um patients should close their
42:45eyes during sensory testing so they
42:46respond only to what they feel rather
42:48than what they see. And we're always
42:50comparing the right and left sides of
42:52the body. Some optional equipment, um,
42:55things like a tuning fork may be useful
42:57to assess vibration, sensation,
42:59position, sense, hearing. Um,
43:04they're actually used less frequently
43:06during routine bedside nursing
43:07assessments, though. Um, so unless there
43:09is a concern for sensory loss or hearing
43:11impairment, we're probably not going to
43:13use a tuning fork. A reflex hammer. This
43:16is used to assess deep tendon reflexes.
43:19So commonly used for the biceps,
43:22triceps, brachioraiialis, patellar,
43:24achilles.
43:26And remember that reflexes help evaluate
43:29the integrity of both the peripheral and
43:31central nervous systems.
43:37So now we're ready to begin the
43:39comprehensive neuro exam. So while there
43:41are many components to the neuro
43:43assessment, remember that each one
43:44builds on the previous step. So we start
43:46by assessing the patient's overall
43:47neurologic status before moving into
43:50more specific tests of cranial nerves,
43:52motor function, sensation, coordination,
43:54and reflexes. So as you perform the
43:56assessment, continue asking yourself, is
43:58this finding normal? Is it symmetrical?
44:02Has it changed from the patient's
44:03baseline? Does this finding help
44:05localize where the neuro problem might
44:08be?
44:09And so we start with the level of
44:11consciousness. Um, this is one of the
44:14most sensitive indicators of neuro
44:15function because it um, any changes in
44:18consciousness often occur before other
44:21neurologic deficits become more obvious.
44:23So, begin by observing our patient. As
44:25soon as we enter the room with our eyes,
44:27we're asking ourselves, are they awake?
44:29Are they alert? Do they make eye
44:31contact? Are they responding
44:33appropriately? Can they follow commands?
44:35Um, so for a routine health assessment,
44:37we're simply documenting whether the
44:39patient is alert and oriented. If the
44:41patient appears altered, we're
44:43determining um orientation to person,
44:46place, time, and situation. Um so that
44:50if the patient has any altered level of
44:52consciousness, you might want to perform
44:54a Glasco scale assessment, which we
44:56discussed earlier.
44:58And remember, even subtle changes in
45:00level of consciousness deserve a lot of
45:02attention because they may indicate
45:04worsening neurologic status.
45:07Next, we're evaluating the patients
45:08cognitive abilities. This assessment
45:10tells us how well the cerebral cortex is
45:12functioning. So during normal
45:14conversation, we're assessing the
45:16patient can answer questions
45:17appropriately, recall recent and remote
45:20information, follow simple and complex
45:23commands, they're maintaining attention,
45:26they're thinking logically, they're ste
45:28uh demonstrating appropriate judgment.
45:30Um so examples of these questions is
45:33what brought you to the hospital today?
45:36Um so they might tell you a story. Um,
45:38is that accurate? Can you tell me
45:41today's date? Who is the current
45:43president? Or another culturally
45:44appropriate orientation question. Can
45:46you tell me what you would do if you
45:49smelled smoke in your house? So, these
45:51questions are going to help us evaluate
45:53memory, orientation,
45:56judgment, abstract thinking, and
45:58attention.
46:02Communication. So, as you're talking to
46:03the patient, you're already assessing
46:05communication. And we're listening
46:06carefully for clear articulation,
46:09appropriate word choice, fluency,
46:11comprehension, voice quality, and we're
46:14observing whether speech is clear,
46:16slurred, slowed, rapid, hesitant. And
46:20we're also determining whether the
46:21patient understands your questions, can
46:23follow directions, responds
46:25appropriately. And so in this phase of
46:29our assessment, we're remembering the
46:31difference between aphasia, so a
46:33language disorder where the patient has
46:34difficulty understanding or producing
46:36language
46:38um disarthria. So this is a motor speech
46:41disorder. The patient knows what they
46:42want to say, but weakness of the speech
46:45muscles causes slurred speech. Um this
46:48can be common in a lot of chronic
46:50neurologic disorders.
46:54Next, we're assessing the pupils. We're
46:55using our pen light to evaluate this.
46:57Again, size, shape, equality, reactivity
47:00to light
47:02and accommodation.
47:08And then finally, we're observing the
47:10patient for any involuntary movements.
47:12Um, and we're doing this while the
47:14patient is sitting, talking, holding
47:17their arms out, walking. We're looking
47:19for any tremors, muscle twitching,
47:22viciculations, any ticks. Cora, donia,
47:26any restlessness. So certain movement
47:28patterns are associated with specific
47:30neurologic disorders. Um for example, a
47:33resting tremor is a characteristic of
47:35Parkinson's disease. Um
47:45now we're going to work through the 12
47:46cranial nerves which originate from the
47:48brain and brain stem. These nerves
47:51control many of the functions we assess
47:52every day, including smell, vision, eye
47:54movements, facial sensation, hearing,
47:57swallowing, and tongue movement. So, a
48:00full cranial nerve assessment is often
48:01performed during a comprehensive
48:03neuroexam
48:05um usually by a neurologist or a
48:08specialized um nurse um who has been
48:13trained in cranial nerve assessment. But
48:16as bedside nurses, we're typically
48:18performing our focused assessment,
48:19especially for patients with suspected
48:21stroke or neurologic changes. So, um, as
48:25you're going through these, remember
48:26that some cranial nerves are sensory,
48:29some are motor, some perform both
48:32sensory and motor functions.
48:35Um, so cranial nerve one, olfactory.
48:38This is sensory and function. Sense of
48:40smell. Um, this nerve is not routinely
48:43assessed during a standard nursing
48:44assessment, but if indicated, um, have
48:47the patient close one nostril and
48:49identify a familiar odor such as coffee
48:51or peppermint. We're trying to avoid
48:54irritating substances like alcohol
48:56because they stimulate pain receptors
48:58rather than smell receptors. Um, so the
49:00patient should be able to identify
49:02familiar smells in each nostril.
49:07Cranial nerve two, optic. This is sens
49:10sensory and functional. Um this is
49:12responsible for vision visual fields. Um
49:16carrying information from the retina to
49:18the brain. So we're assessing this with
49:20the visual acuity using a smelling chart
49:22uh if appropriate peripheral vision by
49:26confrontation and inspecting the optic
49:28disc with the opth opthalmoscope during
49:32a complete eye exam.
49:36Cranial nerve three ocular motor. Um,
49:38this is also motor and function. So,
49:41it's controlling most eye movements,
49:43eyelid elevation, pupilary constriction,
49:46and accommodation. So, we're asking our
49:48patients to follow our finger while you
49:50assess extra ocular movements. And we're
49:52checking eyelid position, pupil size,
49:55direct and consensual light reflexes.
50:00Cranial nerve four is the troplear. Uh,
50:02this is motor and functional. It
50:04controls movement of the superior
50:05oblique muscle which allows the eye to
50:08move downward and inward. Um we're
50:10assessing this nerve um during
50:12extraocular movement testing. So having
50:15the patient again follow our finger
50:16downward towards the nose.
50:19It should be smooth downward eye
50:21movement. No double vision.
50:24Cranial nerve five. This is the
50:26trigeminal. Both sensory and motor
50:28function. It provides facial sensation
50:30muscles of chewing. So, we're assessing
50:32for sensation with light touch to the
50:35forehead, cheeks, and jaw. And we're
50:37asking if both sides feel the same. For
50:39the motor aspect, we're asking our
50:41patient to clench their teeth, open and
50:43close the jaw, and we're palpating the
50:45temporal and massitor muscles.
50:49Cranial nerve six, the abducins. This is
50:52motor and function. It moves the eye
50:55laterally. So, we're this is also
50:57included with the extraocular eye
50:59movement testing. Um so having the
51:01patients follow our finger from side to
51:03side. Um they should move their eyes
51:06laterally without any difficulty.
51:09Cranial nerve seven this is a facial uh
51:11both sensory and motor function. This
51:13controls our facial expressions. Taste
51:15on the anterior two/irds of the tongue.
51:18Tear production and salvation. So we're
51:20asking asking our patient to raise their
51:22eyebrows, close their eyes tightly,
51:24smile, show their teeth and puff out
51:26their cheeks. Taste is rarely assessed.
51:29again during routine nursing
51:31examinations. Um but patients with
51:33strokes um affecting this cranial nerve
51:36might say um that they um are tasting
51:41things a little bit differently um than
51:44normal.
51:48Cranial nerve 8 vestibular coclear
51:51sensory and functional um responsible
51:54for hearing and balance. So we're
51:56assessing hearing by you know our
51:58conversation with the patient. Uh also
52:02you can do the whisper test um where you
52:04whisper in their ear. We can assess
52:06balance by observing their gate.
52:09Um so normal findings would be that
52:12they're hearing appropriately. They have
52:14good balance and no dizziness.
52:16Cranial nerve 9. This is a
52:18glossopareneal.
52:20Uh both sensory and motor function. It's
52:22responsible for swallowing. taste on the
52:25posterior one-third of the tongue and
52:27gag reflex. So, we're assessing by
52:29observing the patient swallowing. Um,
52:31again, gag reflex is generally not
52:33tested routinely unless clinically
52:35indicated because it can be
52:37uncomfortable and um elicit the pain
52:40response. But normal findings should be
52:42that the patient swallows easily, they
52:44have clear speech and no choking.
52:47Cranial nerve 10, this is the vagus
52:49nerve. Both sensory and motor function.
52:51So it controls swallowing, voice, pallet
52:54elevation, parasympathetic functions of
52:56thoracic and abdominal organs. So we're
52:58assessing this by asking the patients to
53:01say ah and we're observing the soft
53:03pallet rises equally. The uvula remains
53:06midline. We're listening to voice
53:09quality and observing swallowing. So
53:11normal findings would be that the uvula
53:13is midline. We have a symmetric pallet
53:15elevation and a clear voice.
53:19Ex uh cranial nerve 11 is the accessory.
53:23This um is motor and functional. It
53:26controls the sternoc collidal mastoid
53:29muscles, the trapezius muscles as well.
53:32And we're assessing this by asking our
53:34patients to shrug their shoulders
53:35against resistance and turn their head
53:38against your hand um for strength. So
53:40that it should be strong equal shoulder
53:42shrug and strong head rotation.
53:46And then finally cranial nerve 12. This
53:48is the hypoglossal
53:50um which affects motor and functional
53:53controls tongue movement. Um so we're
53:55asking our patients to stick out their
53:56tongue, move it side to side, push it
53:58into each cheek while we apply
54:01resistance. Um so the tongue should ma
54:03remain midline. Um strong tongue
54:06strength and smooth movement.
54:12So now that we've assessed mental
54:13status, cranial nerves will move into
54:15evaluating motor function, cerebellar
54:17function, and sensory. And these
54:19assessments tell us how well the brain,
54:20spinal cord, peripheral nerves, and
54:22muscles are working together. So as with
54:25the rest of the neuro exam, we're always
54:26comparing the right and left sides of
54:28the body. Um, symmetry is one of the
54:30most important aspects of the neurologic
54:32assessment. So starting with motor
54:34function which evaluates the patients
54:36ability to produce voluntary movement
54:38and helps determine whether the motor
54:40pathways of the brain, spinal cord,
54:42peripheral nerves and muscles are
54:44intact. So we're assessing three major
54:46components. Muscle bulk, muscle tone,
54:49and muscle strength. So muscle bulks,
54:52we're going to start by simply observing
54:54the patient's muscles. And we're
54:55observing for symmetry, size, and shape.
54:58And the muscles of both sides of the
55:00body should appear relatively equal.
55:02We're looking for any muscle atrophy,
55:04which is a decrease in muscle size.
55:08We're also observing for
55:10faciciculations, which are small
55:11involuntary muscle twitches, and it may
55:14indicate lower motor neuron disease.
55:18Next, we're assessing muscle tone. We're
55:20um passively moving the patient's arms
55:22and legs through their range of motion
55:23while the patient relaxes. Normal muscle
55:26tone provides slight resistance to
55:28passive movement. Um, abnormal findings
55:31would be hypotonia or decreased muscle
55:34tone where the limbs feel really floppy
55:37or hypertonia which is increased
55:39resistance movement.
55:42Muscle strength. So, we're asking our
55:44patients to push and pull against our
55:46hands. Um common muscle groups include
55:49upper extremities with hand grasps, arm
55:52flexion, arm extension, and the lower
55:54extremities with hip flexion, knee
55:57extension, foot dorsif flexion, foot
55:59plantar flexion. Again, we're comparing
56:02both sides. And strength is typically
56:04graded on a 0 to five scale. So five out
56:06of five would be normal. Four out of
56:08five slight weakness, three out of five
56:11move, they have movement against gravity
56:13only. two out of five they have movement
56:16only when gravity is eliminated and then
56:19one out of five where muscle contraction
56:20without movement and then zero out of
56:23five with no muscle contraction
56:25whatsoever.
56:26So documenting um
56:29zero out of five
56:32and then one simple bedside assessment
56:34of upper extremity weakness is the
56:35pronator drift test. So, we're asking
56:38our patients to extend both arms
56:40forward, turning the palms upward,
56:42closing their eyes, and holding the
56:44position for about 20 to 30 seconds.
56:46Normal would be that the arms remain
56:48steady, and abnormal would be we see one
56:51arm drifting down or the palm turns
56:55inward or pronates. Um, a pronator drift
56:58is a sensitive indicator of subtle upper
57:00motor neuron weakness and it's commonly
57:03performed during stroke assessments.
57:13Now looking at s the cerebellum which is
57:16responsible for coordinating voluntary
57:18movement, maintaining posture and
57:20preserving balance. So a patient with
57:22cerebellar dysfunction may have normal
57:24muscle strength but poor coordination.
57:27Um so something we do is a finger to
57:29nose test. We're asking our patients to
57:31touch their nose then touch our finger
57:33and we want to repeat that several
57:34times. observing whether the pat the
57:37movement is smooth and accurate. Um,
57:39difficulty performing this task may
57:41indicate cerebellar dysfunction. And
57:44then the heel to shin test, we're having
57:45our patients slide one heel down the
57:47opposite shin from knee to ankle. Normal
57:50movement would be smooth and controlled.
57:52Any jerky or inaccurate movement
57:54suggests cerebellar dysfunction.
57:57Rapid alternating movements. So asking
58:00the patient to rapidly flip their hands
58:02over repeatedly on their thighs or tap
58:04the palm and back of the hand
58:06alternatively.
58:08Any difficulty performing rapid
58:10alternating movement is called um
58:14distanisia.
58:18Wow,
58:20butchered that.
58:22Um
58:24but this is another commonly associated
58:27with um cerebellar disease.
58:30Ataxia, this refers to uncoordinated
58:32movement where patients may demonstrate
58:35a wide base gate, any staggering or
58:37difficulty turning and poor balance and
58:41it commonly results again from
58:42cerebellar disease. Um we also can see
58:45it in alcohol intoxication, sometimes
58:47multiple sclerosis, stroke or vestibular
58:51disorders. Um so we're observing the
58:53patient's gate whenever possible.
58:56And then finally, we're assessing
58:57sensation um whether information from
59:01the skin is successfully reaching the
59:03brain. Um, so the having the patient
59:05close their eyes during testing, always
59:07comparing right to left and going from
59:09distal versus proximal.
59:14Again, light touch um sometimes using a
59:17cotton swab and then superficial pain
59:20sensation using um a disposable neurotip
59:24um by alternating the sharp and dull
59:26ends.
59:28You'll see neurologists do that.
59:35And the final component of a
59:36comprehensive neuro assessment is
59:38evaluating deep tendon reflexes um which
59:41provide information about the integrity
59:42of peripheral nerves, spinal cord and
59:44upper motor neuron pathways. So while
59:47you as a nurse may not perform a
59:49complete reflex exam on every patient um
59:52or any patient in a medical surgical
59:54setting, understanding how reflexes are
59:57graded is going to help you interpret
59:58neurologic findings and communicate them
1:00:02um accurately. Why do we test reflexes?
1:00:05Um so deep tendon reflexes evaluate
1:00:07whether the reflex arc is intact.
1:00:10Remember the components of a ref reflex
1:00:12arc. A sensory receptor detects the
1:00:15stimulus. The sensory nerve carries the
1:00:17impulse to the spinal cord. The spinal
1:00:19cord processes the information. Um, a
1:00:22motor nerve carries the response back
1:00:24and the muscle contracts. So if any part
1:00:27of that pathway is disrupted, the reflex
1:00:30may become diminished or absent. So on
1:00:32the other hand, if the brain is no
1:00:34longer properly regulating the spinal
1:00:36cord, um, sometimes as occurs with upper
1:00:38motor neuron lesions, the reflexes may
1:00:41come may become really exaggerated.
1:00:45Um common deep tendon reflexes include
1:00:48the bicep biceps reflex um which is C5
1:00:53and C6. Brachio radiialis reflex again
1:00:56C5 and C6 um triceps reflex C7 and C8
1:01:02patella reflex L2 to L4 and Achilles
1:01:06reflex which is S21 to S2.
1:01:10And you don't have to remember the
1:01:11spinal levels for your routine bedside
1:01:13assessments, but it's really helpful to
1:01:14know that each reflex corresponds to a
1:01:17different spinal nerve level.
1:01:20How to test a reflex. So, when testing
1:01:22reflexes, we're positioning the muscle
1:01:24so it's relaxed. We're supporting the
1:01:26extremity and striking the tendon, not
1:01:29the muscle, with the broad end of the
1:01:31reflex hammer. And we're using a quick
1:01:33wrist motion rather than swinging our
1:01:35entire arm. Again, always comparing
1:01:37right and left sides and symmetry is
1:01:40often more important than the absolute
1:01:41reflex grade.
1:01:45Um, so looking at this grading scale, I
1:01:48think it's pretty um self-explanatory.
1:01:54So, now that we've completed our
1:01:55neurologic assessment, the next step is
1:01:57using those findings again to make sound
1:02:00clinical decisions. Um, while diagnostic
1:02:03testing can help confirm a diagnosis,
1:02:06our assessment is often what first
1:02:08identifies something wrong with the
1:02:10neurologic system. Um, so when we're
1:02:13identifying abnormal neurologic
1:02:14findings, we're asking ourselves, is
1:02:16this expected finding or does this
1:02:18require immediate action?
1:02:24Um, we're also, you know, inquiring
1:02:26about interprofessional collaboration.
1:02:29Depending on the patient's deficits, you
1:02:30may work with providers, physical
1:02:32therapy, occupational therapy, speech,
1:02:35language pathology. Um,
1:02:39so
1:02:40you know, including them in your
1:02:42communication of the patient. Um, coming
1:02:45up with an individualized plan of care
1:02:52throughout the patient's care. We're
1:02:54continuing to evaluate whether our
1:02:55interventions are improving outcomes or
1:02:58whether the patient's neurologic status
1:02:59is changing and requires further
1:03:01intervention.
1:03:05And that is it for today. I know this is
1:03:07a long one. Um the neurologic assessment
1:03:10is quite indepth. Um so I can't wait to
1:03:13see you for our last lab. I hope you
1:03:15have a great day.

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