ASSESSMENT: Neurologic

ExaminationMa. Tosca Cybil A. Torres, RN, MAN

AN IMPORTANT ASPECT OF THE NEUROLOGIC

ASSESSMENT IS THE HISTORY OF

THE PRESENT ILLNESS

HEALTH HISTORY

Should include: • Onset• Character• Severity• Location • Duration • Frequency of s/sx• Associated complaints• Precipitating and

aggravating factors• Progression, remission,

and exacerbation

• Presence and absence of similar symptoms among family members

• Review of medical history

• History of falls or trauma• Use of alcohol,

medications and illicit drugs

Common Clinical Manifestations

• Pain (chronic or acute) • Seizures• Dizziness and vertigo • Visual disturbances • Weakness• Abnormal sensation

Physical Examination

• A neurological assessment is divided into five components: I. Cerebral function

II. Cranial nerves

III. Motor system

IV. Sensory system

V. Reflexes

• Follows a logical sequence and progresses from higher levels of cortical function (ex: abstract thinking) to lower levels of function (ex: determination of the integrity of the peripheral nerves)

I. Assessing cerebral function

Interpretation and documentation of neurologic abnormalities, particularly mental status abnormalities, should be

SPECIFIC and NONJUDGMENTAL.

Mental Status

• Assessment begins by observing client’s appearance and behavior• Posture• Gestures• Movements• Facial expressions• Motor activity • Manner of speech • LOC• Orientation

State of Awareness

State Description

Full consciousness Alert; oriented to time, place, person; understands verbal and written words

Disoriented Not oriented to time, place, or person

Confused Reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgment

Somnolent Extreme drowsiness but will respond to stimuli

Semicomatose Can be aroused by extreme or repeated stimuli

Coma Will not respond to verbal stimuli

Intellectual function

• Serial 7s• Interpretation of well-known

proverbs/idioms• Capacity to recognize similarities• Judgement

Though Content

¥ Is the patient’s thoughts: ø Spontaneous ø Naturalø Clearø Relevant ø Coherent

Check: • Illusions• Hallucinations• preoccupations

Emotional Status

• Assess:µAffectµMoodµConsistency of verbal

communication to non verbal cues

Perception

Agnosia- inability to interpret or recognize objects seen through the special senses.

♠Visual ♠Auditory ♠Tactile ♠Body parts and relationships

Motor Ability

• Ask client to perform a skilled act• Successful performance requires the

ability to understand the activity desired and normal motor strength

Language Ability

Aphasia- deficiency in language function• Broca’s Aphasia (non-fluent aphasia)- speech

output is severely reduced and is limited mainly to short utterances of less than four words.

• Wernicke’s Aphasia (fluent aphasia) -ability to grasp the meaning of spoken words is chiefly impaired, while the ease of producing connected speech is not much affected.

• Global aphasia- most severe form of aphasia, and is applied to patients who can produce few recognizable words and understand little or no spoken language. Global aphasics can neither read nor write.

Broca’s Aphasia

Wernicke’s Aphasia• Ex:

• I called my mother on the television and did not understand the door.

• It was too breakfast, but they came from far to near.

• My mother is not too old for me to be young.

II. Examining the Cranial Nerves CRANIAL NERVE CLINICAL EXAMINATION

I (OLFACTORY) With eyes closed, ask patient to identify familiar odor. Each nostril tested separately

II (OPTIC) Snellen Chart; ophthalmoscopic examination

III (OCULOMOTOR), IV (TROCHLEAR),VI (ABDUCENS)

Test for ocular rotations, nystagmus, conjugate movements Test for pupillary reflexes, ptosis

V (TRIGEMINAL) With eyes closed, touch forehead, cheeks, and jaw for sensitivity to sharp or dulls objects. If responses are incorrect, test for temperature sensationWhile looking up, lightly touch a wisp of cotton against each corneaHave client clench and move the jaw from side to side

VII (FACIAL) Observe symmetry while client performs facial movements Assess taste

CRANIAL NERVE CLINICAL EXAMINATION

VIII (ACOUSTIC) Whisper or watch-tick testTest for lateralization (Weber Test)Test for air and bone conduction (Rinne Test)

IX (GLOSSOPHARYNGEAL) Assess ability to swallow and discriminate b/w sugar and salt on posterior 3rd of tongue

X (VAGUS) Assess gag reflexNote hoarseness in voice and ability to swallow

XI (SPINAL ACCESSORY) Palpate and note strength of trapezius muscles while client shrugs shoulders against resistancePalpate and note strength of sternocleidomastoid muscle as client turns head against opposing pressure of the examiner’s hand

XII (HYPOGLOSSAL) While protruding the tongue, note any deviation or tremors. Ask client to move tongue from side to side against a tongue depressor

III. Examining the Motor System

• Assess muscle size, tone, and strength, coordination, and balance

• Note for rigidity, spasticity and flaccidity

• Muscle Strength Grading

0 – No contraction1 – Slight contraction, no movement2 – Full range of motion without gravity3 – Full range of motion with gravity4 – Full range of motion , some resistance5 – Full range of motion, full resistance

Balance and Coordination

• Rapid, alternating movements• Point-to-point testing • Ataxia- incoordination of voluntary muscle

action • Romberg test

• Stretch or Deep Tendon Reflexes A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmental level, and grading of DTR's is listed below.

Grading DTR's

0 – Absent1 – Decreased but present2 – Normal3 – Brisk and excessive4 – With clonus

IV. Examining the Reflexes

Reflexes

• Biceps reflex• Triceps reflex• Brachioradialis reflex• Patellar reflex• Ankle reflex

• Superficial reflexes• Corneal • Abdominal reflexes• Gag• Cremasteric• Plantar• perianal

V. Sensory Examination

The sensory examination is

largely subjective and

requires the cooperation of the patient.

• Assessment of the sensory system involves: • Tactile sensation • Superficial pain • Vibration • Integration of sensation • Proprioception • Stereognosis

Diagnostic Evaluation

• CT scan

• CT scan

• MRI

Cerebral angiography

Myelography

• An x-ray of the spinal subarachnoid space after injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture

Post myelography care

• Head elevated to 30-45 degrees for 3H or as prescribed by the AP

• Encouraged to increase OFI • Assess VS and ability to void • Untoward signs------headache, fever, stiff

neck, photophobia, and seizures

Electroencephalography (EEG)

Electromyography (EMG)

Lumbar Puncture

• CSF analysis• Queckenstedt’s test

• End of discussion