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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- survey, Review of Central 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 (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 , 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 arc of ▼ Janet T. Crimlisk, MS, RNCS, NP, Nurse Educator, Boston Medical sensory and motor fibers. The 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

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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 (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.

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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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TABLE 2 Respiratory Patterns in Neurologic Dysfunction

Type Pattern Location of Injury

Cheyne Stokes Crescendo, decrescendo Cerebral cortex Central hyperventilation (Kussmaul’s breathing) Rapid, deep, and regular Brainstem Apneustic Prolonged inspiratory hold Pons Ataxic Completely irregular, deep, and shallow Medulla

Biot’s Shallow, irregular with stops and starts Medulla,→

eye, pupillary focusing, and ability to track movement. A Posturing Response can be checked in patients who are coma- Evaluate the response to noxious stimuli (deep pain/pres- tose. Remove any contact lenses first, lightly touch the sure) when grading the GCS (Figure 2). The patient could cornea with a wisp of cotton, and look for bilateral blinks, have decorticate response (flexion) with upper extremi- indicating intact CNs 5 and 7. ties flexed and lower extremities extended. This is seen in corticospinal tract damage above the brainstem. Muscle Strength, Symmetry, and Hand Grasp Decerebrate posture (extension) presents with rigid Evaluate upper and lower extremities for weakness, atro- extension; arms pronated; wrists, fingers, and jaw flexed; phy, flaccidity, spasticity, or rigidity, which are all poten- and back arched with lower extremities extended and feet tial signs of neurologic deficits. Muscle strength is graded plantar flexed. This is seen in more serious brainstem or on a 0–5 scale, with 0 being no contraction and 5 full midbrain injuries. Hemiplegia, seen in a cerebrovascular range of motion against resistance (see Table 3). Note if accident (CVA), can present with unilateral flaccidity or the responses are symmetric or if there are any involun- spasticity with voluntary movement on the unaffected tary movements. Observe for arm drift by asking the side. patient to close his or her eyes while holding both arms out straight with the palms up. If one arm develops a drift Sensory Evaluation: Dermatomes with the palm turning down (pronator drift) suggesting a To evaluate sensation, test in a few locations and test mild hemiparesis, notify the physician. To evaluate hand opposite sides, going side to side. Start at either the feet strength or grasp bilaterally, have the patient grasp the or the head of the patient (whichever is more appropri- first two fingers of your hands and note if the strength in ate), and systematically move side to side, up or down both hands is equal with a tight grasp. If the response is the body. If any definite differences are noted, stop and unequal or decreased, that is abnormal (Seidel, Bail, determine at what level of dermatome the change has Dains, & Benedict, 1995). occurred. Dermatome charts are available to identify specific spinal cord levels. Generally, a light hand touch or cold alcohol pad is sufficient unless changes are noted. If changes are seen, both sharp and dull responses with cotton wisp and sharp end of Q-Tip may be per- formed.

Cranial Nerves The 12 CNs can be evaluated by the staff nurse simply during routine care (see Table 4). Generally, CN 1 (smell) is not assessed. Vision (CN 2), pupil response (CNs 3, 4, 6), chewing (CN 5), facial symmetry (CN7), hearing (CN

TABLE 3 Graded Muscle Strength: 0–5 Scalea

Score Strength

0 No contraction 1 Slight contraction 2 Full passive range of motion (ROM) 3 Full ROM 4 Full ROM, against some resistance FIGURE 3. Assessment of the eye and pupillary responses. 5 Full ROM, against full resistance Adapted with permission from Kerr, M. E. (2000). Intracranial problems. In Lewis, S. M., Heitkemper, M. M., Dirksen, S. R. (eds.). aNote any atrophy, weakness, flaccidity, rigidity, spasticity, or invol- Medical surgical nursing (5th ed.) (p. 1620). St. Louis: Mosby Inc. untary movements during the muscle testing.

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TABLE 4 Cranial Nerve Function: A Quick Reference

Nerve Name Function

1 Olfactory Smell 2 Optic Vision 3, 4, 6 Oculomotor, trochlear, abducens Ptosis, pupillary response, accommodation 5 Trigeminal Chewing, clenching jaw, corneal reflex 7 Facial Facial symmetry, taste 8 Acoustic Hearing 9 Glossopharyngeal Gag, swallow 10 Vagus Speech, uvula symmetry 11 Spinal accessory Shoulder shrug 12 Hypoglossal Tongue movement

8), swallow (CN 9), speech (CN 10), shoulder shrug (CN Deep Tendon Reflexes 11), and tongue movement (CN 12) can all be easily eval- DTRs are routinely evaluated by the physician and some- uated during nursing care. times may be assessed by the staff nurse. The five reflexes checked (biceps, triceps, brachioradialis, patellar, and Achilles ) are scored on a 0 (no response) to Supplemental Physician Tests ϩ 4 (hyperactive) scale. The DTRs are absent in LMN at the Bedside lesions and increased in UMN lesions. Superficial Cutaneous Reflexes A gag reflex, a plantar reflex, and the anal wink reflex are evaluated by the physician. The gag reflex (CNs 9, 10) The Complete Nursing Neurologic may be assessed by the RN. The gag is seen when the pos- Assessment: Putting It All Together terior wall of the pharynx is stimulated with a tongue blade and the gag is absent when damage to CNs 9 and 10 Focused History occur. The plantar reflex (L5, S1) is assessed by running a When eliciting information from a patient, focus on the stimulus, generally a pointed object, along the outer heel current neurologic problem and identify any signs or up to the ball of the foot, and a normal response is the symptoms such as dizziness, vertigo, headache, tinnitus, curling. An abnormal plantar reflex (the positive weakness, difficulty swallowing or speaking, numbness, Babinski sign), which is seen when the big toe moves tingling, changes in sensation, pain, confusion, paralysis, upward with fanning out of the other toes (Seidel et al., or loss of strength. When identifying the specific symp- 1995), indicates corticospinal tract disease and UMN tom, analyze for type, location, severity, duration, and lesions. The anal wink reflex (S3, S4, and S5) is stimu- influencing factors. Include any related history, such as lated by stroking the perianal area and looking for con- medication, alcohol, illegal drug use, recent neurologic traction of the anal sphincter. This is evaluated in spinal tests, recent illnesses, and previous level of function (see cord injury and by anesthesiologists when using epidural Box 1). anesthesia blocks. Focused Physical Examination Vestibular Reflexes A general inspection looking at the patient’s posture, Physicians may ask for help while testing vestibular func- movement and eliciting orientation, mental and behavior tion in the patient who is comatose; cervical spine x-rays state, and overall appearance can be done while taking must be cleared first. The oculocephalic reflex (“doll’s vital signs. A physical examination starts with the head eyes reflex”) is tested when there is a question of brain- and neck, looking for symmetry, pupil response, neck stem disease in patients who are comatose. The patient’s mobility, bruises, and drainage. The musculoskeletal and head is briskly rotated in the opposite direction while the neurologic systems with CNs are assessed next. eyelids are held open. Normal response is for the eyes to remain fixed on the same point even with the head turned Critical Thinking (Gelb, 2003). Critical thinking is necessary to process all this data, pri- Oculovestibular reflex (cold calorics) is another reflex oritize the nursing interventions, and formulate a nursing that activates eye movements by using an ice solution. A plan of care. After a complete neurologic assessment, the syringe filled with 50–100 mL of ice-cold water is injected RN compares this to the patient’s baseline status and into the ear against the tympanic membrane. A normal identifies if there are any changes. It is important to response is deviation of both eyes toward the ear being watch for and recognize changes that are potentially stimulated. Absence of this reflex indicates pons, expected outcomes attributed to patient history, side medulla, or CN 3, 6, or 8 dysfunction (Gelb, 2003). effects of medications, procedures, or treatments.

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BOX 1 BOX 2 Neurologic Assessment: Putting It All Together Case Presentation and Bedside Documentation

History Case Presentation Demographic data Mr. Smith is a 60-year-old male s/p open laminectomy for Current neurologic complaint protruding discs L5-L6. No other significant medical prob- Significant related history lems. He arrives on your unit at 3 PM. Routine neuro signs include: A&O ϫ 3, appropriate responses to questions, VSS, Physical examination PERRL bilateral, muscle strength 5/5, GCS 15. He requests General inspection pain meds for his postoperative pain. Vital signs At 5 PM Mr. Smith complains of numbness in his left LOC, GCS, affect, behavior, cognition lower extremity (LLE), and you note weakness in LLE. Head and neck Preoperative assessment indicates no prior neurological Pupils, facial symmetry, neck mobility, ear drainage, deficits. You stat page the physician at 5 PM. gag, swallow Musculoskeletal Bedside Documentation Strengths 5/5, grasps, posturing, abnormal Date/Time 3 PM 5 PM movements Temperature 98.6 Neurologic Heart rate 100 80 Gait, coordination, sensation, Blood pressure 140/80 134/84 Critical thinking Resp rate 22 18 Comparison to previous data O2 saturation 99% 98% Identification of untoward outcomes O2 device/flow rate RA RA Communication of pertinent data Pupils Accurate, concise documentation Right 2mm 2mm Size/response B B Left 2mm 2mm Size/response B B GCS Unpredictable, serendipitous neurologic changes can also Eyes 4 4 occur that are unrelated to the primary diagnosis. A good Motor 6 6 nursing assessment can identify changes and gives the Verbal 5 5 nurse the chance to initiate immediate interventions Total GCS 15 15 before more serious sequelae occur. The RN reports any Muscle strength: 0-5 changes to the physician and collaborates to formulate an RU/LU 5/5 (R); 5/5 (L) 5/5 (R); 5/5 (L) individualized plan of care. RL/LL 5/5 (R); 5/5 (L) 5/5 (R); 4/5 (L) The RN also must use critical thinking to decide when Pain scale: 0-10 (site) 6/10 (incision) 2/10 (incision) to perform a neurologic assessment. Every interaction with the patient automatically includes a basic mental RA, room air; pupil response: B-brisk, S-sluggish, F-fixed; RU, right status, which may trigger the in-depth neurologic evalua- upper, LU, left upper, RL, right lower, LL, left lower. tion. As a general rule, a patient who has had any neuro- PUPIL GAUGE (mm) 8 logic change from his or her baseline or a patient who is 6 7 4 5 at risk for a neurologic change resulting from procedures, 2 3 tests, or surgeries involving the brain or spinal cord requires a complete neurologic assessment.

Documentation Accurate, consistent, and standardized documentation of the neurologic assessment is the key to early detection of One mechanism to organize documentation of neuro- changes. Concise nursing documentation allows the logic assessment is to document the PERRL, GCS, mus- caregiver to compare his or her assessment to the cle strength, and vital signs together in the bedside docu- patient’s previous status and identify changes. It is cru- mentation (see Box 2). Appropriate flow sheets or cial to document in detail to allow for comparison of progress notes can be used to document other pertinent assessments. neurologic assessments (see Boxes 2 and 3). Acute care facilities have many different forms and methods of documentation. The first step is to identify the recommended method of documentation. Then, the Conclusion acute medical surgical nurse must document the assess- A systematic neurologic assessment approach is the ment accurately to communicate the findings to future first step to identifying the early signs of neurologic caregivers. Standardization of documentation by all changes. Complete evaluation of a patient suspected of nurses can alert the clinical staff to any potential change having a neurologic injury is critical. The regular use in the patient’s presentation. If it is standardized, it will and documentation of this neurologic assessment gives also save time when looking for previous assessments. staff more vital information and helps in detecting both

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BOX 3 obvious and subtle changes in neurologic status. Be alert for changes, document concerns, and communi- Progress Note Using DARP Method* cate any significant findings immediately to the physi- cian to ensure that the patient receives timely interven- 1/7/2003 5:30 PM Nursing Note: Postop Laminectomy tion and treatment. D: Pt c/o of numbness in LLE at 5 PM; weakness in LLE noted with muscle strength decreased to 4. No other REFERENCES neuro changes. VSS. Dressing dry and intact. Hemovac Gelb, D. (2003). The neu rological examination in special cir- with no output in last 2 hours. Sharp, nonradiating pain cumstances. UpToDate, (10.3) p. 8. Retrieved January 13, 6/10 at incision site. Pain medication at 3:30 PM with 2003, from http://www.uptodate.com. pain decreased to 2/10. Kerr, M. E. (2000). Intracranial problems. In S. M. Lewis, M. M. Heitkemper, & S. R. Dirksen (eds.). Medical surgical A: Dr. Smith notified of change in sensation and muscle nursing (5th ed). St Louis: Mosby Inc. strength in LLE. Dr Smith in to see patient at 5:15 PM Murray, T. A., Kelly, N. R., & Jenkins, S. (2003). Neurological and discussed changes and potential causes with patient. examination. Advance for Nurses, 11(1), 16. R: Stat MRI ordered. Patient instructed to call RN if any Robertson, L. (2002). The neuro evaluation, Wild Iris change in pain, sensation, muscle strength or any Medical Education. p. 5. Retrieved January 13, 2003, from change in functional ability. http://www.nursingceu.com. P: MRI scheduled tonight. Continue to assess neurovascu- Seidel, H. M., Bail, J. W., Dains, J. E., & Benedict, G. W. lar status q 1 hr. Monitor dressing for drainage. (1995). Mosby’s guide to physical examination (3rd ed). St. Medicate for pain. Louis: Mosby-Year Book, Inc. Staff Nurse, RN *DARP: D, data, A, action, R, response, P, plan of care.

Publisher’s Note

The American Academy of Nursing is an organization of distinguished leaders in nurs- ing who have been recognized for their outstanding contributions to the profession of nursing and to healthcare. It is my pleasure to inform you that Mary Faut Rodts, MS, MSA, APRN, ONC, Editor of Orthopaedic Nursing, was inducted as a Fellow of the Academy on Saturday, November 14, 2003. Academy Fellows are recognized nationally and internationally as nursing leaders in education, management, practice, and research. Mary has contributed selflessly to these areas of nursing. Her commitment to excellence in practice and research is evi- dent in her work as Editor of Orthopaedic Nursing. As the Publisher of Orthopaedic Nursing, it has been my privilege and pleasure to work with Mary on the journal. On behalf of LWW, I congratulate Mary on this milestone achievement in her nurs- ing career and offer our sincere gratitude for her contributions to nursing and Orthopaedic Nursing.

Sandy Kasko Publisher

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