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Neurological assessment

neurological assessment by Ms. LithaThomas

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NEUROLOGICAL ASSESSMENT
PREPARED BY :-
Ms. LITHA THOMAS
M.Sc(N)
,
• The CNS includes the Brain and spinal cord,
• It also includes the meninges, CSF, ventricles, brain
stem, cerebrum, cerebellum, hypothalamus and
thalamus
• The PNS includes the cranial nerves and the spinal
nerves.
• The cranial nerves (12) are attached to the brain and
arise from the brain stem
• The spinal nerves (31) arise from the spinal cord.
Neurological assessment
Neurological assessment
Neurological assessment

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Neurological assessment

  • 1. NEUROLOGICAL ASSESSMENT PREPARED BY :- Ms. LITHA THOMAS M.Sc(N)
  • 2. ,
  • 3. • The CNS includes the Brain and spinal cord, • It also includes the meninges, CSF, ventricles, brain stem, cerebrum, cerebellum, hypothalamus and thalamus • The PNS includes the cranial nerves and the spinal nerves. • The cranial nerves (12) are attached to the brain and arise from the brain stem • The spinal nerves (31) arise from the spinal cord.
  • 8. HISTORY TAKING 1. Biographic and Demographic Data 2. Chief Complaints 3. Past Health History :- a. Childhood and infectious diseases like Rubella, CMV,Herpes Simples, meningitis,influenza etc b. Immunization c. Major illness and hospitalization d. Medications such as CNS stimulants, sedatives, antidepressants, etc 4. Family Health History 5. Personal History 6. Psychosocial History
  • 9. PHYSICAL EXAMINATION/NEUROLOGICAL ASSESSMENT 1. Vital signs 2. Mental Status 3. Head neck and Back examination 4. Cranial nerve examination 5. Motor System Examination 6. Sensory function Examination 7. Reflex Activity examination
  • 10. 1. VITAL SIGNS • Check Vitals like TPR, BP, LOC, ICP, ECG, tissue perfusion etc
  • 11. 2. MENTAL STATUS 1. Level of Consciousness :- • Firstly check LOC spontaneously and then provide stimuli like verbal, visual, tactile, noxious agent or at last painful pressure like sternal pressure, supraorbital ridge pressure or sternocleidomastoid muscle pain. • Glasglow coma scale may be used
  • 13. 2. Orientation :- to time, place, person and event. 3. Memory :- Check long term, recent and short term memory 4. Mood and Affect :- Ask Questions, observe facial expressiosn and decide mood and affect like anxiety, fear, depression etc 5. Intellectual Development :- Check G.K, calculations etc 6. Judgment & Insight :- Check Reasoning, abstract thinking, problem solving, clients perception of any situation etc 7. Language and Communication 8. Comprehension and Expression
  • 14. 3. HEAD, NECK & BACK EXAMINATION 1. Inspection :- • Inspect head for shape, size, contour, symmentry etc. • Note any ecchymosis behind eyes , ears • Drainage of CSF, blood • Any skull fracture trauma etc 2. Palpation :- • Note Masses, nodules, bogginess, depressions, rigidity of muscles etc. 3. Percussion:- • Gentle percussion over spinous process may produce abnormal pain or tenderness 4. Auscultation:- • Ausculcate the blood vessels of neck for abnormal sounds
  • 15. 4. CRANIAL NERVES EXAMINATION 1. Olfactory Nerve ( CN-I ) :- • Purely sensory • Ask Pt to close eyes and provide different things of different smell and to identify them like lemon/orange peel, vinegar, coffee etc
  • 17. 2. Optic Nerve (CN-II) :- • Purely sensory function of the eyes • Check ACFRO (Acuity, Colour, field, reflex, opthalmoscopy) • Test Visual Activity/acuity by giving newspaper to read or using the Snellen s chart • Test Vision Color using the Ishihara Colour Plate to detect any colour blindness
  • 21. • Visual fields are tested by asking the patient to look directly at you whilst you wiggle one of your fingers in each of the four quadrants. Ask the patient to identify which finger is moving. (Confrontation test to find out visual inattention)
  • 23. • Also ask patient to look at your face and to close one eye . Extend your arm and slowly bring it closer from the periphery and ask the patient to tell when he sees your hand or wriggling finger. For accurate results the examiner too can close his opposite eyes and compare when he starts seeing the finger. • Do this in all quadrants and with both eyes
  • 26. • Visual reflexes comprise direct and concensual reflexes. Place one hand vertically along the patients nose to block any light from entering the eye which is not being tested. Shine a pen torch into one eye and check that the pupils of the examined eye (direct) and the other eye (concensual) constrict. This should be tested on both sides. Perform the swinging light test also
  • 28. • Inspect eyes and fundus for any abnormalities by opthalmoscopy examination.
  • 29. 3. Occulomotor, Trochlear and Abducens nerve ( CN – III, IV, VI) • All the three have motor functions. • Check the pupillary constriction by using torchlight Check eye responses to light, eye lid movement, drooping etc. • Test Accomodation by having the client look across the room away from the light source and then at your finger about 6 inches away from the clients nose. The pupils should converge and constrict a little. Check for nystagmus • Check eye movements in all six cardinal directions of gaze. Hold pts head still and ask patient to follow your finger as you move it in all directions (drawing H). • Check for any extra occular movement.
  • 32. 4. Trigeminal Nerve ( CN – V) • Has a motor and a sensory division. • Motor division innervates the muscles of mastication. • Ask the patient to clamp the jaws shut, and then feel the masseter and temporalis muscle. • Ask the pt to open the mouth against resistance, open mouth widely, move jaw from side to side and make chewing movements. • A jaw jerk reflex can be tested by placing a finger over the patient's chin and then tapping the finger with a reflex hammer. Normally the jaw moves minimally.
  • 36. • Sensory division mediates all sensations for entire face, scalp, cornea, nasal and oral cavity and has 3 branches:- ophthalmic, maxillary and mandibular. • With clients eyes closed, test sensations such as pain (sharp pain), touch (wisp of cotton) and temperature (hot & cold objects) on both sides on forehead, near eyes, cheeks and jaw • Test corneal reflex by gently touching cornea with a sterile wisp of cotton or gently stroking the eye lashes.
  • 39. 5. Facial Nerve (CN – VII) • Has motor division and sensory division. • Motor division innervates muscles controlling facial expressions. • Ask patient to smile, frown, raise the forehead & eyebrows, tightly close the eyes and resist attempt to open them, whistle, show the teeth, puff out the cheeks etc. • To test the sensory division ask the pt to stick out the tongue, close the eyes and place various tastes like sweet, sour, bitter etc on the anterior part of the tongue and ask pt to identify the taste • Test tearing sensation by irritating the eyes
  • 44. 6. Vestibocochlear/Accoustic Nerve (CN – VIII) • It is a sensory nerve with two divisions :- Vestibular and Cochlear. • Test the Vestibular nerve or balance using Romberg test, caloric test, Electronystagmography etc • Test Cochlear Nerve or Hearing Activity by having the client to listen and respond to some noise, tuning fork or Audiometry, Rinne s and Webers test etc
  • 48. 7. Glossopharyngeal and Vagus Nerve (CN – IX & X) • Both nerves have motor & sensory components. • Bothe nerves innervate the pharynx, so they are assessed together. • Ask Pt to open the mouth widely and say “Ahh”. Place a tongue depressor on 1st third of the tongue and observe position and movement of the uvula and palate. • The palate should rise symmetrically with the uvula.
  • 49. • Test gag reflex by gently touching the each side of pharynx with tongue depresssor which will normally elicit a brisk coughing response. • Use small amount of water to assess the ability to swallow. • Test posterior end of the tongue for taste just life CN – VII • To test CN – X, ask the patient to cough and speak and note any hoarseness or change of voice.
  • 51. 8. Spinal Accessory Nerves (CN – XI) • It has only motor component • Ask the patint to elevate and shrug the shoulder against resistance to check the trapezius muscle. • Ask the patient turn the head to one side and then the other against resistance to check the sternocleidomastoid muscle.
  • 54. 9. Hypoglossal Nerve (CN XII) • Only motor component. • Innervates the tongue • Ask patient to open the mouth widely, stick out the tongue , rapidly move tongue from one side to other and in and out. • Assess strength by having pt push the tongue against inside of cheek while applying external pressure.
  • 57. 5. MOTOR SYSTEM a) Muscle Size :- – Inspect all major muscles bilaterally for symmentry, hypertrophy & atrophy. B) Muscle Strength :- – Assess and rate muscle strength on a 5 point scale in all the four extremities, comparing one side with other :- – 5/5 :- Normal full strength. Muscles move actively through the full range of motion against the effects of gravity and applied resistance. – 4/5 :- Muscles moves actively through the full range of motion against the effect of gravity with weakness to applied resistance
  • 58. – 3/5 :- Muscles moves actively against the effect of gravity alone – 2/5 :- Muscles moves across a surface but cannot overcome gravity. – 1/5 :- Muscle contraction is palpable and visible, trace or flicker movement occurs – 0/5 :- Muscle contraction or movement is undetectable C) Muscle Tone :- • Move each extremity through its range of passive motion • When tone is decreased (hypotonicity) the muscles are soft, flabby or flaccid • When tone is increased (hypertonicity), the muscles are resistant to movement, rigid or spastic
  • 59. D) Muscle Co-Ordination :- – Test alternating movement by asking client to touch finger by thumb quickly in succession. – Ask client to pat thighs with palms, then back of hands quickly – For point to point testing hold up an index finger approx. 18 inches from client. Ask client first to touch his or her nose, then touch index finger and then nose again in succession. – Test lower extremity co-ordination by asking client to place the heel of the foot below the other knee and then to slide the heel towards the great toe. – Test Truncal Balance by asking patient to sit without support, lean and then return to normal position.
  • 60. E ) Gait and Station – Ask the patient to stand straight without any support. – Ask patient to walk with one foot in front of the other. F ) Movement :- • Check range of motion • Check for involuntary movements
  • 61. 6. SENSORY FUNCTION • Check the sensory functions by testing patient for touch, pain, vibration, hearing, vision, taste, smell, position and discrimination
  • 62. 7. REFLEXES Mainly there are two types of reflexes :- 1. Superficial (Cutaneous) reflexes 2. Deep tendon (Muscle Stretch) reflexes. 1. Superficial Reflexes :- • These are caused by stimulation of skin or mucous membrane with an object that will not cause damage. a) Abdominal reflex :- Lightly stroking of the abdominal skin causes contraction of abdominal muscles and moves umbilicus towards the stimulated side
  • 63. b) Planter Reflex :- Scratching the foots outer aspect of planter surface from the heel towards the toe normally contracts or flexes the toes (planter flexion). c) Corneal Reflex :- Gently touching the cornea with a wisp of cotton causes reflex blinking d) Pharyngeal Reflex :- Gently stimulating with a tongue blade at back of throat and pharynx produces a gagging reflex e) Anal reflex :- stimulating the perianal skin or inserting a gloved finger into rectum causes contraction of the rectal sphincter
  • 66. 2. Deep Tendon Reflexes :- • They are produced by sharply striking a muscle tendon’s point of insertion with a sudden brief blow of reflex hammer. a) Bicep’s reflex :- A forearm flexion is produced by tapping the biceps brachii tendon due to biceps muscle contraction b) Tricep’s reflex :- A forearm or elbow extension is produced by tapping the triceps brachii tendon at elbow due to triceps muscle contraction
  • 70. c) Brachio Radialis Reflex :- Flexion of elbow, supination of forearm & flexion of fingers and hand is produced by taping the styloid processes of the radius about 1-2 inches above wrist due to brachioradialus muscle contraction. d) Patellar Reflex (knee jerk) :- A leg extension is produced by tapping the quadriceps femoris tendon just below the patella due to quadriceps muscle contraction. e) Achilles Reflex (ankle jerk) :- Planter Flexion of foot is produced by tapping the Achilles tendon due to Gastrocnemius muscle contraction