Neurological Exam and Screening: Clinical Pearls for the Nurse Practitioner

Neurologic screening is a long and complicated but essential part of evaluating a patient with a neurologic complaint. Neurologic complaints, such as headaches, dizziness, memory loss, and loss of consciousness, are widespread issues that Nurse Practitioners in a primary care setting will surely see and need to address. This article will cover some of the essential parts of the neurological exam and help guide Nurse Practitioners through the diagnostic process. 

Related: Neurology Expert Exam: Clinical Pearls for the Nurse Practitioner 

What is the most essential component of the neurological exam? 

History is the most important part of a neurological exam. As with other body systems, an accurate report of the patient’s history will provide the Nurse Practitioner with the diagnosis 80-90% of the time. 

However, neurology has a unique complication: The patient may not be able to provide an accurate and complete history. Especially in the cases of delirium or dementia, patients may not be able to provide Nurse Practitioners with an accurate picture of their neurologic history. They may even report no abnormalities at all. In talking with the patient’s family members, a Nurse Practitioner will get a very different story. 

When Nurse Practitioners are working to understand a patient’s symptoms in their neurologic history, they must receive reports not only from the patient, but also from family members, caregivers, or witnesses. Finally, remember that you as the Nurse Practitioner seeing the patient can also assess the patient’s symptoms as you see them. 

Do patients with neurologic complaints require a full systems assessment? 

It is important for Nurse Practitioners to remember that neurologic symptoms can be triggered by cardiac events or other underlying conditions. Therefore, when seeing patients with neurologic complaints, Nurse Practitioners should always complete a thorough review of systems.  

Why is it important to know what medications a patient is taking? 

It is important for Nurse Practitioners to ask patients about their medications when taking a full neurologic history of the patient. Certain medications can cause or exacerbate symptoms of neurologic disorder. For example, calcium-channel blockers can cause individuals to present with syncope or near-syncope.  

Beta-blockers are another medication that has the potential to cause many side effects on the central nervous system. These include delirium, hallucinations, and fatigue. Understanding a patient’s current and recent medication list is an essential step in properly conducting a neurologic assessment. 

Why do Nurse Practitioners ask about menstrual cycles when conducting a neurological exam? 

Another important consideration for a neurological exam is pregnancy. Pregnancy-induced headaches are a common neurologic complaint, and it is important to be able to rule out pregnancy when evaluating a patient with this type of neurologic complaint. 

What are the most common neurological complaints? 

The five most common complaints a Nurse Practitioner will see in neurology are: 

  • Headaches or migraines 
  • Loss of consciousness or syncope 
  • Dizziness or vertigo 
  • Memory impairment 
  • Sensory changes, such as numbness, tingling, and pain 

What is involved in a symptom analysis? 

The symptom analysis in a neurological exam should include the following:  

  • How long the symptoms have been going on 
  • The location of particular symptoms 
  • What people have tried to make it better 
  • What is aggravating the complaint 
  • What is making the complaint better 

What are the essential parts of a neurological examination? 

Evaluating a patient for a neurologic injury or disorder involves several screenings. First, the Nurse Practitioner must conduct tests to assess the health of the cranial nerves. Then, a motor examination assesses a patient’s coordination, strength, and stability. Finally, the sensory screening examination assesses touch, pain, vibration, and position sensation to check for neuropathy. 

What tests are involved in an assessment of the cranial nerves? 

As there are twelve cranial nerves, there are twelve tests that must be completed to ensure the relevant cranial nerve is functioning properly. 

  • Olfactory: The patient must be able to identify a common scent from each nostril with their eyes closed. Be sure not to use a non-astringent odor, like alcohol.  
  • Optic: Test visual acuity and visual fields (testing each eye separately and then together) and conduct the fundoscopic exam. 
  • Oculomotor: A test of accommodation, the patient focuses from a distant to a near object. This allows a Nurse Practitioner to see the pupils constrict and the eyes converge. 
  • Trochlear: This cranial nerve controls depression, adduction, and intorsion of the eye. Assess by asking a patient to follow your finger through the six cardinal positions of gaze.  
  • Trigeminal: Assessment of Cranial Nerve V involves light touch and pain response. Palpate facial muscles to elicit blinking in response to corneal sensation. 
  • Abducens: This cranial nerve controls abduction (or lateral movement) of the eye. Test in conjunction with Cranial Nerve IV. 
  • Facial: Examine facial structures while the patient is at rest, smiling, frowning, puffing out their cheeks, raising eyebrows, and showing teeth. 
  • Glossopharyngeal: The glossopharyngeal nerve governs the gag reflex. While evaluating Cranial Nerve X, ask the patient to say ‘ahh.’  
  • Vagus: The vagus nerve is also responsible for autonomic fibers to the esophagus, stomach, small intestine, heart, and trachea. While this is not evaluated in primary care, it is important for Nurse Practitioners to know. 
  • Spinal accessory: Have the patient rotate their head against resistance. Test the patient’s shoulder elevation with and without resistance.  
  • Hypoglossal: Test the patient’s motor control of the tongue.  

What is involved in a motor examination? 

After completing a cranial nerve exam, Nurse Practitioners can move on to the motor examination. There are five main components of the motor examination: 

  • Gait: Arms should swing at their sides with no instability or incoordination. Gait problems may arise from Midline Cerebellar Syndrome, Unilateral Cerebellar Syndrome, or Parkinson’s Disease. 
  • Heel-to-toe ambulation, or tandem walking: Assess for instability, impaired coordination, or the presence of ataxia. Abnormalities would be present in cases of Parkinson’s, Hemiplegia, Front lobe abnormalities, or Cerebellar abnormalities. 
  • Strength: Check for both upper and lower extremity strength and ensure bilateral symmetry. 
  • Pronator drift: Patients unable to maintain the position of palms up and hands extended out have a positive pronator drift. This may be a symptom of a lesion in the spinal tract.  
  • Reflexes: Lastly, Nurse Practitioners must conduct deep tendon reflex tests to ensure a response is present and the same bilaterally. It is important to compare both sides of the body to ensure a bilateral response, as its absence is a clear indication of a neurologic injury to that area.   

What is involved in a Sensory Neurologic Screening Examination? 

In the third part of the neurological examination, the sensory exam, Nurse Practitioners must assess for sensation to light touch, pain, vibratory, and position sense. The absence of sensation may be indicative of a nerve root injury or a neuropathy such as diabetic neuropathy or peripheral neuropathy. 

Nurse Practitioners must assess the sensory response of both upper and lower extremities and be sure to ask the patient to confirm bilateral symmetry of the sensation. Assess light touch using a cotton swab and pain with a light pinprick.  

Why is it important for Nurse Practitioners to conduct a full sensory examination on patients? 

To assess vibration, a Nurse Practitioner can use a tuning fork and ensure the patient can feel the vibration. This step is especially important because patients with diabetic neuropathy often lose vibratory sensation first. It is estimated that neuropathy may already be present in up to 40-75% of patients at the time of diabetes diagnosis. 

Earn CE hours with our online course on Neurology Expert Exam: Clinical Pearls for the Nurse Practitioner (free with Passport Membership)! 

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