Date post: | 11-Jun-2015 |
Category: |
Health & Medicine |
Upload: | anu-radha |
View: | 356 times |
Download: | 11 times |
THE NEUROLOGICAL EXAMINATION
Anuradha .Y
INTRODUCTION:
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired.
Neurological Anatomy
• Nervous system- divided into 2 structural parts
• Central Nervous System (CNS)- brain & spinal cord
• Peripheral Nervous System – cranial nerves (carry impulses to and from brain) & spinal nerve (carry messages to and from spinal cord
ASSESSMENT OF THE NERVOUS SYSTEM
Interview to identify presence of: • headache • difficulty with speech (dysphasia)• inability to read or write • alteration in memory • altered consciousness • confusion or change in thinking • disorientation • decrease in sensation, tingling or pain • motor weakness or decreased strength • decreased sense of smell or taste • change in vision or diplopia • difficulty with Swallowing (dysphagia) • decreased hearing • altered gait or balance ,vertigo• dizziness ,syncope,• tremors, twitches or increased tone
Neurological Assessment
NEUROLOGICAL EXAM
• MENTAL STATUS
• CRANIAL NERVES
• REFLEXES
• MOTOR EXAM– STRENGTH– GAIT– CEREBELLAR
• SENSATION
• Assessment• Ask if the client has noted signs of reduced
sensation or weakness in extremities• Determine history of seizures or convulsion• Screen client for headache,
tremors ,numbness ,dizziness• Discuss with spouse family members or friends
any recent change in behavior• Assess client for history of change in vision
hearing smell taste or touch• Review past history for head or spinal cord injury
hypertension or psychiatric disorders
Equipment
• Wisps of cotton (light touch)
• Penlight
• Opposite tip of cotton swab or tongue blade(pain Sensation)
• Tuning fork
• Flavors (sugar ,salt, lemon juice,)
• Knee hammer
• Test tubes of hot and cold water (skin temp)
• Pins or Needles (Tactile discrimination)
NeuroExam Tools
Planning
• Explain the procedure to the patient or family
• Wash hands
• Arrange the equipment in the bedside
Implementation
MENTAL STATUS (LOC)
• Cognitive (Intellectual)
• Affective (Emotional)
Level of Consciousness
• Awake and alert
• Agitated
• Lethargic– Arousal with
• Voice
• Gentle stimulation
• Noxious stimulation
• Painful/vigorous stimulation
• Comatose
LANGUAGE Aphasia vs Dysarthria Receptive Language: lost ability to
understand written or spoken words.– Command Following
Expressive Language; loss of power to express– Fluency, Word Finding
Repetition– Screens for Receptive, Expressive, and
Conductive Aphasias
MEMORY
• IMMEDIATE: recall information happened within seconds(repeat series 7-4-3 digits) (average 5 to eight in sequence and four to six in reverse order)
• RECENT : recall information happened earlier in the day (Breakfast)
• REMOTE :recall past events from months or yrs. (childhood experience, marriage, schooling)
Historical or personal events
ORIENTATION
• PERSON: Ability to recognize other person
• PLACE: Where they are
• TIME: when (recognize day or night )
OTHER COGNITIVE FUNCTIONS
• CALCULATION, CONCENTRATION OR ATTENTION SPAN
• WORLD” backwards
Months of the Year Backwards)
SUBSTRACTION (serial 7 or 3)
• SIMILARITIES/DIFFERENCES
• JUDGEMENT
Assessing LOC
• Glasgow Coma Scale (GCS)– Three Categories:
• Eye opening
• Best motor response
• Best verbal response
– Scoring• Highest or best possible score 15
• A score of < 8 indicates coma
• Lowest or worst possible score 3
Glasgow coma scale
CRANIAL NERVES
Olfactory NerveCranial nerve I Distinguish Coffee from Cinnamon Smelling Salts irritate nasal mucosa and test . Disorders of Smell result from closed head injuries
DON’T USE A NOXIOUS STIMULUS
Optic Nerve
Cranial nerve II
– VISUAL ACUITY– VISUAL FIELDS– FUNDOSCOPIC EXAM
CNII: Fundo scopic exam
CN III Oculomotor: moves
eyes in all directions except
outward and down & in; opens
eyelid; constricts pupil
CN IV Trochlear:moves eyes
down and in…..
CNII & III: Pupillary function
• Normal pupils are equal in size and shape and are situated in center of iris
• •Pupillary size varies with intensity of ambient light, but at average intensity is
• 3-4 mm
• –Miosis < 2 mm
• –Mydriasis > 5 mm
• –Anisocoria = pupillary asymmetry
Check pupil size in lighted room, and reactivity to light in a darkened room.
Unequal pupil size can be a sign of a serious brain injury.
CN VI Abducens: moves eyes outward
EOM’s:
(extraoccular movement) assessment of eye
movement in all
directions ( III, IV VI)
Trochlear Nerve
c.n. IV
Oculomotor NerveCn III
Abducens NerveCn VI
Trigeminal Nerve – V
• sensation to the face,
cornea and scalp;
• opens jaw against
resistance
Masseter strength Jaw jerk
Facial Nerve-VII
•OBSERVE FOR FACIAL ASYMMETRY• FOREHEAD WRINKLING, EYELID CLOSURE, WHISTLE/PUCKER
Vestibulocochlear Nerve-VIII
Vestibulocochlear Nerve CN VIII
Hearing and Balance• Patients will complain of tinnitis, hearing loss, and/or
vertigo Weber and Renee Test
• Differentiates Conductive vs Sensorineural hearing loss
Glossopharyngeal and Vagus Nervesc.n.’s IX and X
CN IX Glossopharyngeal:
moves the pharynx (swallow, speech & gag)
CN X Vagus: voice quality
Spinal Accessory Nervec.n. XI
Trapezius strength
Sternocleido-Mastoid strength
CN XI Spinal Accessory:
turns head and elevates
shoulders
ShoulderShrug
Hypoglossal Nervec.n. XII
Hypoglossal Nerve
Protrudes the tongue to the opposite side
REFLEXES
MUSCLE STRETCH REFLEXES (DEEP TENDON
REFLEXES)
– 0 - ABSENT– 1 – MINIMAL ACTIVITY (hypoactive)– 2 - NORMAL– 3 – MORE ACTIVE THAN NORMAL– 4 – MAXIMAL ACTIVITY (hyperactive)
DTR• BICEPS
• BRACHIORADIALIS
• TRICEPS
• PATELLAR REFLEX(KNEE)
• ACHILLES REFLEX (ANKLE )
• Superficial reflex:
• PLANTAR REFLEX(BABINSKI) Negative in adults
Biceps Reflex • Test c5-c6• Partially flex the arm at
the client’s elbow. Rest forearm over thethigh,placingthe palm of the hand down.
• Place the thumb horizontally over biceps tendon
• Deliver a blow• Observe the normal slight flexion
of the Elbow and feel biceps contraction to your thumb.
TRICEPS REFLEX(C7- C8)
Flex the client’s arm at the elbow ,and support it in the palm of non dominant hand.
palpate the triceps tendon about 2 to 5cm above the elbow
Deliver a blow with the percussion hammer directly to the tendon
Observe the normal slight extension of the elbow.
Brachioradialis Test c5-c6
Rest the clients forearm in a relaxed position externally rotated on firm surface
Deliver a blow with the percussion hammer directly on the radius 2- 5cm above the wrist or the stylloid process
Observe the normal flexion and supination of the forearm fingers of the hand may extend slightly.
Patellar reflex(kneeJerk)TEST L-2 L3 L4
Ask the client to sit on the edge of the examining table ,legs hang freely
Locate patellar tendon directly below the patella (knee cap)
Deliver a blow with the percussion hammer directly to the tendon
Observe normal extension of the leg.
ACHILLES REFLEX
TESTS S1 ,S2
ask client to sit on the edge of table ,dorsiflex the clients client’s ankle slightly by supporting the ball of the foot lightly in the hand.
Deliver a blow with the percussion hammer directly to the achilles tendon just above the heel.
Observe and feel the normal plantar flexion of the foot.
PLANTAR REFLEX
The Plantar,or Babinski reflex is superficial it may be absent in adults without Pathlogy.
Plantar reflex
MOTOR EXAMINATION
Motor function• Walking gait
• Romberg test
• Standing on one foot with eyes closed
• Heel toe walking
• Finger to nose test
• Finger to nose and nurse’s finger
• Fingers to fingers
• Fingers to thumb
• Heel down opposite shin
Romberg Sign
• Ask the client to stand with feet together and arms resting at the sides first with eyes open and then closed. Be close with the client during this test. to prevent client from falling.
• If client can not maintain balance with eyes close (positive sign) indicates lack of coordination.
Motor function
Standing on one foot with eyes closedHeel toe walking
Ask the client to walk a straight line ,placing the heel of one foot directly in front of the toes of other foot.
Toe or heel walking:
Ask client to walk on toe or heel several steps.
Motor functionFinger to nose test:
Ask the client abduct and extend the hand at shoulder level and rapidly touch the nose with one index finger then other with eyes close
Finger to nose and to the nurses finger
Ask the client to touch the nose and then nurses index finger with distance of 18 inch.
Fingers to fingers
Ask the client to spread arms broadly at shoulder level and then bring the fingers together at midline.
Motor functionFingers to thumb
Ask client to touch each finger of one hand to the thumb of the same hand
Heel down opposite shin:
Ask the client to place the heel of one foot just below the opposite knee and run the heel down the shin to the foot .repeat with the other foot.
STRENGTHGraded 0 - 5
0 - Paralysis
1 -10%normal strength no movement
2 – 25% normal strength movement against gravity with support
3 – 50% normal strength movement against gravity
4 – 75% normal strength movement against minimal resistance
5 – 100 %normal strength. movement against full resistance and gravity.
SENSORY EXAMINATION
SENSORY EXAMLight touch sensation
Ask the client to close eyes respond yes or no whenever the client feels the cotton wisp touching skin. ask to point the spot.
Pain sensation
Ask client to close eyes and say sharp r dull pain sensation when broken tongue depressor is felt.
SENSORY EXAMTemperature sensation:
This test done when pain sensation is not normal. Touch skin areas with test tubes filled with hot and cold water.
Position or kinesthetic sensation
Move toe ask client position of the toes Tactile discrimination
SENSORY EXAM
One and two point discrimination
Stimulate skins with two pins simultaneously and with one pin. Ask client whether client feels one or two)
Stereognosis :ability to recognize objects by touching them)
Graphesthesia : ability to identify numbers, letters, or shapes drawn on the skin)
Extinction phenomenon
Stimulate two symmetric areas of the body simultaneously thighs, cheeks hands.
128-Hz tuning fork •Test toe & finger Count seconds still stops •Compare side to side •If impaired, move proximally
Vibration sense
Stereognosis & Graphesthesia
Documentation
• Document findings in the client record using forms or checklist.
• Describe any abnormal findings.
Evaluation
• Perform detailed follow-up examination of other systems based on findings
• Relate findings with previous data if available.
• Report significant findings to the Physician
Than Q