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Clinical Nursing Skills

26.2 Physical Assessment

Clinical Nursing Skills26.2 Physical Assessment

Learning Objectives

By the end of this section, you will be able to:

  • Perform a comprehensive neurological assessment
  • Understand abnormalities identified during the assessment of the neurological system
  • Recall proper documentation of neurological assessment

The neurological exam is a clinical assessment of the functioning of the CNS and PNS. Routine neurological exams performed by registered nurses during their daily clinical practice include assessing mental status and level of consciousness, pupillary response, motor strength, sensation, and gait. The Glasgow Coma Scale (GCS) is also frequently used to objectively monitor level of consciousness in patients with neurological damage such as a head injury or cerebrovascular accident, or stroke (Figure 26.7). Periodic reevaluations are performed when the patient has experienced an acute injury or illness causing neurological deficits, such as a stroke, which require frequent monitoring for change in condition.

Comprehensive Neurological Assessment

The comprehensive neurological assessment requires the nurse to collect both subjective and objective data through an interview as well as a detailed physical exam. This exam is more extensive and performed on patients with a neurological concern. In addition to the components included in a routine neurological exam, the examiner may also assess cranial nerves, detailed cerebellar function, deep tendon reflexes, and complete a Mini-Mental State Exam (MMSE).

Subjective Data

The subjective data are collected during an interview and guide the focus of a physical exam. It is crucial that the nurse collects a complete health history using effective communication to identify any current or potential issues, because some issues may only be identified through precise questioning during the interview. For example, the nurse will want to ask questions regarding loss of sensation, loss of concentration, or dizziness to identify potential problems (Table 26.5). Follow-up questions may also be required to identify when a patient’s symptoms started and any associated signs. The nurse may also ask about other signs and symptoms such as headaches, seizures, confusion, vertigo, recent injury, numbness, tingling, weakness, dysphagia (difficulty swallowing), dysphasia (difficulty speaking), or loss or coordination.

Interview Questions Follow-up
Are you experiencing any current neurological concerns such as headache, dizziness, weakness, numbness, tingling, tremors, loss of balance, or decreased coordination?
Have you experienced any difficulty swallowing or speaking?
Have you experienced any recent falls?
If the patient is seeking care for an acute neurological problem, use the PQRSTU method to further evaluate their chief complaint.
Note: If critical findings of an acute neurological event are actively occurring, such as signs of a stroke, obtain emergency assistance according to agency policy.
Have you ever experienced a neurological condition such as a stroke, transient ischemic attack, seizure, or head injury? Describe the condition(s), date(s), and treatment(s).
Are you currently taking any medications, herbs, or supplements for a neurological condition? Please describe.
Table 26.5 Interview Questions for Subjective Assessment of Neurological System

Patient Conversations

The Older Adult and the Nervous System Interview

Scenario: A nurse is collecting subjective data about a 79-year-old male in the clinic.

Nurse: Hi. My name is Suzie, and I’m the nurse who will be taking care of you today. May I have your name and date of birth?

Patient: My name is Fred Reid, date of birth January 21, 1944.

Nurse: Great, thank you. What brings you in today?

Patient: I am just here for a check-up. I have been feeling off lately.

Nurse: Okay, can you describe for me what that means?

Patient: Well, I have just been dizzy some.

Nurse: Do you feel light-headed also, and do you notice if it occurs with a particular activity or when you change positions?

Patient: Mainly when I stand up. I start to lose my balance some.

Nurse: When did this start?

Patient: Oh, maybe a week or so ago.

Nurse: Have you experienced any recent falls or medication changes?

Patient: No falls yet. That is why I am here, so I can try to figure this out and not fall. I did get started on Lasix about 10 days ago.

Nurse: Okay, a common side effect of Lasix is called orthostatic hypotension. It is a condition where your blood pressure can lower suddenly when standing from a seated or lying position. It can cause light-headedness or a loss of balance. It is important for you to change positions slowly. So, for example, when you are getting out of bed, you’ll want to sit up on the side of the bed and wait a minute or so before standing up to give your body time to adjust to the position changes. You will want to make sure you feel steady before moving, so even if it takes you a few minutes to get your bearings, that is okay.

Patient: Oh, that makes sense.

Nurse: Yes sir. I will let Dr. Caldwell know, and he may order additional testing regarding this while you are here.

Patient: Okay.

Nurse: Have you experienced any other neurological signs or symptoms, like difficulty swallowing or speaking, seizures, headaches, numbness, tingling, or tremors?

Patient: No ma’am.

Nurse: Okay, we will review your other body systems and then move into a physical exam if you are ready.

Scenario follow-up: Now that the nurse has completed the nervous system assessment, they can move on to the other body systems.

Objective Data

The objective data collected during an exam are used to assess the patient’s mental status as well as motor and sensory function, cranial nerve function, and deep tendon reflexes. In addition, this part of the comprehensive exam will require the nurse to observe the patient’s posture, ability to walk, and personal hygiene, as well. Table 26.6 describes common objective exams used to evaluate various components of the nervous system.

Test What It Assesses How to Perform
Glasgow Coma Scale Mental status/level of consciousness Scoring tool that assesses eye opening response, verbal response, and motor response (Figure 26.7).
National Institutes of Health Stroke Scale Neurological function (mental status, ability to communicate, motor function) Tool used to assess for suspected cerebrovascular accident. Uses the mnemonic “BEFAST”:
B: Balance (Is there a sudden loss of balance?)
E: Eyes (Any loss of vision in one or both eyes?)
F: Face (Does the face appear uneven, is there any drooping?)
A: Arm (Any weakness or numbness in either arm?)
S: Speech test (Any slurred speech or trouble speaking? Does patient appear confused?)
T: Time to call for immediate assistance
Mini-Mental State Exam Cognitive status 30-point test used to assess for dementia (chronic, irreversible confusion) or delirium (acute, reversible confusion that may be due to an infection, fever, or lack of oxygen). Scoring is as follows: 24–30, no impairment; 18–23, mild cognitive impairment; and <18, severe cognitive impairment.
Table 26.6 Common Tests of the Nervous System
A table presents details on the Glasgow Coma Scale.
Figure 26.7 The GCS is a scoring tool used to assess a person’s level of consciousness. A score of 15 or higher is rated as the best response, less than 8 is rated as comatose, and 3 or less is rated unresponsive. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Cranial Nerves

Cranial nerve assessment is also a part of an objective assessment. The nurse should remember to compare each side of the face when assessing each cranial nerve. The cranial nerves can be assessed as followed in Table 26.7.

Cranial Nerve How to Assess
I (olfactory) Ask the patient to identify a smell with their eyes closed, such as an alcohol swab or coffee.
A photograph shows a simulated patient sniffing an object to test olfactory nerve.
(credit: “Cranial Exam Image 11” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
II (optic) The Snellen chart assesses far vision. The patient should cover one eye and read the letters from the lowest line they can from 20 feet away. The patient may use glasses or contact lenses. The nurse will need to document the results as “corrected vision.”
An image shows the Snellen Chart for testing eyesight.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
III, IV, and V (oculomotor, trochlear, and abducens) These nerves are tested together using the acronym PERRLA (pupils are equal, round, and reactive to light and accommodation). This is done as follows:
  • Pupils are tested for movement with a penlight. The patient should follow the light only with their eyes. Any involuntary shaking of the eye is an abnormal finding and is called nystagmus.
  • The pupils should be equal, round, and reactive to light. Both pupils should be compared. The diameter generally falls between 2 to 5 millimeters. Abnormal findings may be pinpoint pupils, which are associated with respiratory depression or coma.
  • Test the reaction to light by shining the light directly in one pupil coming from the side. The pupil should constrict. Repeat on the other side and assess for the same reaction. An abnormal finding would be if one pupil is larger than the other or responds more slowly than the other.
    Photo showing assessment of simulated patient’s pupil reaction to light source
    (credit: “Cranial Exam Image 1” and “Pupillary Exam image 1” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
  • Test for convergence and accommodation by assessing the patient’s ability to adjust from near to far vision (accommodation) and the action of the eyes moving inward to focus with near vision (convergence). This is done by having the patient look at an object 4–6 inches away and then moving the object to 12 inches away. The pupils should be constricted while using near vision and dilated while using far vision.
    Photo showing simulated patient being assessed for eye convergence and accommodation
    (credit: “Cranial Nerve Exam 8” and “Cranial Nerve Exam image3” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
V (trigeminal) Test the patient’s sensory function by lightly touching their face, forehead, and chin with a wisp of a cotton ball while the patient’s eyes are closed. The patient should feel each touch.
Photos of simulated patient being assessed for trigeminal sensory function
(credit: “Neuro Exam Image 28”, “Cranial Exam Image 14”, and “Neuro Exam Image 36” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
Test the patient’s motor function by palpating the temporalis of the masseter muscles for strength while the patient is clenching their teeth. The patient should be able to symmetrically open and close their mouth as well as clench their teeth.
Photo showing simulated patient being assessed for trigeminal motor function
(credit: “Cranial Exam image 11”, “Neuro Exam Image 35”, and “Neuro Exam Image 4” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
VII (facial) Test motor function and assess for symmetry and facial muscle strength while the patient smiles, shows teeth, closes both eyes, puffs their cheeks, frowns, and raises eyebrows.
Photo of simulated patient making three different faces
(credit: “Cranial Exam image 15.png”, “Cranial Exam image 7.png”, “Cranial Exam Image 10.png” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
Test sensory function by having the patient taste separate cotton applicators that are moistened with salt, sugar, and lemon. The patient should identify each correctly.
Photo of simulated patient having a cotton swab placed on his tongue by nurse
(credit: “Neuro Exam Image 17.png” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
VIII (vestibulocochlear) Test auditory function by whispering at an arm length’s away. Each ear should be tested individually while the patient occludes the ear not being tested. The nurse should exhale and use as quiet of a voice as possible while whispering a combination of letters and numbers (e.g., 3-R-5). The patient should be asked to repeat what they heard. A patient is considered passing if they answer three of the six correctly. If the patient does not respond correctly, the nurse should test again but using a different sequence of letters and numbers. The opposite ear should be testing using a different sequence also.
Photo showing a nurse whispering to simulated patient to assess hearing
(credit: “Whisper Test Image 1.png” By Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
Test balance by using the Romberg test. This test is used to assess balance by having the patient stand with their feet together and eyes closed. The nurse must stand by in case the patient begins to fall. The patient should be able to stand erect and maintain their balance. A positive test occurs if the patient sways or loses their balance.
Photo showing nurse standing behind simulated patient, assessing balance
(credit: “Neuro Exam image 9.png” by Meredith Pomietlo/Chippewa Valley Technical College is licensed under CC BY 4.0)
IX (glossopharyngeal) This nerve is assessed by asking the patient to open their mouth and saying “Ah.” The nurse assesses the symmetry of the upper palate. The tongue and uvula should be midline, and the uvula should symmetrically rise as the patient says “Ah.”
Photo of simulated patient having mouth examined
(credit: “Oral Exam Image 2.png” by Meredith Pomietlo/Chippewa Valley Technical College is licensed under CC BY 4.0)
X (vagus) This nerve is assessed by using a cotton swab or tongue blade to touch the posterior pharynx and observe for a gag reflex, followed by swallowing.
Photo showing simulated patient having mouth and throat examined
(credit: “Oral Exam.png” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
XI (spinal accessory)
  • To assess the spinal accessory nerve, the nurse will test the right sternocleidomastoid muscle by facing the patient and laterally placing their right palm on the patient’s left check. The nurse will then ask the patient to turn their head to left while resisting pressure from the nurse’s hand on their cheek. The nurse will then repeat this on the other side.
  • The sternocleidomastoid muscle is further assessed by the nurse placing the hand on the forehead of the patient and pushing backward while asking the patient to push forward.
  • The trapezius muscle is assessed by asking the patient to face away from the nurse while the nurse observes the shoulder contour for displacement, winging, or hollowing as well as any shoulder drooping. This is then followed by the nurse placing their hands on the patient’s shoulder while the patient shrugs and retracts their shoulders.
    Image showing nurse’s hands on a simulated patient shoulders to assess the cranial nerve XI
    (credit: “Neuro Exam image 10” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
XII (hypoglossal) The hypoglossal nerve is assessed by examining any unilateral weakness while the patient protrudes their tongue or by having the patient touch their cheek with their tongue while the nurse provides resistance on the outside of the cheek.
Photos showing assessment of Hypoglossal nerve on simulated patient
(credit: “Cranial Nerve Exam Image 9.png” and “Cranial Nerve Exam image 11.png” by Meredith Pomietlo/Chippewa Valley Technical College is licensed under CC BY 4.0)
Table 26.7 Cranial Nerve Assessment

Life-Stage Context

Age-Related Changes to Senses

Nurses should be aware of normal age-related changes that can affect a neurological exam. Part of the normal age-related changes is changes to the senses: vision, hearing, tasting, smelling, and touch. As individuals age, the vision becomes slower due to the elasticity loss of the lens. Older adults also have trouble focusing their eyes and their pupils get smaller. The change in pupil size leads to the lens thickening and becoming less transparent, which ultimately results in a reduction of light reaching the retina. Another common visual a change is the loss of near-vision. Cataracts and glaucoma are common in older adults as well. Hearing loss may occur due to injury, genetics, medications, or exposure to repetitive loud noises or other damaging factors over time. Taste and smell are affected due to less saliva being produced, a decrease in the number of taste buds, mouth diseases, and the overall less ability to differentiate sweet and sour tastes. The sense of touch may be altered due to a condition, lack of blood flow, arthritis, or sedentary lifestyle.

Deep Tendon Reflex

Assessment of reflexes is not typically performed by registered nurses as part of a routine nursing neurological assessment of adult patients, but it is used in nursing specialty units and in advanced practice. Spinal cord injuries, neuromuscular diseases, or diseases of the lower motor neuron tract can cause weak or absent reflexes. To perform deep reflex tendon testing, place the patient in a seated position. Use a reflex hammer in a quick striking motion by the wrist on various tendons to produce an involuntary response. Before classifying a reflex as absent or weak, the test should be repeated after the patient is encouraged to relax, because voluntary tensing of the muscles can prevent an involuntary reflexive action.

Reflexes are graded from 0 to 4+, with “2+” considered normal:

  • 0: absent
  • 1+: hypoactive
  • 2+: normal
  • 3+: hyperactive without clonus
  • 4+: hyperactive with clonus (involuntary muscle contraction)

Sensory Response

Testing of peripheral sensation begins with examining the response to light touch according to regions of the skin known as dermatomes. A dermatome is an area of the skin that is supplied by a single spinal nerve that sends information to the brain for processing. To test the sensory fields, ask the patient to close their eyes and then gently touch the soft end of a cotton-tipped applicator on random locations of the skin according to the dermatome region. Instruct the patient to report “Now” when feeling the placement of the applicator. If a patient is unable to feel the sensation of a cotton applicator, an advanced technique applied to comatose patients is to use ice or even the prick of a pin.

It is not necessary to test every part of the skin’s surface during a routine neurological exam; testing a few distal areas with light touch is usually sufficient. In-depth testing is performed when the patient is exhibiting neurological signs or symptoms such as motor deficits, numbness, tingling, and weakness.

Cortical processing that occurs in the cerebral cortex of the parietal lobe is assessed using stereognosis, which is the ability to perceive the physical form and identity of a familiar object such as a key or paper clip, on the basis of tactile stimuli alone. Often this is called a monofilament testing, and it is routinely done in primary care. As shown in Figure 26.8, the nurse performs this test by asking the patient to close their eyes and then placing the object in their hand. The patient can use their finger to move the object around. The nurse will ask the patient to name the object. A different object should be tested in each hand. To perform the stereognosis test, ask the patient to close their eyes; then place a familiar object in their hand and ask them to name it. Each hand should be tested with a different object.

Photo showing male patient demonstrating the stereognosis test with both a coin and a key
Figure 26.8 This test is performed to assess stereognosis, which is the ability to recognize the physical form and identity of a familiar object, such as a key, on the basis of tactile stimuli alone. (credit: “Neuro Exam Image 8.png” and “Neuro Exam Image 31.png,” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)

Motor Strength

Motor and coordination functions are also part of the objective assessment. Motor strength is assessed by performing a brief musculoskeletal assessment of the upper and lower extremities. This testing may include hand grasps, upper body strength, and lower body strength. Expected findings of a motor function test is that the patient will have equal strength bilaterally. For the hand grasp test, the nurse should extend two fingers of each hand and have the patient squeeze both hands at the same time. Upper body strength is assessed by having the patient extend their forearms with palms facing upward. The nurse then places their hands on the patient’s inner forearms. The nurse asks the patient to pull their arms toward them while the nurse provides resistance.

Lower body strength is assessed while the patient is in a seated position and can be done in multiple ways. The first way is for the nurse to place their hands behind the patient’s calves. The nurse will then ask the patient to pull backward with their lower legs while the nurse is providing resistance in the opposite direction. Other tests assess the strength of the patient’s lower thighs by having them to lift their legs upward while the nurse provides resistance downward, or the nurse can place their hands on the top of the patient’s feet and ask them to pull their toes upward while providing resistance. The feet can also be assessed by the nurse placing their hands on the dorsal part of the patient’s feet and asking them to press downward while the nurse provides resistance.

Cerebellar Function

Tests used to evaluate cerebellar function (coordination) include assessment of gait and balance, the finger-to-nose test, and the heel-to-shin test. When assessing gait and balance, as shown in Figure 26.9, the nurse will ask the patient to perform the following actions (using an assistive device if needed): ambulate 10 feet, pivot, and walk back; walk heel to toe while looking straight ahead; walk on their tiptoes; and walk on their heels. An abnormal result occurs if the patient demonstrates any change in gait, shuffling, weakness, jerky movements, loss of balance, or uncoordinated arm swinging.

Photo of simulated patient displaying four gait and balance assessment positions
Figure 26.9 The patient’s steps should be equal and regularly paced while arms are swinging and coordinated with ambulation, and the balance should also be maintained. (credit: “Neuro Exam image 14.png”, “Neuro Exam Image 19.png”, “Neuro Exam image 40.png”, and “Nero Exam Image,” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)

The finger-to-nose test, as shown in Figure 26.10, evaluates equilibrium and coordination. The patient can be in a seated or standing position. The nurse will ask the patient to close their eyes and instruct them to extend their arms outward from the sides of their body. The nurse will then instruct the patient to touch the tip of their nose with their right index finger and return their arm to the extended position. The nurse will then instruct the patient to repeat this motion on the left side. The nurse will also have the patient repeat these steps by alternating arms.

Photo of simulated patient performing a finger to nose balance test
Figure 26.10 The expected finding of this test is that the patient will smoothly touch their nose with alternating index fingers and be able to return their arms to the extended position repetitively. If the patient is unable to alternate fingers or touch their nose, then an abnormal result occurs. (credit: “Neuro Exam image.png,” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)

For the heel-to-shin test, as shown in Figure 26.11, the nurse will place the patient in a supine position. The nurse will then instruct the patient to place the heel of their right foot just below their left kneecap. The next step is to have the patient slide their right heel in a straight line down to the ankle. The nurse will instruct the patient to repeat this motion on the left leg. An abnormal finding is if the patient is not able to perform the steps in smooth, straight motion or if the heel falls off the lower leg.

Photos showing two different positions for the heel to shin test
Figure 26.11 The heel-to-shin test assesses the motor and coordination function. The expected finding is that the patient is able to perform these steps in a smooth, straight movement bilaterally. (credit: “Neuro Exam image 15.png,” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)

Abnormalities of the Neurological Assessment

There are many abnormalities that can affect the neurological assessment. The most common alterations are altered mental status, altered language, altered nerve function, alterations in sensory function, and alterations in motor and coordination function. The nurse should have a foundation in what is an expected versus an unexpected finding, as well as how to properly perform the assessment to ensure a finding is accurate.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Safety

There are various abnormalities of the neurological system that can exist and affect a patient’s safety. It is essential that the nurse performs a thorough assessment of the patient’s cognitive, behavioral, and motor functionality to determine safety risks. Individuals are at risk for falls due to any dysfunction in their neurological status, such as a loss of balance or coordination, dysfunctions with gait, confusion related to cognitive impairments, or any impaired sense of position. The nurse should identify risks and implement interventions to promote a safe environment for patients and reduce their risk of falls. For example, a nurse may identify a patient as a fall risk due to an altered mental status and so activate a bed alarm to alert the nurse’s station if the patient tries to get up by themselves.

Altered Mental Status

An altered mental status or an altered level of consciousness is present when a patient experiences a change in mental function as a result of a disease or condition affecting the brain. The GCS, as previously described, is the standard tool to assess a person’s mental state. This allows the nurse to obtain a baseline to compare against future assessments as well as develop appropriate nursing interventions. Mental status changes can be described as depression, dementia, delirium, and coma.

  • Depression: poor cognition test results, slowed speech, personal withdrawal
  • Dementia: slow, progressive loss of mental capacity. Idiopathic dementia is a slow loss of memory and orientation, graduating to personality changes, decreased social skills, and inability to perform self-care (Alzheimer disease). Vascular dementia is more fluctuating, with the addition of motor changes along with cognitive decline (Patti & Gupta, 2023).
  • Delirium: an acute condition of confusion that can fluctuate from hyperactive to hypoactive states, with periods of lucidity (Patti & Gupta, 2023). Sundowning, or worse delirium at night, is a common phenomenon.
  • Coma: inability to respond to normal stimuli but may retain brain stem reflexes (e.g., cough, gag, corneal, pain stimulus, oculovestibular reflexes) (Patti & Gupta, 2023).

Altered Language

The term aphasia refers to a brain disorder in which an individual has difficulty with all forms of communication: expression, understanding, reading, and writing (National Institutes of Health [NIH], 2017). Aphasia can be caused by various conditions but most commonly from traumatic brain injury and stroke. To ensure accurate findings, the nurse should be aware of any devices the patient may need for communication, such as hearing aids or glasses, before performing an assessment.

An altered finding includes speech that is garbled or slurred, the patient struggling to find the right term or word, problems comprehending written or spoken words, or using words that do not make sense in the context of the conversation. If the nurse is unsure of whether altered language is a new change, the nurse should ask the patients family or caregiver about the patient’s baseline, if available. New changes could be indicative of a stroke and require early intervention.

Patient Conversations

Patient Changes in Speech

Scenario: A nurse is assessing a patient who had a stroke 1 week ago.

Nurse: Hi. My name is Kai. May I have your name and date of birth?

Patient: My name is R-r-r-ob Gome. [looks at wife]

Patient’s wife: His name is Robert Gomes, date of birth is February 10, 1951. He has been having trouble speaking ever since his stroke.

Patient: [nods his head]

Nurse: Okay, that is actually a common finding. It lasts different lengths for every individual but can take a few weeks to months to see improvement. Mr. Gomes, do you mind if I perform an assessment?

Patient: You can.

Nurse: Okay, can you tell me where you are?

Patient: [garbled] Eagle R-r-ranch.

Nurse: Very good.

[Nurse arranges a pen, her cell phone, and a watch on the table.]

Nurse: Mr. Gomes, I have a few things on the table here. Will you point to the item that is the pen?

[Patient correctly points at the pen.]

Nurse: Very good. Will you describe a hamburger to me?

Patient: [garbled] Yes, there is a patty and bread with ve-veg-tables and must or ma-mayonnaise.

[Nurse holds up a paper with the following sentence: It may rain today.]

Nurse: Will you read this sentence for me?

Patient: [garbled] It m-may r-rain today.

Nurse: Very good. Thank you. Your provider will be in soon to discuss your recent hospital stay, the testing that was performed there, and the review of your assessment.

Patient’s wife: Great, thank you. [patient nods his head]

Altered Nerve Function

Cranial nerve deficits can cause pain, numbness, tingling, weakness, or paralysis of the face or eyes. This can be due to nerve damage, poorly controlled diabetes, head injuries, poorly controlled blood pressure, infections, stroke, or tumors affecting the area. Table 26.8 outlines expected versus unexpected findings from a cranial nerve assessment.

Cranial Nerve Expected Findings Unexpected Findings
I (olfactory) Patient is able to identify or describe odor. Anosmia (inability to identify odors)
II (optic) Patient has 20/20 vision (near and far). Decreased visual acuity or visual fields
III (oculomotor) PERRLA (pupils are equal, round, and reactive to light and accommodation) Pupil sizes are not equal or reactive bilaterally.
IV (trochlear) Both eyes follow the examiner’s penlight in the appropriate direction. Patient is unable to follow the penlight with their eyes in the various directions or demonstrates ptosis (eyelid drooping).
V (trigeminal) Patient is able to feel touch and chew without struggle. Weakened chewing muscle responses or decreased sensations to touch
VI (abducens) Eyes move in coordination bilaterally. Patient is unable to look laterally or has diplopia (double vision).
VII (facial) Patient is able to smile, raise eyebrows, puff checks, and close eyes without struggle and is also able to differentiate tastes. Decreased taste sensations, facial paralysis or symmetry (facial drooping)
VIII (vestibulocochlear) Patient is able to hear whispered words in both ears and is able to walk upright and/or maintain balance. Decreased hearing in one or both ears; decreased ability to walk upright and/or maintain balance.
IX (glossopharyngeal) Present gag reflex Absent gag reflex or dysphagia (difficulty swallowing)
X (vagus) Patient is able to speak and swallow without struggle. Slurred speech or dysphagia
XI (spinal accessory) Patient is able to turn head side to side and shrug shoulders against resistance. Patient is unable to turn head side to side and shrug shoulders against resistance.
XII (hypoglossal) Patient’s tongue is midline and able to move without struggle. Patient’s tongue is weak or is not midline.
Table 26.8 Cranial Nerve Expected versus Unexpected Findings

Alterations in Sensory Function

Alterations in sensory function can be caused by a direct insult to the brain or due to aberrant stress responses, such as trauma, severe illness, acute changes in the environment, and surgery, that cause alterations in neurotransmission. Biochemical imbalances, decreased cholinergic functions, or changes in neurotransmitter levels may contribute to such changes. Age-related changes in neurotransmission and intracellular signaling may also occur and lead to sensory alterations (Khan & Khan, 2022).

Damage to the PNS can cause weakness, numbness, or pain from nerve damage also known as peripheral neuropathy. Disorders that may contribute to this sensory alteration include diabetes, autoimmune disorders, metabolic imbalances, smoking, atherosclerosis, nutritional imbalances, kidney or liver disorders, infection, chemotherapy, cancer, and lupus. Types of neuropathies include Guillain-Barre syndrome, diabetic neuropathy, carpal tunnel syndrome, and complex regional pain syndrome.

Alterations in Motor and Coordination Function

Similar to other alterations discussed, there are various reasons for alterations in motor and coordination function. Abnormalities like unsteady gait, abnormal muscle movement, or abnormal posturing can be due to damage to a particular area of the brain, CNS, or PNS in addition to neurodegenerative disorders or neurodevelopmental abnormalities.

When unexpected findings are noted during the motor and coordination function assessment, the nurse should verify any conditions in the patient history that could contribute to the alteration or if this is a new finding. Decreased muscle tone, or hypotonia, can occur on its own or is an underlying medical condition, such as muscular dystrophy or cerebral palsy. Hypotonia is often detected at infancy. Increased muscle tone, or hypertonia, is caused by damage to the CNS, upper motor neuron lesions, or conditions such as stroke, brain tumors, toxins, neurodevelopmental abnormalities, such as cerebral palsy, and neurodegenerative disorders, including multiple sclerosis or Parkinson disease.

Life-Stage Context

Motor Changes in the Aging Adult

There are common motor changes in the aging adult that the nurse should be aware of when performing an assessment to determine what may be normal versus a sign of a neurological dysfunction. The following are changes that may be common among the aging adult population:

  • A reduction in muscle mass and function can make movements slower or less coordinated, and so may also contribute to a risk of falls.
  • A reduction in velocity of contraction and movement can be due to smaller muscle fibers in older adults versus younger adults.
  • Abnormal gait may be due to the deterioration of proprioception mechanisms, visual changes, and osteoarthritis.
  • Arthritis is common among older adults and can affect all tissues of the joint. This may be painful and have swelling, both of which may lead to the patient having an abnormal gait or reduced movement in the joint.
  • Degradation of the synapses of motor nerve and neuromuscular junction is common with aging and causes muscle fiber alterations.

Additionally, older adults may be taking medications that can affect a patient’s sense of awareness as well as contribute to dizziness. The nurse should be aware of the medications and supplements the patient takes daily to be aware of any potential side effects or risks.

Validating and Documenting Findings

Documentation is a crucial component to any nursing assessment. This is the baseline information against which future assessments will be compared for evaluation of improving or worsening signs and symptoms. Nursing documentation should include:

  • assessment tools used to perform the exam
  • detailed findings of each assessment, including any subjective and objective data
  • if the practitioner was notified of any abnormal findings, include the name of the practitioner, date and time of notification, and any interventions performed
  • any teaching provided to the patient and family, including understanding of the teaching and any follow up teaching needed

Consider the following example. The nurse needs to use a combination of tools to gather subjective and objective data about a patient in the emergency department. The nurse documents that the patient reports “numb feeling” on the left side of their body and that their left arm “feels weak.” The nurse notes during the conversation that the patient is struggling to talk, and their speech is difficult to understand. On the motor and sensory components of the exam, the nurse notes the patient’s left arm is weak and they have decreased sensation. They note the time of the exam as well as the time that the patient reported their symptoms began. The nurse also assesses and documents the patient’s MMSE and GCS scores. In the patient’s chart, the nurse documents both the subjective data provided by the patient and the objective data gathered from the exam. Based on what the nurse has observed, they decide the stroke protocol needs to be initiated. The nurse’s assessment and documentation are key steps in the diagnostic workflow. From here, the medical team can quickly take next steps to determine if the patient is having a stroke (e.g., ordering a computed tomography scan of the head; laboratory tests) and start treatment (e.g., administering an anticoagulant) as soon as possible. When assessing a patient for a stroke, swift action on the part of the nurse can be critical. Timing is key for stroke diagnosis and treatment, and the nurse’s role in conducting a prompt but accurate and thorough neurological assessment is essential.

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