Neurologic Assessment

Physiologic Changes with Aging:

 Loss of brain cell with actual loss brain weight. The nerve cell loss usually is diffuse and gradual. The gyri of the brain also atrophy, causing
widening and deepening of the spaces between the gyri.
 Blood flow to the brain decreases, and brain’s ability to auto-regulate its blood supply declines with increased age.
 The ANS control over various body functions remains intact as a person ages but become more labile and unpredictable.
 The velocity of nerve impulses decreases, which slows sensory and motor conduction; sensory conduction decreases faster than motor and is
pronounced in peripheral nerves.

Health History
The nature and extent of the neurologic health history depends on the patient’s condition and the urgency of the situation. The
patient maybe ambulatory, alert, and oriented or maybe experiencing an altered LOC with neurologic deficits. In the latter situation the nurse
conducts the health history in phases over time. The interview not only provides a mechanism for gathering data and dispensing information,
but also serve as a tool for establishing a working relationship with the patient and the family. The nurse explores the patient and family history
along with classic neurological symptoms such as headache, dizziness, vertigo, weakness, paresthesia, and pain.
1.Patient History
 Chronic diseases; use of prescription, over-the-counter, herbal, and recreational drugs, and pattern of alcohol consumption.
 Medical history- previous trauma or injury to the CNS, diagnoses affecting the neuromuscular system such as stroke, seizures,
multiple sclerosis, or Parkinson’s disease; neurological procedures performed along with outcomes.
2. Family History
 Relevant illnesses- neurologic origin and diseases of other body systems that can affect neurologic status (hypertension, diabetes
mellitus, peripheral vascular disease, stroke, seizure, CNS tumor, migraine, headaches, neuropathic disorder).
3. Headache
 Associated signs and symptoms such as nausea, vomiting, aura, tinnitus, lacrimation of the eyes, and vertigo. Transient headache
may occur after a diagnostic test such as lumbar puncture.
4. Dizziness and vertigo
 Dizziness: lightheadedness or syncope (fainting)- related to the cerebral blood flow
 Vertigo: descriptions of room spinning around or the sensation that one is spinning- related to neurologic dysfunction or a problem
with the inner ear.
5. Weakness and paresthesia
 Weakness: associated with neuromuscular disorder such as myasthenia gravis or multiple sclerosis, or attribute to a nutritional
deficiency or hematologic disorder such as anemia.
 Paresthesia: abnormal sensation perceived as burning, tingling, pricking, etc. maybe associated with neuropathy or other arterial
insufficiency. It can also be due to PNS disorder such as herniated disc or nerve impingement thayt can manifest itself in the upper
or lowe extremity.
6. Pain
 Should be quantified using pain scale of 0 to 10.
 A symptom of a variety of disorders in other body system such as angina, toothache, or pleuritic-type of pain. It also indicates
pressure on a sensory nerve as is frequently the case with low back pain caused by trauma or injury.

PHYSICAL EXAMINATION
The neurologic examination depends largely on inspection and palpation with occasional use of percussion. Auscultation may be
used to detect related vascular abnormalities.

Gerontologic Assessment
 Reaction time increases with age.
 Noticeable age-related effects on cognitive abilities include a slight, gradual decline in some intellectual abilities such as short-term memory.
 Age-related changes in vision include a decrease in visual acuity, diminished peripheral vission, increased sensitivity to glare, and difficulty
adapting to dark and light.
 Hearing loss for high-frequency sound is a common finding.
 Tactile sensation decreases; there is difficulty in temperature discrimination and performing fine motor tasks.
 Both taste perception and olfactory sensation decline.
 Deep tendon reflexes are less brisk. Ankle jerks are commonly lost; those in the upper extremities are usually present. Older adults often have
difficulty relaxing their limbs; the examiner should always support the limb when eliciting reflexes.
 Loss of the sensation of vibration at the ankle malleolus is common after age 65. Position sense in the big toe may be absent, but this is less
common.
 Gait may be more slower and more deliberate. Also, the gait may deviate slightly from a midline path because of decreased coordination.
 A decreased in muscle bulk often occurs and is more apparent in the hands. The hand muscles appear wasted; grip strength remains
relatively good.
 Senile tremors occasionally occur and are considered benign.
 Common disorders in older adults include strokes, aneurysms, Alzheimer’s disease, and dementia.

I. Mental Status
1. Change in LOC can be the most sensitive indicator of a person’s level of neurologic function. The functional components of consciousness
are:
a. Arousal (alertness) - mainly controlled by brainstem activity, including the reticular activating system (RAS). Eye opening is crucial
component of arousal. If it does not occur in response to verbal and auditory stimuli, the nurse can apply a painful stimulus to
determine whether the arousal mechanism is intact.
 b. Awareness (content) - requires an intact cerebral cortex and association fibers. Evaluating a patient’s orientation to self, and the
environment assesses awareness. Assessment of person, place and time (day, month, year) is the most effective method to
evaluate awareness.
The state of consciousness depends on successful interaction between the brainstem and cerebral hemispheres.
2. Mood and behavior examination
 Determine whether the person’s mood is appropriate to the situation and topic of conversation.
 Emotional lability (mood shifts easily and quickly from one extreme to the other) is often seen in bilateral (diffuse) brain disease.
 Personality changes (appearance of a violent temper and aggressive behavior) may occur with destructive lesions of the inferior
frontal parts of the limbic system.
3. Test individual’s knowledge and vocabulary
 By referring to current events, tests the ability to think abstractly by asking the person to subtract 7 from 100.
 Dyscalculia is the inability to solve simple problems because of brain injury or disease.
 Recent memory loss is more common in brain disease than in remote memory loss.
 The findings of these gross tests may indicate the need for more definite tests of mental function.
II. Language and Speech
 Language ability is distributed across a variety of areas of the cortex, including parts of the temporal lobe, the temporoparietal-
occipital junction, the frontal of the dominant (usually the left) hemisphere, and the occipital lobe. Lesions in any of these areas can
impair language ability.
 Aphasia – general term used to describe impairment of language function; it represents a disorder of symbolic language.
Types of Aphasia
1.Motor (Expressive) – impairment of ability to speak and write; still able to understand written and spoken words.
Site of lesion: Insula and surrounding region, including Broca’s motor area.
a. Anomic – inability to name objects, qualities, and conditions, although speech is fluent.
Site of lesion: area of angular gyrus
b. Fluent – speech is well articulated and grammatically correct but lacking in content and meaning.
c. Nonfluent – problems in selecting, organizing, and initiating speech patterns.
Site of lesion: Motor cortex at Broca’s area
2. Sensory (Receptive) – impairment of ability to understand written or spoken language.
Site of lesion: Disease of auditory and visual word center.
a) Wernicke’s – same as Receptive
Site of lesion: Wernicke’s area of left hemisphere
3. Mixed Aphasia – combined expressive and receptive aphasia deficits.
Site of lesion: damage to various speech and language areas.
4. Global Aphasia – total aphasia involving all functions that make up speech and communication. Few if any intact language skills.
Site of lesion: Severe damage to speech areas.

 Dysarthria – causes problems with word articulation or enunciation from interference with the peripheral speech mechanisms (e.g. muscles of
the tongue, palate, pharynx, or lips). Limitations may be observed during cranial nerve testing, particularly in cranial nerves V, VII, IX, X, and
XII. Impairment of the motor component of these nerves may produce alterations in phonation, resonance, and articulation. The nurse asks
the individual to produce different speech sounds to help localize the problem – (Methodist, Episcopal, or third riding artillery brigade).

III. Perception
Sensation is integrated and interpreted in the sensory cortex- parietal lobe. It is important for the nurse to recognized perceptual problems,
since they can be more difficult to deal with than changes in the patient’s ability to move or sense. Disorders of perception commonly involved spatial-
temporal relationships or the perception of self.
 Gnosia – is the ability to recognize objects through any of the special senses. One frequently tested ability is stereognosis, the ability to
perceive an objects’ nature and form by touch. This is assessed by asking the person to identify familiar objects that are placed in the
hand one at a time with the eyes closed.
 Apraxia – is another common perceptual problem and involves the ability to perform skilled, purposeful movements in the absence of
motor, sensory, or coordination losses.
Types of Apraxia
1. Constructional – impairment in producing in two or three dimensions; involves copying, drawing, or constructing.
Lesion Site: Occipitoparietal lobe of either hemisphere.

2. Dressing – inability to dress accurately; making mistakes, as putting clothes backward, upside-down, or inside-out or putting both
legs in same pant leg.
Lesion Site: Occipital or parietal lobe, usually in nondominant hemisphere.

3. Motor – loss of kinesthetic memory patterns, which results in inability to perform purposeful motor task although it is understood.
Lesion Site: Frontal lobe of either hemisphere, precentral gyrus

4. Idiomotor – inability to imitate gestures or perform a purposeful motor task on command; may be able to do task spontaneously.
Lesion Site: Parietal lobe of dominant hemisphere, supramarginal gyrus

5. Ideational – inability to carry out activities automatically or on command because of inability to understand the concept of the act.
Lesion Site: Parietal lobe of dominant hemisphere or diffuse brain damage as in arteriosclerosis.
 Sensory Status:
The person should be relaxed and keep eyes closed during all portions of the examination to avoid receiving visual clues. Sensation
is tested on both sides and distally to proximally. Both superficial and deep sensations are tested on the trunk and extremities. An area in
which sensation is absent (anesthesia) is differentiated from an area in which sensation is intensified (hyperesthesia) or lessened
(hyperesthesia or hypoesthesia).

Pain, Temperature, and Touch

 Pain is assessed by lightly stroking or pricking an area with a pin or asking the person when discomfort is perceived. Deep pain is
assessed by applying deep pressure over the nail beds, supraorbitally, or over bony areas such as sternum, and or by squeezing
the trapezius muscle. Pinching may damage the tissues and is avoided whenever possible.
 Temperature is assessed by touching areas of the body with warm to hot, and cool to cold, objects in a random fashion; the person
state whenever sensation is felt. Because pain and temperature sensations use the same nerve pathway (lateral spinothalamic),
testing for temperature can be eliminated if the tests for pain perception is normal.
 Touch is assessed by having the patient close his eyes then lightly touching an area with a cotton ball and requesting the person to
indicate when the touch is felt.
Motion and Position

 Proprioceptive fibers (fasciculus gracilis and fasciculus cuneatus) transmit sensory impulses from the muscles, tendons, ligaments,
and joints. This impulse creates an awareness of the position of one’s limbs in space (kinesthetic sense). The nurse grasps the
sides of the person’s phalanx and moves it up and down to test proprioception. If proprioception is intact, the person reports
correctly the direction in which the joint is being moved. Proprioceptive abilities can also be assessed by Romberg’s Test, in which
the person is asked to stand erect with the feet together and eyes closed. A positive test indicates when the person loses balance-
pathologic conditions.
 Vibrations are assessed by placing the base of the low-frequency tuning fork on a distal bony prominence, such as the finger or toe
of one extremity at a time. The person indicates to the nurse when the vibration is initially felt and when it is stop.
IV. Motor Status
Functions of the motor system are assessed through gait and stance, muscle strength, muscle tone, coordination, involuntary movements,
and muscle stretch reflexes.

1. Gait and Stance – are complex activities that require muscle strength, coordination, balance, proprioception, and vision. Ataxia is a
general term for the lack of coordination in performing a planned, purposeful movement such as walking.
a. Gait – to evaluate, the nurse asks the patient to walk freely and naturally and then walk heel to toe in a straight line,
since this exaggerates any abnormalities.
Abnormal findings:
 Hemiparetic gait – seen in upper motor neuron disease characterized by circumduction of the affected leg and
inversion of the foot.
 Parkinson’s disease – walk with a slow, shuffling gait that may gradually increase in speed until they are almost
running (propulsive). They also have difficulty in stopping, and deviation in the center of gravity can cause
retropulsion or lateropulsion. Loss of associated movements of the arms in walking is noticeable.
 Cerebellar disease – walk with wide-based, staggering gait.

b. Stance – to evaluate, the nurse asks the person to perform Romberg’s test by standing still with the feet close
together, first with eyes open and then with eyes closed. Patients with problem of proprioception have difficulty
maintaining balance with their eyes closed; patients with cerebellar disease have difficulty even with their eyes open.

2. Muscle Strength or Power – is assessed systematically including the trunk and extremities muscle. It involves asking the patient to grasp
the nurse’s hand and squeeze them simultaneously. The nurse compares the squeezing ability of one hand with that of the other. The
nurse may also test the patient for drift by asking him to hold the arms straightly for 20-30 seconds with palms up and eyes closed.
Hemiparesis is suggested when there is pronation of one forearm or a downward drift of the arm. If an impaired muscle is identified, the
nurse documents the extent and degree of muscle weakness.

3. Muscle Tone
 To test muscle tone, the nurse passively moves the person’s limbs through a full range of motion. As skilled practitioner can readily
differentiate hypertonic from hypotonic muscles.
 Hypertonic extremities tend to stay in fixed positions and feel firm; hypotonic extremities assume a position governed by gravity.
 Hyperextension and hyperflexion are found in hypertonia; an initial resistance to passive movement may increase rapidly and then
suddenly give way to spasticity or clasp-knife rigidity.
 A steady, passive resistance throughout the full range of motion is a characteristic of a parkinsonian rigidity; the combination of
passive resistance and parkinsonian tremor with small, regular jerks is called cogwheel rigidity.
 Decorticate rigidity – the upper limbs are flexed and pronated and the lower limbs are extended.
 Decerebrate rigidity – the upper limbs are extended.

4. Coordination
 The cerebellum is primary responsible for coordinating movements so that they are smooth and precise. Disturbances results in
ataxia- difficulty in controlling the range of muscular movement (dysmetria), and an inability to alternate rapid and successful
movements on opposite sides (adiodochokinesia) .
 The nurse evaluates simple motor activities by asking the person to perform rapid, rhythmic movements, such as the nose-finger-
nose test, which requires an individual to alternately touch his nose and the tip of the nurse’s finger; or knee pat (pronation-
 supination). For the latter, the patient places the palms of the hands, turn them over, and touches the knees with the back of the
hands.

5. Involuntary Movements
 It is important to observe the location of muscles involved, amplitude of movement, speed of onset, duration of contraction and
relaxation, and rhythm. Abnormal movements may be the result of organic disease or psychosomatic in origin.
 Tremors consists of rhythmic to-and-from movements, usually small of amplitude. These movements are the results of alternating
contractions of opposite group of muscles, are continuous while the patient is awake, and may or may not be present during sleep.
 Chorea refers to short, sharp, rapid, irregular movements, usually of small excursion, which occur in different parts of the body and
persist during sleep.
 Hemiballismus is a variation of chorea in which movement is confined to one side of the body and primarily affects the limbs.
 Athetosis consists of slow sinuous, and more sustained movements that may be of considerable amplitude; these movements occur
in the neck and trunk, and extremities.
 Myoclonus refers to irregular, abrupt, arrhythmic contractions of a muscle or group of muscles in the extremities, trunk, and face.