The neurological examination that is performed by many nurses today includes only a gross examination of the patient, Most chronic and acute medical and surgical nurses have no need for a detailed exam. However, this course deals with an exam for nurses who are involved with very special nursing situations in which a more detailed neurological examination is necessary.
It will be assumed in this course that you have a basic understanding of the anatomy and physiology of the nervous system. If you need to refresh yourself, you may use any basic anatomy and physiology textbook as a reference. This course will present the nurse with a quick and thorough technique for performing a neurological exam. It will also describe in detail some special nursing situations which are common to the acute care med/surg nurse and the critical care nurse. As you begin your general physical assessment, you may notice some symptoms that will reveal the need for a more detailed neuro examination. This text will provide a step-by-step procedure for performing the exam.
GENERAL NEUROLOGICAL EXAMINATION
A detailed history is always important before starting the examination. If this exam is the first one given to a patient, such as the admission assessment, the nurse will usually complete a general form or questionnaire stating the history of the patient. If any of the questions suggest a neurological problem, the nurse will then ask questions more pertinent to the neuro status of the person. As always, the nurse must intervene if there is an emergency discovered during the examination. However, for this course, we will assume that the patient is “THE AVERAGE PATIENT.”
Some specific items to include in the history are: syncope, pain, bladder or bowel incontinence, seizures, diplopia and others. Often the relatives can give a better history, especially if the patient’s level of coherence is diminished.
In summary, the neurological history is often part of the general medical history. The nurse must be careful to intervene should there be a potentially life-threatening problem encountered. Otherwise, the nurse will continue to assess the neurological status of the patient, while obtaining the general medical history of the patient. After the general questions are asked and answered, the nurse can more carefully assess the neuro status of the patient.
Following, there is a list of items to be included in the medical and neuro exam of the patient. Remember that this is only a partial list. Some items can be excluded if the answers were already obtained at an earlier time; there may be other items which the nurse may wish to add to the list, due to specific patient problems or responses to questions.
Relatives are often a source of information, especially when the patient is unclear or unconscious. Remember to be complete to start with a general medical history if you have not already obtained one,
|General medical considerations:|
|major illnesses||Vascular diseases|
|anemia||taking any medications|
|childhood illnesses||infectious diseases|
|Specific Neurological history|
|bowel or bladder incontinence||headaches|
If any of the above or related problems are present, the nurse will follow up the problem by asking further, very specific questions regarding the problem. For example, if seizures were answered “yes”, the nurse would ask questions such as:
- When did you begin having seizures?
- When was the last one that you ever had?
- How long did they usually last?
- Have you now or ever taken medication for the seizures, and if so, what is the name of the medication(s)?
You will try to localize the problem as much as possible. Always read the medical history that the physician obtained first. You can save asking the patient many repetitive questions, if you first find out what information has already been obtained. Keep all this information in mind, as you proceed through the steps of the neuro exam.
PERMORMING THE NEUROLOGICAL ASSESSMENT
In basic nursing school, you undoubtedly learned a specific order in which to conduct the assessment. In fact, the order of the exam is usually unimportant. Use any specific order for the exam that is logical and makes sense for your patient. For purposes of this text, we will discuss the neuro exam in terms of the three major divisions of the neurological system, and then proceed with the examination:
Parts of the nervous system:
- Central Nervous System
- Autonomic Nervous System
- Peripheral Nervous System
- Central Nervous System (CNS)
- Brain – ventricles, skull, brain stem
- Spinal Cord - reflexes, (deep tendon reflexes): biceps, triceps, ankle, brachioradialis, knee superficial reflexes: abdominal, and others
- Autonomic Nervous System
Sympathetic and parasympathetic divisions: heart rate, respiratory rate, constriction and dilation of pupils, constriction and dilation of blood vessels, salivation, many others.
- Peripheral Nervous System (spinal nerves)
Pain, temperature, balance and the cranial nerves.
The above is a guide to the general sequence of the neurological assessment. Some other authorities divide the exam into different sections, such as cerebral function, motor function, sensory function, etc. However, these are just different terms for the same examination. The above divisions and the guide to follow will be the best method to use if you are a beginner. As you proceed through the exam, keep the following times in mind:
Cerebral function: General behavior, level of consciousness, intellectual functioning, emotional status, thought content (mental status), cortical sensory interpretation, language, etc.
Cranial Nerves: Special senses, facial nerves, other combined sensory/motor nerves
Motor: Muscle tone, muscle size, involuntary movements, muscle strength.
All these systems are a part of basic nursing assessment. However, if you need a review, you may use any textbook in assessment in order to refresh your memory. Once you have reviewed the above, you may proceed to the next section of this text which discusses the aspects of nursing assessment and the acutely ill patient.
Skull X-Ray is usually one of the first tests performed in cases of known or suspected neural injury. This will reveal configuration, intracranial tumors, calcifications, vascular markings and densities. Assessment of the patient, during the procedure, is usually limited to the stabilizing the vital signs and possibly assisting the technicians.
CAT studies (Computerized Axial Tomography) is an imaging method used to provide a cross-sectional view of the skull (or other body part), and shows varying densities of select tissues. This test can be diagnostic of tumors, infarcts and other lesions of the brain and/or spinal cord. Assessment of the patient during the procedure includes stabilization of vital signs as the patient is usually moved to a remote area of the hospital for the test. A permit must usually be signed and the patient instructed to lie very still in order to obtain the best results.
EEF, (electroencephalography) is a non-invasive test. It provides for physiological assessment of the electrical activity of the brain. The test may be done while awake, asleep or during activity. Nursing assessment will include reassurance of the patient since electrodes are placed upon the scalp. Many of the patients think that they are going to get a shock. Also withhold medications as per doctor’s order before the test. Usually any stimulant drug(s) are withheld; coffee, tea, stimulant drugs, etc.
EMG, (electromyography) is used to diagnose the presence of neuromuscular disorders. Needle electrodes are paced into the skeletal muscles in order to study the changes in electrical potentials. Assessment of the patient is usually limited to observation after the test, since there will be some discomfort and muscle soreness, similar to the discomfort experienced after an intramuscular injection.
Air contrast studies, include pneumoencephalogram, fractional pneumoencephalogram and ventriculogram. Air replaces the fluid in the closed spaces of the cranial cavity, in different and selected locations. The air acts as a contrast medium and it is less dangerous than injecting chemical contrast medium. Air is less dense that fluid medium and will outline shadows on x-ray. Assessment includes observations for signs of increased intracranial pressure, level of consciousness, neurological signs, infection, fever, and hydration status.
Radioisotope Brain Scanning, involves intravenous injection of a radioactive substance, and the subsequent measuring of the particles emitted after scanning of the patient. There is usually an increased uptake or decreased uptake of this “dye”” at areas of pathology. The nurse’s role in assessment of patients undergoing this test is limited. There is a minimal danger from radiation, and other than the injection, the test is non-invasive.
Cerebral Angiography, uses an injected contrast medium in X-Ray studies designed to view specific arterial blood flow. This test can help to detect the location of tumors, aneurysms, hematomas, and others. The nursing assessment of these patients includes a neurological assessment, motor assessment, sensory and circulatory assessment. Especially observe for weakness, speech disturbances, blood pressure fluctuations and arrhythmias. Also observe the injection site and evaluate peripheral pulses.
Myelogram, is a test which outlines the subarachnoid space, showing the presence of tumors, cysts, herniated intervertebral discs and other lesions. A lumbar puncture is first performed, and with this, goes all the usual nursing precautions. During this procedure, the contrast medium is injected and x-rays are obtained in order to visualize the subarachnoid space. Most hospitals today, use an absorbable contrast medium which does not have to be aspirated. This helps to reduce the danger t the patient.
The nursing considerations include measuring the level of patient anxiety, as sedation may be needed for some persons. Also included is a neurological assessment, with the measurement of sensory and motor functioning, especially the legs, any headaches present, their ability to void, stiff neck, photophobia and fever.
There certainly are many other diagnostic tests that can be performed to determine neurological functioning. When assessing the patient with a suspected neuro disorder, follow the guidelines at the beginning of this text for the general assessment. If more detailed facts are needed, always approach the assessment with a goal in mind. For example, if the patient has leg weakness, the nurse will examine the history, spinal cord, spinal column and the extremities thoroughly in order to find an abnormality.
- General medical exam findings
- Neurological exam findings
- Intervention (if needed)
- Recording and/or reporting findings
- Nursing care plan:
Formulate a nursing care plan for that patient, considering abnormal findings (if any) from your assessment of the patient. Also consider any diagnostic test results. Nursing care plans may include assessment of the patient after an invasive diagnostic test; or any test which may adversely affect the patient.
The next section will present specific patient conditions often seen in the acute care nursing units and/or the intensive care units. As you study these conditions, keep in mind the objectives of this section dealing with specific conditions.Next: Neurological Assessments Continued