Chapter 21. Nervous System
Much of the neurologic assessment can be integrated with other areas of the assessment. Parents can be valuable aides in performing the neurologic assessment of a child because they are more aware of the child’s usual functioning. Parental concerns are important in alerting health professionals to delays, impairments, behavioral changes, and need for anticipatory guidance.
In performing the neurologic assessment, the nurse must be aware of age-appropriate levels of functioning.
Rationale
A thorough neurologic assessment is necessary whenever a child has sustained a fall, has suffered an injury to the head or spine, complains of headaches, or has a temperature of unknown origin. Children who have an apparent developmental delay or impairment and those with identified neurologic disorders should also undergo neurologic assessment. Neurologic impairment can delay a child’s development and functioning and must be identified early to minimize long-term disability.
Anatomy and Physiology
The nervous system is a complex integrated system, and its scope is beyond that of this text. Essentially the nervous system is composed of the brain, spinal cord, and peripheral nervous system. The brain is divided into the brainstem, cerebrum, and cerebellum. Except for the first cranial nerve, the cranial nerves emerge from the brainstem. The brainstem and the spinal cord are continuous. Consciousness arises from interaction between the cerebrum and brainstem. The cerebellum is primarily responsible for coordination. The full number of adult nerve cells is established midway through the prenatal period. Neurons, responsible for memory, consciousness, sensory and motor responses, and thought control, increase in size but not number after birth. Glial cells increase in both size and number until the age of 4 years. Dendrites, responsible for the transmission of impulses across synapses, increase in number and branchings. Axons increase in length. The size of the brain increases from 325 gm (11 oz) at birth to 1000 gm (2.2 lb) by 1 year of age (the adult brain weighs 1400 gm, or approximately 3 lb). Myelinization, begun in the fourth month of gestation, progresses throughout early infancy and childhood, until the child is able to move voluntarily and to engage in higher cortical functions. The order in which myelinization occurs corresponds to the normal sequence of development.
Equipment for Assessment of Nervous System
▪ Two safety pins
▪ Closed jars containing solutions with distinctive odors
▪ Cotton balls
▪ Reflex hammer
Preparation
Ask whether there is a family history of genetic disorders, learning disorders, or birth defects. Inquire whether the mother had difficulties during pregnancy or delivery. Ask the parent about prenatal history, consumption of drugs (such as alcohol, cocaine, heroin, and marijuana) during pregnancy, type of delivery, birth weight of the infant or child, and whether the infant or child had problems after birth. Ask whether the child has or has had recurrent headaches, neck stiffness, seizures, irritability, or hyperactivity. If the child has sustained an injury, determine the time of occurrence, the events surrounding the injury, the area of impact, whether consciousness was lost, and memory loss for events just before or after the injury. If concussion has been sustained, inquire about symptoms of postconcussion syndrome (PCS) (see box on p. 311).
Assessment of Mental Status
Mental status can be assessed formally and informally throughout the examination and includes intellectual or cognitive functioning, thought and perceptions, mood, appearance, and behavior (see Chapter 24 for a more detailed discussion of assessment of mental health). Intellectual functioning can be formally assessed through the use of the Denver Developmental Screening Test II (Denver II) (see Chapter 22), which is administered at specified intervals in some agencies but can be administered anytime a problem is suspected. Illness, injury, a strange environment, cultural and language differences, and the examiner’s approach can all influence intellectual functioning, mood, and understanding, so the nurse should compare findings against the parent’s observations of the child’s behavior.
| Assessment | Findings | ||
|---|---|---|---|
| Level of Consciousness (LOC) | |||
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Level of consciousness remains the most reliable and earliest indicator of changes in neurologic status and is a less variable indicator than vital signs, reflexes, and motor activity. LOC can be assessed using a pediatric version of the Glasgow Coma Scale (Figure 21-1).
Responses in each category are rated on a scale from 1 to 5. Whenever possible, have a parent present because a child might not respond actively to an unfamiliar person in an unfamiliar environment. It is also important to ask the parent about the child’s normal level of responsiveness.
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Normal children will score 15 on the Glasgow Coma Scale.
Clinical Alert
A score of 8 or less on the Glasgow Coma Scale indicates coma.
A variety of drugs affect pupil size and reaction to light. Pupils are pinpointed and fixed with narcotic ingestion; they are dilated and reactive to light with central nervous system stimulants and hallucinogens.
Photophobia occurs with bacterial meningitis, PCS, and some infectious diseases.
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| Posttraumatic Amnesia (PTA) | |||
| If traumatic brain injury has occurred, recall of events before and after the event can be useful in assessing the extent of the injury. In concussion, this information is included in a variety of grading systems (Table 21-1). Inquire about the child’s memory of the event (e.g., “Tell me what happened. What were you doing just before that? After that?”). | |||
| Assessment | Findings |
|---|---|
| Memory and Orientation | |
| Assess memory and orientation by asking the child for his or her name; city or town of residence; grade or birth date; and day, time, and year (older children). With athletes, studies suggest it might be more useful to ask questions that assess short-term memory, such as “What period were we in?” “What rink are we at?” and “Which side scored the last goal?” |
Clinical Alert
Cognitive function remains relatively intact in sports-related concussions; assessment of general orientation is therefore less sensitive than for other head injuries. Questions of short-term memory are more sensitive with sports-related injuries.
Headache and confusion may be the presenting symptoms in athletic related head injuries.
Athletes may not recognize that they have had a head injury or may be reluctant to report symptoms for fear of not being able to participate in sport.
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| Posture and Motor Behavior | |
| Assess the child’s level of activity, control of impulses, appropriateness of behavior to situation and developmental stage, repetitive movements, presence of culturally appropriate eye contact and interaction, withdrawal, cooperativeness, and argumentativeness. |
Motor behavior will vary with the age of the child and stage of development, what is acceptable within the family, and cultural norms.
Clinical Alert
Soft signs represent more primitive responses than might be expected for age and can indicate minimum brain dysfunction. Signs normally disappear with maturation. These include unusual body movement (e.g., mirroring), short attention span, easy distractibility, impulsivity, lability, hyperactivity, poor coordination, perceptual defects, learning difficulties, and language or articulation difficulties.
Hyperactivity, irritability, and diminished impulse control can indicate attention deficit disorder (ADD) or fetal alcohol syndrome.
Aggressiveness, irritability, disobedience, and emotional lability can indicate PCS when injury has occurred.
Hyperactivity, hypoactivity, and other behavioral changes can accompany the use of commonly abused drugs.
Withdrawal, diminished eye contact (unless culturally appropriate), slumped shoulders, and slowed movements can indicate depression.
Opisthotonus or hyperextension of the neck and spine, accompanied by pain on flexion of the neck, can indicate meningeal irritation or inflammation and should be immediately referred.
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| Assessment | Findings |
|---|---|
| Hygiene and Grooming | |
| Observe hygiene and grooming in older children and adolescents. Inquire if there have been changes in grooming habits lately that are of concern. |
Clinical Alert
Neglect of personal hygiene can indicate family stress, depression, PCS, fatigue related to sleep disturbances or injury, or substance abuse.
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| Mood | |
| Observe mood and intensity of mood (see Chapter 24 for detailed assessment). | |
Motor function can be assessed during assessment of the musculoskeletal system.
| Assessment | Findings |
|---|---|
| Observe the infant or child for obvious abnormalities that can influence motor functioning. Specifically, observe the size and shape of the head and inspect the spine for sacs and tufts of hair. |
Clinical Alert
A large head, enlarged frontal area, and tense fontanels (if open) can indicate hydrocephalus.
A dimple with a tuft of hair or a sac protruding from the spinal column can indicate spina bifida occulta.
A small head or microcephaly is associated with chromosomal abnormalities, prenatal exposure to toxic agents, maternal infections, and trauma during the perinatal period or infancy.
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| Assessment | Findings |
|---|---|
| Observe for handedness. |
Infants and toddlers do not display marked preference for one hand, although they might show some preference.
Clinical Alert
Singular use of one hand by a very young child can indicate paresis of the opposite side.
Failure to develop handedness in a school-age child can indicate failure of the brain to develop dominance.
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Test muscle strength and symmetry by asking the child to squeeze your fingers, press soles of feet against your hands, and push away pressure exerted on arms and legs.
Place all joints through range of motion. Note flaccidity or spasticity.
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Clinical Alert
Report any asymmetry.
Infants normally have the most flexible range of motion.
All school-age children should be able to perform these activities.
Clinical Alert
Retroflexion of the head, stiffness of the neck, and extension of the extremities accompanies the meningeal irritation of meningitis and intracranial hemorrhage.
Head lag after 4 months is an early sign of neurologic damage.
Hypotonia is associated with Down syndrome.
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| Assessment | Findings |
|---|---|
| Cerebellar function can be tested by asking the child to hop, skip, or walk heel-to-toe. A Romberg’s test can be performed by asking the child to stand still, eyes closed and arms at side. Stand near the child to catch the child if leaning occurs. |
Clinical Alert
Leaning to one side during a Romberg’s test indicates cerebellar dysfunction.
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Assessment of Sensory Function
Sensory function is assessed during testing of cranial nerve function.
Assessment of Cranial Nerve Function
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