Adjunct assessments performed if further information required.
- If abnormal findings on routine, add the following to gain more information:
- Brainstem reflexes
- Nuchal rigidity
- Babinski’s Reflex
- Doll’s Eyes
- Brainstem Reflexes
- Use suction catheter if ventilated
- Use yankauer in back of throat to test
- Cotton wisp touching cornea
- Blink = present
- Absence indicates oversedation (i.e. overdose) or neurological deficit
- Nuchal Rigidity
- Stiff neck, unable to flex forward
- Kernig’s sign
- Lying on back, hips flexed
- Can’t straighten knee
- Brudzinski’s sign
- Try to bend head forward, knees automatically pull toward chest
- Indicates meningeal irritation (i.e. meningitis)
- Babinski’s Reflex
- Use dull part of pen or reflex hammer to rub up foot and across the ball
- Toes curl = negative Babinski
- Toes fan out = positive Babinski
- Normal- newborn to 2 years
- Abnormal any time later
- Indicates neurological disorder versus other condition
- Doll’s Eyes
- Hold eyes open, turn head left to right
- If eyes look straight ahead while head turns = negative Doll’s Eyes
- If eyes turn WITH head (as if painted on, like a doll) = positive Doll’s Eyes
- Indicates loss of brainstem function → brain death
- Purpose for assessments
- Possible indication of findings
- Plan of care
- May be educating family if patient is unconscious
In this lesson we’re going to talk about adjunct neuro assessments. These are assessments you can ADD to your routine neuro exam if you need more information or want to go in further depth. These are especially helpful if your patients have abnormal findings on their routine exam.
So we use the adjuncts to determine further severity of neuro deficits and sometimes to rule out certain causes. The most common adjuncts that we can do are the brainstem reflexes – cough, gag, and corneal. In the ICU, these become part of your routine assessment, but in standard practice they are adjuncts. There isn’t really a way to test a cough on someone who isn’t intubated – but if they do have an advanced airway, we use a suction catheter to advance down into their airways. That should elicit a cough when it gets close to the bronchi. For other patients we check the gag reflex. This is especially important because it tells you whether the patient can protect their own airway – we use a yankauer to go into the back of their throat to elicit a gag reflex. If the aren’t coughing and don’t gag, chances are they are not going to be able to protect their airway. Then we assess the corneal reflex, which is the blink reflex by using a cotton swab and lightly touching the cornea – the patient should blink. If none of these reflexes are present, there is a risk of brainstem damage. The other three tests we’ll talk about are nuchal rigidity, babinski, and doll’s eyes.
When we talk about nuchal rigidity, we are usually looking at meningitis. If the patient presents with other symptoms like a headache, high fever, altered mental status, etc., then we will also check nuchal rigidity. With the patient lying on their back, try to lift their chin toward their chest. You’ll see either their shoulders and torso rise with it or you’ll see their knees pop up towards their chest. That’s called Brudzinski’s sign. The other thing you’ll see is that when they’re laying on their back with their hips flexed, like this …they can’t straighten their leg entirely – that’s called Kernig’s sign. All of this is caused by irritation in the meninges, so it’s important to check this to help rule meningitis in or out. Check out the meningitis lesson to learn more about that process.
The babinski reflex is what’s called a primitive reflex. It’s actually normal in children under 2 years old. But anytime after that, you would not expect to see it. So in an adult, when you stroke their foot in an upward and across motion like this, their toes should curl forward. It’s like protection, that’s the normal appropriate response, and that’s a negative Babinski. If their toes fan out and extend, that’s an abnormal finding, that’s considered a positive Babinski – which is a bad sign. Things that could have a positive Babinski would be brainstem lesions, meningitis, neuromuscular disorders, and stroke. Things that will NOT cause a positive Babinski – hyper or hypoglycemia, drug overdose, or metabolic conditions. So if you have a patient come in with altered mental status, doing a babinski reflex can tell you relatively quickly whether you’re dealing with a neurological issue or something. Now, not all neurological issues have it, but you can bet that if you DO have a positive Babinski – it’s a neuro issue.
Now Doll’s Eyes Reflex is something we’ll see tested when we suspect herniation or brain death, which we’ll talk about in a coming lesson. This is only tested on an unresponsive patient. It is automatically considered negative in an alert patient. To test it, you hold the patient’s eyes open and turn their head side to side. If their eyes keep looking straight while their head moves that’s negative. BUT, if the eyes move side to side WITH the head – as if they were painted on like a doll’s eyes – that’s considered positive. Think about it like this – in order for the eyes to move within the eye sockets, it requires muscles. If their eyes stay looking at you while you turn their head, then actually the patient is moving their eyes within their eye sockets . So if they have no brain stem reflexes or are brain dead, they won’t be able to move their eyes within the sockets, so it looks like they’re painted on when you turn their head. This is a hard one to describe, but the first time you see it you will understand.
So remember these tests help us to determine the source of the problem or the severity when we add them to our routine assessments. We check basic brainstem reflexes like cough, gag, corneal – even patients in a coma should have these if there’s no brainstem involvement. Nuchal rigidity will tell us there’s likely meningitis going on. A positive babinski’s tells us it is a neurological disorder as opposed to another source like a drug overdose or metabolic issue. And then Doll’s Eyes help us to determine if the patient still has any brain function or if they might be brain dead. Check out the brain death lesson to learn more about the other ways we test for and confirm that.
Use your clinical judgment to determine which of these adjuncts you might need to add to your neuro exam. You’re gonna be super impressive in clinicals if you ask about the patient’s babinski reflex! Now go out and be your best selves today, and as always, happy nursing!