Neurological disorders 1.

are diseases of the central and peripheral

nervous system
Assess chief complaint
a. A- any associated symptoms with chief complaint
b. P- what provokes (makes worse) or palliates (makes better) symptoms
c. O- quality of symptom
d. R- region and radiation
e. S- severity of symptom on a scale of 1-10
f. T- timing- when did it stop and start, intermittent or constant, duration
Full consciousness 2. Alert, oriented to person, place, and time,
and comprehends written and spoken words
Confusion 3. Disoriented to person, place, and/or time; misinterprets
environment; has poor judgment; unable to think clearly
Lethargic 4. Oriented but slow and sluggish in speech,
mental processes, and motor activity
Obtundation 5. Readily arousable to stimuli;, responds with one or two
words; can follow simple commands when asked, but
quickly drifts back to sleep
Stupor 6. Lies quietly with minimal movement; responds with a
groan or eye opening only to vigorous and repeated verbal
with tactile stimuli; usually localizes painful stimuli
Coma 7. Unarousable to stimuli nonverbal; may exhibit non
purposeful response to stimuli
Light Coma 8. Unarousable; withdraws nonpurposefully to pain; may
decerebrate or decorticate; brainstem reflexes intact
Decorticate 9. Arms are like “C” move in toward the cord, you can see this
with a problem with cervical spinal tract or cerebral hemisphere
Decerebrate 10. Arm are like “E”. Problem within midbrain or pons
Deep Coma 11. Unarousable unresponsive to painful stimuli; brainstem
reflexes usually absent; decerebrate posturing usually noted
Delirium 12. Has rapid onset; brief impairment of cognitition including
a clouding of consciousness and difficulty sustaining and
shifting attention
Dementia 13. A generalized, long-term decline in cognitive abilities
Such as memory language, and clear consciousness
Table 2 Glasgow Coma Scale
Ability Response Score
Best eye response Response Spontaneously 4
(as nurse approaches)
To verbal stimulus (nurse 3
speaks/shouts)
To painful stimulus 2
(pressure on nail bed)
No response to painful 1
stimulus
Best motor response Obeys simple command 6
Localizes pain (locates 5
and attempts to remove
pain source)
Withdrawal (attempts to 4
withdraw from pain
source)
Abnormal flexion 3
Abnormal extension 2
No response to painful 1
stimulus
Best verbal response Oriented to time, person, 5
place
Confused, but able to 4
converse
Inappropriate words- 3
 makes little or no sense;
words are recognizable
Incomprehensible 2
sounds-groans or moans;
words are not
recognizable
No verbal response 1

Table 3 Cranial Nerve Assessment Tests

Nerve Function Normal Findings Nursing
Consideration
Sense of Smell Able to detect various Have client smell a
I I. odors in each nostril nonirritating
substance such as
Olfactory coffee or tobacco
with eyes closed
Test each nostril
separately
Sense of vision Clear (acute vision Snellen eye chart for
I II. near and distant far vision
Read newspaper for
Optic near vision
Ophthalmoscopic
exam
I III. Pupil constriction, Pupil equal in size Instruct client to look
Oculomotor raising of eyelids and equally reactive up, down, inward
to light Observe for
symmetry and eye
opening
Shine penlight into
eye as client stares
straight ahead
Ask client to watch
your finger as you
move it toward
his/her face
Downward and Able to move eyes 9SEE oculomotor0
I IV. inward movement of down and inward
eyes
Trochlear
Motor- jaw Able to clench and Test with pin and
I V. movement relax jaw wisp of cotton over
Sensory – sensation Able to differentiate each division on both
Trigeminal on the face and neck between various sides of face
stimuli to the face Ask client to open
and neck jaw, bite down, move
jaw laterally against
 pressure
Stroke cornea with
wisp of cotton
Lateral movement of Able to move eyes in (See Oculomotor)
I VI. the eyes all directions

Abducens
Motor – facial muscle Able to smile, Observe for facial
I VII. movement whistle, wrinkle symmetry after
Sensory – taste on the forehead asking client to
Facial anterior two-thirds of Able to differentiatefrown, smile, raise
the tongue (sweet and tastes among various eyebrows, close
salty) agents eyelids resistance,
whistle, blow
Place sweet, sour,
bitter, and salty
substances on tongue
Sense of hearing and Hearing intact Test with watch
I VIII. balance Balance maintained ticking into ear,
while walking rubbing fingers
Acoustic together,
Rinne test, weber test
Test posture, standing
with eyes closed
otoscopic exam
Motor – pharyngeal Gag reflex intact, Place sweet, sour,
I IX. movement and able to swallow bitter and salty
swallowing Able to taste substances on tongue
Glossopharyngeal Sensory – taste on Note ability to
posterior one-third of swallow and handle
tongue (sour and secretions
bitter) Stimulate pharyngeal
wall to elicit gag
reflex
Swallowing and Allow to swallow and Inspect soft palate –
I X. speaking speak with a smooth instruct to say “ah”
voice Observe ovula for
Vagus midline position.
Rate quality of voice
Motor – flexion and Able to flex and Inspect and palpate
I XI. rotation of head; rotate head; able to sternocleidomastoid
shrugging of shrug shoulder and trapezius muscles
Spinal accessory shoulders for size, contour, tone
Ask client to move
head side to side
against resistance and
shrug shoulders
against resistance
 Motor- tongue Can move side to Inspect tongue in
I XII. movements side and stick it out mouth
symmetrically and in Ask client to stick out
Hypoglossal midline tongue and move it
quickly from side to
side
Observe midline,
symmetry and
rhythmic movement
Criteria for grading muscle strength
0 = No contraction
1 = Trace of contraction
2 = Active movement
3 = Active movement against gravity
4 = Active movement against gravity and resistance
5 = Normal power
Note: Findings are recorded as a fraction with 5 (highest possible score) as
the denominator; ex. Normal finding is 5/5
Romberg's 14. test by having the client stand with feet together and
eyes closed while you stand close by to prevent falling:
there should be minimal swaying for 20 seconds
*Cerebellar examination: balance and coordination are under the control of
the cerebellum
*assess gait: have the client walk normally and then on heels and toes;
assess coordination: perform a Romberg's by
having the client stand with feet together and eyes closed while you stand
close by to pre vent falling: there should be minimal swaying for 20 seconds
*assess coordination, observe the client's ability to touch own nose and
then touch one of your fingers, then his or her nose again; next observe the
client's ability to touch each finger to the thumb of the same hand; finally,
observe the client's ability to run each heel down the opposite shin while
lying in the supine position
*Sensory function: Have the client close the eyes while you touch the client
on all dermatomes with objects that are sharp, dull, light to touch, and that
vibrate (over bony prominence); the client should be able to discriminate
the location and type of touch
* assess a client's sense of position (kinesthesia) have the client close the
eyes and move the client's finger or toe up or down and ask the client to
describe the movement
* assess for stereognosis, have the client identify an object in his or her hand
with the eyes closed