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8/3/2019 NEURO REPRT
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NEUROLOGIC
ASSESSMENT
Presented by: Ms. Jeceli Alviola Nobleza, BSN-RN
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Learning Objectives:
After the presentation, we should be able to:
• Perform a physical assessment of the
neurologic system
• Document neurologic system findings
• Differentiate between normal and abnormal
findings
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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)
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• 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.
(Dillon,2007)
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REVIEW OF THEANATOMY AND PHYSIOLOGY
OF THE
NEUROLOGIC SYSTEM
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Cont. Review of Ana and Physio
General functions of the neurologic system include:
• Cognition, emotion, and memory.
• Sensation, perception, and the integration of
sensoryperceptual experience.• Regulation of homeostasis, consciousness,
temperature, BP, and other bodily processes.
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There are two types of nerve cells:(1) neuroglia and
(2) neurons
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Neuroglia
• Functions: a. act as supportive tissue, nourishing and protecting
the neurons
b. maintain homeostasis in the interstitial fluid aroundthe neurons and account for about 50 percent of the
central nervous system (CNS) volume
c. have the ability to regenerate and respond to injuryby filling spaces left by damaged neurons.
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Neurons
• Functions: a. have the ability to produce action potentials or
impulses (excitability or irritability) and
b. to transmit impulses (conductivity).
Sensory (afferent) neuron Motor (efferent) neuron
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Sensory (afferent) neuron Motor (efferent) neuron
Nisslbodies
nucleus
Axon
Myelin
Cell body
Receptorsin skin
dendriteNodes ofRanvier
Schwanncell
synapse
Presynapticterminal
Postsynapticmembrene
Postsynapticreceptor
Neurotransmittersubstance
Synapticcleft
Synaptic
vesicles
Neuromuscular junction
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Neurons band together into
- peripheral nerves,
- spinal nerves,- spinal cord, and
- tissues of the brain.
• These structures make up the neurologic system,which is divided into
- the CNS and
- the peripheral nervous system (PNS).
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CENTRAL NERVOUS SYSTEM
• consists of the brain and spinal cord.
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The Human Brain
CoordinationEquilibriumBalance
Visualperception
sensation
EmotionBehaviorIntellect
MotorSpeech Hearing
SmellTasteMemory
Speechcompensation
TEMPORAL LOBE
Broca’s Area
FRONTAL LOBE
Lateral fissure Central fissure
PARIETAL LOBE
Wernicke’s area
OCCIPITAL LOBE
Cerebellum
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The Spinal Cord
• The spinal cord descends through the foramen magnum (large aperture) of the occipital bone of the skull, through
the first cervical vertebra (C1), and through the remainder
of the vertebral column to the first or second lumbar
vertebra.• conducts sensory information from the peripheral nervous
system (both somatic and autonomic) to the brain
• conducts motor information from the brain to our various
effectors- skeletal muscles
- cardiac muscles
- smooth muscles
-glands• serves as a minor reflex center
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Sensory Pathways
• Pathways,either ascending or afferent,allow sensory
data, such as the feeling of a burned hand, to becomeconscious perceptions.
Sensorycortex
Trunk, Arm,Hand, Fingers,Face, Lips,Tongue
Leg
KneeFoottoes
pons
medulla
Posterior rootof the spinal
cord
Posterior columnFine touch, proprioceptionand vibration
Spinal cord
Anterior spinothalamic tract
Crude touch & pressure
Lateral spinothalamic tract
Pain &temperature
M t P th
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Motor Pathways• Motor pathways (descending or efferent) transmit
impulses from the brain to the musclesTrunk, Arm, Hand,Fingers, Face, Lips,
TongueLegKneeFoottoes
Motor Cortex
Skeletalmuscles
Lateral corticospinal(crossed pyramidal tract
Anterior corticospinal
(uncroosed pyramidal tract
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Spinal Reflexes• Spinal reflexes do not depend on conscious
perception and interpretation of stimuli, nor ondeliberate action; in other words, they do not
involve the brain.
• They occur involuntarily, with lightning speed, andare identical in all healthy children and adults,
although they are less developed
• in infants.
Reflex arc
Dorsal root ganglion
Motor nerve
Sensory nerve
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PERIPHERAL NERVOUS SYSTEM
• The peripheral nervous system consists of - the cranial
- spinal nerves and the
- peripheral autonomic nervous system.
Cranial Nerves
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Cranial NervesThe 12 pairs of cranial nerves originate from the brainand are called the peripheral nerves of the brain.
I-Olfactory nerve – Smell (S)
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I Olfactory nerve Smell (S)
II-Optic nerve - Vision (S)
III-Oculomotor nerve (M)
- Eye movement; pupil constrictionIV-Trochlear nerve (M)
- Eye movement
V-Trigeminal nerve (B)- Somatosensory information (touch, pain)
from the face and head; muscles for chewing.
VI-Abducens nerve - Eye movement (M)
VII-Facial nerve (B)
- Taste (anterior 2/3 of tongue); somatosensory
information from ear; controls muscles used
in facial expression.
VIII-Vestibulocochlear nerve/Auditory nerve (S)
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VIII Vestibulocochlear nerve/Auditory nerve (S)
- Hearing; balance
IX-Glossopharyngeal nerve (B)
- Taste(posterior 1/3 of tongue);- Somatosensory information from tongue, tonsil,
pharynx;
- controls some muscles used in swallowing.X-Vagus nerve (B)
- Sensory, motor and autonomic functions of
viscera (glands, digestion, heart rate)
XI-Accessory nerve/Spinal accessory nerve (M)
- Controls muscles used in head movement.
XII-Hypoglossal nerve (M)
- Controls muscles of tongue
Spinal and Peripheral Nerves
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Spinal and Peripheral Nerves• Branching from the spinal cord are 31 pairs of spinal
nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,and 1 coccygeal
• The spinal nerves contain both ascending and
descending fibers, and although there is someoverlap,each is responsible for innervation of a
particular area of the body.
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Dermatomes are regions of the body innervated by the
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Dermatomes - are regions of the body innervated by the
cutaneous branch of a single spinal nerve.
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Components of
Neurologic Exam
• Mental Status
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a. Appearance/ Hygiene/ Grooming/ Odor
b. Behavior
c. Speech/ Communication
d. Level of Consciousness
e. Memory
f. Cognitive function
• Cranial Nerve Function (12 cranial nerves)
• Sensory Functiona. Light touch b. Pain
c. Vibration d. Kinesthetics
e. Streognosis f. Graphesthesia
g. Two-point discrimination h. point localizationi. Sensory Extinction
• Reflex Function
a. Deep tendon reflexes
b. Superficial reflexes
Ensure proper hygiene before seeing a client
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p p yg g
Ensure all equipment is properly cleaned
Equipment Needed:- BP cuff - Tuning fork (128 or 256 Hz)
- Penlight - Nonsterile gloves
- Wisp of cotton - Tongue blade
- Reflex hammer
- Sharp object such as toothpick or sterile needle
- Objects to touch: coin, button, key or paperclip
- Something fragrant: rubbing alcohol or coffee- Something to taste: such as lemon juice, sugar or salt
- Two taste tubes or other vials
- Ophthalmoscope
Introduce self to the client.
Assessing the Mental Status
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Assessing the Mental Status
1. APPEARANCE/ HYGIENE/ GROOMING/ ODOR
a. Begin the assessment as the patient approaches
you.
b. Observe the general appearance, hygiene,
grooming and the odor of the client.
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Normal:
good grooming,
dress in appropriate to
temperature & weather,
no offensive or
unpleasant odor hair well kept or tied
Abnormal:
Poor hygiene
Unpleasant or offensivebody odor
2 BEHAVIOR
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2. BEHAVIOR
a. Assess the client’s mood and emotions b. Observe body language and facial expression or
affect
c. Note his or her posture
Ab lNormal:
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Abnormal:
Lack of facial expression
- Possible psychologicaldisorder (e.g., depression or
schizophrenia) or neurologic
impairment affecting cranial
nerves.
Masklike expression:
- Parkinson’s disease.
Slumped posture:- Depression if
psychological in origin; or stroke
with hemiparesis if physiological
in origin.
Normal:
Verbal expressions
match with thenonverbal behavior
Mood is appropriate to
the situation
Standing in upright
stance with parallel
alignment of hips
&shoulders
3 SPEECH/ COMMUNICATION
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3. SPEECH/ COMMUNICATIONa. Speech and Language
Listen to patient’s rate and ease of speech,including enunciation.
Normal:
Speech flowseasily; patient
enunciates clearly.
Sophistication of
speech matches age,
education, and
fluency.
Abnormal:
■ Hesitancy, stuttering,
stammering, unclear speech:- Lack of familiarity with language,
deference or shyness, anxiety,
neurologic disorder.■ Dysphasia/aphasia:- Neurologic problems such as stroke.
■ Drugs and alcohol can also cause
slurred speech.
b Spontaneous Speech & Motor Speech
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b. Spontaneous Speech & Motor Speech
- Show patient a picture and have him or her
describe what he or she sees.- Have patient repeat, “do, ray, me, fa, so, la, ti,
do.”
Normal:Spontaneous
speech intact.
Motor speechintact.
Abnormal:■ Impaired spontaneous speech:
- Cognitive impairment.
Impaired motor speech(dysarthria):
Problem with CN XII
c Autonomic Speech
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c. Autonomic Speech
Have patient say something that is committed
to memory, such as days of week or months of year.
Normal:
■ Automaticspeech intact.
Abnormal:
■ Impaired automatic speech:Cognitive impairment or
memory problem.
4 LEVEL OF CONSCIOUSNESS
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4. LEVEL OF CONSCIOUSNESS
a. Test orientation to time, place, and person
Normal:
Awake, alert, and
oriented to time,
place, and person
(AAO x 3)
Responds to
external stimuli
Abnormal:
Disorientation may be
physical in origin
Disorientation can also bepsychiatric in origin
(schizophrenia)
Lathargic or somnolentObtunded
Stupor
Coma
Glasgow Coma Scale
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Glasgow Coma Scale
- A standardized objective assessment that
defines the LOC by giving it a numeric value.
- Most often after brain surgery
- Document as E_V_M_; for example, E4V5M6.
GLASGOW COMA SCALE
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Eyes open
E
■ Spontaneously . . . . . . . . 4
■ To command . . . . . . . . . . 3
■ To pain . . . . . . . . . . . . . . . 2
■ Unresponsive. .. . . . . . . . . 1
Findings
Best verbal response
V
■ Oriented . . . . . . . . . . . . . . . 5
■ Confused . . . . . . . . . . . . . . . 4
■ Inappropriate . . . . . . . . . . . . 3
■ Incomprehensible . . . . . . . . 2■ Unresponsive. . . . . . . . . .. . . 1
Findings
Best motor response
M
■ Obeys commands . . . . . . . .. 6
■ Localizes pain. . . . . . . . . . . 5
■ Withdraws from pain. . . . …. 4
■ Abnormal flexion . . . . . . .. . . 3■ Abnormal extension . . . . . . . 2
■ Unresponsive. . . . . . . . . . . . . 1
Findings
Total______
From Wijdicks, et al, 2005, with permission.
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• The three numbers are added; the total score
reflects the brain functional level.
• A fully awake person = 15
• Coma = 7 or less
• The GCS assesses the functional state of the brain
as a whole, not of any particular site in the brain.
(Juarez and Lyon,1995)
Four Score Coma Measurement Scale EYE
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RESPONSE
4
3
2
10
Eyelids open or opened, tracking or blinking to command
Eyelids open but not tracking
Eyelids closed but open to loud voice
Eyelids closed but open to painEyelids remain closed with pain
MOTOR
RESPONSE
4
3
21
0
Thumbs up, fist, or peace sign to command
Localizing to pain
Flexion response to painExtensor posturing
No response to pain or generalized myoclonus status epilepticus
BRAINSTEM
REFLEXES
4
3
2
1
0
Pupil and corneal reflexes present
One pupil wide and fixed
Pupil or corneal reflexes absent
Pupil and corneal reflexes absent
Absent pupil, corneal, and cough reflex
RESPIRATION
4
3
21
0
Not intubated, regular breathing pattern
Not intubated, Cheyne-Stokes breathing pattern
Not intubated, irregular breathing patternBreathes above ventilator rate
Breathes at ventilator rate or apnea
5. MEMORY
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5. MEMORY
a. Test immediate recall:
Ask patient to repeat three numbers, such as “4, 9, 1.” If patient can do so, ask her or him to repeat a series of five
digits.
b. Test recent memory:
Ask what patient had for breakfast.
c. Test long-term memory:
Ask patient to state his or her birthplace, recite his or her
Social Security number, or identify a culturally specific personor event, such as the name of the previous president of the
United States or the location of a natural disaster.
Normal:
I di
Abnormal:
Memory problems can be
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Immediate, recent,
and remote
memory intact.
Memory problems can be
benign or signal a more
serious neurologic problem- such as Alzheimer’s disease.
Forgetfulness - especially for
immediate and recent events- often in older adults.
- With benign forgetfulness,
person can retrace or use memory
aids to help with recall.
Pathological memory loss
- as inAlzheimer’s disease
Cont Abnormal:
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Cont . Abnormal:
Temporary memory loss
- may occur after head trauma.
Retrograde amnesia
- for events just preceding illness or
injury.
Postconcussion syndrome
- can occur 2 weeks to 2 months
after injury and may cause short-term memory deficits.
6. COGNITIVE FUNCTION
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a. Mathematical and Calculative Ability
Ask patient to perform a simple calculation, such asadding 4 x 4. If successful, proceed to more difficult
calculation, such as 11 x 9.
Normal:Mathematical/calculativ
e ability intact and
appropriate for patient’sage, educational level,
and language facility.
Abnormal: Inability to calculate at
level appropriate to age,
education, and languageability requires evaluation
for neurologic impairment.
b. General Knowledge and Vocabulary
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g y
Ask how many days in a week and months in a year.
c. Thought Process
Ask patient to define familiar words such as “apple,”
“earthquake,” and “chastise.”
Begin with easy words and proceed to more difficultones.
Remember to consider the patient’s age, educational
level, and cultural background.
Normal:Thought
Abnormal: Incoherent speech
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Thought
process intact
Incoherent speech
illogical or unrealistic ideas
repetition of words and phrasesrepeatedly straying from topic
suddenly losing train of thought
(examples of altered thought processes thatindicate need for further evaluation)
Inability to define familiar words -
requires further evaluation
d. Abstract Thinking
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Assess the client to think abstractly.
Quote a proverb and ask the client to explain it’s
meaning
Normal:
Able to generalize from
specific example and applystatement to human
behavior.
Children should be ableto distinguish like from
unlike as appropriate for
theirage and language
facility.
Abnormal:
■ Impaired ability to think
abstractly:
- Dementia, delirium, menta
retardation, psychoses.
e. Judgment
Ob ti t’ t t it ti
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Observe patient’s response to current situation.
Ask patient to respond to a situation or
hypothetical situation.
Normal:
Judgment
appropriate and
intact.
Abnormal:
■ Impaired judgment can be
associated with dementia,
psychosis, or drug and alcohol
abuse.
Assessing the CRANIAL NERVES
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1. CN I — Olfactory Nerve
a. Before testing nerve function, ensure patency of each nostril by occluding in turn and asking patient
to sniff.
b. Once patency is established, ask patient to closeeyes.
c. Occlude one nostril and hold aromatic substance
such as coffee beneath nose.
d. Ask patient to identify
substance.
e. Repeat with other nostril.
Normal:■ Patient is able to
Abnormal:■ Anosmia is loss of sense of
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■ Patient is able to
identify substance.
(Bear in mind that
some substances may be
unfamiliar, especially to
children.)
■ Anosmia is loss of sense of
smell.
-May be inherited andnonpathological: chronic rhinitis,
sinusitis, heavy smoking, zinc
deficiency, or cocaine use.
- It may also indicate cranial nervedamage from facial fractures or
head injuries, disorders of base of
frontal lobe such as a tumor, or
artherosclerotic changes.
- Persons with anosmia usually also
have taste problems.
2. CNs II, III, IV, and VI — Optic, Oculomotor,
T hl d Abd N
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Trochlear, and Abducens Nerves
a. Ask the client to read a printed material, observe thedistance between the printed material and the client’s eyes.
b. Use the snellen chart to check/ test:
- distant vision
- colorClient should be 20 feet distant from the chart
Use an object to occlude one eye
Evaluate the vision one eye at a time
c. Evaluate the Extra Ocular Movements of the Eyesd. Convergens & Accomodation
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e. Pupillary Light Reflex
- using direct and consensual pupillary reaction to light
Testing eyemovements
Testing pupilaccommodation
Normal:■ Able to read without
Abnormal:■ CN II deficits
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difficulty
■ Visual acuity intact20/20, both eyes Hippus phenomenon:
- Brisk constriction of
pupils in reaction to light,
followed by dilation and
constriction
- may be normal or signof early CN III
compression.
- can occur with stroke or brain
tumor.■ Changes in pupillary
reactions- can signal CN III deficits.
■ Increased ICP causes
changes in pupillary reaction.
As pressure increases,
response becomes moresluggish until pupils
finally become fixed and
dilated.
3. CN V — Trigeminal Nerve
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a. Testing motor function:
- Ask patient to move jaw from side to side againstresistance and then clench jaw as you palpate
contraction of temporal and masseter muscles, or
to bite down on a tongue blade.
Testing CN V –
motor function
b. Testing sensory function:
A k ti t t l
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- Ask patient to close eyes
- Touch the face with the wisp of cotton
- Instruct to tell you when he or she feels
sensation on the face.
- Repeat the test using sharp and dull stimuli
(toothpick)- Instruct to say “Sharp” or “Dull”
(Be random, don’t establish a pattern)
- Compare both bilaterally.
Testing CN V –
sensory function
c. Testing corneal reflex:
Gentl to ch cornea ith cotton isp
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- Gently touch cornea with cotton wisp.
oTouching cornea can cause abrasions.
Alternative approach is to:
> puff air across cornea with a needless
syringe, or
> gently touch eyelash and look for blink reflex.
Testing corneal
reflex
Normal:
Full range of motion
Abnormal:Weak or absent contraction
Cont. CN V
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Full range of motion
(ROM) in jaw and 15
strength.
Patient perceives
light touch and
superficial painbilaterally.
Weak or absent contraction
unilaterally:
- Lesion of nerve, cervical spine, orbrainstem.
Inability to perceive light touch
and superficial pain
- may indicate peripheral nerve
damage.
■ Tic douloureux:
- Neuralgic pain of CN V caused bythe pressure of degeneration of a
nerve.
■ Corneal reflex test used in
patients with decreased LOC- to evaluate inte rit of brainstem.
4. CN VII — Facial Nerve
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a. Testing motor function:
- Ask patient to perform these movements: smile,frown, raise eyebrows, show upper teeth, show
lower teeth, puff out cheeks, purse lips, close eyes
tightly while nurse tries to open them.
Testing CN VII – motorfunction
b. Testing sensory function:
Test taste on anterior two thirds of tongue for
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- Test taste on anterior two-thirds of tongue for
sweet, sour, salty.
Testing taste sensation
Sweet:
Tip of the tongue
Sour:
Sides of back half of
tongue
Salty:
Anterior sides and tip of
tongue Bitter: Back of tongue
Normal:
Facial nerve intact;
Abnormal:
Asymmetrical or impaired
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Facial nerve intact;
able to make faces.
Taste sensation on
anterior tongue intact.
(Taste decreased inolder adults.)
Asymmetrical or impaired
movement:
- Nerve damage, such as that
caused by Bell’s palsy or stroke.
■ Impaired taste/loss of taste:
- Damage to facial nerve,chemotherapy or radiation
therapy to head and neck.
5. CN VIII — Acoustic Nerve
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a. Perform Weber and Rinne tests for hearing
b. Perform watch-tick test by holding watch close to patient’s ear.
c. Perform Romberg test for balance
- Nurse at the back or side of the pt.
- Instruct client to stand straight, feet together,hands at the side and eyes closed.
(Evaluates the balancing function of the CN VIII)
Watch tick test
Normal:
Hearing intact
Abnormal:
Hearing loss nystagmus
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Hearing intact.
Negative Romberg
test.
Hearing loss, nystagmus,
balance disturbance,
dizziness/vertigo:
- Acoustic nerve damage.
■ Nystagmus:
- CN VIII, brainstem, orcerebellum problem or
phenytoin (Dilantin)
toxicity.
6. CNs IX and X — Glossopharyngeal and Vagus
Nerves
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Nerves a. Observe ability to cough, swallow, and talk.
b. Test motor function:- Ask patient to open mouth and say “ah”
while you depress the tongue with a tongue
blade.- Observe soft palate and uvula. Soft palate
and uvula should rise medially.
Testing CN IX and
X – motor function
c. Test sensory function of CN IX and motor functionof CN X by stimulating gag reflex.
T ll ti t th t i t t h i t i
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- Tell patient that you are going to touch interior
throat- then lightly touch tip of tongue blade to
posterior pharyngeal wall.
- Observe the pharyngeal movement.
- Ask the client to drink a small amount of water
Note the ease & difficulty of swallowing
Note quality of the voice or hoarsenesswhen speaking
Normal:Swallow and cough
Abnormal:Unilateral movement:
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g
reflex intact.
Speech clear.Elevation and
constriction of
pharyngealmusculature and
tongue retraction
indicate positive gag
reflex.
- Contralateral nerve damage.
- Damage to CNs IX and X also impairsswallowing.
■ Changes in voice quality (e.g.,
hoarseness): CN X damage.
- CN X damage may also affect vital
functions, causing arrhythmias because
vagus nerve innervates most of viscera
through parasympathetic system.
■ Diminished/absent gag reflex:
Nerve damage.- Evaluate further because patient is at
increased risk for aspiration.
■ Impaired taste on posterior portion
of tongue: Problem with CN IX.
7. CN XI — Accessory Nerve
a Test motor function of shoulder and neck muscles:
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a. Test motor function of shoulder and neck muscles:
- Ask patient to shrug shoulders upward against
your resistance. (Trapieze muscle)
- Then ask her or him to turn head from side to
side against your resistance.
(Strenoclaidomastoid msucle)- Observe for symmetry of contraction and
muscle strength.
Normal:
Movement
Abnormal:
Asymmetrical
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symmetrical, with
patient moving
against resistance
without pain.
■ Full ROM of neck with +5/5 strength.
y
Diminished
Absent movement
Pain
unilateral or bilateral
weakness:- Peripheral nerve CN XI
damage.
8. CN XII — Hypoglossal Nerve
a. Have patient say “d, l, n, t” or a phrase containing
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a. Have patient say d, l, n, t or a phrase containing
these letters.
- The ability to say these letters requires use
of the tongue.
b. Ask the patient to protrude the tongue.
Observe any deviation from midline, tumors,lesions, or atrophy.
Now ask the patient to move the tongue from
side to side.
Testing CN XII – motor function
Normal:
Can protrude
Abnormal:
Asymmetrical/diminished/
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Can protrude
tongue medially.
No atrophy,
tumors, or
lesions.
y
absent movement/deviation
from midline/protruded tongue:
- Peripheral nerve CN
XII damage.
■ Tongue paralysis results indysarthria.
Assessing Sensory Function
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1. Light Touch
- Brush a light stimulus such as a cotton wisp over
patient’s skin in several locations, including torso and
extremities.
Normal: Identifies areas
stimulated by light
touch.
Abnormal:Diminished/absent cutaneous
perception:-Peripheral nerve damage or damage to
posterior column of spinal cord.
- Peripheral neuropathies can also cause
sensory deficits.
■ Hypesthesia: Increased sensitivity.
■ Paresthesia: Numbness and tingling.
■ Anesthesia: Loss of sensation.
2. Pain - Stimulate skin lightly with sharp and dull ends of
t th i k/ li
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toothpick/ paper clip
-Apply stimuli randomly and ask patient to identifywhether sensation is sharp or dull.
-Touch patient’s skin with test tubes filled with hot or
cold water.
-Apply stimuli randomly, and ask patient to identifywhether sensation is hot or cold.
Normal:
Identifies areas
Abnormal:Diminished or absent pain
perception:
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stimulated and type
of stimulation.
perception:
- Peripheral nerve damage or damageto lateral spinothalamic tract.
■ Hyperalgia:
Increased pain sensation.
■ Hypoalgesia:Decreased pain sensation.
■Analgesia: No pain sensation.
■ Diminished/absent temperature
perception:
- Peripheral nerve damage or damage
to lateral spinothalamic tract
3. Vibration -Place a vibrating tuning fork over a finger joint, and
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then over a toe joint.
-Ask patient to tell you when vibration is felt andwhen it stops.
- If patient is unable to detect vibration, test proximal
areas as well.
Normal:
Vibratory
Abnormal:Diminished/absent vibration
sense:
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sensation intact
bilaterally inupper and lower
extremities.
sense:
- Peripheral nerve damage causedby alcoholism, diabetes, or damag
to posterior column of spinal cord.
4. Kinesthetics (Position Sense) -Determine patient’s ability to perceive passive
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movement of extremities.
- Hold fingers on sides and move up and down, andhave patient identify direction of movement.
-Flex and extend patient’s big toe, and ask patient to
describe movement as up or down. • Avoid moving the patient’s
finger by placing your finger on
top of the patient’s because the
patient may sense the pressure of your finger rather than a true
position change.
• If position sensation is intact
distally, it is intact
proximally.
Normal:
Position sensation
Abnormal:
■ Diminished or absent position
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intact bilaterally in
upper and lowerextremities.
sense:
- Peripheral nerve damage or damageto posterior column of spinal cord.
5. Stereognosis
With patient’s eyes closed, place a familiar object,
h i b i i ’ h d d k
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such as a coin or a button, in patient’s hand, and ask
patient to identify it.■ Test both hands using different objects.
Normal: Stereognosis
intact bilaterally.
Abnormal:■ Abnormal findings suggest a
lesion or other disorder involving
sensory cortex or a disorderaffecting posterior
column.
6. Graphesthesia
- With patient’s eyes closed, use point of a closed
b i ’ h d
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pen to trace a number on patient’s hand
- Ask patient to identify the number.
Normal:
Graphesthesia
intact bilaterally.
Abnormal:
■ Abnormal findings suggest
lesion or other disorder involvingsensory cortex or disorder
affecting posterior
column.
7. Two-Point Discrimination
Ability to differentiate between two points of
i lt ti l ti
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simultaneous stimulation.
- Using ends of two toothpicks/ paper clip,stimulate two points on fingertips
simultaneously.
- Gradually move toothpicks together, and assesssmallest distance at which patient can still
discriminate two points (minimal perceptible
distance).- Document distance and location.
Normal:
Discriminates
bet een t o points
Abnormal:
■ Abnormal findings suggest
l i h di d i l i
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between two points
on fingertips nomore than 0.5 cm
apart and on hands no
more than 2 cm apart.
lesion or other disorder involvin
sensory cortex or disorder
affecting posterior
column.
8. Point Localization
■ Ability to sense and locate area being stimulated.
With ti t’ l d t h th h
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■ With patient’s eyes closed, touch an area; then have
patient point to where he or she was touched.■ Test both sides and upper and lower extremities.
Normal:
Point localizationintact.
Abnormal:
Abnormal findings suggest lesioor other disorder involving sensor
cortex or disorder affecting
posterior column.
9. Sensory Extinction
■ Simultaneously touch both sides of patient’s body
at same point
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at same point.
■ Ask patient to point to where she or he wastouched.
Normal:
Extinction intact.
Abnormal:
Identification of stimulus on onlyone side suggests lesion or other
disorder involving sensory cortical
region in opposite hemisphere.
REFLEXESDocumenting Reflex Findings
• Use these grading scales to rate the strength of each
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g g g
reflex in a deep tendon and superficial reflex assessment.Deep tendon reflex grades
0 absent
+ present but diminished
+ + normal+ + + increased but not necessarily pathologic
+ + + + hyperactive or clonic (involuntary contraction
and relaxation of skeletal muscle)
Superficial reflex grades
0 absent
+ present
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• Documentation of reflex finding
ASSESSING REFLEXES1. Deep Tendon Reflexes
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a. Biceps Reflex■ Rest patient’s elbow in your nondominant hand,
with your thumb over biceps tendon.
■ Strike your thumbnail.
Normal:
■ Contraction of biceps with flexion of forearm.■ +2
b. Triceps Reflex
■ Abduct patient’s arm and flex it at the elbow.
S t th ith d i t h d
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■ Support the arm with your nondominant hand.
■ Strike triceps tendon about 1 to 2 inches above
olecranon process, approaching it from directly
behind.
Normal:
■ Contraction of triceps with extension at elbow.
■ +2
c. Patellar Reflex
■ Have patient sit with legs dangling.
St ik t d di tl b l t ll
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■ Strike tendon directly below patella..
Normal:
■ Contraction of quadriceps with extension of
knee.■ + 2
d. Achilles Reflex
■ Have patient lie supine or sit with one kneeflexed
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flexed.■ Holding patient’s foot slightly dorsiflexed,strike Achilles tendon.
Normal:
■ Plantar flexion of foot.■ + 2
e. Test for Ankle Clonus
■ If you get 4 reflexes while supporting legand foot quickly dorsiflex foot
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and foot, quickly dorsiflex foot.
Normal:
■ No contraction
Abnormal:
■ Absent/diminished DTRs:
Degenerative disease; damage to peripheral nerve
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- Degenerative disease; damage to peripheral nerve
such as peripheral neuropathy; lower motor neuron
disorder, such as ALS and Guillain-Barré syndrome.
■ Hyperactive reflexes with clonus:
- Spinal cord injuries, upper motor neuron disease suchas MS.
■ Rhythmic contraction of leg muscles and foot is
positive sign of clonus- indicates upper motor neuron disorder.
2. Superficial Reflexes
a. Abdominal Reflex
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■ Stroke patient’s abdomen diagonally from upper and lower quadrants toward umbilicus.
■ Contraction of rectus abdominis. Umbilicus
moves toward stimulus.
a. Abdominal Reflex
■ Gently stroke skin around anus with glovedfinger.
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finger.
Normal: ■ Anus puckers.
b. Cremasteric Reflex
■ Gently stroke inner aspect of a male’s thigh.
Normal: ■ Testes rise.
c. Bulbocavernosus Reflex
■ Gently apply pressure over bulbocavernousmuscle on dorsal side of penis.
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muscle on dorsal side of penis.
Normal: ■ Bulbocavernosus muscle contracts.
d. Plantar Reflex (Babinski’s Response)
■ Stroke sole of patient’s foot in an arc from
lateral heel to medial ball.
Normal:
■ Flexion of all toes.
Assessing the Cerebellar Function1. Balance tests
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a. GaitObserve as the person walks 10-20 feet, turns,
and returns to the starting point.
Normal:
Person moves with a
sense of freedom.
Gait is smooth,
rhythmic, andeffortless
Opposing arm swing
is coordinated
The turns are smooth
Abnormal:Stiff, immobile posture. Staggering
or reeling. Wide base of support
Lack of arm swing or rigid arms
Unequal rhythm of steps. Slappingof foot. Scraping of toe of shoe
Ataxia – uncoordinated or unsteady
gait.
Perform Tandem Walking
- ask the person to walk a straight line in a heel-
to-toe fashion.
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to toe fashion.
This decreases the base of support and will
accentuate any problem with coordination.
Normal:
Person can walk Abnormal:Crooked line walk
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straight and staybalanced
Widens base to maintain balanceStaggering, reeling, loss of
balance
An ataxia that did not appear
now. Inability to tandem walk is
sensitive for an upper motor
neuron lesion, such as multiple
sclerosis.
b. The Romberg Test
(discussed previously)
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• Ask the person to perform a shallow knee bend orhop in place, first on one leg, then the other.
- this demonstrates normal position sense, muscle
strength, and cerebellar function.(some individuals cannot hop owing to aging or
obesity)
Normal:
Negative Romberg
test
Abnormal:Sways, falls, widens base of feet
to avoid falling
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Positive Romberg sign-Loss of balance that occurs
when closing the eyes.
-Occurs with cerebellar ataxia
(multiple sclerosis, alcoholintoxication)
-Loss of proprioception, and
loss of vestibular function
2. Coordination and Skilled Movements
a. Rapid Alternating Movements (RAM)
Ask the person to pat the knees with both hands,
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p p ,
lift up, turn hands over, and pat the knees with the
backs of the hands.
Then ask to do this faster.
Normal: done with equal
turning and quick
rhythmic pace
Abnormal:Lack of coordination
Dysdiadochokinesia
- Slow, clumsy, and sloppy
response- occurs with cerebellar
disease
b. Finger-to-Finger test
With the persons eyes open, ask that he or she use
index finger to touch your finger, then his or her
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own nose.After a few times move your finger to a different
spot.
Normal: Movement is
smooth and accurate
Abnormal: Dysmetria
- clumsy movement with
overshooting the mark
- occurs with cerebellar
disorder
Past-pointing
- constant deviation to one side
c. Finger-to-nose test
Ask the person to close the eyes and to stretch out
the arms.
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Ask the person to touch the tip of his or her nosewith each index finger, alternating hands and
increasing speed.
Normal: Done with accurate
and smooth
movement
Abnormal:Misses nose.
Worsening of coordination when
the eyes are closed
- occurs with cerebellar disease
sources• Dillon, Patricia. Nursing Health Assessment. 2nd
Ed. F.A. Davis. 2007
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Ed. F.A. Davis. 2007
• Jarvis, Carolyn. Physical Examination and Health
Assessment. 3rd ed. New York: W.B. Saunder
Company.2000
• Bickley. Lyn and Hoekenan, Robert. Bate’s Guide
to Physical Examination and History Taking. 7th
ed. New York: Lippincott Williams and Wilkins.
1999
• Estes, Mary Ellen Zator. Health Assessment &
Physical Examination. 3rd ed. Delmar Learning.
2006