Neurovascular Assessment

• Nervous System


  Highly integrated and complex system

  
• Nervous System


  • 2 principal parts: CNS and PNS*
  • Responsible for control of cognitive function and both voluntary and involuntary activities

  
• Neuron


  Basic cell of the nervous system
• Brain


  • Largest portion of the CNS
  • Covered and protected by the meninges, the CSF and the bony structure of the skull

  
• Cerebrum


  • Largest portion of the brain
  • The outermost layer, the cerebral cortex is composed of gray matter
  • The cerebral cortex is responsible for all conscious behavior by enabling the individual to perceive, remember, communicate and initiate movements

  
• Four Lobes of Cerebrum

  • Frontal: helps control voluntary skeletal movement, speech, emotions and intellectual activities
  • Parietal: conscious awareness of sensation and somatosensory stimuli, including temperature, pain and shapes
  • Occipital: contains visual cortex that receives stimuli from the retina and interprets visual stimuli in relation to past experiences
  • Temporal: interprets auditory stimuli and contains olfactory cortex that transmits impulses related to smell

  
• Diencephalon


  • Thalamus: gateway to cerebral cortex
  • Hypothalamus: autonomic control center; influences activities such as BP, HR, force of heart contraction, digestive motility, RR and depth and perception of pain, pleasure and fear; regulates body temperature, food intake, water balance and sleep cycles
  • Epithalamus: helps control mood and sleep cycles; contains choroid plexus where CSF is formed
• Brainstem


  • Contains the midbrain, pons and medulla oblongata
  • Located between the cerebrum and spinal cord
  • Connects pathways between the higher and lower structures
  • Influences BP by controlling vasoconstriction and also regulates RR, depth, and rhythm as well as vomiting, hiccupping, swallowing, coughing and sneezing

  
• Cerebellum


  • Located below the cerebrum and behind the brain stem
  • Coordinates stimuli from the cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements
  • Assists with maintaining equilibrium and muscle tone
• Spinal Cord


  • Continuation of the medulla
  • Passes through the skull at the foramen magnum and continues through the vertebral column to the first lumbar vertebra
  • Meninges, CSF and bony vertebrae protect the spinal cord
  • Transmits impulses to and from the brain via the ascending and descending pathways

  
• Reflexes


  • Stimulus-response activities of the body
  • Fast, predictable, unlearned, innate and involuntary reactions to stimuli
  • May be simple and take place at the level of the spinal cord with interpretation at the cerebral level
• Cranial Nerves


  • Originate in the brain and serve various parts of the head and neck
  • The vagus nerve is the only CN to serve a muscle and body region below the neck
  • The composition of the cranial nerve fibers varies producing sensory nerves, motor nerves and mixed nerves

  
• Spinal Nerves


  • 31 pairs of nerves that arise from the spinal cord
  • Categorized by the region of the vertebral column from which they emerge
  • All are mixed nerves because they contain axons of both sensory and motor neurons
  • Grouped into networks or plexuses: cervical, brachial, lumbar and sacral

  
• Physical Assessment: Pre-Assessment


  1. Gather and assemble the needed equipment and supplies

  2. Introduce self and identify the client

  3. Explain the procedure and ask for consent

  4. Assist the client to wear examination gown if necessary and place in a position appropriate to the procedure

  5. Provide privacy and expose only the area(s)/part(s) to be assessed

  6. Do hand hygiene and don gloves if necessary
• Preparation: Equipment


  • Thermometer, BP apparatus, stethoscope, and watch with second hand
  • Soap, coffee, and toothpaste
  • Snellen chart and newspaper
  • Penlight
  • Cotton ball, gauze, cotton applicator sticks, paper clip
  • Tongue blade/depressor
  • Glass of water
  • Gloves and patient's gown
  • Reflex hammer
  • Tuning fork
• Preparation: Prepare the client

  1. Client can sit on the examination table, edge of bed (as long as he/she is comfortable)

  2. Client must wear the hospital gown

  3. Get vital signs
• Mental Status Assessment


  • Note general appearance: hygiene, facial expression, body posture/language, motor activity, speech and ability to follow directions
  • Perform Glasgow Coma Scaling: Assess degree of wakefulness/ alertness/ level of consciousness, Assess neuro vital signs using the Glasgow Coma Scale, Ask questions to assess orientation to time, place and person
  • Assess memory: immediate recall, recent memory, remote memory
  • Assess mood and affect and the appropriateness
  • Assess intellectual capacity: fund of knowledge and calculation ability
  • Assess thought content: ask to interpret a proverb, insight or a situation to assess judgment
  • Assess language and comprehension
• Level of Consciousness


  • Awake: Alert, responds immediately and fully to commands - may or may not be fully oriented
  • Confused: Inability to think rapidly and clearly; There is impaired judgment and decision making
  • Disoriented: The beginning of loss of consciousness; There is disorientation in place, impaired memory and a loss of recognition of self which is the last to deteriorate
  • Obtundation: Can be aroused by stimuli (not pain), i.e. shaking and will then respond to questions or commands; remains aroused as long as stimulation is applied if not will fall asleep; questions are answered with minimal response; during the arousal, client responds but may be confused
  • Stuporous: A condition of deep sleep or unresponsiveness; client can only be aroused or caused to make a motor or verbal response by vigorous and repeated external stimulation (painful); the response initiated is often withdrawal or grabbing at stimulus
  • Comatose: No motor response to the external environment or to any stimuli, even deep pain; there is no arousal to any stimulus; reflexes may be present, abnormal movement (posturing) to pain may be present
• Cranial Nerves Assessment


  1. Assess CN I: Olfactory

  2. Assess CN II: Optic

  3. Assess CNs III, IV, and VI: Oculomotor, Trochlear, and Abducens

  4. Assess CN V: Trigeminal

  5. Assess CN VII: Facial

  6. Assess CN VIII: Acoustic/Vestibulocochlear

  
• CN V: Trigeminal


  • Sensory: assess light and blunt touch using cotton ball and paper clip
  • Motor: ask client to clench teeth and palpate the masseter muscles just above the mandibular angle
  • Assess corneal reflex
• CN VII: Facial


  • Inspect face noting any facial asymmetry including drooping, sagging or smoothing of normal facial creases
  • Ask client to raise eyebrows, close eyes tightly, purse lips, draw back the corners of the mouth in an exaggerated smile, frown and puff out both cheeks
  • Test taste on the anterior 2/3 of the tongue using different tastes (sugar, vinegar, salt, etc)
• Cranial Nerves Assessment


  1. Assess pupillary light reflex

  2. Assess extra-ocular movements

  3. Assess CN V: Trigeminal (sensory, motor, corneal reflex)

  4. Assess CN VII: Facial (inspect face, test facial movements)

  5. Assess CN VIII: Acoustic/Vestibulocochlear (test cochlear, perform Romberg's test)

  6. Assess CN IX and X: Glossopharyngeal and Vagus (test gag reflex, test soft palate elevation, test swallowing)

  7. Assess CN XI: Spinal Accessory (test shoulder shrug, head turn)

  8. Assess CN XII: Hypoglossal (test tongue protrusion, retraction, movement)

  
• Motor Assessment


  1. Observe muscle bulk/size

  2. Assess muscle strength/power

  3. Assess upper extremity strength (pronator drift)

  4. Assess muscle tone (hypotonia, hypertonia, abnormal movements)
• Cerebellar Assessment


  1. Assess balance and gait

  2. Perform finger to nose test

  3. Perform pronation/supination test

  4. Perform heel to shin test
• Sensory Assessment


  1. Assess light touch

  2. Assess pain

  3. Assess temperature

  4. Assess vibration sense

  5. Assess position sense
• Test Cortical Sensory Function

  1. Assess two-point discrimination

  2. Assess graphesthesia

  3. Assess stereognosis
• Reflexes


  1. Assess deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles, Babinski)

  2. Assess abdominal reflex

  3. Assess cremasteric reflex

  4. Assess anal reflex
• Test of Meningeal Irritation

  1. Assess Kernig's sign

  2. Assess Brudzinski's sign
• Post-Assessment


  1. Assist client in changing clothes

  2. Provide after care and hand hygiene

  3. Document findings