Assessment Abstract Assessment by the nurse is a critical component of caring for conscious and unconscious patients with neurologic disorders. A comprehensive assessment includes medical history, mental status examination, review of speech patterns, motor and sensory examination, and evaluation of cerebellar function. Keywords: cerebellar assessment, cranial nerves, Glasgow Coma Scale, intracranial pressure, level of consciousness, motor assessment, reflexes, sensory assessment The nurse is the single most valuable asset for assessing patients in the health care setting. Therefore, all nurses must master good assessment skills. Many diverse components contribute to an adequate assessment of patients with neurologic disorders (Box 2.1 Components of a Neurologic Assessment). Before a physical examination is performed, a thorough history should be obtained from the chart, the patient, and the family. Nurses should strive to gather as much information as possible when interviewing the patient or family. The following topics should be covered: current complaint, health history, family history, social history, and current medications. Box 2.1 Components of a Neurologic Assessment Patient history Vital signs Mental status Level of consciousness Speech Cranial nerve testing Motor assessment Sensory assessment Reflex assessment Cerebellar function Chief complaint or problem Symptoms and their duration What causes aggravation or relief of symptoms Other recent or past illnesses or diseases (e.g., diabetes mellitus, hypertension, and infectious diseases) Any childhood diseases (e.g., measles, mumps, and chickenpox) Detailed report of the patient’s surgical history Medical history of the patient’s parents, siblings, and children Age and health status of each family member (noting cause of death for any deceased immediate family members) Occupation Marital and family status Ethnicity Social habits (e.g., tobacco, alcohol, and drug use); indicate type, amount, and frequency of consumption, if appropriate Recent international travel Include a list of over-the-counter medications and herbal supplements Inquire about history of allergic reactions to any medications Routine assessment of vital signs (e.g., temperature, heart rate, respiration, and blood pressure) is an appropriate way to begin the physical examination, as vital signs may reveal important information about patients with known or suspected neurologic impairment. In Taber’s Cyclopedic Medical Dictionary, the term mental status is defined as “The functional state of the mind as judged by the individual’s behavior, appearance, responsiveness to stimuli of all kinds, speech, memory, and judgment.” Assessment of mental status begins in the first meeting with the patient. The patient’s demeanor, attentiveness, and ability to answer both simple and complex questions should be closely observed. The mental status examination offers insights on the patient’s thinking, reasoning, and other functions. Attention Memory Appearance Behavior Orientation Affect Abstraction If there is any uncertainty or concern about a patient’s mental status, other screening tests may offer a more detailed and advanced evaluation (Box 2.2 Mental Status Screening Test Options). Any patient with a neurologic disorder should be screened for cognitive impairment. Box 2.2 Mental Status Screening Test Options Mini–Mental State Examination Rankin Scale Karnofsky Performance Status Scale Barthel Index of Activities of Daily Living National Institutes of Health Stroke Scale The most basic level of assessment is the level of alertness, which can be divided into two categories: cognition and consciousness. Cognition refers to the intellect and to the ability to gather and process information. It includes the capacity for various mental processes. Attention Organization Planning Perception Judgment Learning Memory Safety awareness Cognitive deficits are commonly associated with cases of neurologic impairment. These deficits can be obvious (e.g., short-term memory loss), or they can be subtle (e.g., impaired safety awareness). In all patients with neurologic impairment, cognitive deficits must be identified to ensure that the patient receives appropriate care and is well-versed in safety at the time of discharge. Dementia refers to the deterioration of cognitive function with a clear sensorium. It is associated with a variety of pathologic processes that progressively damage and destroy brain cells. According to the Alzheimer’s Association, a patient must meet specific criteria to receive a diagnosis of dementia. Decline is noted in at least two of the following cognitive functions: memory; ability to speak and understand spoken language; capacity to plan, make judgments, and carry out plans; and ability to process and interpret visual information Decline is severe enough to interfere with daily life Most forms of dementia are progressive and irreversible. However, dementia may be reversible with prompt treatment when it is associated with a pathologic process. Drug intoxication Depression Certain vitamin deficiencies Normal pressure hydrocephalus Delirium is a transient condition characterized by disorientation and fluctuation in levels of awareness and consciousness throughout the day. Patients with delirium may exhibit various symptoms. Restlessness Agitation Emotional lability Paranoid or delusional thoughts Decreased cognition Inability to focus and maintain attention Hallucinations (visual, auditory, or tactile) Altered sleep-wake cycles “Sundowning” (i.e., increased levels of confusion as the day progresses) Delirium is usually transient (lasting anywhere from several hours to many days) and is caused by an underlying condition. Possible underlying conditions may include the following: Infection, especially urinary tract infection (UTI), pneumonia, or viral illness (Box 2.3 Age Awareness: Urinary Tract Infection and Delirium) Drug or alcohol withdrawal Cerebral hypoxia Structural causes (e.g., vascular blockage, subdural hematoma, and brain tumors) Metabolic encephalopathy Certain medical conditions (e.g., hypothyroidism, hyperthyroidism, hypokalemia, anoxia, and hyponatremia) Prolonged intensive care unit (ICU) stay (“ICU psychosis”) Change of environment, especially in elderly patients Overmedication, especially in elderly patients Chemical poisoning (e.g., carbon monoxide, lead, or mercury) Vitamin deficiency (e.g., thiamine and vitamin B1) Adverse reaction to a common medication (e.g., antiepileptic drugs, digoxin, cimetidine, aspirin, corticosteroids [dexamethasone], narcotics, tricyclic antidepressants, or medications used to treat Parkinson’s disease) Box 2.3 Age Awareness: Urinary Tract Infection and Delirium Work-up for unexplained delirium in elderly patients should always include testing for a UTI Dementia and delirium are not the same (▶ Table 2.1). Variable Dementia Delirium Onset Insidious and gradual Acute and fluctuating Level of consciousness May be unchanged Decreased Medical condition Alzheimer’s disease, neurologic injury (e.g., stroke and trauma) May include infection, drug toxicity, and hypoxia Mood Flat affect Labile, irritable, and confused Consciousness refers to one’s state of awareness to self and to the environment. Alterations in consciousness may be multifactorial. They may occur slowly, over the course of several months, or they may occur rapidly, over the span of several minutes (Box 2.4 Terms to Describe Decreased Level of Consciousness). A decline in neurologic status often starts with a decrease in the level of consciousness (LOC). Neurologic decline is frequently preceded by increased lethargy, but it can sometimes commence with restlessness, confusion, or agitation. These changes are warning signs, especially if they are new and different for the patient. Decreased LOC can have many causes, and not all causes are neurologic (Box 2.5 Common Nonneurologic Causes of Altered Level of Consciousness). Box 2.4 Terms to Describe Decreased Level of Consciousness Drowsy Sleepy Lethargic Obtunded Stuporous Coma Box 2.5 Common Nonneurologic Causes of Altered Level of Consciousness Infection Medication Fever Metabolic factors Hypoxia The Glasgow Coma Scale (GCS) is a standardized scale often used to describe LOC in patients with neurologic disorders. It was developed in Scotland in 1974 to allow clinicians everywhere to report LOC in a uniform way. The GCS evaluates patients’ responses in three areas. Eye opening (E) Verbal response (V) Motor response (M) The patient receives points in each category based on best response. The GCS score is the sum of these points (▶ Table 2.2). The GCS is a useful reporting tool for the assessment of neurologic function, but it is not appropriate for all patients. For example, it will not be useful for reporting neurologic function for patients with spinal cord injuries. It is most useful for patients with actual or suspected brain trauma or disease. Points Eye opening (E) Verbal response (V) Motor response (M) 6 Obeys commands 5 Oriented Moves purposefully 4 Eyes open spontaneously Confused Withdraws to pain 3 Eyes open to voice Inappropriate speech Decorticate positioning 2 Eyes open to pain Incomprehensible speech Decerebrate positioning 1 No eye opening No verbal output No response to pain Note: Patients are scored on four eye responses, five verbal responses, and six motor responses. Glasgow Coma Scale (GCS) values will total 3–15, with 3 being the worst and 15 being the best. A GCS score of 8 or less indicates a severe injury, 9–12 indicates a moderate injury, and 13 or higher indicates a mild brain injury. The term vegetative state refers to a condition that follows a period of depressed consciousness. Plum and Posner describe a vegetative state as being the return of alertness but without awareness or cognition. Patients in this state may have spontaneous eye opening and complete sleep–wake cycles but do not communicate, follow commands, or exhibit purposeful movements. Brainstem functions such as breathing remain intact. The term persistent vegetative state refers to a permanent vegetative state. Patients in a persistent vegetative state who receive outstanding nursing and medical care may live for many years. Locked-in syndrome is characterized by paralysis of all four extremities, resulting in the inability to move one’s limbs. Affected patients are often mistakenly deemed unresponsive, because it is exceedingly difficult for those in this condition to communicate. Locked-in patients may only be able to move their eyes. Neither consciousness nor cognitive function is affected. This syndrome results from a lesion or a neurologic event (e.g., stroke) in the pontine region of the brainstem. See Chapter 1: Anatomy. Brain death is defined as the permanent and irreversible absence of all brain functions, including brainstem functions, which results in apnea and coma. Brain death is a clinical diagnosis made by a physician following a strict protocol, which may vary slightly among institutions. When brain death is suspected or imminent, the nurse should contact the appropriate donor procurement organization, provided that organ donation is in accordance with the patient’s advance directive (Box 2.6 Ethical Considerations: Brain Death). Box 2.6 Ethical Considerations: Brain Death Brain death is determined by a physician and is based on the following criteria Absence of brainstem reflexes Fixed pupils Absent corneal reflexes Absent vestibuloocular reflexes (cold calorics) Absent oculocephalic reflex (doll’s eyes) Absent gag reflex No spontaneous respirations upon apnea challenge testing* No response to deep central pain Determination of brain death is inappropriate in patients who may be intoxicated from alcohol or drug abuse It is critical to distinguish between brain death and conditions that can mimic brain death (e.g., alcohol intoxication, barbiturate overdose, sedative overdose, and hypothermia) Organ donation should be considered for patients in whom brain death is an imminent possibility *Diagnostic criteria for apnea testing may differ by institutional policy and guidelines. An important component of the neurologic assessment is determining the patient’s ability to communicate. Language is a basic tool of communication, and it is often one of the first areas affected by neurologic deficits. The patient must demonstrate the ability to express thoughts and ideas, in both speech and writing (▶ Table 2.3). It is also necessary for the patient to understand both the spoken and the written word. Speech deficits are categorized according to the disorders listed below. Speech characteristic Testing mechanism Fluency Listen to the patient’s flow of speech. Repetition Ask the patient to repeat words or phrases (e.g., “No ifs, ands, or buts”). Naming Ask the patient to name several common objects (e.g., watch, pen, clock, and ring). Word comprehension Ask the patient to follow simple commands. Start with a one-step command, such as “Stick out your tongue.” Reading comprehension Have the patient read an instruction written by the examiner or a sentence taken from a newspaper and then ask the patient to follow the instruction or explain the meaning of the sentence. Reduction or loss of language skills resulting from brain injury (▶ Table 2.4) Nonfluent (expressive) A type of aphasia in which the person can understand speech but has difficulty formulating words Grammar may become simplified, with expressions limited to one or two words Fluent (receptive) A type of aphasia in which verbal expression (i.e., talking speed, grammar, and intonation) remains normal Comprehension is markedly reduced, but patients with aphasia may be unaware of their language deficits Diagnosis Primary characteristics Location of associated lesion Broca’s aphasia Impaired verbal expression Broca’s area of the left frontal lobe Wernicke’s aphasia Impaired auditory comprehension Global aphasia Severely impaired spontaneous speech, auditory comprehension, naming, writing, and reading Left middle cerebral artery territory lesions involving Broca’s and Wernicke’s areas Not a language deficit; rather, a motor planning disruption Involves the loss of ability to properly sequence or process the voluntary muscle movements that produce speech Not a language deficit; rather, a deficit of motor control of speech Refers to a group of speech disorders that result in disruption of muscle control of the speech mechanism Patients with dysarthria are unable to perform motor functions of speech, which can affect speed, strength, range, and coordination of speech Dysarthria may also affect breathing, resonation, and rhythm of speech Inability to speak Results from a deficit in speech production Characterized by a reduction in vocal quality May be caused by surgical trauma; see Chapter 1: Anatomy Cranial nerve assessment is an integral part of the neurologic examination, because it provides revelatory information about the functioning of various areas of the brain. This assessment is especially useful in determining whether there is damage to the brainstem, the region where most of the cranial nerves originate (▶ Table 2.5 and ▶ Table 2.6). Cranial nerve Motor function Sensory function Olfactory (CN I) None Smell Optic (CN II) None Vision Oculomotor (CN III) Medial, inferior, and superior rectus None Inferior oblique (all extraocular muscles, except superior oblique and lateral rectus) Pupillary constriction Levator palpebrae (controls eyelid elevation) Trochlear (CN IV) Superior oblique extraocular muscle None Trigeminal (CN V) Muscles of mastication Its three branches supply sensation to face, scalp, nasal and oral cavities, and the anterior two-thirds of the tongue Abducens (CN VI) Lateral rectus None Facial (CN VII) Facial expression, eyelid closure, and eyebrows Taste from anterior two-thirds of tongue Vestibulocochlear (CN VIII) None Balance and hearing Glossopharyngeal (CN IX) Swallow Taste from posterior one-third of tongue Vagus (CN X) Swallow Sensory for pharynx and larynx (involved with swallowing) Spinal accessory (CN XI) Shoulder shrugs None Hypoglossal (CN XII) Intrinsic and extrinsic muscles of tongue None Abbreviation: CN, cranial nerve. Testing method Documentation of normal findings Documentation of abnormal findings CN I Identification of specific odors Sense of smell present bilaterally Unable to identify odors (indicate whether this inability is present in the left or right nostril, or bilaterally) CN II Visual acuity Visual acuity grossly intact Document decreased visual acuity in left eye, right eye, or both eyes Snellen chart Document visual acuity (e.g., 20/20) Document test score for each eye Visual field Visual fields full to confrontation Document presence of visual field deficit (may use drawings) CN III, CN IV, and CN VI Bilateral pupil response to light Pupils equal and reactive to light (PERL) May document size of pupil, before and after response to light Document size and response of each pupil to light if pupils are unequal Extraocular movements Extraocular movements intact (EOMI) bilaterally Document deficit in movement of each eye, indicating direction CN V Facial sensation in all three branch distributions (V1, V2, and V3) Light touch intact in VI, V2, and V3 bilaterally Document deficit in light touch sensation by area (V1, V2, and V3) bilaterally Corneal reflex Corneal reflex present bilaterally Corneal reflex absent (right or left) CN VII Facial symmetry Face symmetric Presence of facial weakness (indicate side) (may use House-Brackmann scale) CN VIII Hearing Hearing intact bilaterally Decreased hearing (right or left) CN IX and CN X Swallow Swallow present bilaterally; palate raises bilaterally Decreased swallow noted (right or left) CN XI Shoulder shrugs Shoulder shrugs intact bilaterally Shoulder shrugs decreased (right or left) CN XII Tongue protrusion Tongue midline Tongue deviation (to right or left) Abbreviation: CN, cranial nerve. There are 12 cranial nerves They come in pairs, a left and a right Some cranial nerves serve purely motor functions, some purely sensory, and some both They are denoted with Roman numerals (i.e., CN I–CN XII) The function of each cranial nerve should be tested separately, but some can be examined together They are always tested bilaterally In this section, we present the cranial nerves not in numerical order but rather in groups according to which nerves they should be tested with. For example, CN VI is presented directly after CN III and CN IV, with CN V presented later. Often overlooked, the olfactory nerve (CN I) provides the sense of smell, the loss of which is called anosmia (Box 2.7 Clinical Correlation: Potential Causes of CN I Dysfunction). To test CN I Present nonirritating scents such as peppermint, vanilla, citrus, and coffee for the patient to identify; occlude the patient’s nostrils one at a time to test both sides Do not test CN I with agents such as ammonia because they can irritate the sensitive nasal mucosa Box 2.7 Clinical Correlation: Potential Causes of CN I Dysfunction
2.1 History
2.1.1 Current Complaint
2.1.2 Health History
2.1.3 Family History
2.1.4 Social History
2.1.5 Current Medications
2.2 Vital Signs
2.3 Mental Status
2.4 Level of Alertness
2.4.1 Cognition
Altered States of Cognition
Dementia
Delirium
2.4.2 Consciousness
Glasgow Coma Scale
Altered States of Consciousness
Persistent Vegetative State
Locked-In Syndrome
Brain Death
2.5 Speech
Progress to a two-step command, such as “Pick up the paper and set it on the floor.”
2.5.1 Aphasia
Writing ability same as speech
Wernicke’s area of the temporal lobe
Fluent speech
Poor error awareness
Writing ability mirrors speech ability
2.5.2 Apraxia
2.5.3 Dysarthria
2.5.4 Mutism
2.5.5 Dysphonia
2.6 Cranial Nerve Assessment
2.6.1 Examination of Cranial Nerves
CN I: Olfactory Nerve
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