Rn Alterations In Neurologic Function Assessment

Alterations in neurologic function can manifest in diverse ways, impacting a person's ability to think, move, feel, and interact with the world around them. A Registered Nurse (RN) plays a pivotal role in the assessment of these alterations, serving as the frontline professional who identifies, monitors, and responds to changes in a patient's neurologic status. The RN's comprehensive assessment skills are essential for early detection, accurate diagnosis, and effective management of neurologic disorders. This article will delve into the various aspects of neurologic function assessment performed by RNs, including the key components of the assessment, common alterations encountered, and the significance of accurate and timely intervention.

The Importance of Neurologic Assessment by RNs

Neurologic assessment is a systematic evaluation of the nervous system's function. It is crucial because it:

• Detects early changes: Subtle changes in neurologic function can be the first sign of a serious underlying condition. Early detection allows for prompt intervention and potentially prevents irreversible damage.
• Establishes a baseline: An initial neurologic assessment provides a baseline against which future assessments can be compared, allowing nurses to identify trends and deviations from the patient's normal state.
• Guides treatment: The findings of the neurologic assessment help physicians and other healthcare providers determine the appropriate course of treatment.
• Monitors treatment effectiveness: Serial neurologic assessments are used to monitor the patient's response to treatment and make adjustments as needed.
• Provides a comprehensive picture: A thorough neurologic assessment provides a comprehensive picture of the patient's neurologic status, which is essential for planning and implementing individualized care.

Key Components of Neurologic Function Assessment

A comprehensive neurologic assessment typically includes the following components:

1. Level of Consciousness (LOC)

LOC is the most fundamental aspect of neurologic assessment. It reflects the overall function of the brain and its ability to respond to stimuli. LOC is assessed on a continuum, ranging from full alertness to coma.

• Alert: The patient is fully awake, aware of their surroundings, and able to respond appropriately to questions and commands.
• Lethargic: The patient is drowsy and may require gentle stimulation to stay awake and respond to questions.
• Obtunded: The patient is difficult to arouse and requires constant stimulation to maintain attention. Responses may be slow and confused.
• Stuporous: The patient is only arousable with vigorous and repeated stimulation. Responses may be minimal or incomprehensible.
• Comatose: The patient is unresponsive to all stimuli, including pain.

The Glasgow Coma Scale (GCS) is a standardized tool used to assess LOC. It evaluates three components: eye opening, verbal response, and motor response. Each component is assigned a numerical score, and the total score ranges from 3 (deep coma) to 15 (fully alert).

Glasgow Coma Scale (GCS)

Response	Score	Description
Eye Opening
Spontaneous	4	Opens eyes spontaneously, without any prompting.
To Speech	3	Opens eyes in response to verbal commands or speech.
To Pain	2	Opens eyes in response to painful stimuli, such as a sternal rub or trapezius squeeze.
No Response	1	Does not open eyes in response to any stimuli.
Verbal Response
Oriented	5	Answers questions correctly and appropriately. Knows their name, location, date, and the reason for being there.
Confused	4	Responds to questions but is disoriented, confused, or provides incorrect information. May be unable to recall recent events.
Inappropriate Words	3	Speaks words that are discernible but are nonsensical or unrelated to the questions being asked.
Incomprehensible Sounds	2	Makes sounds that are moaning, groaning, or unintelligible.
No Response	1	Does not make any verbal sounds.
Motor Response
Obeys Commands	6	Follows simple motor commands, such as "squeeze my hand" or "lift your arm."
Localizes to Pain	5	Moves their body purposefully towards a painful stimulus or attempts to remove it.
Withdraws from Pain	4	Pulls away from a painful stimulus.
Abnormal Flexion (Decorticate)	3	Flexes their arms and wrists and internally rotates their legs in response to pain. Indicates severe brain damage.
Abnormal Extension (Decerebrate)	2	Extends their arms and legs and arches their back in response to pain. Indicates more severe brain damage than decorticate posturing.
No Response	1	Does not make any motor movements in response to any stimuli.

2. Orientation

Orientation refers to a person's awareness of themselves, their location, the time, and the situation. It is typically assessed by asking the patient questions such as:

• "What is your name?"
• "Where are you right now?"
• "What is today's date?"
• "Why are you here?"

Orientation is often abbreviated as "A&O" and is documented as A&O x 1 (person only), A&O x 2 (person and place), A&O x 3 (person, place, and time), or A&O x 4 (person, place, time, and situation).

3. Cranial Nerve Assessment

There are 12 pairs of cranial nerves that originate from the brain and brainstem and control various functions, including vision, hearing, taste, smell, facial movement, and swallowing. Assessing cranial nerve function is an important part of the neurologic assessment.

• Cranial Nerve I (Olfactory): Smell. The patient is asked to identify familiar odors, such as coffee or peppermint.
• Cranial Nerve II (Optic): Vision. Visual acuity, visual fields, and pupillary response to light are assessed.
• Cranial Nerve III (Oculomotor), IV (Trochlear), and VI (Abducens): Eye movement. Extraocular movements are assessed by having the patient follow a moving object with their eyes. Pupillary size, shape, and reaction to light are also assessed.
• Cranial Nerve V (Trigeminal): Facial sensation and muscles of mastication. The patient is asked to clench their teeth and move their jaw from side to side. Sensation is tested by touching different areas of the face with a cotton swab.
• Cranial Nerve VII (Facial): Facial expression and taste. The patient is asked to smile, frown, raise their eyebrows, and puff out their cheeks. Taste is tested by applying different solutions to the tongue.
• Cranial Nerve VIII (Vestibulocochlear): Hearing and balance. Hearing is tested using a tuning fork or by whispering words near the patient's ear. Balance is assessed by observing the patient's gait and stability.
• Cranial Nerve IX (Glossopharyngeal) and X (Vagus): Swallowing, gag reflex, and voice. The patient is asked to swallow and speak. The gag reflex is tested by touching the back of the throat with a tongue depressor.
• Cranial Nerve XI (Accessory): Shoulder and neck movement. The patient is asked to shrug their shoulders and turn their head against resistance.
• Cranial Nerve XII (Hypoglossal): Tongue movement. The patient is asked to stick out their tongue and move it from side to side.

4. Motor Function

Motor function is assessed by evaluating muscle strength, tone, coordination, and gait.

• Muscle strength: Muscle strength is assessed using a standardized scale, such as the Medical Research Council (MRC) scale, which ranges from 0 (no movement) to 5 (normal strength). The patient is asked to move different body parts against resistance.
• Muscle tone: Muscle tone is the resistance of a muscle to passive movement. It is assessed by moving the patient's limbs through their range of motion. Increased tone (rigidity or spasticity) or decreased tone (flaccidity) can indicate neurologic dysfunction.
• Coordination: Coordination is assessed by observing the patient's ability to perform smooth, accurate movements. Common tests of coordination include finger-to-nose testing, heel-to-shin testing, and rapid alternating movements.
• Gait: Gait is assessed by observing the patient's walking pattern. Abnormalities in gait, such as shuffling, wide-based gait, or ataxia, can indicate neurologic problems.

5. Sensory Function

Sensory function is assessed by testing the patient's ability to perceive different sensations, such as light touch, pain, temperature, vibration, and position sense.

• Light touch: Light touch is tested by gently touching the skin with a cotton swab. The patient is asked to indicate when they feel the touch.
• Pain: Pain is tested by gently pricking the skin with a sharp object. The patient is asked to distinguish between sharp and dull sensations.
• Temperature: Temperature is tested by applying warm and cold objects to the skin. The patient is asked to identify the temperature.
• Vibration: Vibration is tested by placing a vibrating tuning fork on bony prominences. The patient is asked to indicate when they feel the vibration.
• Position sense: Position sense is tested by moving the patient's fingers or toes up or down. The patient is asked to identify the direction of movement.

6. Reflexes

Reflexes are involuntary muscle contractions in response to a stimulus. Assessing reflexes can help identify lesions in the central or peripheral nervous system.

• Deep tendon reflexes (DTRs): DTRs are elicited by tapping on tendons with a reflex hammer. Common DTRs include the biceps, triceps, brachioradialis, patellar, and Achilles reflexes. DTRs are graded on a scale of 0 (absent) to 4+ (hyperactive).
• Superficial reflexes: Superficial reflexes are elicited by stroking the skin with a blunt object. Common superficial reflexes include the abdominal and plantar reflexes. The plantar reflex is tested by stroking the lateral aspect of the sole of the foot. Normal response is plantar flexion of the toes. An abnormal response, called Babinski's sign, is dorsiflexion of the big toe and fanning of the other toes, which can indicate damage to the corticospinal tract.

7. Cerebellar Function

The cerebellum plays a crucial role in coordination, balance, and motor learning. Cerebellar function is assessed by evaluating gait, balance, and coordination.

• Gait: Observe the patient's walking pattern for any abnormalities, such as ataxia (uncoordinated movements) or a wide-based gait.
• Balance: Assess balance by having the patient stand with their feet together and eyes closed (Romberg test). Inability to maintain balance with eyes closed suggests cerebellar dysfunction.
• Coordination: Evaluate coordination through tests like finger-to-nose, heel-to-shin, and rapid alternating movements.

8. Meningeal Signs

Meningeal signs indicate irritation of the meninges, the membranes that surround the brain and spinal cord.

• Nuchal rigidity: Nuchal rigidity is stiffness of the neck that resists flexion. It is assessed by gently trying to flex the patient's neck forward.
• Kernig's sign: Kernig's sign is elicited by flexing the patient's hip and knee to 90 degrees and then attempting to extend the knee. Pain and resistance to knee extension suggest meningeal irritation.
• Brudzinski's sign: Brudzinski's sign is elicited by passively flexing the patient's neck forward. Involuntary flexion of the hips and knees suggests meningeal irritation.

9. Vital Signs

While not strictly a component of the neurologic exam itself, monitoring vital signs (blood pressure, heart rate, respiratory rate, and temperature) is critical. Changes in vital signs can be indicative of increased intracranial pressure (ICP) or other neurologic complications.

Common Alterations in Neurologic Function

RNs encounter a wide range of alterations in neurologic function in their practice. Some common examples include:

• Seizures: Seizures are sudden, uncontrolled electrical disturbances in the brain that can cause changes in behavior, movement, or consciousness.
• Stroke: Stroke occurs when blood flow to the brain is interrupted, leading to brain cell damage.
• Traumatic Brain Injury (TBI): TBI is an injury to the brain caused by a blow or jolt to the head.
• Spinal Cord Injury (SCI): SCI is damage to the spinal cord that can result in loss of motor and sensory function below the level of the injury.
• Multiple Sclerosis (MS): MS is a chronic autoimmune disease that affects the brain and spinal cord.
• Parkinson's Disease: Parkinson's disease is a progressive neurodegenerative disorder that affects movement.
• Alzheimer's Disease: Alzheimer's disease is a progressive neurodegenerative disorder that affects memory and cognitive function.
• Meningitis: Meningitis is an inflammation of the meninges, the membranes that surround the brain and spinal cord.
• Encephalitis: Encephalitis is an inflammation of the brain.

Documentation and Communication

Accurate and timely documentation of neurologic assessments is essential for effective communication among healthcare providers. The documentation should include:

• Date and time of the assessment
• Patient's LOC and orientation
• Cranial nerve findings
• Motor and sensory function
• Reflexes
• Cerebellar function
• Meningeal signs
• Vital signs
• Any changes from previous assessments
• Interventions performed
• Patient's response to interventions

RNs must promptly communicate any significant changes in the patient's neurologic status to the physician or other appropriate healthcare provider. Clear and concise communication is crucial for ensuring timely and effective treatment.

Nursing Interventions

Based on the findings of the neurologic assessment, RNs implement a variety of nursing interventions to promote patient safety, prevent complications, and optimize neurologic function. These interventions may include:

• Monitoring vital signs and neurologic status
• Administering medications
• Maintaining airway patency
• Preventing aspiration
• Providing skin care
• Preventing falls
• Providing emotional support
• Educating patients and families

Conclusion

The RN plays a critical role in the assessment and management of alterations in neurologic function. A thorough and systematic neurologic assessment is essential for early detection, accurate diagnosis, and effective treatment of neurologic disorders. By understanding the key components of the neurologic assessment, recognizing common alterations, and implementing appropriate nursing interventions, RNs can significantly improve patient outcomes and quality of life. Continuous education and training are vital for RNs to maintain and enhance their neurologic assessment skills and stay abreast of the latest advancements in neurologic care. The ability to rapidly and accurately assess neurologic changes is an indispensable skill for nurses working in a variety of settings, allowing them to provide the best possible care for patients with neurological conditions.