Neurological Assessment


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Neurological Assessment

  1. 1.  Developmental Psychosocial Cultural & Environmental
  2. 2.  COLDSPA Character Onset Location Duration Severity Pattern Associated Factors
  3. 3.  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?
  4. 4.  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?
  5. 5.  Do you smoke? Describe your usual diet? Do you lift heavy objects?
  6. 6.  Mental Status Cranial Nerves Motor & Cerebellar System Sensory System Reflexes
  7. 7.  Provide information about cerebral cortex function 4 major component: (a) Appearance (b) Behavior (c) Cognition (d) Thought process
  8. 8.  Posture Body Movements Dress Grooming & Hygiene
  9. 9. 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
  10. 10. 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
  11. 11.  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)
  12. 12.  Orientation – Person, place & time Attention Span Recent Memory Remote Memory New Learning Judgment
  13. 13.  Thought Processes Thought Content Perceptions Screen for Suicidal Thoughts
  14. 14.  Provide information regarding transmission of motor & sensory messages (head & neck) Are evaluated during the head, neck, eye & ear examinations
  15. 15. 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)
  16. 16. 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
  17. 17. 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
  18. 18. - check forsmell“ANOSMIA”– absence ofsmell
  19. 19. Visual Acuity-Test for near vision  Presbyopia – impaired near vision-Test for distantvision (Snellen’s Chart)  Myopia – “nearsightedness”  Hyperopia – “farsightedness”
  20. 20. 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)
  21. 21. Visual Fields by ConfrontationNormal Findings: Inferior: 70degrees Superior: 50degrees Temporal: 90degrees Nasal: 60degrees
  22. 22. 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
  23. 23. 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
  24. 24. * Abnormal: strabismus ptosisNystagmus -rythmic oscillationof the eyesStrabismus –lack of musclecoordination diplopiaDiplopia –double vision
  25. 25. 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
  26. 26.  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
  27. 27. 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
  28. 28. Bell’s Palsy
  29. 29. 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
  30. 30.  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
  31. 31. Caloric TestTest the vestibularportion of the nervePerformed onlywhen client isexperiencingdizziness or vertigo.
  32. 32. 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
  33. 33. Trapezius MuscleNormal: > symmetric,strong contractionsAbnormal: > asymmetricmuscle contraction > drooping of theshoulder
  34. 34. Sternocleidomastoid MuscleNormal: > ease of movement > wide range ofmotionAbnormal: > muscle weakness > muscle atrophy > uneven shoulders
  35. 35. Movement &strength of tongueNote atrophy,tremors & paralysisNormal: > Movement issymmetrical &smooth > Bilateral strength isapparent > tongue at midlineAbnormal: > Fasciculation –PNS disease
  36. 36.  To determine functioning of the pyramidal & extrapyramidal tracts To determine balance & coordinationFocus on: Body position Involuntary movements Characteristics of the muscles Coordination
  37. 37.  Natural walk › Note posture, freedom of movement, symmetry, rhythm & balance › Normal: Steady; opposite arm swings
  38. 38. observe for: stiffness or relaxation equality of steps pace of walking position & coordination of arms ability to maintain balance
  39. 39. 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
  40. 40. 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
  41. 41. Cerebellar Ataxiawide-based,staggering, unsteadygait(+) Romberg’s testCerebellar diseasesor alcohol & drugintoxication
  42. 42. Parkinsonian GaitShuffling gait, turns invery stiff mannerStooped-over posturewith flexed hips & kneeSeen in Parkinsonsdisease
  43. 43. Scissors Gaitstiff, short gaitThighs overrlap eachother with each stepSeen in partialparalysis of the leg
  44. 44. Spastic HemiparesisFlexed arm heldclose to bodywhile client dragstoe of legs orcircles it stifflyoutward & forwardlesions of UMN =CVA
  45. 45. Footdrop (steppagegait)Liftsfoot & knee highwith each step, thenslaps the foot down hardon the groundCannot walk on heelsLMN disease
  46. 46.  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
  47. 47. Finger – to –nose – testa.Normalb.Ataxiac.IntentionTremor
  48. 48. Test for Pronator DriftNormal:Able to hold arm inthis position wellAbnormal:Downwardmovement of arm w/flexion of fingers &elbow
  49. 49. 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)
  50. 50. Heel to shin TestNormal: able to run eachheel smoothlydown each shinAbnormal: Deviation of heelto one side =cerebellar disease
  51. 51.  Test several kinds of sensation: › Pain & temperature (spinothalamic tracts) › Position & vibration (posterior columns) › Light touch ( both of these pathways) › Discriminative sensations
  52. 52.  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
  53. 53. 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
  54. 54.  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
  55. 55.  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)
  56. 56. Test Stereognosis ability to identifyobject withoutseeing it astereognosis –inability to identifyobject correctly
  57. 57. Test Graphesthesia  ability to perceive writing on the skin
  58. 58. 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
  59. 59.  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
  60. 60.  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
  61. 61.  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
  62. 62. Evaluation 0 NR 1+ Diminished 2+ Normal 3+ Brisk, above normal 4+ Hyperactive
  63. 63. 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
  64. 64. 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
  65. 65. 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
  66. 66. 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
  67. 67. 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
  68. 68. 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)
  69. 69. 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
  70. 70. 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
  71. 71.  Hyperreflexia = UMN lesion Hyporeflexia = LMN lesion Clonus = severe hyperreflexia - repeated rhythmic contraction elicited by striking a tendon/dorsiflexing the ankle
  72. 72. 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
  73. 73. 1. Brudzinski SignApproach:  Flex the neck  Watch the hips & kneesNormal:  Remain relax & motionlessAbnormal:  Pain & flexion of hips & knees  Meningeal inflammation
  74. 74. 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