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Neurologic Assessment Skills for the Acute Medical Surgical Nurse

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Neurologic Assessment Skills for the Acute Medical Surgical Nurse on230103.qxd 1/20/2004 12:01 PM Page 3 Neurologic Assessment Skills for the Acute Medical Surgical Nurse Janet T. Crimlisk ▼ Margaret M. Grande Practical and efficient neurologic assessment skills are vital for when neurologic conditions are changing and what acute care nurses. During an acute neurologic event, the should be the nurse’s immediate response? nurse needs a focused assessment of the pertinent history and symptom analysis and an immediate head-to-toe survey, Review of Central Nervous System eliciting any abnormal signs to identify and correctly report the medical problem. When a patient requires routine moni- To identify appropriate assessment information and toring of neurologic signs, the nurse’s role includes a neuro- apply these skills, a brief overview of the central nervous system (CNS) is presented. The CNS consists of the brain, logic assessment, collecting and assimilating that data, inter- which comprises the cerebrum, cerebellum, and brain- preting the patient problem, notifying the physician when stem (see Figure 1). The brain consists of two central appropriate, and documenting that data. This article presents hemispheres, right and left, which form the largest part of an overview of a staff nurse’s neurologic assessment, explains the brain. There are four main lobes: frontal (Broca’s common neurologic tests performed at the bedside, identifies area, judgment, insight, problem solving, and emotion), an efficient way to perform the assessment, and indicates temporal (auditory, comprehension, speech, and taste), what to include and document when “neuro signs” are parietal (sensory and proprioception), and occipital ordered. (vision). In the central part of the cerebrum is the dien- KEY WORDS: Neurologic assessment, Education, Medical surgi- cephalon, which surrounds the third ventricle and forms cal nurse the central core and contains the thalamus and the hypo- thalamus (the autonomic nervous system regulator). Below this is the brainstem, with the midbrain, pons, and atients can have neurologic changes that can be slow medulla. The medulla contains the cardiac, respiratory, Pand subtle or fast and devastating. The acute care and vasomotor centers. In the brainstem are cranial nurse is usually the first to see the changes, and use of nerves (CNs) 3 to 12, as well as ascending and descending good assessment skills may uncover early warning signs, fibers. In brainstem herniation, the brainstem is com- preventing a neurologic crisis. The constant observation, pressed and respiratory arrest can occur. The cerebellum, assimilation of assessment data, anticipation of potential the “little brain,” is located posterior and is involved in complications, and immediate response of the nurse all coordination, voluntary movement, muscle tone, equilib- affect the severity of the patient’s outcome. Nurses are rium, and posture. Finally, there is the spinal cord, with trained to be watchful and diligent in their assessment, spinal nerves and 12 CNs. Spinal cord tracts are two-way but the questions remain...what are the important signs, conduction paths between peripheral nerves and the symptoms, and presentations that are critical to identify brain. The motor tracts descend through the spinal cord to lower motor neurons (LMN) in the anterior horn of the spinal cord. The anterior horn consists of a reflex arc of ▼ Janet T. Crimlisk, MS, RNCS, NP, Nurse Educator, Boston Medical sensory and motor fibers. The reflex arc is lost in LMN Center, MA. lesions, and the patient complains of weakness, paralysis, ▼ Margaret M. Grande, MS, RNC, Nurse Educator, Boston Medical areflexia, and flaccidity. The upper motor neurons (UMN) Center, MA. originate in the cerebrum and end in the brainstem and The authors have no conflict of interest. spinal cord. Patients with UMN lesions have spasticity or Orthopaedic Nursing January/February 2004 Volume 23 Number 1 3 on230103.qxd 1/20/2004 12:01 PM Page 4 ous posturing are evaluated as part of the overall physical assessment. Evaluating Mental Status Changes in mental status may be the earliest indication of a neurologic event and require immediate attention and intervention. Physical appearance (grooming, hygiene, and dress), behavior (mood, feelings, and reactions to questions), speech (articulate, coherent, and comprehension), and body language (facial expressions, body movements, and posture) are assessed with every encounter. Cognitive abilities can be evaluated by testing for orientation to per- son, place, and time and documented as “oriented ϫ 3.” Make sure the person can follow at least one complicated command. If the responses are appropriate and they give coherent medical history, no further evaluation is needed. To evaluate responsiveness and level of consciousness (LOC), identify whether the patient can: (1) see you (sight); (2) hear you, if you call out loudly to the patient (hearing) and if he or she verbally responds (speech); (3) feel your hand on him or her when you touch or shake gently (sensation) and, if the patient is not responsive, shake him or her more vigorously; and (4) if still unre- sponsive, respond to painful stimuli (deep pressure). Response to painful stimuli can be elicited by several dif- ferent techniques: trapezius squeeze, supraorbital pres- sure, Achilles squeeze, or, more commonly, the sternal rub. Observe the patient’s response and body posturing to this deep pressure test (see Figure 2). A frequent tool in evaluating LOC is the Glasgow coma scale (GCS) (Murray, Kelly, & Jenkins, 2003). This scores a patient’s response to voice and deep pressure using eye opening FIGURE 1. Major divisions of the central nervous system. and verbal and motor responses (see Table 1). If the Adapted with permission from Ozuna, J. M. (2000). Neurologic patient has a tracheostomy or endotracheal tube, the ver- system. In Lewis, S. M., Heitkemper, M. M., Dirksen, S. R. (eds.). bal response score includes a “T” to identify the patient’s Medical surgical nursing (5th ed.) (p. 1587). St. Louis: Mosby Inc. functional limitation. A GCS of 8 or less out of a possible score of 15 defines coma in 90% of cases (Robertson, 2003). Vital Signs paralysis, increased deep tendon reflexes (DTR), and The vital signs are truly vital. Increased intracranial pres- decreased voluntary function. sure (ICP) can be suspected by specific changes in vital signs. Cushing’s triad, which is seen in acute ICP, presents with three signs: (1) increasing systolic blood pressure Bedside Assessment Skills and with widening pulse pressure, meaning a high systolic Diagnostic Tests pressure with a widening gradient between the systolic There are short efficient assessment skills and tests that and diastolic numbers; (2) bradycardia; and 3) irregular can be done at the bedside that evaluate neurologic func- breathing patterns (Kerr, 2000). Biot’s breathing, which is tion, diagnose, or point to a neurologic injury and help irregular breathing with apneic episodes, is a type of plan a course of action. The basic evaluation starts with breathing that may be seen in ICP. inspection, evaluation of appearance, and mental state; a Respiratory patterns that may indicate neurologic physical assessment, functional abilities, and cognitive causes include Cheyne-stokes breathing, Biot’s breathing, responses are all assessed. central hyperventilation, apneustic, cluster, and ataxic breathing patterns (see Table 2). Describe the breathing General Inspection, Appearance, and Mental and pattern as it is seen rather than using the names of the Functional Status breathing pattern exclusively. The description is more Assessment occurs with each interaction with the patient. helpful and allows staff to assess for any changes in the The inspection includes an initial overview of the specific breathing pattern. patient’s appearance, mental state, functional status, and Other vital sign changes suggesting a neurologic injury cognitive responses. This can be done while taking vital can include bradycardia, hypertension then hypotension, signs. Any significant pupillary responses, muscle move- and loss of thermal control with hypothermia or hyper- ments, hand grasps, coordination, gait, balance, and obvi- thermia. 4 Orthopaedic Nursing January/February 2004 Volume 23 Number 1 on230103.qxd 1/20/2004 12:02 PM Page 5 Decerebrate Rigid extension; arms fully extended; forearms Brainstorm pronated; wrists and fingers flexed; jaws clenched, neck extended, back may be arched; feet plantar flexed; may occur spontaneously, intermittently, or in response to a stimulus Hemiplegia Unilateral flaccidity or spasticity; voluntary movement on unaffected side FIGURE 2. Posturing, often found in unresponsive patients. Reprinted with permission from Seidel H. M., Bail, J. W., & Benedict, G. W. (1995). Mosby’s Guide to physical examination (3rd ed.) (p. 755). St. Louis: Mosby-Yearbook, Inc. Pupillary Responses object and then close up while observing the pupil Neurologic changes can be reflected in pupil responses. response. Pupils that are equal, are round, and react to To test pupillary response, shine a bright light into each light and accommodation (PERRLA) are normal. Figure pupil and check for constriction; bring the light into the 3 presents a general assessment of the eye and displays eye field from the side, and also check the opposite pupil normal and abnormal pupillary responses. When observ- for a consensual response to the light. Accommodation ing the eyes, look for ptosis of the lid, nystagmus (rhyth- can be elicited by having the patient look at a distant mic oscillation of the eyes), any blood or drainage in the TABLE 1 Glascow Coma Scale a Score Eyes Open Score Motor Response Score Verbal Response b 4 Spontaneous 6 Obeys command 5 Oriented 3 To verbal command 5 Localizes to pain 4 Disoriented 2 To pain 4 Withdrawals from pain 3 Inappropriate words 1 No response 3 Decorticate flexion 2 Incomprehensible sounds 2 Decerebrate extension 1 No response 1 No response aMaximum total score 15; a score of 8 or below defines coma. Total score ϭ eye response ϩ motor response ϩ verbal response; range 3–15. bBest verbal response: for intubated or tracheostomy patients, record T next to the score.
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