The Neurological System
Neurological Exam 5 Components <ul><li>Mental status </li></ul><ul><li>Cranial nerves </li></ul><ul><li>Reflexes </li></ul...
Mental Status Examination <ul><li>Examination  - ABCT </li></ul><ul><ul><li>Appearance </li></ul></ul><ul><ul><li>Behavior...
Assessing LOC: Glasgow Coma Scale <ul><li>Eye opening </li></ul><ul><li>Verbal responsiveness  </li></ul><ul><li>Motor res...
Glasgow Coma Scale
Physical  Examination <ul><li>Levels of Consciousness </li></ul><ul><li>Alert- awake or easily aroused </li></ul><ul><li>L...
Cranial Nerves <ul><li>“  O n  o ld  O lympus’  T owering  T ops  a   F inn  a nd  G erman  V iewed  s ome  h ops .” </li>...
Neurological :  Physical  Examination Sensory System Function <ul><li>With eyes closed </li></ul><ul><ul><ul><ul><li>Inter...
Physical  Examination <ul><li>Sensory Function Tests : </li></ul><ul><li>Touch  </li></ul><ul><ul><li>Light touch 1 st  th...
Sensory Function Tests : Sensory Exam: Light Touch
Sensory Function Tests : Sensory Exam: Vibration
Sensory Function Tests : Proprioception: Position sense
Sensory Function Tests : Stereognosis
Sensory Function Tests : Graphesthesia
Sensory Function Tests : Two-point discrimination
Sensory Function Tests : Dermatomes
Motor Examination <ul><li>Symmetry, size, and presence f involuntary movements </li></ul><ul><li>Full ROM of joints </li><...
Cerebellar Function <ul><li>1.  Gait and posture </li></ul><ul><ul><li>Heel to toe in straight line </li></ul></ul><ul><ul...
<ul><li>Cerebellar Function,  con’t </li></ul><ul><li>2.  Coordination of hands and legs </li></ul><ul><ul><li>RAM </li></...
Cerebellar Function,  con’t RAM
Cerebellar Function,  con’t Nose –to - Finger Test
Cerebellar Function,  con’t Heel to Shin
Cerebellar  con’t <ul><li>Romberg:  </li></ul><ul><li>Stand upright, place feet together, then close eyes </li></ul><ul><l...
4 types of Reflexes <ul><li>Superficial (abdominal reflex, Cremasteric reflex) </li></ul><ul><li>Visceral (pupillary respo...
Reflexes-Cont: PERRL/PERRLA
Reflexes-Cont: Babinski’s Reflex (Adult)
Reflexes-Cont:  Reflex Arc  – Deep Tendon Reflex
Reflexes-Cont:  Deep Tendon Reflexes <ul><li>Technique </li></ul><ul><li>Position limb so muscle is slightly stretched </l...
BRACHIORADIALIS BICEPS TRICEPS PATELLAR ACHILLES/PLANTAR DEEP TENDON REFLEXES
Grading of DTRs <ul><li>4+ very brisk </li></ul><ul><li>3+ brisker than average </li></ul><ul><li>2+ average, normal </li>...
Assessment Guide: Neurological  <ul><li>LOC : alert, comatose, lethargic, obtunded </li></ul><ul><li>GCS </li></ul><ul><ul...
Assessment Guide : cont.. <ul><li>Seizure </li></ul><ul><ul><li>Describe: tonic clonic, absence, status epilepticus </li><...
<ul><li>Altered mental status : yes, no </li></ul><ul><li>Aphasia : present, none </li></ul><ul><li>Intelllectual function...
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The Neurological System 2 Neurological Exam 5 Components

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  • Check both sides
  • Light touch – assessing the trigeminal nerve CN V
  • vibration
  • dermatomes
  • Ex: traffic school – show videos of sobriety test – walk in straight line, finger to nose
  • Note smoothness of motion Perform bilaterally
  • Ex sobriety test
  • The Neurological System 2 Neurological Exam 5 Components

    1. 1. The Neurological System
    2. 2. Neurological Exam 5 Components <ul><li>Mental status </li></ul><ul><li>Cranial nerves </li></ul><ul><li>Reflexes </li></ul><ul><li>Motor- includes Cerebellar function </li></ul><ul><li>Sensory </li></ul>
    3. 3. Mental Status Examination <ul><li>Examination - ABCT </li></ul><ul><ul><li>Appearance </li></ul></ul><ul><ul><li>Behavior </li></ul></ul><ul><ul><li>Cognition </li></ul></ul><ul><ul><li>Thought processes (thought content & perceptions) </li></ul></ul><ul><li>Mini Mental State Exam </li></ul><ul><li>Glasgow Coma Scale </li></ul>
    4. 4. Assessing LOC: Glasgow Coma Scale <ul><li>Eye opening </li></ul><ul><li>Verbal responsiveness </li></ul><ul><li>Motor responsiveness </li></ul>
    5. 5. Glasgow Coma Scale
    6. 6. Physical Examination <ul><li>Levels of Consciousness </li></ul><ul><li>Alert- awake or easily aroused </li></ul><ul><li>Lethargic- not fully alert, drifts off when not stimulated </li></ul><ul><li>Obtunded- sleeps most times, difficult to arouse (loud noise, vigorous shaking or pain) </li></ul><ul><li>Stupor- need persistent loud noise or pain for arousal; responds to stimuli </li></ul><ul><li>Coma- no response </li></ul><ul><li>(Jarvis CH 2) </li></ul>
    7. 7. Cranial Nerves <ul><li>“ O n o ld O lympus’ T owering T ops a F inn a nd G erman V iewed s ome h ops .” </li></ul><ul><li>I – Olfactory VII - Facial </li></ul><ul><li>II – Optic VIII – Auditory (V-C) </li></ul><ul><li>III – Occulomotor IX - Glossopharyngeal </li></ul><ul><li>IV – Trochlear X - Vagus </li></ul><ul><li>V – Trigeminal XI – Spinal Accessory </li></ul><ul><li>VI – Abducens XII - Hypoglossal </li></ul>
    8. 8. Neurological : Physical Examination Sensory System Function <ul><li>With eyes closed </li></ul><ul><ul><ul><ul><li>Interpret sensations </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Discriminate side to side </li></ul></ul></ul></ul><ul><li>Examine in detail if: </li></ul><ul><ul><ul><ul><li>Reduced sensation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Numbness or pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Motor or reflex abnormal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Skin changes </li></ul></ul></ul></ul><ul><ul><li>Be specific: “tell me where I touch” </li></ul></ul>
    9. 9. Physical Examination <ul><li>Sensory Function Tests : </li></ul><ul><li>Touch </li></ul><ul><ul><li>Light touch 1 st then Pain & Temperature </li></ul></ul><ul><li>Vibration </li></ul><ul><li>Proprioception: Position sense </li></ul><ul><li>Stereognosis </li></ul><ul><li>Graphesthesia </li></ul><ul><li>2-point discrimination </li></ul>
    10. 10. Sensory Function Tests : Sensory Exam: Light Touch
    11. 11. Sensory Function Tests : Sensory Exam: Vibration
    12. 12. Sensory Function Tests : Proprioception: Position sense
    13. 13. Sensory Function Tests : Stereognosis
    14. 14. Sensory Function Tests : Graphesthesia
    15. 15. Sensory Function Tests : Two-point discrimination
    16. 16. Sensory Function Tests : Dermatomes
    17. 17. Motor Examination <ul><li>Symmetry, size, and presence f involuntary movements </li></ul><ul><li>Full ROM of joints </li></ul><ul><li>Check strength against resistance </li></ul><ul><li>Neuro patients: Assess hand grips and foot pushes if bedridden </li></ul>
    18. 18. Cerebellar Function <ul><li>1. Gait and posture </li></ul><ul><ul><li>Heel to toe in straight line </li></ul></ul><ul><ul><li>Walking on toes and heels </li></ul></ul><ul><ul><li>Hop on one foot </li></ul></ul><ul><ul><li>Note width of gait </li></ul></ul>
    19. 19. <ul><li>Cerebellar Function, con’t </li></ul><ul><li>2. Coordination of hands and legs </li></ul><ul><ul><li>RAM </li></ul></ul><ul><ul><li>nose to examiner’s finger </li></ul></ul><ul><ul><li>heel to shin coordination </li></ul></ul>
    20. 20. Cerebellar Function, con’t RAM
    21. 21. Cerebellar Function, con’t Nose –to - Finger Test
    22. 22. Cerebellar Function, con’t Heel to Shin
    23. 23. Cerebellar con’t <ul><li>Romberg: </li></ul><ul><li>Stand upright, place feet together, then close eyes </li></ul><ul><li>loss of balance means + Romberg test </li></ul><ul><li>Be prepared to protect client from falling! </li></ul>
    24. 24. 4 types of Reflexes <ul><li>Superficial (abdominal reflex, Cremasteric reflex) </li></ul><ul><li>Visceral (pupillary response to light) PERRL </li></ul><ul><li>Pathologic </li></ul><ul><ul><li>+ Babinski in adults </li></ul></ul><ul><li>DTRs (e.g. knee) </li></ul>Abdominal Reflex Cremastic Reflex
    25. 25. Reflexes-Cont: PERRL/PERRLA
    26. 26. Reflexes-Cont: Babinski’s Reflex (Adult)
    27. 27. Reflexes-Cont: Reflex Arc – Deep Tendon Reflex
    28. 28. Reflexes-Cont: Deep Tendon Reflexes <ul><li>Technique </li></ul><ul><li>Position limb so muscle is slightly stretched </li></ul><ul><li>Reflex hammer should strike tendon briskly to stretch tendon </li></ul><ul><li>Get patient to relax </li></ul>
    29. 29. BRACHIORADIALIS BICEPS TRICEPS PATELLAR ACHILLES/PLANTAR DEEP TENDON REFLEXES
    30. 30. Grading of DTRs <ul><li>4+ very brisk </li></ul><ul><li>3+ brisker than average </li></ul><ul><li>2+ average, normal </li></ul><ul><li>1+ diminished, low normal </li></ul><ul><li>0 no response </li></ul>
    31. 31. Assessment Guide: Neurological <ul><li>LOC : alert, comatose, lethargic, obtunded </li></ul><ul><li>GCS </li></ul><ul><ul><li>Eye opening: spontaneously, to speech, to pain </li></ul></ul><ul><ul><li>Verbal Response: oriented, confused, inappropriate, incomprehensible </li></ul></ul><ul><ul><li>Motor Response: obeys, command, localizes pain, withdraws, flexion, extension </li></ul></ul>
    32. 32. Assessment Guide : cont.. <ul><li>Seizure </li></ul><ul><ul><li>Describe: tonic clonic, absence, status epilepticus </li></ul></ul><ul><ul><li>Timing: once at 10 am; 2 pm and 2:45 pm </li></ul></ul>
    33. 33. <ul><li>Altered mental status : yes, no </li></ul><ul><li>Aphasia : present, none </li></ul><ul><li>Intelllectual functioning : intact; short attention span, dementia, memory loss </li></ul><ul><li>Itnerventions in use : </li></ul><ul><ul><li>Seizure precautions : side rails padded, oral airway at bedside </li></ul></ul><ul><ul><li>Med List : Klonopin, Aricept, Neurontin, Dilantin, etc. </li></ul></ul>
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