13.4 Brief Scan of the Neurological System
A brief scan of the neurological system involves an assessment that allows you to quickly recognize neurological signs, changes in clinical status, and cues of clinical deterioration. This brief scan will influence your decision on whether immediate action is required and whether a focused assessment is needed.
Steps of a brief scan include:
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- Assess airway patency. Are they having any difficulties breathing, talking, swallowing?
- Level of consciousness and level of orientation. Are they confused or disoriented about person, place, time, self? Are they unable to respond appropriately to questions such as: Can you tell me who I am? Can you tell me where you are? What year is it? Who are you?
- Assess vital signs. Are the vital signs within the normal ranges or have there been any changes?
- Pupillary light reflex is often assessed as well. More to come on how to do so later in the chapter.
- Speech. Is their speech unclear, slurred, delayed, not making sense?
- Mobility and balance. Are they having any difficulty with balance (standing, walking, sitting upright), movement of limbs, or exhibiting drooping of the face/eyelids/mouth?
The following common tests are often used to evaluate mobility and innervation of muscles in hospitalized clients:
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- Hand grip: Stick out the index and middle finger of both of your hands, and ask the client to grasp them and squeeze.
- Manual muscle testing—arms: Ask the client to extend their arms out in front of them and then bend their arms toward them (elbow flexion) and resist your force when you apply pressure in the movement of flexion, and then extension.
- Pronator drift: Ask the client to close their eyes and extend their arms out in front of them with palms facing up for 30 seconds.
- Movement: Ask the client to wiggle their toes.
- Manual muscle testing—feet: While the client is lying supine, place your hands on the balls of the feet and ask the client to resist your pressure when you push.
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Note: Clients should have equal muscle strength bilaterally in hands and feet, and be able to wiggle their toes and maintain their arms out in front of them (see Video 1 for a demonstration).
- Mental health status. Are there any concerning cues, e.g., inattentive, flat affect, or labile affect? Has the client verbalized that they are not feeling quite themselves or provided a vague statement about their mental health?
Knowledge Bites: Cognitive Impairment
When conducting a neurological brief scan, it’s essential to assess key areas that provide early indicators of neurological compromise. Below is a detailed guide covering the critical components to consider:
Airway Patency and Breathing
Ensure the patient’s airway is clear and unobstructed. Observe for signs of breathing difficulty (e.g., labored breathing, stridor, or gasping).
Clinical Tip: Difficulty swallowing or speaking could indicate a neurological issue affecting cranial nerves or the brainstem. Patients with airway concerns may have conditions like stroke or brainstem compression, requiring immediate intervention.
Level of Consciousness (LOC) and Orientation
Assess the patient’s level of consciousness (alert, drowsy, unresponsive) and their orientation to person, place, time, and situation.
Ask questions like: “Can you tell me your name? Where are you? What year is it?”
Clinical Tip: Confusion or disorientation to person, place, or time may indicate a neurological decline, such as in cases of head injury, stroke, or encephalopathy. Any change in orientation or inability to respond appropriately is significant and warrants further evaluation.
Vital Signs
Check the patient’s vital signs, including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
Clinical Tip: Vital signs outside of the normal range may signal a worsening neurological condition. For example, bradycardia, hypertension, or abnormal respirations can indicate increased intracranial pressure (Cushing’s triad). Subtle changes may be early signs of deterioration.
Pupillary Light Reflex
Assess pupillary response by shining a light into each eye, observing for pupil size, shape, and reaction to light (PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation).
Clinical Tip: Changes in pupil size (e.g., dilated or unequal pupils) or slow reactivity may indicate increased intracranial pressure, brain herniation, or cranial nerve dysfunction. Immediate action should be taken if there is a significant difference between the pupils or if one or both pupils are fixed and nonreactive.
Speech
Observe the patient’s speech patterns. Is their speech clear and appropriate, or is it slurred, delayed, or nonsensical?
Clinical Tip: Slurred or unclear speech may be a sign of a stroke or other neurological disorder affecting motor speech pathways (e.g., dysarthria or aphasia). A sudden change in speech is a key indicator of neurological compromise and should be addressed promptly.
Mobility and Balance
Assess the patient’s mobility by observing their ability to move limbs, sit upright, and stand or walk. Look for signs of difficulty in balance or muscle weakness. Additionally, check for any facial drooping (e.g., of the eyelids, mouth, or one side of the face).
Clinical Tip: Impaired balance, weakness in the limbs, or facial asymmetry may indicate a stroke or nerve involvement. Even subtle changes in coordination or gait (e.g., unsteadiness) should raise concern, especially if new or progressive.
Summary of Clinical Tip
When performing a neurological brief scan, focus on these six essential components: airway and breathing, LOC and orientation, vital signs, pupillary reflex, speech, and mobility/balance. Any changes or abnormalities, especially compared to baseline, could indicate early signs of neurological compromise, requiring immediate follow-up. This comprehensive approach can help quickly identify critical changes in a patient’s condition and guide timely intervention.
Various tools are available to support assessment when cognitive impairment is observed during the brief scan or if the client or family member indicates the client is having some problems with memory. These include:
- The Mini-Mental State Exam (MMSE) and the Standardized Mini-Mental State Exam (SMMSE), which are used to evaluate cognitive function and detect cognitive impairment (Vertesi et al., 2001). Some nurses prefer the SMMSE because it is timed, meaning that clients are given a limited amount of time to answer a question (e.g., What year is it?).
- Montreal Cognitive Assessment Test (MoCA), which is particularly useful for detecting “mild” cognitive impairment (MoCA Cognition, 2023). For example, if the client/family has indicated problems with memory but the MMSE/SMMSE results are normal, you might decide to use the MoCA. Training and certification is encouraged for health care professionals to maintain the validity of the test.
Clinical Tips: Common Tests as Part of the Brief Scan
Video 1: Common tests to evaluate mobility and innervation of muscles in hospitalized clients
Priorities of Care
Any issues with airway patency and respiratory distress (e.g., stridor, difficulty breathing, difficulty/inability to speak) are significant cues of concern.
- Stay with the client and call for help (an experienced nurse, physician, or nurse practitioner).
- If an airway is not patent, try to open the airway with a head-tilt-chin-lift and inspect the mouth and nose for obstructions.
- If oxygen saturations are low, try to wake the client if they are sleeping, sit them upright, and ask them to take a few deep breaths. Supplemental oxygen can be applied if there are standing orders on your unit.
- You may need to keep the client in a supine position if you suspect that they are deteriorating quickly and may go into respiratory or cardiac arrest. Activate a “Rapid Response” or notify the critical care response team (CCRT) or call a code in this case. Bag-mask-ventilation may be needed if the client is in respiratory arrest.
- If you suspect the client is choking, stay with the client and call for help while you place them in a high Fowler’s position. If they are able to, encourage them to cough and clear their airway. You may need to suction the oral cavity and airway, if possible. If you suspect a complete obstruction, use a combination of back blows, abdominal thrusts, and chest thrusts (A.D.A.M Medical Encyclopedia, 2023).
All other abnormal cues of the brief scan (particularly if they are new onset) require immediate attention and a focused assessment. Abnormal cues can be associated with many conditions, stroke being of the most concern. For example, a sudden change and decrease in consciousness or aphasia or limb weakness are potential signs of a stroke and are critical findings that require immediate action and must be reported to a physician or nurse practitioner. Complete a primary survey (ABCCS) and perform a focused assessment. Be aware that time from first symptom to treatment is a factor in permanent disability and/or death.
References
A.D.A.M. Medical Encyclopedia. Choking: Adult or child over age 1. [reviewed 2023 Jan 2]. Available from: https://medlineplus.gov/ency/article/000049.htm
Cote, R. et al. (1986). The Canadian Neurological Scale: A preliminary study in acute stroke. Stroke, 17(4), 731-737.
MoCA Cognition (2023). About us. https://mocacognition.com/about/
Vertesi, A., Lever, J., Molloy, W., Sanderson, B., Tuttle, I. Pokoradi, L., & Principi, E. (2001). Standardized Mini-Mental State Examination. Canadian Family Physician, 47(10, 2018-2023.
