6.10 Neurological Assessment

Now that we have reviewed tests included in a neurological exam, let’s review components of a routine neurological assessment typically performed by registered nurses. The neurological assessment begins by collecting subjective data followed by a physical examination.

Subjective Assessment

Subjective data collection guides the focus of the physical examination. Collect data from the patient using effective communication and pay particular attention to what the patient is reporting, including current symptoms and any history of neurological illness. Ask follow-up questions related to symptoms such as confusion, headache, vertigo, seizures, recent injury or fall, weakness, numbness, tingling, difficulty swallowing (called dysphagia) or speaking (called dysphasia), or lack of coordination of body movements.^[1]

See Table 6.10a for sample interview questions to use during the subjective assessment

Table 6.10a Interview Questions Related to Subjective Assessment of Neurological System

Life Span Considerations

Newborn

At birth, the neurologic system is not fully developed. The brain is still developing, and the newborn’s anterior fontanelle doesn’t close until approximately 18 months of age. The sensory and motor systems gradually develop in the first year of life. The newborn’s sensory system responds to stimuli by crying or moving body parts. Initial motor activity is primitive in the form of newborn reflexes. Additional information about newborn reflexes is provided in the “Assessing Reflexes” section. As the newborn develops, so do the motor and sensory integration. Specific questions to ask parents or caregivers of infants include the following:

• Have you noticed your infant sleeping excessively or having difficulty arousing?
• Has your infant had difficulty feeding, sucking, or swallowing?

Children

Depending on the child’s age and developmental level, they may answer questions independently or the child’s parent/guardian may provide information. Specific questions for children include the following:

• Have you ever had a head injury or a concussion?
• Do you experience headaches? If so, how often?
• Have you had a seizure or convulsion?
• Have you noticed if your child has any problems with walking or balance?
• Have you noticed if your child experiences episodes of not being aware of their environment?

Older Adults

The aging adult experiences a general slowing in nerve conduction, resulting in a slowed motor and sensory interaction. Fine coordination, balance, and reflex activity may be impaired. There may also be a gradual decrease in cerebral blood flow and oxygen use that can cause dizziness and loss of balance. Examples of specific subjective questions for the older adult include the following:

• Have you ever had a head injury or recent fall?
• Do you experience any shaking or tremors of your hands? If so, do they occur more with rest or activity?
• Have you had any weakness, numbness, or tingling in any of your extremities?
• Have you noticed a problem with balance or coordination?
• Do you ever feel lightheaded or dizzy? If so, does it occur with activity or change in position?

Educate older adults to change positions slowly, especially when standing up from a lying or sitting position. Light-headedness and loss of balance during these activities increase the risk for falls.

Objective Assessment

The physical examination of the neurological system includes assessment of both the central and peripheral nervous systems. A routine neurological exam usually starts by assessing the patient’s mental status followed by evaluation of sensory function and motor function. Comprehensive neurological exams may further evaluate cranial nerve function and deep tendon reflexes. The nurse must be knowledgeable of what is normal or expected for the patient’s age, development, and condition to analyze the meaning of the data that are being collected.

Inspection

Nurses begin assessing a patient’s overall neurological status by observing their general appearance, posture, ability to walk, and personal hygiene in the first few minutes of nurse-patient interaction. For additional information about obtaining an overall impression of a patient’s status while performing an assessment, see the “General Survey” chapter.

Level of orientation is assessed and other standardized tools to evaluate a patient’s mental status may be used, such as the Glasgow Coma Scale (GCS), NIH Stroke Scale, or Mini-Mental State Exam (MMSE). Read more information about these tools under the “Assessing Mental Status” section earlier in this chapter.

The nurse also assesses a patient’s cerebellar function by observing their gait and balance. See the “Assessing Cerebellar Function” section earlier in chapter for more information.

Auscultation

Auscultation refers to the action of listening to sounds from the heart, lungs, or other organs with a stethoscope as a part of physical examination. Auscultation is not typically performed by registered nurses during a routine neurological assessment. However, advanced practice nurses and other health care providers may auscultate the carotid arteries for the presence of a swishing sound called a bruit. Bruits suggest interference with cerebral blood flow that can cause neurological deficits.

Palpation

Palpation during a physical examination typically refers to the use of touch to evaluate organs for size, location, or tenderness, but palpation during the neurologic physical exam involves using touch to assess sensory function and motor function. Refer to sections on “Assessing Sensory Function,” “Assessing Motor Strength,” “Assessing Cranial Nerves,” and “Assessing Reflexes” earlier in this chapter for additional information on how to perform these tests.

See Table 6.10b for a summary of expected and unexpected findings when performing an adult neurological assessment.

Table 6.10b Expected Versus Unexpected Findings on Adult Neurological Assessment