Chapter 15 – Neurological system assessment
Brief Scan of the Neurological System
A brief scan of the neurological system involves an assessment that allows you to quickly recognize neurological signs, changes in clinical status, and cues of clinical deterioration. This brief scan will influence your decision on whether immediate action is required and whether a focused assessment is needed.
Steps of a brief scan include:
- Assess airway patency. Are they having any difficulties breathing, talking, swallowing?
- Level of consciousness and level of orientation. Are they confused or disoriented about person, place, time, self? Are they unable to respond appropriately to questions such as: Can you tell me who I am? Can you tell me where you are? What year is it? Who are you?
- Assess vital signs. Are the vital signs within the normal ranges or have there been any changes?
- Speech. Is their speech unclear, slurred, delayed, not making sense?
- Mobility and balance. Are they having any difficulty with balance (standing, walking, sitting upright), movement of limbs, or exhibiting drooping of the face/eyelids/mouth?
- Mental health status. Are there any concerning cues, e.g., inattentive, , or ? Has the client verbalized that they are not feeling quite themselves or provided a vague statement about their mental health?
Pupillary light reflex is often assessed as well. More to come on how to do so later in the chapter.
Knowledge Bites: Cognitive Impairment
Various tools are available to support assessment when cognitive impairment is observed during the brief scan or if the client or family member indicates the client is having some problems with memory. These include:
- The Mini-Mental State Exam (MMSE) and the Standardized Mini-Mental State Exam (SMMSE), which are used to evaluate cognitive function and detect cognitive impairment (Vertesi et al., 2001). Some nurses prefer the SMMSE because it is timed, meaning that clients are given a limited amount of time to answer a question (e.g., What year is it?).
- Montreal Cognitive Assessment Test (MoCA), which is particularly useful for detecting “mild” cognitive impairment (MoCA Cognition, 2023). For example, if the client/family has indicated problems with memory but the MMSE/SMMSE results are normal, you might decide to use the MoCA. Training and certification is encouraged for healthcare professionals to maintain the validity of the test.
Another tool is The Canadian Neurological Scale, which was developed to monitor and evaluate neurological functioning during the acute phase of a client with a stroke (Cote et al., 1986). The main components include mentation and motor response. Check it out: The Canadian Neurological Scale
Clinical Tips – Common Tests as Part of the Brief Scan
The following common tests are often used to evaluate mobility and innervation of muscles in hospitalized clients:
- Hand grip: Stick out the index and middle finger of both of your hands, and ask the client to grasp them and squeeze.
- Manual muscle testing – arms: Ask the client to extend their arms out in front of them and then bend their arms toward them (elbow flexion) and resist your force when you apply pressure both in the movement of flexion, and then extension.
- Pronator drift: Ask the client to close their eyes and extend their arms out in front of them with palms facing up for 30 seconds.
- Movement: Ask the client to wiggle their toes.
- Manual muscle testing – feet: While the client is lying supine, place your hands on the balls of the feet and ask the client to resist your pressure when you push.
Note: Clients should have equal muscle strength bilaterally in hands and feet, able to wiggle their toes, and maintain their arms out in front of them (see Video 1 for a demonstration).
Video 1: Common tests to evaluate mobility and innervation of muscles in hospitalized clients
Priorities of Care
Any issues with airway patency and respiratory distress (e.g., stridor, difficulty breathing, difficulty/inability to speak) are significant cues of concern.
- Stay with the client and call for help (an experienced nurse, physician, or nurse practitioner).
- If an airway is not patent, try to open the airway with a head-tilt-chin-lift and inspect the mouth and nose for obstructions.
- If oxygen saturations are low, try to wake the client if they are sleeping, sit them upright, and ask them to take a few deep breaths. can be applied if there are on your unit.
- You may need to keep the client in a supine position if you suspect that they are deteriorating quickly and may go into respiratory or cardiac arrest. Notify the (CCRT) or call a code in this case. may be needed if the client is in respiratory arrest.
- If you suspect the client is choking, stay with the client and call for help while you place them in a High Fowler’s position. If they are able to, encourage them to cough and clear their airway. You may need to suction the oral cavity and airway, if possible. If you suspect a complete obstruction, use a combination of back blows, abdominal thrusts, and chest thrusts (Canadian Red Cross – What to do if an adult is choking).
All other abnormal cues of the brief scan (particularly if they are new onset) require immediate attention and a focused assessment. Abnormal cues can be associated with many conditions, stroke being of the most concern. For example, a sudden change and decrease in consciousness or aphasia or limb weakness are potential signs of a stroke and are critical findings that require immediate action and must be reported to a physician or nurse practitioner. Complete a primary survey and perform a focused assessment. Be aware that time from first symptom to treatment is a factor in permanent disability and/or death.
References
Cote, R. et al. (1986). The Canadian Neurological Scale: A preliminary study in acute stroke. Stroke, 17(4), 731-737.
MoCA Cognition (2023). About us. https://mocacognition.com/about/
Vertesi, A., Lever, J., Molloy, W., Sanderson, B., Tuttle, I. Pokoradi, L., & Principi, E. (2001). Standardized Mini-Mental State Examination. Canadian Family Physician, 47(10, 2018-2023.
refers to no emotional expression.
refers to rapid and exaggerated changes in mood.
is oxygen added in addition to what a person normally breathes in from the air, often provided via a face mask or nasal prongs.
are written protocols that authorize designated members of the health care team (e.g., nurses) to complete certain tasks (e.g., apply oxygen) without a physician order.
is an interdisciplinary group of practitioners trained in critical care and have expertise in assessing and intervening during code or pre-code situations when a client is deteriorating.
refers to a mask that fits over the mouth/nose during an emergency situation and is attached to a self-inflating bag with 100% oxygen that is squeezed to ventilate the lungs.
