ASSESSMENT: Neurologic Examination Ma. Tosca Cybil A. Torres, RN, MAN
AN IMPORTANT ASPECT OF THE NEUROLOGIC ASSESSMENT IS THE HISTORY OF THE PRESENT ILLNESS
HEALTH HISTORY Should include: Onset Character Severity Location Duration Frequency of s/sx Associated complaints Precipitating and aggravating factors Progression, remission, and exacerbation Presence and absence of similar symptoms among family members Review of medical history History of falls or trauma Use of alcohol, medications and illicit drugs
Common Clinical Manifestations Pain (chronic or acute) Seizures Dizziness and vertigo Visual disturbances Weakness Abnormal sensation
Physical Examination A neurological assessment is divided into five components: Cerebral function Cranial nerves Motor system Sensory system Reflexes Follows a logical sequence and progresses from higher levels of cortical function (ex: abstract thinking) to lower levels of function (ex: determination of the integrity of the peripheral nerves)
I. Assessing cerebral function Interpretation and documentation of neurologic abnormalities, particularly mental status abnormalities, should be SPECIFICandNONJUDGMENTAL.
Mental Status Assessment begins by observing client’s appearance and behavior Posture Gestures Movements Facial expressions Motor activity Manner of speech LOC Orientation
State of Awareness
Intellectual function Serial 7s Interpretation of well-known proverbs/idioms Capacity to recognize similarities Judgement
Is the patient’s thoughts:
Illusions Hallucinations preoccupations
Emotional Status Assess:
Consistency of verbal communication to non verbal cues
Perception Agnosia- inability to interpret or recognize objects seen through the special senses.
Body parts and relationships
Motor Ability Ask client to perform a skilled act Successful performance requires the ability to understand the activity desired and normal motor strength
Language Ability Aphasia- deficiency in language function Broca’s Aphasia (non-fluent aphasia)- speech output is severely reduced and is limited mainly to short utterances of less than four words. Wernicke’s Aphasia (fluent aphasia) -ability to grasp the meaning of spoken words is chiefly impaired, while the ease of producing connected speech is not much affected. Global aphasia- most severe form of aphasia, and is applied to patients who can produce few recognizable words and understand little or no spoken language. Global aphasics can neither read nor write.
Wernicke’s Aphasia Ex: I called my mother on the television and did not understand the door. It was too breakfast, but they came from far to near. My mother is not too old for me to be young.
II. Examining the Cranial Nerves
III. Examining the Motor System Assess muscle size, tone, and strength, coordination, and balance Note for rigidity, spasticity and flaccidity
Muscle Strength Grading 0 – No contraction1 – Slight contraction, no movement2 – Full range of motion without gravity3 – Full range of motion with gravity4 – Full range of motion , some resistance5 – Full range of motion, full resistance
Balance and Coordination Rapid, alternating movements Point-to-point testing Ataxia- incoordination of voluntary muscle action Romberg test
IV. Examining the Reflexes Stretch or Deep Tendon Reflexes A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmental level, and grading of DTR's is listed below. Grading DTR's 0 – Absent1 – Decreased but present2 – Normal3 – Brisk and excessive4 – With clonus
V. Sensory Examination The sensory examination is largely subjective and requires the cooperation of the patient.
Assessment of the sensory system involves: Tactile sensation Superficial pain Vibration Integration of sensation Proprioception Stereognosis
Diagnostic Evaluation CT scan
Myelography An x-ray of the spinal subarachnoid space after injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture
Post myelography care Head elevated to 30-45 degrees for 3H or as prescribed by the AP Encouraged to increase OFI Assess VS and ability to void Untoward signs------headache, fever, stiff neck, photophobia, and seizures