NEUROLOGIC EXAMINATIONS & NURSING RESPONSIBILITIES

MENTAL STATUS EXAM Begins when you talk to the patient during the health history Responses to your questions reveal clues about the patient’s orientation & memory Use such clues as guide during the physical assessment Make sure that you ask questions that require more than yes-or-no answers Otherwise, confusion or disorientation might not be apparent If you have doubts about a patient’s mental status, perform a screening examination To quickly screen your patient for disordered thought processes, ask the questions below. An

incorrect answer to any question may indicate the need for a complete mental status examination. Make sure that you know the correct answers before asking the questions.

QUICK CHECK OF MENTAL STATUSQUESTION FUNCTION SCREENED

What’s your name? Orientation to personWhat’s your mother’s name? Orientation to other peopleWhat year is it? Orientation to timeWhere are you now? Orientation to placeHow old are you? MemoryWhere were you born? Remote memoryWhat did you have for breakfast? Recent memoryWho is the President of the Philippines? General knowledgeCan you count backward from 20 to 1? Attention span & calculation skills

Use the mental status examination to check these three parameters:1. Level of Consciousness (LOC)

Watch for any change in the patient’s LOC. Earliest & most sensitive indicator of change in neurologic status Describe the patient’s response to different stimuli

Alert- Patient follows commands & responds completely & appropriately to stimuliLethargic- Patient is drowsy, has delayed responses to verbal stimuli & may drift off to sleep during

examinationStupurous- Patient requires vigorous stimulation for a responseComatose- Patient doesn’t respond appropriately to verbal or painful stimuli & can’t follow

commands or communicate verbally

Start quietly by observing the patient’s behavior. If the patient is sleeping, try to rouse him by providing an appropriate stimulus, in this

order:- Auditory- Tactile- Painful Always start with a minimal stimulus, increasing intensity as necessary

Glasgow Coma Scale Offers an objective way to assess the patient’s LOC

Test Patient’s Response ScoreEye-opening Response Spontaneous 4

To verbal command 3To pain 2No response 1

Verbal Response Oriented 5Confused 4Uses inappropriate words 3Makes incomprehensible sounds 2

No response 1Motor Response To verbal command 6

To painful stimuli 5Withdraws 4Abnormal flexion (Assumes decorticate posture) 3Abnormal extension (Assumes decerebrate posture) 2No response 1 Total

GCS Score Indication15 Alert, conscious, coherent & oriented to person, place & time12-14 Minor brain injury, 85% chance of moderate disability or good recovery9-11 Moderate brain injury, not in come5-8 Critical score, in coma3-4 Severe neurologic damage, in coma

Cranial Nerve ExaminationCranial Nerve Type Assessment Function AlterationsI. Olfactory Sensory Different scents of aromas Sense of smelling Ansomia (inability

to smell)II. Optic Sensory Snellen’s Chart Sense of vision Blurred vision,

blindnessIII. Oculomotor Motor Assess the six ocular

movement; penlight; pupil chart

Extraocular eye movement (EOM), constriction of pupil to light

Anisucuria

IV. Trochlear Motor Assess the six ocular movement

EOM Nystagmus (rolling of the eyeballs)

V. Trigeminal Both Cotton tip applicator, safety pin, hot & cold test tubes

Sensation of the face, controls muscles for mastication

Trigeminal neuralgia (Tic doloureux)

VI. Abducens Motor Eye movement test Lateral movement of the eye

Diplopia

VII. Facial Both Ask the client to do facial expression like smiling, raising the eyebrows. Ask the client to taste some food

Muscle for facial expression, sensation of the anterior 2/3 of the tongue

Bell’s palsyAgeusia (loss of sense of taste on the anterior 2/3 of the tongue)

VIII. Acoustic Sensory Hearing acuity test, checking the balance

Sense of hearing & balance

Hearing loss, tinnitus & vertigo

IX. Glossopharyngeal

Both Ask the client to taste some food. Ask the client to swallow

Sensation of posterior 1/3 of the tongue

Aguesia, dysphagia

X. Vagus Both Assess the client’s speech for hoarseness

Sensation of the pharynx & larynx

Dysphagia

XI. Spinal Accessory

Motor Ask the client to move the head & shrug the shoulders

Movement of the head & shrugging the shoulders

Inability to move the head & shrug the shoulders

XII. Hypoglosal Motor Ask the client to move the tongue

Movement of the tongue

Inability to move the tongue

NEUROLOGIC EXAMINATIONS & NURSING RESPONSIBILITIES

MENTAL STATUS EXAM

QUICK CHECK OF MENTAL STATUSQUESTION FUNCTION SCREENEDWhat’s your name?What’s your mother’s name?What year is it?Where are you now?How old are you?Where were you born?What did you have for breakfast?Who is the President of the Philippines?Can you count backward from 20 to 1?

Use the mental status examination to check these parameters:Level of Consciousness (LOC)

Alert

Lethargic

Stupurous-

Comatose-

Glasgow Coma Scale

Test Patient’s Response ScoreEye-opening Response Spontaneous

To verbal commandTo painNo response

Verbal Response OrientedConfusedUses inappropriate wordsMakes incomprehensible soundsNo response

Motor Response To verbal commandTo painful stimuliWithdrawsAbnormal flexion (Assumes decorticate posture)Abnormal extension (Assumes decerebrate posture)No response Total

GCS Score Indication1512-149-115-83-4

Cranial Nerve ExaminationCranial Nerve Type Assessment Function AlterationsI. Olfactory

II. Optic

III. Oculomotor

IV. Trochlear

V. Trigeminal

VI. Abducens

VII. Facial

VIII. Acoustic

IX. Glossopharyngeal

X. Vagus

XI. Spinal Accessory

XII. Hypoglosal