Chapter 6

Neurologic Assessment

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Learning Objectives
After reading this chapter you will be able to:
Define key terms related to neurologic
assessment
Describe functional anatomy of the
nervous system
Explain the cortical function of different
lobes of the brain
Describe common techniques used to
assess the mental status

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Learning Objectives (contd)

Describe functions of the brainstem, the

cerebellum, and 12 pairs of cranial nerves
Identify the parameters necessary to
obtain a Glasgow Coma Scale and be able
to interpret the results
Describe common techniques to assess
the cranial nerves, the sensory system, the
motor system, coordination, and gait

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Learning Objectives (contd)

Describe the importance of assessing

sedation and delirium in the ICU
Describe techniques used to assess deep,
superficial, and brainstem reflexes
Explain the relationship between vital signs
and neurologic status
Identify the importance of ICP monitoring
and the value of assessing cerebral
perfusion pressure

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Overview

Injuries of the nervous system

May affect respiratory system

May affect patient cooperation with respiratory
procedures

History may indicate nature of dysfunction

Exam localizes and quantifies severity of
dysfunction
Initial interaction with patient is first step in
neurologic assessment

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Overview (contd)

Neurologic assessment evaluates:

Mental status
Cranial nerve function
Motor system
Coordination
Sensory system
Reflexes

Meaningful neurologic assessment

requires adequate stimulation

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Functional Neuroanatomy

Neurologic system

Central nervous system

Brain: cerebrum, brainstem, cerebellum
Spinal cord
Peripheral nervous system
Cranial nerves
Spinal nerves

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Functional Neuroanatomy (contd)

Functional division

Sensory system (afferent)

Motor system (efferent)

Cerebrum

Functions: movement, LOC, ability to speak

and write, emotions, memory

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Functional Neuroanatomy (contd)

Brainstem

Consists of midbrain, pons, medulla oblongata

Most cranial nerves originate in brainstem
Regulation of heart rate, blood pressure, and
breathing

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Functional Neuroanatomy (contd)

Cerebellum

Posterior part of the brain

Responsible for equilibrium, muscle tone, and
coordination
Cerebellar lesions cause:
Loss of coordination (ataxia)
Tremors
Disturbances in gait and balance

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Functional Neuroanatomy (contd)

Spinal cord

From base of the brain down to L1 (45 cm)

Connects brain to the body for motor and
sensory function
31 spinal nerves
C1-C8, T1-T12, L1-L5, S1-S5, one coccygeal
Posterior (dorsal) roots = sensory
Anterior (ventral) roots = motor

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Functional Neuroanatomy (contd)

Spinal cord

Herniated vertebral disk is the most common

spinal nerve root pathology
Involvement of multiple nerve roots
Guillain-Barr
Phrenic nerves arise from spinal roots C3 to
C5
Damage can result in diaphragmatic paralysis

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Mental Status and LOC

LOC and mentation: most important parts

of the neurologic exam
Changes due to CNS dysfunction
Initial goal of exam is to determine
patients awareness

Starts with patient encounter

Compromise of LOC may be due to:

Generalized dysfunction (e.g., overdose)

Abnormality in specific area

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Glasgow Coma Scale (GCS)

Most widely used instrument to quantify

neurologic impairment
Test

Motor response
Verbal response
Poorly suited for patients with impaired verbal
response (e.g., aphasia, hearing loss, tracheal
intubation)

Eye opening

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Glasgow Coma Scale (contd)

Scale goes from 3 (deep coma) to 15 (fully

awake)
GCS of 12-15 = non-ICU observation
GCS of 9-12 = significant insult
GCS <9 = severe coma = requires
endotracheal intubation

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Mini-Mental State Examination

MMSE or Folstein test

30-point questionnaire to assess cognition

Samples various functions
Arithmetic, memory, orientation
Score interpretation
>27/30 = normal
20-26 = mild dementia
10-19 = moderate dementia
<10 = severe dementia

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Sedation and Delirium in the ICU

Delirium occurs in 60% to 80% of

mechanically ventilated patients
Associated with:

Longer hospital stay

Higher mortality
Poor long-term cognitive function

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Sedation and Delirium in the ICU

(contd)

Richmond Agitation Sedation Scale

(RASS)

Titrate sedation

Confusion Assessment Method for the ICU

(CAM-ICU)

Evaluates delirium

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Cranial Nerve Exam

12 cranial nerves = sensory and motor

function

Midbrain (CN III, IV)

Pons (CN VIII)
Medulla (CN IX to XII)

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Cranial Nerve Exam (contd)

Ipsilateral findings except on CN V

Acoustic problem (CN VII, VIII)

Pupillary response (CN II, III)
Corneal reflex (CN V, VII)
Gag reflex (CN IX, X)

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Sensory Exam

Somatosensory pathways

Spinothalamic (ST) = pain, temperature

Dorsal column-medial lemniscus (DCML) =
vibration, position sense (proprioception)

Evaluates ability to perceive sensations

with eyes closed
Assessment of light touch, pinprick, and
temperature

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Motor Exam

Patients ability to move on command

Motor strength and range of motion
Scale from 0 (no movement) to +5 (full
range of motion and full strength)
If unconscious = response to pain

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Motor Exam (contd)

Upper motor neuron (UMN)

Babinskis sign, hyperreflexia, clasp-knife

Decorticate and decerebrate posture

Lower motor neuron (LMN)

Loss of strength, tone and reflexes, muscle

waste and fasciculations

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Deep Tendon Reflexes

Evaluate spinal nerves

Triceps, biceps, brachioradialis, patellar,

Achilles tendon
Westphals sign = absence of patellar reflex

Scale from 0 (no reflex), +2 (normal), +5

(hyperreflexia)
Myasthenia gravis and botulism have
abnormal deep tendon reflexes

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Superficial Reflexes

Plantar reflex
Tested when suspected L4-L5 or S1-S2
injury
Babinskis sign

Dorsiflexion of the great toe with fanning of

remaining toes
Normal in children 12 to 18 months of age

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Brainstem Reflexes

Gag reflex (CN IX, X)

Its absence may increase risk for aspiration

Cough reflex (CN X)

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Brainstem Reflexes (contd)

Pupillary reflex (CN II, III)

PERRLA
Pupils equal round reactive to light and
accommodation

Anisocoria
Myosis = pontine hemorrhage, narcotics
Mydriasis = brain injury, anticholinergics
Mid-position fixed pupils = severe cerebral
damage

Corneal reflex (CN V, VII)

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Coordination, Balance, and Gait

Assessment of cerebellar function

Patient should be able to follow commands
during exam

Dysmetria = under- and overshooting of goaldirected movements

Romberg test = balance

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Vital Signs and Neurologic System

Brainstem = breathing
Lesions from cerebrum to cervical cord
cause changes of breathing patterns
Cheyne-Stokes respiration

Intracranial cause, hypoxemia, cardiac failure

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Vital Signs and Neurologic System

(contd)

Ataxic breathing: marker of brainstem

dysfunction
Increased ICP = Cushings triad

Hypertension, widening pulse pressure,

bradycardia, bradypnea

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Intracranial Pressure Monitoring

Indications

Monitor patients at risk for life-threatening

intracranial hypertension
Monitor evidence of infection
Assess effects of therapy for reducing ICP

Although hyperventilation decreases ICP,

cerebral perfusion pressure (CPP) is the
most critical element to monitor

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