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  2. 2. INTRODUCTION: A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical history but not deeper investigation such as neuroimaging. It can be used both as a screening tool and as an investigative tool.
  3. 3. Examples of Definitions • Alert: o awake, looks about o responds in a meaningful manner to verbal instructions or gestures • Drowsy: o oriented when awake but if left alone will sleep • Confused: o disoriented to time, place, or person o memory difficulty is common o has difficulty with commands o exhibits alteration in perception of stimuli, may be agitated
  4. 4. • Stuporous: o generally unresponsive except to vigorous stimulation o may make attempt at verbalization to vigorous/repeated stimuli o Opens eyes to deep pain • Comatose: o unarousable and unresponsive o some localization or movement may be acceptable within the comatose category depending on the coma definitions e.g. light coma to deep coma o Does not open eyes to deep pain
  5. 5. The difference between Coma and Sleep: • sleeping persons respond to unaccustomed stimuli • sleeping persons are capable of mental activity (dreams) • sleeping persons can be roused to normal consciousness • cerebral oxygen uptake does not decrease during sleep as it often does in coma
  6. 6. Special States of Altered Levels of Consciousness • Brain Death: An irreversible loss of cortical and brain stem activity. • Persistent Vegetative State: A condition that follows severe cerebral injury in which the altered state becomes chronic or persistent. • Locked-in Syndrome: A state of muscle paralysis, involving voluntary muscles, while there is preservation of full consciousness and cognition.
  7. 7. Indications: A neurological examination is indicated whenever a physician suspects that a patient may have a neurological disorder. Any new symptom of any neurological order may be an indication for performing a neurological examination.
  8. 8. Organic Disease ?  Signs &/or symptoms that cannot be faked must be examined closely.  Examples include, asymmetry in pupils, abnormal retinal exams, nystagmus, muscle atrophy, and muscle fasciculation.
  9. 9. Where are the Connections  Upper Motor Neurons (UMN) are defined as the connections of motor nerves before they leave the spinal cord  Lower Motor Neurons (LMN) are defined as after the synapse (connection) into the peripheral nerve cell bodies.
  10. 10. Objectives  Organize Exam into the 6 Subsets of Function  Concept of Screening Examination  Understand Afferent and Efferent Pathways for Brainstem Reflexes  Differentiate Between Upper and Lower Motor Neuron Findings
  11. 11. Six Subsets of the Neuro Exam  Here’s what you need to examine.  Mental Status  Cranial Nerves  Motor  Sensory  Coordination  Reflexes
  12. 12. Concept of a Screening Exam Screening each of the subsets allows one to check on the entire neuroaxis (Cortex, Subcortical White Matter, Basal Ganglia/Thalamus, Brainstem, Cerebellum, Spinal Cord, Peripheral Nerves, NMJ, and Muscles) Expand evaluation of a given subset to either • Answer questions generated from the History • Confirm or refute expected or unexpected findings on Exam
  13. 13. Neurological Examination Mental Status Exam  “FOGS”  Family story of memory loss  Orientation  General Information  Spelling &/or numbers  Recognition of objects
  14. 14. 1. INTERVIEW The patient/family interview will allow the nurse to: • ƒgather data: both subjective and objective about the patient's previous/present health state • ƒprovide information to patient/family • ƒclarify information • ƒmake appropriate referrals • ƒdevelop a good working relationship with both the patient and the family • ƒinitiate the development of a written plan of care which is patient specific
  15. 15. Interview to identify presence of: • headache • difficulty with speech • 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 • decreased hearing • altered gait or balance • dizziness • tremors, twitches or increased tone
  16. 16. Physical Examination Considerations • Level of Consciousness – Most important aspect of neurologic examination – Level of consciousness first to deteriorate; changes often subtle, therefore requiring careful monitoring. • Consciousness: – Composed of Two Components: • Arousal (Alertness) • Awareness (Content) – Assessment: Orientation vs. Disorientation » Person, Place & Time » Varying sequence of questions is important !!
  17. 17. 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
  18. 18. Glasgow Coma Scale
  19. 19. Pupillary Examination • The pupillary examination can be quickly and easily performed in the unconscious or minimally responsive patient when a TBI is suspected, and can provide valuable information about the degree of initial or progressing brain injury. Several types of TBI’s may cause pupillary changes, which indicate the need for rapid interventions to decrease ICP caused by cerebral bleeding and/or edema. Nurses are in a key position to detect early changes in a patient's condition and administer or advocate for immediate interventions.
  20. 20. Check pupil size in lighted room, and reactivity to light in a darkened room.
  21. 21. Unequal pupil size can be a sign of a serious brain injury.
  22. 22. Brain Injury with bleeding or swelling Rapid interventions are needed to prevent death or permanent brain damage – TBI’s can progress rapidly!
  23. 23. Mental Status Level of Alertness • Subjective view of Examiner • Definition of Consciousness • Terminology for Depressed Level of Consciousness • Concept of Coma • Delerium Degree of Orientation • To what?
  24. 24. Mental Status Concentration • Serial 7’s or 3’s • “WORLD” backwards • Months of the Year Backwards • Try to quantify degree of impairment * A and O and Concentration need to be intact for other aspects of the Mental Status Exam to have localizing value!
  25. 25. Mental Status Memory Immediate Recall • A task of concentration Short-Term Memory • “3/3 objects after 5 minutes” Long-Term Memory • Last thing to go
  26. 26. Mental Status Language Aphasia vs Dysarthria Receptive Language • Command Following Expressive Language • Fluency • Word Finding Repetition • Screens for Receptive, Expressive, and Conductive Aphasias
  27. 27. Language
  28. 28. Mental Status Calculations, R-L confusion, finger agnosia, agraphia • Gerstmann’s Syndrome (Dominant Parietal Lobe) Hemineglect • Non-Dominant Parietal Lobe Delusional Thinking, Abstract Reasoning, Mood, Judgement, Fund of Knowledge, etc • Important for Psychiatry • Does not localize well to one region of the cortex • Neurocognitive Testing required to get at more specific deficits
  29. 29. Olfactory Nerve - I
  30. 30. Olfactory Nerve  Distinguish Coffee from Cinnamon  Smelling Salts irritate nasal mucosa and test V2 Trigemminal Sense  Disorders of Smell result from closed head injuries
  31. 31. Optic Nerve Cranial nerve II
  32. 32. Optic Nerve  Visual Acuity  Visual Fields  Afferent input to Pupillary Light Reflex • APD  Look at the Nerve (Fundoscopic Exam) “VA equals 20/20 OU at near” “PERRLA”
  33. 33. Trochlear Nerve c.n. IV Oculomotor Nerve Cn III Abducens Nerve Cn VI
  34. 34. 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…..
  35. 35. CN VI Abducens: moves eyes outward EOM’s: (extraoccular movement) assessment of eye movement in all directions ( III, IV VI)
  36. 36. Trigeminal Nerve - V
  37. 37. CN V Trigeminal: 3 branches; sensation to the face, cornea and scalp; opens jaw against resistance
  38. 38. Facial Nerve-VII
  39. 39. CN VII Facial: moves the face; taste. CN VII paralysis
  40. 40. Vestibulocochlear Nerve-VIII
  41. 41. Vestibulocochlear Nerve Hearing and Balance • Patients will complain of tinnitis, hearing loss, and/or vertigo Weber and Renee Test • Differentiates Conductive vs Sensorineural hearing loss Afferent input to the Oculocephalic Reflex • Doll’s Eye Maneuver • Cold Calorics • Not “COWS” “Hearing grossly intact AU”
  42. 42. Glossopharyngeal and Vagus Nerves c.n.’s IX and X
  43. 43. CN IX Glossopharyngeal: moves the pharynx (swallow, speech & gag) CN X Vagus: voice quality
  44. 44. Spinal Accessory Nerve c.n. XI Trapezius strength Sternocleido- Mastoid strength
  45. 45. CN XI Spinal Accessory: turns head and elevates shoulders Shoulder Shrug
  46. 46. Hypoglossal Nerve c.n. XII
  47. 47. Hypoglossal Nerve Protrudes the tongue to the opposite side Tongue in cheek (strength) Hemi-atrophy and fasiculations (LMN)
  48. 48. Strength Tone DTR’s Plantar Responses Involuntary Movements
  49. 49. Strength Medical Research Council Scale 5/5 = Full Strength 4/5 = Weakness with Resistance 3/5 = Can Overcome Gravity Only 2/5 = Can Move Limb without Gravity 1/5 = Can Activate Muscle without Moving Limb 0/5 = Cannot Activate Muscle
  50. 50. Weakness Describe the Distribution of Weakness • Upper Motor Neuron Pattern • Peripheral neuropathy Pattern • Myopathic Pattern
  51. 51. Tone  Tone is the resistance appreciated when moving a limb passively  “Normal Tone”  Hypotonia • “Central Hypotonia” • “Peripheral Hypotonia” Increased Tone • Spasticity (Corticospinal Tract) • Rigidity (Basal Ganglia, Parkinson’s Disease) • Dystonia (Basal Ganglia)
  52. 52. DTR’s 0/4 = Absent 1-2/4 = Normal Range 3/4 = Pathologically Brisk 4/4 = Clonus
  53. 53. Involuntary Movements Hyperkinetic Movements • Chorea • Athetosis • Tics • Myoclonus Bradykinetic Movements • Parkinsonism (Bradykinesia, Rigidity, Postural Instability, Resting Tremor) • Dystonia
  54. 54. Drift Assessment Drift Assessment: test for motor weakness Arm: hold arms out with palms up; eyes closed • Pronator drift: hands pronate (roll over); • Motor drift: arm “drifts” downward • Cerebellar drift: arm “drifts” back toward head or out to side Leg: no need to close eyes motor: leg “drifts”toward bed
  55. 55. Movement Assessment Movements are purposeful or non-purposeful purposeful: picking at tubings or bed linens, scratching nose localizing: moving toward or removing a painful stimulus; must cross the midline; occurs in the cortex withdrawal: pulling away from pain; occurs in the hypothalamus non-purposeful: do not cross the midline abnormal flexion: (decorticate) rigidly flexed arms and wrists; fisted hands; occurs in upper brainstem abnormal extension: (decerebrate) rigidly, rotated inward extended arms with flexed wrists and fisted hands; occurs in midbrain or pons. Decorticate Decerebrate
  56. 56. Primary Sensory Modalities  Light Touch (Multiple Pathways)  Pain/Temperature Sensation (Spinothalamic Tract)  Vibration/Position Sensation (Posterior Columns) Cortical Sensory Modalities  Stereognosis  Graphesthesia  Two-Point Discrimination  Double Simultaneous Extinction
  57. 57. Pain and Temperature • Pinprick (One pin per patient!) • Sensation of Cold • Look for Sensory Nerve or Dermatomal Distribution Vibration Sensation • C-128 Hz Tuning Fork (check great toe) Joint Position Sensation • Check great toe • Romberg Sign
  58. 58. Higher Cortical Sensory Function Graphesthesia Stereognosis Two-Point Discrimination Double Simultaneous Extinction Gerstmann’s Syndrome (acalculia, right-left confusion, finger agnosia, agraphia) • Usually seen in Dominant Parietal Lobe lesions
  59. 59. Hemisphere Dysfunction  Dysmetria on Finger-Nose-Finger Testing*  Irregularly-Irregular Tapping Rhythm*  Dysdiadochokinesis*  Impaired Check*  Hypotonia*  Impaired Heel-Knee-Shin*  Falls to Side of Lesion*  Nystagmus (Variable Directions) * All Deficits are Ipsilateral to the side of the lesion
  60. 60. Midline Dysfunction Truncal Ataxia Titubation Ataxic Speech Gait Ataxia • Acute Ataxia (unsteady Gait) • Chronic Ataxia (wide-based, steady Gait)
  61. 61. REFLEXES
  64. 64. OTHER REFLEXES • Upper motor neuron dysfunction – BABINSKI • present or absent • toes downgoing/ flexor plantar response – HOFMAN’S – JAW JERK • Frontal release signs – GRASP – SNOUT – SUCK – PALMOMENTAL
  65. 65. Abmornal Reflexes Abnormal Reflexes: Babinski: initial inflection of great toe in response stroking of sole; upgoing toe is abnormal Grasp: involuntary grasp in response to stimulation of palm; abnormal in an adult Doll’s eyes: impairment of eye movement to opposite side when head is turned = damage to brainstem; no movement = loss of brainstem
  66. 66. Neuro Aessessment Quiz • 1. Peripheral Nervous System (PNS) is made up of the following except:: a) Cranial nerves (12) b) Ventricles c) Axons and Neurons d) Spinal nerves (31) e) Cerrebellar nerves • 2. The Autonomic Nervous System contains both the Sympathetic Division of nerves and the Parasympathetic Division of nerves. True or False________________. • 3. Intracranial Hemorrhage can occur in the following places except: a) Epidural space b) Subdural space c) Subarachnoid space d) Ethmoid space • .4. A Coup Contracoup injury is defined as: When the head strikes a fixed object, the coup injury occurs at the site of impact and the contrecoup injury occurs at the opposite side. True or False____________________ • 5. The Facial nerve controls: a) Movement of the chin, tongue and parotid glands. b) Movement of the tongue, soft palete and eyebrows. c) Movement of the chin and cheeks muscles. d) Movement of all the facial expression muscles. • 6. Which nerve controls movement on the neck and shoulders? a) Abducens b) Accoustic c) Spinal Assesory d) Occulomotor
  67. 67. • 7. A serious injury to the cervical spine and spinal cord most likely will result in the following condition: a) Hemiplegia b) Quadraplegia c) Paraplegia d) Contralateral paralysis • 8. Any suspected head, neck or spine injured victim should immediately be given spinal immobilization precautions, except: a) When the victim complains of pain only upon turning his head to one side. b) When the victim refuses to allow spinal immobilization even after listening carefully to multiple attempts to explain the dangers and risk involved. c) When the victim is intoxicated on alcohol and cannot speak clearly. d) When the victim was never unconscious and denies any pain. • 9. When assessing a patient with altered LOC, you feel his state of awareness/arousal is best described as “Obtunded”, this means: a) Very drowsy, when not stimulated, but can follow simple commands when stimulated (i.e. shaking or shouting); verbal responses include one or two words, but will drift back to sleep without stimulation. b) A state of drowsiness; client needs increased external stimuli to be awakened but, remains easily arousable; verbal, mental & motor responses are slow or sluggish. c) Awakens only to vigorous and continuous noxious (painful) stimulation; minimal spontaneous movement; motor responses to pain are appropriate but, verbal responses are minimal and incomprehensible (i.e. moaning). d) Vigorous external stimulation fails to produce any verbal response; both arousal and awareness are lacking; no spontaneous movements but, motor responses to noxious stimuli maybe be purposeful
  68. 68. • 10. The Glasgow Coma scale tests for three kinds of responses, they are: a) Eye Opening b) Motor Response c) Verbal Response d) Auditory Response • 11. The best and worst possible score on the GCS is: a) 15 and 0 b) 13 and 3 c) 15 and 3 d) 18 and 5 • 12. When assessing pupillary response, you are looking for the following conditions except: a) Coordinated eye movement and bilateral blinking. b) Reactivity to and accommodation to light. c) Symmetry of pupils and accommodation to light. d) Abnormal pupil shape. • 13. A constricted “pin point” pupil indicates: (best answer) a) Brain Stem herniation b) Cardiac Arrest c) Cerebral Infarction of the parietal lobe d) Cerebral Infarction of the occipital lobe e) A wide variety of conditions, some being extremely life threatening. • 14. What Cranial nerve(s) controls the movement of the eyes down and in? a) CN VI Abducens b) CN III Oculomotor c) CN IV Trochlear d) CN II Optic • 15. The Motor strength scale goes from 0/5 to 5/5, 0 being no strength at all and 5 being normal strength. A person with a motor strength of 4/5 would be: a) overcomes gravity; offers no resistance b) strong against resistance c) weak against resistance d) no muscle movement
  69. 69. • 16. Match the following postures with its definition: • Decerebrate_____________ • Decorticate______________ a) Abnormal flexion: rigidly flexed arms and wrists; fisted hands; occurs in upper brainstem b) Abnormal extension: rigidly, rotated inward, extended arms with flexed wrists and fisted hands; occurs in midbrain or pons. • 17. The Babinski reflex is the initial inflection (extension) of great toe in response stroking of the sole of the foot, select the correct answer: a) An upgoing great toe is abnormal. b) An upgoing great toe is normal. c) An upgoing great toe is abnornal in adults. d) An upgoing great toe is normal in infants. • Answers • 1 e • 2 True • 3 d • 4 True • 5 d • 6 c • 7 b • 8 b • 9 a • 10 d • 11 c • 12 a • 13 e • 14 c • 15 c • 16 Decer = b. Decor = a • 17 c&d