Neurological Assessment Tips . If a patient develops any decrease in level of consciousness, the priority is to promptly identify and treat alterations in ABCGS (Airway, Breathing, Circulation, Glucose or Seizures) that may be causing the deterioration. If the neurological change persists despite normalization of the ABCGS, a detailed neurological assessment should be performed. The examination should attempt to determine if focal findings are present (suggesting a structural abnormality, such as stroke) or absent (suggesting generalized neurological depression, as seen with sedation or septic encephalopathy). Change is the most important finding in any neurological assessment and should be reported promptly to ensure timely medical intervention (if warranted). To ensure that neurological findings are communicated effectively at change of shift, nurses should perform a neurological examination together with the oncoming shift. Propofol may be used to sedate patients with brain injury to facilitate rapid awakening and assessment. Remember that propofol does not provide analgesia, and pain can raise intracranial pressure. In patients with brain injury due to multiple trauma, analgesia should be provided with sedatives. Propofol should not be stopped for routine neurological assessment unless approved by neurosurgery. “Brain rest” is often the goal in the first 48 hours following brain injury. Steps to Neurological Assessment in the ICU: 1. Assess mental status/higher function: A. Conscious patient: 1) Talk to patient and ask questions that avoid yes/no answers if possible. • Evaluate orientation, attention, coherence, comprehension, memory/recall • Screen for delirium • Identify symptoms such as headache, nausea or visual problems 2) Determine Glasgow Coma Scale (GCS) B. Altered patient: 1) Assess for response to: a) Normal voice b) Loud voice c) Light touch d) Central pain Differentiate between higher function of “awareness” (e.g., purposeful movement, recognition of family) versus arousability (grimacing to pain only). 2) Determine Glasgow Coma Scale (GCS) 2. Consider whether seizures could be present Look for evidence of seizures (non-convulsive seizures should be considered in patients with unexplained decrease in level of consciousness or failure to awaken, especially after TBI or stroke). 3. Test Cranial Nerves (see next pages for CN and brainstem testing) In rapid neurologic examination, pupil assessment is the primary CN examination. Loss of reactivity to direct and consensual light with pupillary dilation suggests compression of CN III (top of brainstem). Fixed and pinpoint pupils suggests lower brainstem dysfunction in the area of the pons. 4. Assess motor function (look for asymmetry) Evaluate movement in response to command, with and without resistance if possible. Observe spontaneous movement or response to pain if unable to obey. 5. Assess sensory function (look for asymmetry) Test response to pin and light tough; patient must be able to obey; important part of spinal cord testing for at risk patients (trauma with uncleared C Spine, ASCI, thoracic aneurysm). 6. Assess cerebellar function Patient must be able to obey; cerebellum responsible for ipsilateral coordination of movement. Tests of rapid alternating movement can be performed in ICU. Examples: 1) examiner holds finger up and asks patient to touch his/her own nose, then the examiner’s finger. 2) Have patient touch each finger tip to thumb tip in succession. CRANIAL NERVES: . The cranial nerve are arranged in pairs in descending order along the brainstem. There are 3 sensory nerves (CN I, II and VIII), 5 motor nerves (CN III, IV, VI, XI and XII) and 4 mixed motor and sensory nerves (CN V, VII, IX and X). Cranial nerve dysfunction produces ipsilateral effects (same side)* . All cranial nerves can be tested in an awake and alert patient who is able to participate in the examination. Only some of the cranial nerves can be tested in patients who are unconscious. These are tested by stimulating a sensory nerve and watching for a reflex motor response. When brainstem herniation syndromes occur, cranial nerve function can be lost in descending order (if the origin of the injury is above the tentorium). CN I and II are located above the brainstem; CN III through XII are located along the brainstem. CN XI (accessory) has its origin from the spine, rising up to give the appearance of a CN located between X and XII. CN III is located at the level of the tentorium; sudden loss of CN III function (decreased reactivity and dilation of the pupil) suggests herniation at the top of the brainstem. This is the most important CN to test in critical care; sudden decrease in function is an urgent finding. Asymmetrical loss of any CN function may indicate unilateral compression . Because of their arrangement along the brainstem, most of the brainstem reflex tests involve testing cranial nerve function. *for accuracy, CN IV (the only cranial nerve that arises form the posterior cord) provides contralateral function. Because of its length and point of crossing, compression typically occurs after crossing, therefore, symptoms remain ipsilateral. This is rarely a significant CN to test in the critical care population. CN I Branches CN II of CN V: CN III V1 CN IV V2 CN VI Tested together by assessing for conjugate eye movement in vertical, V3 horizontal and diagonal directions. CN V CN VII CN VIII CN IX CN X CN XII CN XI CN Name Main Function Testing in ICU (assess symmetry) I Olfactory (sensory) • Smell • Block one nare and test ability to smell from contralateral nare (cloves, coffee) (may be injured with anterior basal skull #) • Dysfunction causes food to lose its taste II Optic (sensory) • Sight • Recognition of objects or people. Sight information from each of the 4 visual • If alert, ability to see objects in all 8 fields of each eye travels via a unique fields. pathway between the retina and brain. One • Eye chart, Reading or more visual fields can be lost due to • Detailed testing post ICU discharge damage anywhere between the retina, optic • Light reflex tests CN II and III nerves or brain (occipital lobe). • Remember to test with glasses on III Oculomotor • Pupil constriction • Light reflex (motor) • Eyelid opening • Eye opening • Eye movement (all directions except • Ability to follow an object upward, those of CN IV and VI; CN III, IV and horizontally toward nose, straight VI tested together) down and downward/laterally IV Trochlear (motor) • Downward and nasal rotation of eye • Ability to follow object in downward, nasal field of vision V Trigeminal • Primarily Sensory: feeling to face in • Light touch and pin sensation to (sensory and three branches: V1(forehead, forehead, cheek and jaw region motor) cornea, nose), V2 (cheeks), V3 (jaw) • Ability to raise cheeks (chew) • Motor: Chewing • Corneal reflex tests V1 branch of CN V (sensation) and CN VII (blink) VI Abducens (motor) • Horizontal and lateral movement of • Ability to follow an object in the the eye horizontal/temporal gaze VII Facial (motor and • Primarily Motor: • Eye closure sensory) • Face movement • Face movement (smile, assess • Eyelid closure nasolabial fold, show teeth) • Tearing of eye • Inability to wrinkle forehead on side • Salivation of facial weakness indicates CN VII • Sensation/taste to front 2/3 of dysfunction; forehead wrinkle tongue preserved in stroke VIII Auditory or • Hearing • Response to voice or sound vestibulocochlear • Balance • Tuning fork (sensory) • Vestibular system sends information • Balance during mobilization about head movement to pons; • Detailed testing post ICU discharge makes CN III/VI move eyes together • Doll’s Eyes and Cold Caloric test for horizonatal eye movement IX Glossopharyngeal • Sensation to back of tongue/tonsils • CN IX and X collectively tested by (sensory and • Parotid secretion touching each side of the back of the motor) • Contraction stylopharyngeus muscle throat and observing for gag response X Vagal (sensory • Contraction larynx/pharynx and motor) • Parasympathetic fibers of thoracoabdominal viscera XI Accessory/ • Shoulder shrug • Ability to shrug or turn cheek against spinal (motor) • Head rotation resistance XII Hypoglossal • Tongue movement • Ability to move tongue side to side (motor) Cranial Nerve Testing: Awake Patient 1. Sense of smell (CN I [Olfactory]): . Block one nare after another and test ability to smell a strong aroma such as cloves or coffee. Assess for symmetrical sensation (testing omitted in most critical care assessments) 2. Vision (CN II [Optic]): . If patient wears glasses, test with glasses on. Can patient identify objects or the number of digits held up by examiner? Can they read? . Does patient recognize family members? . Observe response to visual stimulation from either side of bed; occipital lobe stroke causes loss of vision to the opposite visual field of one or both eyes (e.g., a left occipital lobe stroke can cause blindness to all or part of the right visual field of the right and/or left eye). With patient looking ahead, ask patient to indicate when he/she can see a pen that is randomly wiggled into each of the 8 visual fields, shown below. Deficits will need to be confirmed at a later time by proper visual field assessment. 1 . 3 5 7 2 4 6 8 3. Light Reflex (CN II [Optic and CN III [Oculomotor]): . Conduct 4 point assessment: a) direct light response in L eye; b) direct light response in R eye; c) consensual light response in L eye; and d) consensual light response in R eye. Both pupils should constrict to light shone in either eye; true CN III compression should cause decreased responsiveness to both direct and consensual testing. 4. Eye Opening (CN III [Oculomotor]): . Ask patient to open eyes wide; observe for upward movement of lids. Look at the white portion of each eye. Ptosis (eyelid droop) may be present if there is less white showing on the affected side. 5. Eye Movement (EOM) (CN III [Oculomotor], IV [Trochlear] and VI [Abducens]): . Hold a pen in front of the patient.