NEUROLOGIC ASSESSMENT

INTRODUCTION
The human nervous system is a unique system that allows the body to interact with the environment as well as to maintain the activities of internal organs. The nervous system acts as the main circuit board for every body system. Because the nervous system works so closely with every other system, a problem within another system or within the nervous system itself can cause the nervous system to short-circuit. (Dillon,2007)

INTRODUCTION
A major goal of nursing is early detection to prevent or slow the progression of disease. So it is important for nurses to accurately perform a thorough neurologic assessment and to understand the implications of subtle changes in assessment findings. By doing so, we can initiate timely interventions that can save lives.

Function
Responsible for many functions including initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought process control of speech and storage of memory

Anatomy and Physiology

Structural Classification Central Nervous System Brain Spinal Cord Peripheral Nervous System Cranial Nerves Spinal Nerves

Anatomy and Physiology

Functional Classification Sensory/ Afferent Division Motor/ Efferent Division Somatic Nervous System Autonomic Nervous System Sympathetic Parasympathetic

Central Nervous System

consists of the brain and spinal cord

The Human Brain

 It is approx. 2% of the total body weight  It weighs approx. 1400 g in an average young adult  In weighs an average of 1200 g in the elderly  It is divided into three major areas: cerebrum, brain stem and the cerebellum

CEREBRUM

Cerebrum
It consists of two hemispheres that are incompletely separated by the great longitudinal fissure It is separated into right and left hemispheres by sulcus It is joined at the lower portion by corpus callosum It has wrinkled appearance due to presence of folded layers or convolutions called gyri It has an external of outer portion made up of gray matter approx. 2 to 5 mm in depth and is made up of billions of neurons and cell bodies It has an innermost layer made up of white matter and is composed of nerve fibers and neuroglia

Four Lobes of the Cerebrum

Frontal Lobe Largest lobe Controls concentration, abstract thought, information storage or memory, and motor function Contains Brocas area, a speech association area that participates in word formation Responsible for large part of individuals affect, judgment, personality and inhibitions

Frontal Lobe

Parietal Lobe
Predominantly a sensory lobe Contains primary sensory cortex, which analyzes sensory information and relays the interpretation of this information to the thalamus and other cortical areas Controls awareness of the body in space, orientation in space and spatial relations

Parietal Lobe

Temporal Lobe
Contains auditory receptive areas Contains a vital area called interpretative area, which provides integration of somatization, visual and auditory areas

Temporal Lobe

Occipital Lobe
Contains visual areas, which play important role in visual interpretation

Other Areas of Cerebrum

Corpus Callosum Thick collection of nerve fibers that connects the two hemispheres of the brain and is responsible for the transmission of information from one side of the brain to the other Information transferred is sensory, memory and learned discrimination

Corpus Callosum

Basal Ganglia
Masses of nuclie located deep in the cerebral hemispheres Responsible for motor control of fine body movements

Thalamus
Lies on either side of the third ventricle Acts primarily as a relay station for all sensation except smell All memory, sensation and pain impulses pass through this section

Thalamus

Hypothalamus
Located anterior and inferior to the thalamus It includes the optic chiasm and mamillary bodies Plays a role in the regulation of pituitary secretion of hormones that influence metabolism, reproduction, stress response and urine production Called as hunger and satiety centers Regulates sleep-wake cycle, blood pressure, aggressive and sexual behaviors, and emotional responses

Hypothalamus

Brain Stem

Brain Stem
Contains the midbrain, pons and medulla oblongata The midbrain contains sensory and motor pathways and serves as the center for auditory and visual reflexes The pons contains motor and sensory pathways, and controls the heart, respiration and blood pressure The medulla oblongata transmits both sensory and motor fibers, and is the bodys respiratory center

Cerebellum

Cerebellum
Separated from the cerebral hemispheres by a fold of dura matter, the tentorium cerebelli Has both excitatory and inhibitory actions and is largely responsible for coordination of movement Controls fine movement, balance, position sense and integration of sensory input

Structures Protecting the Brain

Meninges Fibrous connective tissues that cover the brain and spinal cord Provides protection, support and nourishment to the brain and spinal cord Composed of dura mater, arachnoid and pia mater

 Dura mater Outermost layer Arachnoid Middle membrane Extremely thin, delicate membrane which resembles a spider web Appears white because of absence of blood supply Contains the choroid plexus, which produces the cerebrospinal fluid (CSF) Contains arachnoid villi, which absorb CSF Pia mater Innermost membrane Thin, transparent layer that hugs the brain closely and extends into every fold of the brains surface

Meninges

Cerebrospinal Fluid (CSF)

Clear and colorless fluid with a specific gravity of 1.007 Cushions and nourishes the brain Produced in the ventricles and is circulated around the brain and the spinal cord by the ventricular system The organic and inorganic contents of CSF are similar to those of plasma but differs in concentration Analyzed for presence of protein, glucose, chloride and immunoglobulins Normally contains minimal number of WBCs and no RBCs

Cerebrospinal Fluid

Cerebral Circulation
The brain requires 20% of the oxygen of the body The brain requires 65-70% of the glucose in the body The brain requires 1/3 of the cardiac output The brain does not store nutrients and has a high metabolic demand that requires high blood flow The brain lacks additional collateral blood flow, which may result in irreversible damage when blood flow is occluded

Cerebral Circulation

Arterial Supply
The arterial blood supply to the brain is provided by two internal carotid arteries and two vertebral arteries At the base of the brain, a ring is formed between the vertebral and internal carotid arterial chains called circle of Willis The arterial anastomosis along the circle of Willis is a frequent site of aneurysms

Arterial Supply

Venous Drainage
The veins of the brain reach the brains surface and join larger veins which empty into the dural sinuses Dural sinuses are vascular channels lying within the tough dura mater The network of the sinuses carries venous outflow for the brain and empties into the internal jugular veins, which return the blood into the heart Cerebral veins and sinuses are unique because they dont have valves

Blood-Brain Barrier
Formed by the endothelial cells of the brain capillaries, which form continuous tight junctions, creating a barrier to macro molecules and many compounds All substances entering the CSF must filter through the capillary membranes of the choroid plexus Often altered by trauma,cerebral edema And cerebral hypoxemia

Spinal Cord

Spinal Cord
Serves as a connection between the brain and the periphery Approx. 45 cm (18 in) long and about the thickness of a finger Extends from the foramen magnum at the base of the skull to the lower border of the first lumbar vertebra, where it tapers to a fibrous band conus medullaris Below the second lumbar space are nerve roots that extend beyond the conus, which are called cauda equina Contains gray matter, located at the center, and white matter on its sides

Sensory and Motor Pathways: The Spinal Tract

Fiber bundles with a common function are called tracts There are six (6) ascending tracts conducting sensation such as perception of touch, pressure, vibration, position and passive motion from the same side of the body Ex. Spinocerebellar tracts conduct sensory impulses from muscle spindles, providing necessary input for coordinated muscle contraction

 There are eight (8) ascending tracts, seven of which are engaged in motor function Examples: 1. Corticospinal tracts(2)- voluntary muscle activity 2. Vestibulospinal tracts(3)- autonomic functions such as sweating, pupil dilation and circulation 3. Corticobulbar tract- voluntary head and facial muscle movement 4. Rubrospinal and reticulospinal tractsinvoluntary muscle movement

Vertebral Column
Surrounds and protects the spinal cord and consists of7cervical, 12 thoracic, 5 lumbar and 5 sacral Nerve roots exit from the vertebral column through the intervertebral foramina Separated by disks, except for the first and second cervical, sacral and coccygeal vertebrae Each vertebra has a ventral solid body and a dorsal segment or arch, which is posterior to the body

Vertebral Column

PERIPHERAL NERVOUS SYSTEM

Cranial Nerves There are 12 pairs of cranial nerves that emerge from the lower surface of the brain and pass through the foramina in the skull Three (3) are entirely sensory ( CN I, II, VIII), five (5) are motor (CN III, IV, VI) and four (4) are mixed (CN V, VII, IX, X) They are numbered in the order in which they arise from the brain

Cranial Nerves

Cranial Nerves
Cranial Nerves I. Olfactory Functions Smell Abnormal Findings Anosmia (absence of smell) Papilledema; blurred vision; scotoma; blindness Anisucuria; pinpoint pupils; fixed, dilated pupils Nystagmus

II. Optic

Vision

III. Oculomotor

Pupil constriction; elevation of upper lid Eye movement; controls superior oblique

IV. Trochlear

Cranial Nerves
V. Trigeminal

Functions
Control muscles of mastication; sensations for the entire face Eye movements; controls the lateral rectus muscle Controls muscles for facial expression; anterior 2/3 of the tongue Cochlear branch permits hearing; vestibular branch helps maintain equilibrium

Abnormal Findings
Trigeminal neuralgia (Tic douloureux)

VI. Abducens

Diplopia; ptosis of the eyelid

VII. Facial

Bells palsy; ageusia (loss of sense of taste) on the anterior 2/3 of the tongue Tinnitus; vertigo

VIII. Acous tic/ Vestibulocochlear

Cranial Nerves IX. Glossopharyngeal

Functions Controls muscles of the throat; taste of posterior 1/3 of the tongue Controls muscles of the throat; PNS stimulation of thoracic and abdominal organs Controls sternocleidomastoid and trapezius muscles

Abnormal Findings Loss of gag reflex; drooling of saliva; dysphagia; dysphonia; posterior third ageusia Loss of gag reflex; drooling of saliva; dysphagia; dysarthria; bradycardia; increased HCl secretion Inability to rotate the head and move the shoulders

X.Vagus

XI. Spinal Accessory

XII. Hypoglossal

Movement of the tongue

Protrusion of the tongue; deviation of the tongue to one side of the mouth

Spinal Nerves
Composed of 31 pairs of spinal nerves: 8 cervical; 12 thoracic; 5 lumbar; 5 sacral; and 1 coccygeal The dorsal roots are sensory and transmit impulses from specific areas of the body, known as dermatomes, to the dorsal ganglia The sensory fibers maybe somatic, carrying information about pain, temperature, touch, and position sense (proprioception) from the tendons, joints and body surfaces Fibers can also bevisceral, carrying information from the visceral organs

Spinal Nerves
The ventral roots are motor and transmit impulses from the spinal cord to the body These fibers can either be somatic or visceral The visceral fibers include autonomic fibers that control the cardiac muscles and glandular secretions

Spinal Nerves

AUTONOMIC NERVOUS SYSTEM: Sympathetic Nervous System vs. Parasympathetic Nervous System
Structure or Activity Pupil of the Eye Circulatory System: Rate and force of heart beat Blood Vessels In the heart muscle In skeletal muscle In abdominal viscera and skin Blood pressure Respiratory System: Bronchioles Rate of breathing PNS Constricted Decreased SNS Dilated Increased

Constricted * * Decreased Constricted Decreased

Dilated Dilated Constricted Increased Dilated Increased

Structure or Activity Digestive System: Peristalsis Muscular sphincters Secretion of salivary gland Secretions of stomach, intestine and pancreas Conversion of liver glycogen to glucose Genitourinary System: Urinary bladder Muscular walls Sphincters

PNS

SNS

Increased Relaxed Thin, watery Increased *

Decreased Contracted Thick, viscid * Increased

Contracted Relaxed

Relaxed Contracted

Structure or Activity Integumentary System: Secretion of sweat Pilomotor muscles Adrenal Medullae

PNS

SNS

* * *

Increased Contracted Secretion of catecholamines

Developmental consideration
Infants and Children The growth of the nervous system is rapid during the fetal period During infancy, the neurons mature, which allows more complete actions to take place 1. cerebral cortex thickens 2. brain size increases 3. myelinization occurs The advances in the nervous system are responsible for the cephalocaudal and proximodistal refinement of development, control and movement

Developmental consideration
The neonate has several reflexes at birth: sucking, stepping, startle (Moro) and Babinski reflexes Babinski and tonic neck reflexes are normal until two (2) years of age By about one (1) month of age, the reflexes begin to disappear

Developmental consideration
Pregnant Women The pressure of the growing uterus on the nerves of the pelvic cavity produces neurologic changes in the legs As pressure is relieved in the pelvis, the changes in the lower extremities are resolved As the fetus grows, the center of gravity of the female shifts, and the lumbar curvature of the spine is accentuated This change in posture can place pressure on roots of nerves, causing sensory changes in the lower extremities Hyperactive reflexes may indicatepregnancyinduced hypertension (PIH)

Developmental consideration
Older Adults Impulse transmission decreases Reflexes diminish and coordination weakens Senses decrease (hearing, vision, smell, taste and touch) Muscle mass decreases Gait becomes short, shuffling, uncertain and unsteady

Neurologic Assessment

Health History
Biographical and demographic data - it includes personal profile of the patient, source of history and the clients mental status

Health History
Current health a. Chief complaint- obtains a detailed description of the event that have led the client to seek care. Use open ended question. b. Symptom analysis-

Health History
Past health history a. Childhood infectious disease and immunizations Rubella and rubeola Meningitis Herpes simplex virus cytomegalovirus influenza

Health History
b. Major illnesses and hospitalizations Pernicious anemia Cancer DM Infections Hypertension Liver and renal disease F & E imbalances Acid-Base Imbalances Head trauma Seizures and stroke c. Medications CNS stimulants Sedatives and hypnotics Antidepressives Analgesics Anti hypertensive and stroke d. Growth and development

Mental Status Examination

An indication of how patient is functioning as a whole and how the patient is adapting to the environment 1.General appearance2.Intellectual capacity or performanceconsists of fund of knowledge and calculation activity

Mental Status Examination

3. LOC-the most sensitive indicator of changes in the neurologic status -begin by observing spontaneous behavior -visual cue -verbal cues -tactile -Noxious agent- use of central stimulus rather than peripheral (nail bed pressure) because it may elicit a reflex a. sterna pressure b. supraorbital ridge pressure c. sternocleidomastoid muscle pinch

Mental Status Examination

4. Orientation- to time, place and event or situation 5.Memory- retrograde (long-term memory) and anterograde (recent memory or shortterm) 6. Mood/affect 7.Judgment/Insight- include reasoning, abstract thinking, problem solving and the clients perception of the situation. 8. Language/communication

MENTAL STATUS ASSESSMENT WITH ABNORMAL FINDINGS

Unilateral neglect (lack of caring of the other side of the body); strokes involving middle cerebral artery. Poor hygiene and grooming: dementing disorders Abnormal gait and posture: transient ischemic attacks (TIAs) , strokes, and Parkinsons disease Emotional swings, personality changes: strokes

MENTAL STATUS ASSESSMENT WITH ABNORMAL FINDINGS

Aphasia-defective or absent language function: TIAs, strokes involving anterior/posterior artery; general term for impairment of language Dysphonia- change in tone of voice Dysarthria- (different in speaking); is indistinctness of words in word articulation resulting from interference with the peripheral speech mechanisms (e.g. muscles of the tongue, palate, pharynx, or lips) [Phipps, 1998, p. 1901] Decreased level of consciousness Confusion, Coma

COGNITIVE FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Disorientation to time and place: stroke of right cerebral hemisphere 1. Memory deficits 2. Emotional defense

CRANIAL NERVE ASSESSMENTS

Cranial I (Olfactory): Anosmia 1.lesions of frontal lobes 2.impaired blood flow to middle cerebral artery. Cranial II (Optic) 1. blindness in eye: strokes of internal carotid artery, TIAs 2. Homonymous hemianopia - impaired vision or blindness in one side of both eyes; blockage of posterior cerebral artery. 3. Impaired vision: strokes of anterior cerebral artery; brain tumors

Homonymous hemianopia

CRANIAL NERVE ASSESSMENTS

Cranial nerve III, IV, VI (Oculomotor, Trochlear, Abducens)-motor nerves that arise from the brainstem 1.Nystagmus - involuntary eye movement; strokes of anterior, inferior, superior, cerebellar arteries 2.Constricted pupils: may signify impaired blood flow to vertebralbasilar arteries. 3.Ptosis (eyelid fall down); dropping of the upper eyelid over the globestrokes of posterior inferior cerebellar artery; myasthenia gravis, palsy of CN III

CRANIAL NERVE ASSESSMENTS

Cranial nerve V (Trigeminal)largest cranial nerve wit motor and sensory components: changes in facial sensations impaired blood flow to carotid artery 1.Decreased sensation of face and cornea on same side of body; strokes of posterior inferior cerebral artery 2.Lip and mouth numbness 3.Loss of facial sensation: contraction of masseter and temporal muscles, lesions CN V 4.Severe facial pain: trigeminal neuralgia (tic dorlourex)

CRANIAL NERVE ASSESSMENTS

Cranial VII (Facial nerve)mixed nerve concerned with facial movement and sensation of taste 1.Loss of ability to taste 2.Decreased movement of facial muscles 3.Inability to close eyes, flat nasolabial fold, paralysis of lower face, inability to wrinkle the forehead 4.Eyelid weakness; paralysis of lower face; paralysis of upper motor neuron 5.Pain, paralysis, sagging of facial muscles: affected side in Bells palsy

CRANIAL NERVE ASSESSMENTS

Cranial VIII (Acoustic)composed of a cochlear division related to hearing and a vestibular division related to equilibrium (Phipps, 1998, p. 1909) Decreased hearing or deafness: strokes of vertebral basilar arteries or tumors of CN VIII Cranial IX (Glossopharyngeal) and cranial X (Vagus)chief function of cranial nerve IX is sensory to the pharynx and taste to the posterior third of tongue; cranial nerve X is the chief motor nerve to the soft palatal, pharyngeal and laryngeal muscles (Phipps, 1998, p. 1909) 1.Dysphagia (difficulty swallowing) 2.Unilateral loss of gag reflex

 Cranial XI (Spinal accessory)motor nerve that supplies the sternocleidomastoid muscle and upper part of trapezius muscles 1. Muscle weakness 2.Contralateral hemiparesis: strokes affecting middle cerebral artery and internal artery Cranial XII (Hypoglossal) 1.Atrophy, fasciculations (twitches): LMN disease 2.Tongue deviation toward involved side of the body

Sensory Function
The center for sensory perception is located in the parietal lobe, which enables us to perceive pressure, temperature, texture and pain The ability to perceive sensory stimuli is Called stereognosis The inability to perceive sensory stimuli is called agnosia

SENSORY FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Altered sensation occurs with variety of neurologic pathology Altered sense of position: lesions of posterior column of spinal cord Inability to discriminate fine touch: injury to posterior columns

Assessment of Motor Function

BalanceTest (Gait) Heel-to-toe walk Rombergs Test Assess coordination and equilibrium (CN VIII) If swaying greatly increases or if the client falls, disease of the posterior column of the spinal cord is suspected Finger-to-nose Test With the eyes closed, the client with cerebellar disease will reach beyond the tip of the nose because the position sense is affected

 Rapid Alternating Action Test Inability to perform the task may indicate upper motor neuron weakness Heel-to-shin Test Inability to perform the test may indicate disease or lesion of the posterior spinal tract

MOTOR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Muscle atrophy: LMNs disease Tremors (groups, large of muscle fibers)Parkinsons disease (tremors at rest), multiple sclerosis (tremors observed in activity) Fasciculations (single muscle fiber): disease or trauma to LMN, side effects of medications, fever, sodium deficiency, anemia

MOTOR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Flaccidity (decreased muscle tone): disease or trauma to LMN and early stroke Spasticity (increased muscle tone): disease of corticospinal motor tract Muscle rigidity: disease of EP motor tract Cogwheel rigidity (muscular movement with small regular jerky movement; parkinsons disease Muscle weakness-in arms, legs, hands: TIAs

MOTOR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Hemiplegia-paralysis of half of body vertically Flaccid paralysis: strokes of anterior spinal artery, multiple sclerosis or myasthenia gravis Total loss of motor function: below level of injury Spasticity of muscle: incomplete cord injuries

CEREBELLAR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Ataxia (lack of coordination and clumsiness of movement, staggering, wide-based and unbalanced gait) Steppage gait (client drags or lifts foot high, then slaps foot onto floor; inability to walk on heels; disease of LMN Sensory ataxia (client walks on heels before bringing down toes and feet are held wide apart; gait worsens with eyes closed

CEREBELLAR FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS

Parkinsonian gait (stooped over position while walking with shuffling gait with arms held close to the side) Rombergs test (Positive)- With feet approximated, the patient stands with eyes open and then closed; if closing the eyes increases the unsteadiness, a loss of proprioceptive control is indicated

Parkinsonian gait

Rombergs test

REFLEX
Evaluates the integrity of specific sensory & motor pathways Info. On the natures, location and progression of nuerologic d/o 2 type: Superficial Deep tendon Reflex

 Superficial cutaneous Stoking a sensory zone Abdominal Plantar Corneal Pharyngeal (gag) Cremasteric Anal

 Deep tendon mycotactic Rapid muscle contraction that results from rapid stretching of the muscle Sharply striking a muscle tendons point of insertion with a sudden brief blow of a reflex hammer Biceps, triceps, brachoradial, patella, ankle jerk (achilles tendon)

Reflex Corneal Reflex

Assessment Tech. Light touch at corneoscleral junction Light touch to soft palate and pharynx Stroke skin of upper, middle and lower abdomen toward umbilicus Stroke medial of upper thigh

Expected Response Closure of the eyelids

Pathway Involved CN V, VII

Palatal and Pharyngela Reflex Abdominal Reflex

Elevation of palate; gagging Contraction of abdominal wall toward stimulus

CN IX,X

Upper T7-9 Middle: T9-11 Lower: T9-11

Cremasteric Reflex

Elevation of epsilateral scrotum and testicle Contraction of external sphincter Plantar Flexion of the toes

T12-L2

Anal Reflex

Stroke perianal region Stroke sole of the foot

S3-5

Plantar Reflex (normal)

L4-S2

Reflex Biceps

Assessment Tech. Blow on examiners thumb placed over biceps tendon Styloid process of radius is tapped while forearm is in semiflexion and semipronation Strike on tricep tendon just above olecranon Tap on patellar tendon

Expected Response Flexion of the elbow

Pathway Involved C5-6

Flexion of elbow C5-6

Brachoradial (Supinator)

Extension of elbow C6-8 (primarily C7) Leg extends L2-4 Plantiflexion of foot

Tricep

Patellar (knee jerk) Achilles (ankle jerk)

Tap on achillers tendon

S1-2

Abnormal reflex pathologic Indicates nuerologic d/o Often related to spinal cord injury/higher centers Babanski Snout Rooting Sucking Glabella Grasp Chewing reflex

Special Neurologic Assessment

Brudzinskis sign (pain, resistance, flexion of hips and knees when head flexed to chest with client supine)

Special Neurologic Assessment

Positive Kernigs sign - excessive pain when examiner attempts to straighten knees with client supine and knees and hips flexed

Special Neurologic Assessment

Decorticate posturing (up) - decorticate response, mummy baby, flexor posturingdamage to mesencephalic region and the corticospinal tract

Special Neurologic Assessment

Decerebrate posturing (down)- extensor posturing- the head is arched back, the arms are extended by the sides, and the legs are extended. Decerebrate posturing indicates brain stem damage or rather damage below the level of the red nucleus (eg. mid-collicular lesion)

Altered Level of consciousness

Requires: 1.Arousal: alertness; dependent upon reticular activating system (RAS); system of neurons in thalamus and upper brain stem 2. Cognition: complex process, involving all mental activities; controlled by cerebral hemispheres

Process that affect LOC:

a. Increased ICP b.Stroke, hematoma, intracranial hemorrhage c. Tumors d. Infections e. Demyelinating disorder

Systemic Conditions affecting LOC

Hypoglycemia F/E imbalance Accumulated waste products from liver or renal failure Drugs affecting CNS: alcohol, analgesics, anesthetics Seizure activity: exhausts energy metabolites Level of Consciousness

Level of Consciousness
Level I: Conscious, cognitive, coherent ( 3 Cs) Level II: Confused, drowsy, lethargic, obtunded, somnolent Level III: Stuporous, responds only to noxious, strong or intense stimuli (e.g. sternal pressure, trapezius pinch, pressure at the base of the nail, and very strong light or very loud sound) Level IV: Light Coma: Response is only grimace or withdrawing of limb from pain; primitive and disorganized response to painful stimuli Deep Coma: Absence of response to even the most painful stimuli

Glasgow Coma Scale (GCS)

It is an objective measure to describe level of consciousness It is based on the clients response in three areas: eye opening, motor response and verbal response

 The GCS scores is the sum of the three scores received for the eye, verbal and motor responses. In the case of an intubated patient (one with a tube in their trachea to help them breath), verbal function cannot be tested. These patients are given the worst score, a !, but a modifier is usually attached to indicate this. For example, a T (for tube) or V (for ventilated) is added, such as GCS 8T Remember the lowest score attainable is a 3 and this person would be comatose.

Reflex Testing
Reflexes are fast, predictable, unlearned, innate, and involuntary responses to stimuli Occurs at the level of the spinal cord but interpreted a the brain The center for reflex act is the spinal cord The cerebral cortex determines the motor response

Interpretation of Reflexes
0 = No response 1+= Diminished 2+= Normal 3+= Brisk, above normal 4+=Hyperactive