Neurologic System - Examination and Findings

Assessment of the neurological system should be completed as part of a comprehensive client assessment, or as part of a focused exam if the client is experiencing issues that might be related to neurological function, like a facial droop or confusion. Now, let's review the process of completing a neurological assessment.

Okay, the supplies you'll need include a cotton ball; a tuning fork; an object that can be easily recognized by touch like a paper clip, key, or coin; a reflex hammer; a tongue blade; drapes, and gloves. Then, prepare for the exam by ensuring your client is in a comfortable position, that your hands are warm, and that the temperature in the room is comfortable. Provide privacy by closing the door and curtains, properly draping your client, and only exposing areas of their body as needed to perform your examination. Before getting started, explain the procedure to your client and be sure to answer any questions they might have before obtaining verbal consent. Then, perform hand hygiene and collect your supplies.

While much of the neurological system assessment involves observation, you will need to locate the deep tendon reflexes to assess spinal cord intactness. Commonly tested deep tendon reflexes include the triceps, biceps, brachioradialis, patellar reflexes, and achilles reflexes.

Alright, the methods of assessment for the neurological system include inspection and palpation. Your assessment will evaluate your client's cerebellar function, which includes the client's balance and coordination; sensory function, which includes their ability to feel and differentiate between light touch and pain; and motor function, which includes deep tendon reflexes.

Okay, begin your assessment of cerebellar function by observing your client's gait, or how they walk. You can take the opportunity to do this as they enter the examination room or, if they are seated or in a bed, you can ask them to stand and walk across the room. While they ambulate, take note of their posture, coordination, and the movement of their legs and feet. Their gait should appear smooth and steady without hesitation, shuffling, or swaying.

Next, test balance and equilibrium with the Romberg test. Ask your client to stand with their feet together with their eyes open, and their arms at their sides. They should remain balanced and their body shouldn't sway. Next, ask them to close their eyes for about 30 seconds while you observe their ability to stay upright. Be sure to stay close to your client to support them in the event they lose their balance. Your client should be able to maintain their balance with only mild swaying. The Romberg test is abnormal if your client demonstrates a loss of balance, by excessive swaying, moving their feet, or if they begin to fall.

Finally, assess your client's coordination by testing rapid alternating movements. This is done by asking them to tap the tip of their thumbs to the tip of each finger on their hands as quickly as possible. You should expect swift movement while making contact between the thumb and each finger. You can also perform this test by asking them to pat their thighs with both hands and then flip their hands, so they are alternating the palmar and anterior aspects of the hands. Your client should be able to make smooth contact with the surface of their thighs with increasing speed without pausing or faltering. Slow, uncoordinated, or jerky movements is called dysdiadochokinesis, and is an unexpected finding.

Okay, moving on to sensory function. Begin by testing your client's ability to detect superficial touch. To do this, ask your client to close their eyes, and use a cotton wisp to gently touch the surface of the skin, on their face, arms, or legs. Expect them to tell you when and where they feel the cotton touch their skin. Next, evaluate pain perception. Using the sharp and dull edges of a broken tongue depressor, and using the same technique as you did to test superficial touch, gently touch the pointed edge and dull edge to the skin, alternating between the two sides. Expect them to correctly identify the location and type sensation.

Now, to test for vibratory sensation, instruct your client to close their eyes, and place the stem of a vibrating tuning fork on a bony prominence, like the great toe joint. Expect them to tell you when they feel the vibration and when it stops. Now, you can also evaluate sensation by testing stereognosis, which is the ability to perceive the form of an object by touch. To do this, ask your client to close their eyes, and then place a familiar object like a key or paperclip in your client's hand. You'll want to test both hands with different objects. Expect them to correctly identify the objects bilaterally.

Lastly, test graphesthesia, which is the ability to identify characters written on the skin. To do this, ask your client to close their eyes and open one of their hands exposing their palm. Then, use your finger or the dull edge of the tongue depressor to write a number on their palm; and repeat with a different number on the other hand. Expect them to correctly identify the number you wrote on each palm. An inability to correctly identify the sensation during these tests can be related to damage to peripheral nerves or the spinal nerve that supplies that region of the body being tested.

Finally, assess deep tendon reflexes to evaluate motor function. Starting with the triceps reflex, flex your client's arm at the elbow to a 90 degree angle, supporting the arm. Then, use the reflex hammer to strike the triceps tendon 1 to 2 inches just above the olecranon process. You should observe contraction of the triceps muscle and extension of the elbow. Next, for the biceps reflex, flex their arm to a 45 degree angle. Place your thumb over the biceps tendon at the antecubital fossa and strike your thumb with the reflex hammer. You should observe contraction of the biceps muscle with flexion of the elbow.

Now, for the brachioradialis reflex, flex their arm to a 45 degree angle and support their arm so it is slightly pronated. Strike the brachioradialis tendon, which is located about 2 to 3 inches above the wrist, and observe for flexion of the elbow, along with slight supination of the forearm. Okay, moving on to the lower extremities. The patellar reflex can be located by positioning your client's knee at a 90 degree angle. Allow the leg to hang dependently, and then, strike the patellar tendon just below the patella. Observe for extension of the lower leg, contraction of the quadriceps, and extension of the knee.

Next, assess the achilles reflex. With the client's knee flexed at a 90 degree angle, support the client's foot and slightly dorsiflex it. Then strike the achilles tendon, observing for plantar flexion. During your assessment, grade each reflex on a 0 to 4 scale, where 0 means there is no response; 1+ means the reflex is sluggish or diminished; 2+ means the reflex is normal and as expected; 3+ indicates the reflex is more brisk than expected; and 4+ means the reflex is hyperactive or that clonus, which is an involuntary contraction and relaxation of the skeletal muscles, is present. Hypo- or hyperactive reflexes can be due to problems like severe electrolyte imbalances, spinal cord injuries, and peripheral nerve damage, as well as upper or lower motor neuron damage.

As the nurse, it's your responsibility to correctly assess, interpret, report, and document your assessment findings. If your assessment reveals something that's potentially abnormal or emergent, like depressed reflexes or diminished sensation, this should be reported to the health care provider, while monitoring client progress and changes from baseline.

Alright, as a quick recap… Assessment of the neurological system helps identify problems with cerebellar, motor, and sensory function. Supplies you'll need include a cotton ball; a tuning fork; an object that can be easily recognized by touch like a paper clip, key, or coin; a reflex hammer; a tongue blade; drapes, and gloves. Methods of assessment include inspection and palpation. As the nurse, it's your responsibility to correctly assess, interpret, report, and document findings.