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Neurological Assessment

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    Neurological Assessment Neurological Assessment Presentation Transcript

    •  Developmental Psychosocial Cultural & Environmental
    •  COLDSPA Character Onset Location Duration Severity Pattern Associated Factors
    •  Do you experience any numbness or tingling? When & where does this occur? Do you experience seizure? How often? Does anything seem to initiate a seizure? Do you experience headaches/ When do they occur & what do they feel like? Do you have muscle weakness? Do you have slurring of speech?
    •  Any head injury with or w/o loss of consciousness? What treatment did you receive? Have you ever had meningitis, encephalitis, injury to spinal cord, stroke? Family history of HPN, stroke, Alzhiemer’s?
    •  Do you smoke? Describe your usual diet? Do you lift heavy objects?
    •  Mental Status Cranial Nerves Motor & Cerebellar System Sensory System Reflexes
    •  Provide information about cerebral cortex function 4 major component: (a) Appearance (b) Behavior (c) Cognition (d) Thought process
    •  Posture Body Movements Dress Grooming & Hygiene
    • LEVEL OFCONSCIOUSNESS LEVEL ResponseAlert Responds fully & appropriately to stimuliLethargic Drowsy, responds to questions then fall asleepObtunded Open eyes, responds slowly, confusedStuporous Arouses from sleep only from painful stimuliComatose Unarousable with eyes closed
    • ScoreEye Opening Response Spontaneous opening 4 To verbal command 3 To pain 2 No response 1Most integral motor response Obeys verbal commands 6 Localizes pain 5 Withdraws from pain 4 Flexion (decorticate rigidity) 3 Extension (decerebrate rigidity) 2 No response 1Most appropriate verbal response Oriented 5 Confused 4 Inappropriate words 3 Incoherent 2 No response 1TOTAL SCORE 3-15
    •  Facial Expression Speech › Quantity › Rate › Volume › Fluency & rhythm Mood & Affect › Mood – a sustained state of inner feeling › Affect – how do the patient appear to you (labile, blunted or flat)
    •  Orientation – Person, place & time Attention Span Recent Memory Remote Memory New Learning Judgment
    •  Thought Processes Thought Content Perceptions Screen for Suicidal Thoughts
    •  Provide information regarding transmission of motor & sensory messages (head & neck) Are evaluated during the head, neck, eye & ear examinations
    • No. Cranial Nerve Function I Olfactory Sense of smell II Optic VisionIII Oculomotor Pupillary constriction, opening the eye & most extraocular movementsIV Trochlear Downward, inward movement of the eye V Trigeminal Motor – temporal & masseter muscles (jaw clenching), lateral movement of the jaw Sensory – facial. 3 divisions: (1) ophthalmic (2) maxillary (3) mandibularVI Abducens Lateral deviation of the eyeVII Facial Motor – facial movements: facial expressions, closing the eye, closing the mouthVIII Vestibulochoclear Hearing (cochlear division) & balance (Acoustic) (vestibular division)
    • No. Cranial Nerve FunctionIX Glossophrayngeal Motor – phraynx Sensory – posterior portions of the eardrum & ear canal, the phraynx, posterior tongue, including tasteX Vagus Motor – palate, pharynx, larynx Sensory – pharynx & larynxXI Accessory Motor – sternocledomastoid & upper portion of the trapeziusXII Hypoglossal Motor - tongue
    • Cranial TestNerveI SmellII Visual acuity, visual fields & ocular fundiIII, IV, VI Pupillary reactions, Extraocular movementsV Corneal reflexes, facial sensation & jaw movementsVII Facial movementsVIII HearingIX, X Swallowing & rise of the palate, gag reflexV, VII, X, XII Voice & speechXI Trapezius & Sternocleidomastoid contractionXII Inspection of the tongue
    • - check forsmell“ANOSMIA”– absence ofsmell
    • Visual Acuity-Test for near vision  Presbyopia – impaired near vision-Test for distantvision (Snellen’s Chart)  Myopia – “nearsightedness”  Hyperopia – “farsightedness”
    • Optic FundiAbnormalities : Retrobulbar neuritis –inflammatory process ofthe optic nerve behindthe eyeball (MS)Papilledema (chokeddisk) swelling of the opticnerve as it enters theretina (tumors ofhemorrhage)Optic atrophy – changein color of the disc &decreased visual acuity(MS, tumor)
    • Visual Fields by ConfrontationNormal Findings: Inferior: 70degrees Superior: 50degrees Temporal: 90degrees Nasal: 60degrees
    • CN III, IV and VI inspect margins ofeyelids – eyelid covers2mm of iris * Ptosis = weak eyemuscles assess for extraocularmovements > six cardinal fields: H method or wheelmethodsTest for convergence
    • Muscle Cranial Nerve FunctionLateral Rectus VI Moves eye laterallyMedial Rectus III Moves eye mediallySuperior Rectus III Elevates eyeInferior Rectus III Depresses eyeInferior Oblique III Elevates eye ; turns it laterallySuperior Oblique IV Depresses eye, turns it laterally
    • * Abnormal: strabismus ptosisNystagmus -rythmic oscillationof the eyesStrabismus –lack of musclecoordination diplopiaDiplopia –double vision
    • Pupillary Reaction to Light& Accomodation (PERRLA) round, equal in size &shape in the center of theeye Pupil inequality of <0.5mm = ANISOCORIA Direct light reflex =pupillary constriction in thesame eye Consensual light reflex =pupillary constriction in theopposite eye * both pupils shouldconstrict briskly
    •  Motor function  Temporal & masseter mucsles contract bilaterally  Abnormal:  PNS or CNS dysfunction (bilateral)  Lesion of CN V (unilateral) Sensory function  3 division: ophthalmic, maxillary & mandibular  absence: lesion in the:  Trigeminal nerve  Spinothalamic tract  Posterior columns Corneal Reflex  absence: lesions in the:  Trigemeinal nerve  Motor part of CN VII
    • Motor Function:Facial expressionsMovements –symmetricalAbnormal:  Bell’s Palsy  Paralysis lower part of the faceSensory Function: identify differentflavorsAbnormal: inabilityto identify correctflavor = CN VIIimpairmentCorneal Reflex regulates themotor response
    • Bell’s Palsy
    • Weber’s TestEvaluate conduction of soundwaves through bonesHelps distinguish betweenconductive hearing & sensorineuralhearing  conductive hearing – sound waves transmitted by the external & middle ear  sensorineural hearing – sound waves transmitted by the inner earNormal: vibrations heard equallyin both earsAbnormal:  Tinnitus  deafness  Conduction hearing loss  Sensorineural hearing loss
    •  Rinne Test  Compares air & bone conduction sounds  Normal:  Air conduction heard longer than bone conduction  Abnormal:  Conductive hearing loss – BC > AC  Sensorineural hearing loss – AC > BC
    • Caloric TestTest the vestibularportion of the nervePerformed onlywhen client isexperiencingdizziness or vertigo.
    • Motor function: Sensory Function:Normal: soft palate  Gag Reflexrises, uvula remains in Normal:midline  intact gag reflex  symmetrically diminishedAbnormal: or absent in some normal > soft palate does peoplenot rise – bilateral lesion Abnormal:of CN X risk for aspiration > unilateral rising ofsoft palate & deviation Motor activity of pharynxof uvula to the normal Normal:side – unilateral lesion  swallows w/o difficultyCN X  no hoarseness noted Abnormal:  Dysphagia  vocal changes
    • Trapezius MuscleNormal: > symmetric,strong contractionsAbnormal: > asymmetricmuscle contraction > drooping of theshoulder
    • Sternocleidomastoid MuscleNormal: > ease of movement > wide range ofmotionAbnormal: > muscle weakness > muscle atrophy > uneven shoulders
    • Movement &strength of tongueNote atrophy,tremors & paralysisNormal: > Movement issymmetrical &smooth > Bilateral strength isapparent > tongue at midlineAbnormal: > Fasciculation –PNS disease
    •  To determine functioning of the pyramidal & extrapyramidal tracts To determine balance & coordinationFocus on: Body position Involuntary movements Characteristics of the muscles Coordination
    •  Natural walk › Note posture, freedom of movement, symmetry, rhythm & balance › Normal: Steady; opposite arm swings
    • observe for: stiffness or relaxation equality of steps pace of walking position & coordination of arms ability to maintain balance
    • Heel to toe walk on toes walk on heels› Abnormal: Affected by disorder of the motor, sensory, vestibular & cerebellar systems : drug or alcohol intoxication, motor neuron weakness or muscle weakness
    • Romberg’s Test assesses coordination &equilibrium (CN VIII) note any unsteadiness orswayingNormal: stands erect withminimal swaying with eyesopen or closed Abnormal: swaying greatlyincreases, moving feet apart =disease of posterior columns ,vestibular dysfunctions orcerebellar disorders
    • Cerebellar Ataxiawide-based,staggering, unsteadygait(+) Romberg’s testCerebellar diseasesor alcohol & drugintoxication
    • Parkinsonian GaitShuffling gait, turns invery stiff mannerStooped-over posturewith flexed hips & kneeSeen in Parkinsonsdisease
    • Scissors Gaitstiff, short gaitThighs overrlap eachother with each stepSeen in partialparalysis of the leg
    • Spastic HemiparesisFlexed arm heldclose to bodywhile client dragstoe of legs orcircles it stifflyoutward & forwardlesions of UMN =CVA
    • Footdrop (steppagegait)Liftsfoot & knee highwith each step, thenslaps the foot down hardon the groundCannot walk on heelsLMN disease
    •  Finger – to – nose Test › Pass – point test › Assesses coordination & equilibrium › Observe for movement of arms  Smoothness of movement  Point of contact of finger › Normal: able to touch fingers to nose with smooth, accurate movements with little hesitation › Abnormal: cerebellar disease
    • Finger – to –nose – testa.Normalb.Ataxiac.IntentionTremor
    • Test for Pronator DriftNormal:Able to hold arm inthis position wellAbnormal:Downwardmovement of arm w/flexion of fingers &elbow
    • Rapid alternating movements observe rhythm, rate &smoothness of the movements Normal:  able to touch finger to thumb rapidly  rapidly turns palms up & downAbnormal: Unable to perform rapidalternating movementrs =cerebellar disease, upper motorneuron weaknessUncoordinated movements ortremors ( dysdiadochokinesia –impairment of the power toperform alternating movementsin rapid, smooth & rhythmicsuccession)
    • Heel to shin TestNormal: able to run eachheel smoothlydown each shinAbnormal: Deviation of heelto one side =cerebellar disease
    •  Test several kinds of sensation: › Pain & temperature (spinothalamic tracts) › Position & vibration (posterior columns) › Light touch ( both of these pathways) › Discriminative sensations
    •  Pay special attention to: › Where there are symptoms such as numbness or pain › Where there are motor or reflex abnormalities that suggest a lesion of the spinal cord or PNS › Where there are trophic changes
    • Sensory Function Test for senses and stimulus responseGeneral Approach: Instruct the patient to identify the sensations as you change stimulus and respond to your questions as needed Keep the patient’s eyes closed Do the procedures in random, letting the patient assess location of the area tested
    •  Test for spinothalamic tract › Light touch Abnormal:  Anesthesia - absence of touch sensation  Hypoesthesia – decreased sensitivity to touch  Hyperesthesia – increased sensitivity to touch › Sharp and Dull test Abnormal:  Analgesia –absence of pain sensation  Hypoalgesia – decreased sensitivity to pain  Hyperalgesia – increased sensitivity to pain › Temperature testing
    •  Test for Posterior Column TractA. Vibration › Tuning fork over bony prominences (toes, ankle, knee, iliac crest, spinal process, fingers, sternum, wrist, elbow) › Inability = posterior column disease or peripheral neuropathy (DM, chronic alcohol abuse)
    • Test Stereognosis ability to identifyobject withoutseeing it astereognosis –inability to identifyobject correctly
    • Test Graphesthesia  ability to perceive writing on the skin
    • Test for Two pointDiscrimination ability to identify thesmallest distancebetween two pointsDistances & locations:  Fingertips - 0.3 to 0.6cm  Hands & feet 1.5 – 2cm  Lower leg 4cmAbnormal: cortical disease
    •  Test Topognosis - ability to identify an area that has been touched Abnormal: sensory or cortical disease Test position sense of joint movement - great toe is dorsiflexed, plantar flexed or abducted
    •  Reflect integrity of the reflex at specific spinal levels and cerebral cortex function Approach › Done last › Patient in sitting position › Limbs to be tested should be relaxed, partially stretched  Clenching teeth, humming, counting ceiling blocks, interlocking of hands
    •  Reflex hammer  Hold handle of the reflex hammer between thumb & index finger so it swings freely  Palpate the tendon that you will need to strike  Tap the tendon, not the muscle or bone!  With a relaxed hold, Apply a short, quick & direct blow using the reflex hammer onto the muscle’s insertion tendon • Pointed end - smaller target (finger) • Flat end – wider target, produce diffuse impact
    • Evaluation 0 NR 1+ Diminished 2+ Normal 3+ Brisk, above normal 4+ Hyperactive
    • Biceps Reflex Evaluates function of spinallevels C5 & C6 Approach:  Partially bend patient’s arm with elbow with palm up  Place your thumb over the biceps tendon  Strike your thumb with the reflex hammerNormal: 1+ to 3+ flexion &contraction of biceps muscleAbnormal: NR or exaggerated
    • Triceps Reflex Evaluates function of spinallevels (C6 & C7) Approach:  Ask patient to hang his arm freely while supported with your nondominant hand  With elbow flexed, tap the tendon above the olecranon processNormal:  1+ to 3+ elbow extends, triceps contractsAbnormal:  NR or exaggerated
    • Brachioradialis Reflex Evaluates function ofspinal levels C5 & C6Approach:  Ask patient to flex elbow with palm down  Hand resting on abdomen or lap  Tap the tendon of the radius (2 inches above wrist)Normal:  1+ to 3+ forearm flexes & supinatesAbnormal:  NR or exaggerated
    • Patellar/Knee Reflex Evaluates function of spinallevels L2, L3 & L4 Approach:  Ask patient to hang both legs freely off examination table  Tap the patellar tendon located just below the patellaNormal:  1+ to 3+, knee extends, quadriceps muscle contractsAbnormal:  NR or exaggerated
    • Achilles Reflex Evaluates function of spinallevels S1 & S2Approach:  Patient’s leg hanging freely, dorsiflex the foot  Tap achilles tendon with the reflex hammerNormal:  1+ to 3+, plantar flexion of the footAbnormal:  NR or exaggerated* May be absent or difficult toelicit for older clients
    • Ankle Clonus Testing(Hyperreflexia)Done when other reflexes havebeen hyperactiveApproach:  Place one hand under the knee to support leg  Briskly dorsiflex the foot toward the client’s headNormal:  No rapid contractions or oscillations (clonus) of the ankleAbnormal:  Repeated rapid contractions or oscillations of ankle & calf muscle ( lesions of upper motor neurons)
    • Plantar/Babinski ReflexEvaluates function of spinal levelsL5, S1Approach:  Use the end of the reflex hammer  Stroke lateral aspect of the sole from heel to the ball of the foot  Curve medially across the boardNormal:  Flexion of the toesAbnormal:  Extension (dorsiflexion) of the big toe & fanning of all toes = normal in children 2 yrs & below, lesions of UMN, drug & alcohol intoxication, brain injury, subsequent epileptic seizure
    • Abdominal ReflexesEvaluates function of spinal levels T8,T9, T10 for upper & T10, T11, T12 forlower)Approach:  Use the wooden end of a cotton tipped applicator  Lightly & briskly stroke each side of the abdomen  Above & below the umbilicusNormal:  Abdominal muscles contract  Umbilicus deviates toward the side being stimulatedAbnormal:  Absent = LMN or UMN lesions* Abdominal reflex may be concealedbecause of obesity or muscularstretching from pregnancy
    •  Hyperreflexia = UMN lesion Hyporeflexia = LMN lesion Clonus = severe hyperreflexia - repeated rhythmic contraction elicited by striking a tendon/dorsiflexing the ankle
    • Neck Mobility Make sure there is no cervical vertebrae or cervical cord injury Approach: › supine position › Place hand behind patient’s head › Flex neck forward until chin touches the chest if possible Normal: › supple neck › Easily bend head & neck forward Abnormal: Nuchal Rigidity › Pain in the neck › Resistance to flexion  Meningeal irritation, arthritis or neck injury
    • 1. Brudzinski SignApproach:  Flex the neck  Watch the hips & kneesNormal:  Remain relax & motionlessAbnormal:  Pain & flexion of hips & knees  Meningeal inflammation
    • 2. Kernig’s SignApproach:  Flex patient’s leg at both the hip & knee  Then straighten the kneeNormal:  Discomfort behind the knee during full extension  No pain is feltAbnormal:  Pain & increased resistance to extending the knee  Bilateral = meningeal irritation