RN.com’s Assessment Series:
                Focused Neurological
                     Assessment




                     ...
Acknowledgements________________________________________________________________________ 2

Purpose & Objectives _________...
ACKNOWLEDGEMENTS


RN.com acknowledges the valuable contributions of…
… Lori Constantine MSN, RN, C-FNP, a nurse of nine y...
PURPOSE & OBJECTIVES
The fundamental processes of the brain and nervous system are key to understanding why nurses perform...
INTRODUCTION
The neurological history and exam allows the examiner to pinpoint various areas of the brain or nervous syste...
FOCUSED NEUROLOGICAL HISTORY

When your patient is conscious, you can ask the patient the following history questions. If ...
Infant, Pediatric, and Aging Considerations
Additional history questions you may wish to ask regarding your infant, pediat...
THE COMPLETE NEUROLOGIC EXAM
Integrate the steps of the neurological history with the steps taken during the complete exam...
12 Cranial Nerves
The cranial nerves arise directly from the central nervous system. Most often, a neurological problem is...
When testing the cranial nerves, follow the following guidelines for each cranial nerve.


Cranial Nerve I: Olfactory
Eval...
Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, and Abducens
Instruct the patient to follow the penlight or ophthalmo...
Cranial Nerve IX & X: Glossopharyngeal and Vagus
Ask the patient if they have difficulty swallowing and then ask them to s...
When testing muscle strength in the legs ask your patient to do the following against resistance:
       Lift legs up     ...
Finger to Nose Test
Have your patient touch their nose with their index finger of each hand with eyes shut. Patients shoul...
Assess Posterior Column Tract
Assessing the posterior column tract may identify lesions of the sensory cortex or vertebral...
Stretch or Deep Tendon Reflexes
Deep tendon reflexes, also known as muscle stretch reflexes, are reflexes elicited in resp...
The following reflexes are considered ABNORMAL in adults. Absence of superficial reflexes or unilateral
suppression of sup...
THE NEUROLOGICAL RECHECK OR ABBREVIATED
                  NEURO EXAM
Perform the neurological recheck exam at periodic int...
Glasgow Coma Scale
The Glasgow Coma Scale assesses how the brain functions as whole and not as individual parts (Teasdale,...
CONCLUSION

Integrating the neurological health history and physical exam takes practice. It is not enough to simply ask t...
REFERENCES

Agone, K., Elder, A., Foley, M., Kraut, P., Michael, K., & Tscheschlog, B. (Eds.). (1997). Expert 10-minute ph...
POST TEST VIEWING INSTRUCTIONS

In order to view the post test you may need to minimize this window and click “TAKE TEST”....
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RN.com's Assessment Series: Focused Neurological Assessment

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RN.com's Assessment Series: Focused Neurological Assessment

  1. 1. RN.com’s Assessment Series: Focused Neurological Assessment Presented by: RN.com 12400 High Bluff Drive San Diego, CA 92130 This course has been approved for two (2) contact hours. This course expires on October 5, 2006. Copyright © 2004 by RN.com. All Rights Reserved. Reproduction and distribution of these materials are prohibited without the express written authorization of RN.com. First Published: October 5, 2004
  2. 2. Acknowledgements________________________________________________________________________ 2 Purpose & Objectives _____________________________________________________________________ 3 Introduction _____________________________________________________________________________ 4 Focused Neurological History _______________________________________________________________ 5 Adult Patient___________________________________________________________________________ 5 Infant, Pediatric, and Aging Considerations _________________________________________________ 6 The Complete Neurologic Exam _____________________________________________________________ 7 Mental Status __________________________________________________________________________ 7 12 Cranial Nerves _______________________________________________________________________ 8 Inspect and Palpate the Motor System_____________________________________________________ 11 Check Cerebellar Function ______________________________________________________________ 12 Assess the Sensory System_______________________________________________________________ 13 Assess the Spinothalmic Tract ___________________________________________________________ 13 Assess Posterior Column Tract___________________________________________________________ 14 Check the Reflexes _____________________________________________________________________ 14 The Neurological Recheck or Abbreviated Neuro Exam ________________________________________ 17 Motor Function________________________________________________________________________ 17 Pupillary Response_____________________________________________________________________ 17 Glasgow Coma Scale ___________________________________________________________________ 18 Conclusion______________________________________________________________________________ 19 References ______________________________________________________________________________ 20 Post Test Viewing Instructions _____________________________________________________________ 21 1
  3. 3. ACKNOWLEDGEMENTS RN.com acknowledges the valuable contributions of… … Lori Constantine MSN, RN, C-FNP, a nurse of nine years with a broad range of clinical experience. She has worked as a staff nurse, charge nurse and nurse preceptor on many different medical surgical units including vascular, neurology, neurosurgery, urology, gynecology, ENT, general medicine, geriatrics, oncology and blood and marrow transplantation. She received her Bachelors in Nursing in 1994 and a Masters in Nursing in 1998, both from West Virginia University. Additionally, in 1998, she was certified as a Family Nurse Practitioner. She has worked in staff development as a Nurse Clinician and Education Specialist since 1999 at West Virginia University Hospitals, Morgantown, WV. 2
  4. 4. PURPOSE & OBJECTIVES The fundamental processes of the brain and nervous system are key to understanding why nurses perform a focused neurological assessment. If there is a disruption to any of these processes, the whole body suffers. This course will discuss specific neurological history questions and exam techniques for your adult patient. Physical exam techniques such as inspection, palpation, percussion, and auscultation will be highlighted. Additionally, throughout the course, you will learn how alterations in your neurological assessment findings could indicate potential nervous system abnormalities. After successful completion of this course, the participant will be able to: 1. Outline a systematic approach to neurological assessment. 2. Discuss history questions which will help you focus your neurological assessment. 3. Describe abnormal neurological assessment findings associated with inspection, auscultation, percussion, and palpation. 3
  5. 5. INTRODUCTION The neurological history and exam allows the examiner to pinpoint various areas of the brain or nervous system that may be dysfunctional. Specific signs and symptoms manifested by your patient are associated with specific areas of the brain. Nurses observe for signs and symptoms that may be abnormal and link them to general areas of the nervous system that may be causing the disturbance. You must also recognize when further neurological injury is manifesting, intervene appropriately, and notify the physician for a change in plans for the patient. Integrate the steps of the neurological history with the steps taken during the complete physical examination. It may not be necessary to perform the entire neurological exam on a patient with no suspicion of neurological disorders. You should perform a complete, baseline neurological examination on any patient that has verbalized neurological concerns in their history. Recheck the neuro exam at periodic intervals with any patient that has a neurological deficit (Agone, et al., 1997; Jarvis, 1996). The exam and history should be in an orderly, symmetrical fashion. This way, you will be certain that all areas are Neuro assessed. Each side of the body should be compared with the other side to detect any abnormalities. When reporting off, it Most healthcare providers is wise to perform a brief exam with the oncoming nurse at the shorten the term neurologic or bedside. This ensures the subjectiveness of your exam is not neurological to “neuro”. We misinterpreted by the next examiner. It allows for baseline will do the same in this course. neurological status to be ascertained at the beginning of each shift. Also, when a change in neurological function is experienced by the patient it is more easily identified. 4
  6. 6. FOCUSED NEUROLOGICAL HISTORY When your patient is conscious, you can ask the patient the following history questions. If they are not conscious, sometimes a family member or friend can provide some of this information. Their past medical records may also provide some answers to the following questions as well. Adult Patient When assessing the nervous system with your adult patient, ASK the following: Any past history of head injury? (location, loss of consciousness) This question may give you clues to underlying neurological damage that may change your patient’s baseline. Do you have frequent or severe headaches? (when, where, how often) Pain is a neurologic phenomenon. Most patients do not complain of pain in the neurological history. Their complaints of pain are mentioned more in association with an extremity, back, or head assessment. Any dizziness or vertigo? (frequency, precipitating factors, gradual or sudden) Syncope is a sudden lack of strength, a sudden loss of consciousness usually due to a lack of cerebral blood flow. It is also known as fainting. Vertigo is experienced as a rotational spinning. It is usually due to neurological disorder or an inner ear disturbance. Ever had/or do you have seizures? (when did they start, frequency, course and duration, motor activity associated with, associated signs, post-ictal phase, precipitating factors, medications, coping strategies) Seizures typically occur in disorders such as epilepsy. Often, the patient will describe an aura; an auditory, visual, or motor warning of the impending seizure. Any difficulty swallowing? (solids or liquids, excessive saliva) Difficult swallowing may clue you in to a possible abnormality with cranial nerves IX and X. Any difficulty speaking? (forming words or actually saying what you intended) If the patient answers yes to this question, then ask when it was first noticed and how long did it last. These questions may clue you in to potential transischemic attacks (TIA’s), which may be a warning signal for impending stroke. Do you have any coordination problems? (describe) Muscle tone and strength may be affected by both peripheral and central abnormalities. Do you have any numbness or tingling? (describe) Any abnormal sensations such as numbness or tingling may be referred to as parasthesias. Any significant past neurologic history? (CVA, spinal cord injuries, neurologic infections, congenital disorders) Specific neurological infections include meningitis and encephalitis. Environmental or occupational hazards? (If so, explain type, length, and nature of exposure) Exposure to insecticides, lead, organic solvents, drugs, and alcohol may all manifest in neurological symptoms. (Jarvis, 1996). 5
  7. 7. Infant, Pediatric, and Aging Considerations Additional history questions you may wish to ask regarding your infant, pediatric, or aging patients are listed in the table below: Additional History for Infants Additional History for Additional History for Elderly Children Patients Did the mother have any health Does the child have any balance Any problems with dizziness? If problems during pregnancy? problems? Any unexplained so when does it occur? falling? Muscle weakness? Difficulty getting up and down stairs? Tell me about the baby’s birth? Does the child have any seizures? Any decrease in memory or Premature or term? Birth Describe the circumstances change in mental functioning? weight? Apnea? APGAR around which they occurred. Scores? Any congenital defects? Did motor and development Any tremors in your hands or milestones occur during the face? appropriate age range? Are sucking and swallowing Has your child had any Any sudden vision changes or coordinated? environmental exposure to lead? sudden blindness? Does baby turn his head toward Any learning problems in school? Any sudden weakness on one touch? side of the body and not the other? Does baby startle with a loud Any family history of Ever experience loss of noise? neurological disorders? consciousness? (Jarvis, 1996) 6
  8. 8. THE COMPLETE NEUROLOGIC EXAM Integrate the steps of the neurological history with the steps taken during the complete examination. It may not be necessary to perform the entire neuro exam on a patient with no suspicion of neuro disorders. You should perform a complete baseline neurological examination on any patient that has verbalized neuro concerns in their history. Recheck the neuro exam at periodic intervals with any patient that has a neuro deficit (Agone, et al., 1997; Jarvis, 1996). When performing the complete neuro exam, EXAMINE the following: Mental Status The mental status portion of the examination is a series of detailed but simple questions designed to test cognitive ability including: the patient's awareness and responsiveness to the environment and the senses, appearance and general behavior, mood, content of thought, and orientation with reference to time, place, and person. Most nurses will not perform a detailed mental status exam. Therefore, assessing key parts of the aforementioned will be sufficient for most nurses to ascertain accurate mental status in their patients. Specifically nurses should establish if their patient is oriented to person, place, and time. Additionally, determine if your patient is alert. If not, what does it take to get them alert - calling their name, light touch, vigorous touch, pain? Verbal response to your questions should also be noted. Nurses should know that many neurological diseases, such as dementia, cause changes in intellectual status or emotional responsiveness, and specific personality features. If other parts of the neurological exam are normal, and you still feel the patient’s neurological status is impaired, a neurological consult to complete a full mental status exam may be warranted. 7
  9. 9. 12 Cranial Nerves The cranial nerves arise directly from the central nervous system. Most often, a neurological problem is detected through the assessment of these nerves. The cranial nerves are composed of twelve pairs of nerves that stem from the nervous tissue of the brain. Some nerves have only a sensory component, some only a motor component, and some both. The motor components of cranial nerves transmit nerve impulses from the brain to target tissue outside of the brain. Sensory components transmit nerve impulses from sensory organs to the brain. A summary of the functions of the cranial nerves is listed in the table below. Cranial Nerve Major Functions Cranial Nerve I: Olfactory Sensory Smell Cranial Nerve II: Optic Sensory Vision Cranial Nerve III: Oculomotor Sensory and Motor – Eyelid and eyeball movement Primarily Motor Cranial Nerve IV: Trochlear Sensory and Motor – Innervates superior oblique Primarily Motor eye muscle Turns eye downward and laterally Cranial Nerve V: Trigeminal Sensory and Motor Chewing Face and mouth touch and pain Cranial Nerve VI: Abducens Sensory and Motor – Turns eye laterally Primarily Motor Proprioception (sensory awareness of part of the body) Cranial Nerve VII: Facial Sensory and Motor Controls most facial expressions Secretion of tears and saliva Cranial Nerve VIII: Vestibulocochlear Sensory Hearing (auditory) Equilibrium sensation Cranial Nerve IX: Glossopharyngeal Sensory and Motor Taste Senses carotid blood pressure Muscle sense – proprioception, sensory awareness of the body Cranial Nerve X: Vagus Sensory and Motor Senses aortic blood pressure Slows heart rate Stimulates digestive organs Taste Cranial Nerve XI: Spinal Accessory Sensory and Motor – Controls trapezius and Primarily Motor sternocleidomastoid controls swallowing movements Muscle sense - proprioception Cranial Nerve XII: Hypoglossal Sensory and Motor – Controls tongue movements Primarily Motor Muscle sense - proprioception 8
  10. 10. When testing the cranial nerves, follow the following guidelines for each cranial nerve. Cranial Nerve I: Olfactory Evaluate the patency of the nasal passages bilaterally by asking the patient to breathe in through their nose while the examiner occludes one nostril at a time. Once patency is established, ask the patient to close their eyes. Occlude one nostril, and place a small bar of soap or other familiar smell near the patent nostril and ask the patient to smell the object and report what it is. Making certain the patient's eyes remain closed. Switch nostrils and repeat. Furthermore, ask the patient to compare the strength of the smell in each nostril. Very little localizing information can be obtained from testing the sense of smell. This part of the exam is often omitted, unless there is a reported history suggesting head trauma or toxic inhalation. Cranial Nerve II: Optic First test visual acuity by using a pocket visual acuity chart. Perform this part of the examination in a well lit room and make certain that if the patient wears glasses, they are wearing them during the exam. Hold the chart 14 inches from the patient's face, and ask the patient to cover one of their eyes completely with their hand and read the lowest line on the chart possible. Have them repeat the test covering the opposite eye. If the patient has difficulty reading a selected line, ask them to read the one above. Note the visual acuity for each eye. Next evaluate the visual fields via confrontation. Face the patient about one foot away, at eye level. Tell the patient to cover their right eye with their right hand and look the examiner in the eyes. Instruct the patient to remain looking you in the eyes and have the patient indicate when the examiner's fingers enter from out of sight, into their peripheral vision. Then, extend your arm and first two fingers out to the side as far as possible. Beginning with your hand and arm fully extended, slowly bring your outstretched fingers centrally, and notice when your fingers enter your field of vision. The patient should indicate seeing your fingers at the same time you see your fingers. Repeat this maneuver a total of eight times per eye, once for every 45 degrees out of the 360 degrees of peripheral vision. Repeat the same maneuver with the other eye. If you are an advanced practice nurse, you may want to use an ophthalmoscope, observe the optic disc, physiological cup, retinal vessels, and fovea. Note the pulsations of the optic vessels, check for a blurring of the optic disc margin and a change in the optic disc's color from its normal yellowish orange. Cranial Nerves II & III: Ask the patient to focus on any object in the distance. Observe the diameter of the pupils in a dimly lit room. Note the symmetry between the pupils. Next, shine the Direct Light Response: penlight or ophthalmoscope light into one eye at a time When a light shines into one eye the and check both the direct and consensual light responses pupil constricts. in each pupil. Note the rate of these reflexes. If they are sluggish or absent, test for pupillary constriction via Consensual Light Response: accommodation by asking the patient to focus on the light pen itself while the examiner moves it closer and When a light shines into one eye the closer to their nose. Normally, as the eyes other eye’s pupil will also constrict. accommodate to the near object the pupils will constrict. The test for accommodation should also be completed in a dimly lit room. 9
  11. 11. Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, and Abducens Instruct the patient to follow the penlight or ophthalmoscope with their eyes without moving their head. Move the penlight slowly at eye level, first to the left and then to the right. Then repeat this horizontal sweep with the penlight at the level of the patient's forehead and then chin. Note extra-ocular muscle palsies and horizontal or vertical nystagmus, which would be abnormal. Eye movements should be coordinated and smooth. Cranial Nerve V: Trigeminal First, palpate the masseter muscles (muscles of chewing or Palsy: of the jaw) while you instruct the patient to bite down Uncontrolable tremor or quivering hard. Note via observation if there is any masseter muscle wasting. Next, ask the patient to open their mouth against Nystagmus: resistance applied by the instructor at the base of the Rapid oscillation (movement) of the patient's chin. eye in any direction, but generally in a back-and-forth manner. Next, test gross sensation of Cranial Nerve V. Tell the patient to close their eyes and say "sharp" or "dull" when they feel an object touch their face. Using a semi-sharp object and a dull object, randomly touch the patient's face with either object. Touch the patient above each temple, next to the nose and on each side of the chin, all bilaterally. Ask the patient to also compare the strength of the sensation of both sides. If the patient has difficulty distinguishing pinprick and light touch, then proceed to check temperature and vibration. Finally, test the corneal reflex using a large Q-tip with the cotton extended into a wisp. Ask the patient to look at a distant object and then approaching laterally, touch the cornea (not the sclera) and look for the eye to blink. Repeat this on the other eye. Often, the patient will blink before the object touches the cornea. This is also normal. Cranial Nerve VII: Facial Nerve Inspect the face during conversation and rest noting any facial asymmetry including drooping, sagging or smoothing of normal facial creases. Ask the patient to raise their eyebrows, smile showing their teeth, frown and puff out both cheeks. Note asymmetry and difficulty performing these tasks. Ask the patient to close their eyes strongly and not let the examiner pull them open. When the patient closes their eyes, simultaneously attempt to pull them open with your fingertips. Normally the patient's eyes cannot be opened by the examiner. Once again, note asymmetry and weakness. Cranial Nerve VIII: Acoustic (Vestibulocochlear) Assess hearing by instructing the patient to close their eyes and Lateralization: to say "left" or "right" when a sound is heard in the respective Localization of a function or ear. Vigorously rub your fingers together very near to, yet not activity to one side of the touching, each ear and wait for the patient to respond. After this body. test, ask the patient if the sound was the same in both ears, or louder in a specific ear. If lateralization or hearing abnormalities exist, and you are a nurse practitioner, perform the Rinne and Weber tests. These will not be described in this article. 10
  12. 12. Cranial Nerve IX & X: Glossopharyngeal and Vagus Ask the patient if they have difficulty swallowing and then ask them to swallow and note any difficulty doing so. Next, note the quality and sound of the patient's voice. Is it hoarse or nasal? Ask the patient to open their mouth wide, protrude their tongue, and say "AHH". While the patient is performing this task, flash your penlight into the patient's mouth and observe the soft palate, uvula and pharynx. The soft palate should rise symmetrically, the uvula should remain midline and the pharynx should constrict medially like a curtain. Often the palate is not visualized well during this task. One may also try telling the patient to yawn, which often provides a greater view of the elevated palate. Also at this time, use a tongue depressor and the butt of a long Q- tip to test the gag reflex. Perform this test by touching the pharynx with the instrument on both the left and then on the right side, observing the normal gag or cough. Cranial Nerve XI: Spinal Accessory Inspect for wasting of the trapezius muscles by observing the patient from behind. Ask the patient to shrug their shoulders as strong as they can while the examiner resists this motion by pressing down on the patient's shoulders with their hands. Next, ask the patient to turn their head to the side as strongly as they possibly can while the examiner once again resists with their hand. Repeat this test on the opposite side. The patient should normally overcome the resistance. Note asymmetry. Cranial Nerve XII: Hypoglossal Have your patient "stick out their tongue" and move it side to side. Normally, the tongue will be protruded from the mouth and remain midline. Have the patient say “light, tight, dynamite” and note the clarity of each distinct word in pronunciation. Note deviations of the tongue from midline, a complete lack of ability to protrude the tongue, tongue atrophy and fasciculation (muscle twitches) on the tongue. Inspect and Palpate the Motor System Muscle Size Does your patient have appropriate size muscles for body type, age, and gender? Atrophy is abnormally small muscles with a wasted appearance. This can occur with disuse, injury, motor neuron diseases, and muscle diseases. Hypertrophy occurs with athletes and body builders. It is characterized by increased size and strength of muscles. Muscle Strength Test muscle strength against resistance using a 0 – 5 scale, with 0 = no movement and 5 = strong muscle strength. Muscle strength should be equal bilaterally. When testing muscle strength in the arms ask your patient to do the following against resistance: Lift arms away from side Lift wrist up; push wrist down Push arms towards side Squeeze examiners finger Pull forearm towards upper arm Pull fingers apart Push forearm away from upper arm Squeeze fingers together 11
  13. 13. When testing muscle strength in the legs ask your patient to do the following against resistance: Lift legs up Pull lower leg towards upper leg Push legs down Push lower leg away from upper leg Pull legs apart Push feet away from legs Push legs together Pull feet towards legs Muscle Tone Abnormal findings can include: limited range of motion, pain on motion, flaccidity, decreased resistance, spasticity, or rigidity. Involuntary Movements Tics, tremors, and fasciculations (involuntary contraction of a muscle) are all examples of abnormal involuntary movements you may note on exam. Check Cerebellar Function Checking cerebellar functioning includes testing balance, coordination, and skilled movements. Gait Have the patient walk heel to toe in a straight line - forwards and backwards. Assess for abnormalities such as stiff posture, staggering, wide base of support, lack of arm swing, unequal steps, dragging or slapping of foot, and presence of ataxia. Romberg’s Test With eyes closed, have the patient stand with feet together and arms extended to the front, palms up. Your patient should be able to maintain their balance. Stay next to the patient when they are performing this test in particular, so if they begin to fall, you can catch them. Balance should be maintained. Rapid Alternating Movements Have your patient rapidly slap one hand on the palm of the other, alternating palm up and then palm down - test both sides. Abnormal findings might be lack of coordination, or slow, clumsy movements. Finger to Finger Test Have your patient touch your index finger with their index finger, as you move your index finger in the space around them. Patients should be able to do this without missing the mark. 12
  14. 14. Finger to Nose Test Have your patient touch their nose with their index finger of each hand with eyes shut. Patients should be able to do this without missing the mark. Heel to Shin Test While standing, have your patient touch the heel of one foot to the knee of the opposite leg. While maintaining this contact, have the patient run the heel down the shin to the ankle. Test each leg. If your patient misses the mark, lower extremity coordination may be impaired. Assess the Sensory System Testing the sensory system checks the intactness of peripheral nerves, sensory tracts, and higher cortical discrimination. Have your patient close his eyes while checking sensory perception. Check the following bilaterally: Light Touch Can your patient feel light touch equally on both sides of the body? Sharp/Dull Can your patient distinguish between a sharp or dull object on both sides of the body? Hot/Cold Can your patient distinguish between a hot or cold object on both sides of the body? Assess the Spinothalmic Tract Checking the spinothalmic tract tests your patient’s ability to sense pain, temperature, and light touch. Presence of Pain “-algesia” = Pain can be tested by a simple pin prick with the patient’s eyes closed. Abnormal sensation findings would include hypalgesia, hyperalgesia, and analgesia. Temperature Temperature should be tested only if pain test is normal. Hot and cold objects may be placed on the patient’s skin at various locations bilaterally to test for temperature sensation. Light touch With a cotton ball or soft side of a Q-tip, touch the patient’s body bilaterally with “-esthesia” = their eyes closed. Ask them to indicate when you have touched them. Abnormal sensitivity responses include hypesthesia, anesthesia, and hyperesthesia. 13
  15. 15. Assess Posterior Column Tract Assessing the posterior column tract may identify lesions of the sensory cortex or vertebral column. Vibration Test the patient’s ability to feel vibrations by placing a tuning fork over various boney locations on the patient’s toes and feet. If these areas are normal, then you may assume the proximal areas are also normal. Position Position or kinesthesia is tested by having the patient close their eyes and move their big toe up and down. The patient should be able to tell you which way there toes are moving. Tactile discrimination Tactile discrimination tests the discrimination ability of the sensory cortex. Stereognosis tests the patient’s ability to recognize objects by feeling them. You can place car keys, a spoon, a pencil, or other common object in your patient’s hand. They should be able to identify that object by feel only. Graphesthesia is the ability to “read” a number “written” in your palm. Two point discrimination Two point discrimination tests the brain’s ability to detect two distinct pin pricks on the skin. An increase in the distance it normally takes to identify two distinct pricks occurs with sensory cortex lesions (Jarvis, 1998; Shaw, 1998). Check the Reflexes Reflexes are involuntary actions in response to a stimulus sent to the central nervous system. Alterations in reflexes are often the first sign of neurological dysfunction such as upper motor neuron disease, diseases of the pyramidal tract, or spinal cord injuries. 14
  16. 16. Stretch or Deep Tendon Reflexes Deep tendon reflexes, also known as muscle stretch reflexes, are reflexes elicited in response to stimuli to tendons. Normally, when a specific area of the muscle tendon is tapped with a soft rubber hammer, the muscle fibers contract. Abnormal responses may indicate injury to the nervous system pathways that produce the deep tendon reflex. Deep tendon reflexes can be influenced by age, metabolic factors such as thyroid dysfunction or electrolyte abnormalities, and anxiety level of the patient. The main spinal nerve roots involved in testing the deep tendon reflexes are summarized in the following table: Reflex Main Spinal Nerve Roots Involved Biceps C5, C6 Brachioradialis C6 Triceps C7 Patellar L4 Achilles Tendon S1 Check the deep tendon reflexes with a reflex hammer to stretch the muscle and tendon. The limbs should be in a relaxed and symmetric position. Strike the reflex hammer across the selected tendon with a moderate tap. If you cannot elicit a reflex, you can sometimes bring it out by certain reinforcement procedures. For example, have the patient grit their teeth then try to elicit the reflex again. Or you may have them clench their fists together when checking lower extremity reflexes. When reflexes are very brisk, clonus is sometimes seen. This is a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch. Deep tendon reflexes are often rated according to the following scale: Rating Reflex Response 0 absent reflex 1+ trace, or seen only with reinforcement 2+ normal 3+ brisk 4+ Non-sustained clonus (i.e., repetitive vibratory movements) 5+ sustained clonus Deep tendon reflexes are considered normal if they are 1+, 2+, or 3+. Reflexes that are asymmetric, or there is a large difference between the arms and legs, or are rated as 0, 4+, or 5+ abnormal (Jarvis, 1998). Superficial Reflexes The following reflexes are considered normal in adults. Can you define Ipsilateral? Upper Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side. It means on the same side or Lower Abdominal: Ipsilateral contraction of abdominal affecting the same side muscles on the stroked side. Cremasteric: Stroke inner thigh, elicits elevation of testes. 15
  17. 17. The following reflexes are considered ABNORMAL in adults. Absence of superficial reflexes or unilateral suppression of superficial reflexes often results from upper motor lesions subsequent to a stroke. Presence of primitive reflexes in adults is often a sign of frontal lobe lesions. Reflex Name Method to Elicit Babinski Sign Stroking the bottom of the foot elicits fanning (eversion) of big toe. When the external malleolar skin area is irritated, extension of the great toe Chaddock's Reflex occurs in cases of organic disease of the corticospinal reflex paths. Scratching the inner side of leg elicits extension of toes. Sign of cerebral Oppenheim's Sign irritation. Squeeze the calf muscles and note the response of the great toe. Fanning or Gordon's Sign extension is considered abnormal. Flexion of the terminal phalanx of the thumb and of the second and third Hoffman's Sign phalanges of one or more of the fingers when the palmar surface of the terminal phalanx of the fingers is flicked. Gently tapping or rubbing the upper lip elicits a reflexive sucking or Suck Reflex puckering response. Grasp Reflex Stroking the patient's palm, causing him to grasp your fingers. A positive test occurs when the patient does not let go of your fingers. Palmomental Sign Rub the thenar eminence (area of palm just below the thumb) ------> elicit reflexive contraction of the muscles of the chin. (Agone, et al., 1997; Jarvis, 1996) 16
  18. 18. THE NEUROLOGICAL RECHECK OR ABBREVIATED NEURO EXAM Perform the neurological recheck exam at periodic intervals with any patient that has a neuro deficit. This exam is also useful for your inpatient with a head injury or systemic disease process that may be manifesting as a neuro symptom. When performing this abbreviated exam, EXAMINE the following, in addition to any previously identified neurological deficits noted from the complete exam: Level of Consciousness (Monitors for signs of increasing intracranial pressure) Is your patient oriented to person, place, and time? Is your patient alert? If not, what does it take to get them alert - calling their name, light touch, vigorous touch, pain? Motor Function Ask your patient to squeeze your fingers with their hands and let go (tests for strength and symmetry of strength in the upper extremities) Ask your patient to push and pull their arms toward and away from you when their elbows are bent. Provide some resistance. (tests for strength and symmetry of strength in upper extremities) Ask your patient to dorsiflex and plantarflex their feet, while providing some resistance (tests for strength and symmetry of strength in lower extremities) Ask your patient to perform straight leg raises with and without resistance (tests for strength and symmetry of strength in lower extremities) Pupillary Response Size, shape, and symmetry of both pupils should be the same Each pupil should constrict briskly when a light is shined into the eyes Each pupil should have consensual light reflex 17
  19. 19. Glasgow Coma Scale The Glasgow Coma Scale assesses how the brain functions as whole and not as individual parts (Teasdale, 1975). The scale assesses three major brain functions: eye opening, motor response, and verbal response. A completely normal person will score 15 on the scale overall. Scores of less than 7 reflect coma. Using the scale consistently in the healthcare setting allows healthcare providers to share a common language and monitor for trends across time (Jarvis, 1996). Glasgow Coma Scale Best Eye Opening 1 = No response Response 2 = To pain 3 = To speech 4 = Spontaneously Best Motor Response 1 = No response 2 = Extension – abnormal 3 = Flexion - abnormal 4 = Flexion – withdrawal 5 = Localizes pain 6 = Obeys verbal commands Best Verbal Response 1 = No response 2 = Sounds - incomprehensible 3 = Speech - inappropriate 4 = Conversation - confused 5 = Oriented X 3 18
  20. 20. CONCLUSION Integrating the neurological health history and physical exam takes practice. It is not enough to simply ask the right questions and perform the physical exam. As the patient’s nurse, you must critically analyze all of the data you are obtaining, synthesize the data into relevant problem areas, and identify a plan of care for your patient based upon this synthesis. As the plan of care is being carried out, reassessments must occur on a periodic basis. How often these reassessments occur is unique to each patient and is based upon their physical disorder. Knowing when and how often to reassess is based on the specific patient, evidence presented, and facility policies, standards, and protocols. Please Read: This publication is intended solely for the use of healthcare professionals taking this course, for credit, from RN.com It is designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com. 19
  21. 21. REFERENCES Agone, K., Elder, A., Foley, M., Kraut, P., Michael, K., & Tscheschlog, B. (Eds.). (1997). Expert 10-minute physical examinations. St. Louis: Mosby. American Association of Critical Care Nurses (1998). The Nervous System. In J. Alspach (Ed.), Core curriculum for critical care nursing (5th ed., Rev., pp. 399-459). Philadelphia: Saunders. Folin, S. (Ed.). (2004). Rapid Assessment: A flowchart guide to evaluating signs and symptoms. Springhouse, PA: Lippincott, Williams & Wilkins. Jarvis, C. (1996). Physical examination and health assessment. Philadelphia: W.B. Saunders. Shaw, M. (Ed.). (1998). Assessment made incredibly easy. Springhouse, PA: Springhouse. Teasdale, G. (1975). Acute impairment of brain function. Nursing Times, 71, 914-917. © Copyright 2004, AMN Healthcare, Inc. 20
  22. 22. POST TEST VIEWING INSTRUCTIONS In order to view the post test you may need to minimize this window and click “TAKE TEST”. You can then restore the window in order to review the course material if needed. 21

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