attachment.pdf neurologic disorder for 3rd year student

Nursing Intervention of Patients with
Neurologic Disorders
By: Dr. Alazar. E.(MD, BSc)
June, 2024
1

Contents
Anatomic and physiologic overview
Assessment of Neurologic system
Neurologic manifestations
Management protocols
2

Anatomic and Physiologic Overview
NS is one of the body’s control systems
Central Nervous System (CNS) (brain and spinal
cord)
The brain contains more than 100 billion cells
Peripheral Nervous System (cranial nerves,
spinal nerves, and autonomic nervous system)
3

Overview…
A neuron is composed of the nucleus (within the cell
body), a dendrite, an axon, and the axon terminals
 Neuroglial cells, 50 times greater in number than
neurons,
Support, protect, and nourish neurons
Neurons can be
Afferent – carry to CNS
Efferent – away from CNS to muscles and glands
Mixed
4

Brain
 Covered with skull
 Accounts 2% of total body weight
Cerebral cortex
 Outermost cover
 Composed of neural cell bodies, gray appearance
 right and left cerebral hemisphere
Also divided as
 Frontal lobe - speech articulation, behavior, moral decision
making, and emotional outburst
 Parietal lobe -- interprets sensory stimuli, pain, and touch.
 Temporal lobe -- auditory processing, language interpretation
(Wernicke’s area), and memory formation, and storage.
 Occipital lobe – houses the visual cortex
7

Brain…
 The hypothalamus controls neuroendocrine function and
maintains homeostasis,
 The brainstem (pons, medulla oblongata, and midbrain)
Cerebellum
 Coordination of movement.
 It also controls fine movement, balance, position sense
(awareness of where each part of the body is), and
integration of sensory input.
The meninges
 Fibrous connective tissues that cover the brain and spinal
cord
 Provide protection, support, and nourishment to the brain
and spinal cord.
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Cerebro-Spinal Fluid (CSF)
Clear and colorless fluid
Produced in the ventricles and is circulated around
the brain and the spinal cord
Four ventricles: the right and left lateral, and the
third and fourth ventricles.
CSF analysis report usually contains information
on
Color, Specific gravity, Protein count,
WBC count, Glucose, and other electrolyte levels;
It may also be tested for immunoglobulins or lactate
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Blood-Brain-Barrier (BBB)
 BBB create a barrier to macromolecules and many
compounds.
The spinal cord
 Extension of brain stem
 Around 45cm long
 Has a thickness of finger
 From base of skull to L1 or L2
 The anterior horns (motor): voluntary and reflex
activity.
 The posterior (sensory): serve as a relay station in the
sensory/reflex pathway.
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Vertebral Column
 Bones surround and protect the spinal cord
Consist of
 7 cervical,
 12 thoracic, and
 5 lumbar vertebrae,
 5 sacral
 1 coccyx.
 The vertebrae are separated by disks, except for the first
and second cervical, the sacral, and the coccygeal
vertebrae.
13

Autonomic Nervous System
 Regulates the activities of internal organs such as the
heart, lungs, blood vessels, digestive organs, and
glands.
 Sympathetic nervous system, and parasympathetic
NS
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Nursing Assessment of Neurologic System
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History (Ask for)
 Headache,
 Head injury,
 Dizziness or vertigo,
 Seizures,
 Tremors,
 Weakness or in coordination,
 Numbness, or tingling,
 Difficulty of swallowing,
 Difficulty of speaking,
 Significant past history.
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Neurological Assessment
Sequence for the complete neurologic
examination.
Mental status
Cranial nerves
Motor system
Sensory system
Reflexes
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Mental status (A, B, C, T)
o Appearance (posture, body mov’t, dress, grooming)
o Behavior (Facial expression, LOC, speech, Mood
and affect)
o Cognition (Orientation, recent & remote memory ),
and
o Thought processes, content,
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1.1 Appearance
Look for posture. Normally it is erect and position is
relaxed.
Normal body movements are voluntary, deliberate,
coordinated, smooth and even.
Dress should be appropriate for setting, season, age, gender
and social group.
Note grooming & hygiene. Normally it should be clean,
well-groomed, and hair should be neat and clean.
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1.2 Behavior
1. Level of consciousness: look, is the person awake,
alert and aware of stimuli from the environment and
responds appropriately?
2. Facial expression: look, is facial expression
appropriate to the situation and changes appropriately
with the topic?
3. Speech: Pace of conversation should be moderate and
stream of talking should be fluent. Articulation should
be clear and understandable.
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Behavior …
4. Mood (affect): judge the mood of the patient. You can do
this in two ways:
1. Focus on body language and facial expression
2. Ask directly “how do you feel today?”
 The mood should be appropriate to the person’s place
and should change appropriately with topic.
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Level of consciousness…
Level of Consciousness (Arousal):Techniques and Patient Response
LEVEL TECHNIQUE
Alertness Speak to the patient in a normal tone of voice.
An alert patient opens the eyes, looks at you,
and responds fully and appropriately to stimuli
Lethargy Speak to the patient in a loud voice( call the
patient’s name or ask “How are you?”
Obtundation Shake patient gently as if awakening a sleeper.
Stupor Apply a painful stimulus(pinch a tendon, rub
the sternum, or roll a pencil across a nail bed
Coma Apply repeated painful stimuli.
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The Glasgow coma scale (GCS)
The GCS evaluates consciousness by scoring a
response in three areas:
A. Eye opening
B. Motor response
C. Verbal performance.
The application of the GCS requires skill to achieve
consistency in scoring.
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GCS EXERCISES
32
1. What is a 3 on the motor portion of the GCS?
The patient follows commands correctly
The patient displays decorticate posturing
The patient displays decerebrate posturing
The patient groans to painful stimuli

GCS EXERCISES
33
2. Your patient's vocal response is confused, but they are still
able to speak in full sentences.What score would you give
them for the verbal portion of the GCS?

GCS EXERCISES
34
3. Your patient opens their eyes to verbal stimulation but is
unable to follow commands and displays a localization pain
response.They grunt when noxious stimuli are provided
but do not produce words.What is their GCS?

GCS EXERCISES
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4. Your patient is completely unresponsive to noxious stimuli
and makes no sounds.They do not move when noxious
stimuli is provided.What is their GCS?

GCS EXERCISES
36
5. Your patient's eyes do not open to noxious stimuli and they
respond incorrectly when asked questions and localize to
pain.What is their GCS?

GCS EXERCISES
37
6. Your patient's eyes are open spontaneously but they do not
make any verbal response when noxious stimuli is
provided.They display abnormal flexion when noxious
stimuli is provided.What is their GCS?
7. You are called to respond for a patient who difficult to
rouse.Your patient is somnolent and will only open their
eyes to verbal stimuli but are able to engage in conversation
and follow commands.What is their GCS?

GCS EXERCISES
38
8. You are called to respond for a patient who was
unconscious and unresponsive.When you arrive on scene,
your patient is awake and shouting that they do not need
help.The patient is able to follow commands and states that
they were just sleeping off a hangover.What is their GCS?
9. Your patient opens their eyes to verbal stimulation and has
a dysconjugate gaze.They are able to form words, but the
words are not correct for the situation or questions asked.
They are able to follow commands with one side of their
body.What is their GCS?

GCS EXERCISES
39
10. Your patient does not open their eyes to noxious stimuli
and groans when noxious stimuli is provided.They attempt
to get away from the noxious stimuli.What is their GCS?

1.3 Cognitive functions
Orientation: assess the following:
1. Time: by asking day of week, date or year
2. Place: ask present location or name of city
3. Person: ask own name, age, or name of well-known
person.
 Disorientation can occur with organic brain disorders.
 Orientation is usually lost first to time, then to place, and
finally to person.
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Attention
These tests of attention are commonly used. Include the 3
test( digit span, serial 7s and spelling backward)
Digit Span:
list a series of digits, starting with two at a time and
speaking each number clearly at a rate of about one per
second.
Ask the patient to repeat the numbers back to you.
 If this repetition is accurate, try a series of 3 numbers,
then 4, and so on as long as the patient responds correctly.
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Use street numbers, zip codes, telephone numbers, and
other numerical sequences that are familiar to you, but
Avoid consecutive numbers, easily recognized dates, and
sequences that possibly are familiar to the patient.
starting with a series of two, ask the patient to repeat the
numbers to you backward.
Normally, a person should be able to repeat correctly at
least five digits forward and four backward.
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Cont’d…
Serial 7s:
Instruct the patient, “Starting from a hundred, subtract 7,
and keep subtracting 7. . . .” Note the effort required and
the speed and accuracy of the responses.
Spelling backward: Say a five-letter word, spell it, e.g., W-
O-R-L-D, and ask the patient to spell it backward.
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Memory
Remote (long-term memory) – ask the patient
questions about past events that can be validated, such
as dates of anniversaries or historical events.
Recent (short-term memory) – ask the patient to recall
a mutually known event that occurred earlier in the
day or within the previous 24 hours
Immediate (recall memory) – give the patient 2 or 3
common objects to remember; ask the patient to list
them 5 to 10 minutes later
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Higher cognitive functions
Calculating Ability:
Test the patient’s ability to do arithmetical calculations,
starting at the rote level with simple addition (“What is 8 +
7?”) and multiplication (“What is 5 x 6? Then more
difficult by using two-digit numbers (“15 + 12” or “25 x
6”).
Poor performance may be a useful sign of dementia
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Higher cognitive functions…
Abstract Thinking
Proverb
Similarity
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1.4 Thought Process & Perceptions
1. Thought process: to check this ask your self “does this
person make sense? Can I follow what the person is
saying?”
 The way a person thinks should be logical, goal directed,
coherent and relevant.
 The person should complete a thought.
 As abnormalities with thought process there may be
illogical, unrealistic thought process & evidence of
blocking.
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Thought Process & Perceptions …
2. Thought content: what the persons says should be
coherent and consistent as well as logical.
3. Perceptions: the person should consistently be aware
of reality and his perceptions should be congruent with
your own (the examiner’s).
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Ask questions like
“How do people treat you?
Do other people talk about you?
Do you feel you are being watched or followed?” just to
check the perceptions of your patient.
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Obsessions and compulsions are abnormalities of
thought content.
Illusion and hallucinations are abnormalities of
perception.
Auditory and visual hallucination occur with psychiatric
and organic brain disorders.
Tactile hallucination occur with alcohol withdrawal.
51

52
 Illusion: a false perception due to misinterpretation of stimuli
arising from an object.
 Obsessions: a recurrent thought, feeling, or action that
is unpleasant and provokes anxiety but can not be got
rid of. Although an obsession dominates the person,
he(she) realizes its senselessness and struggles to expel
it.
 Compulsions: obsession that takes the form of a motor act,
such as repetitive washing based on a fear of contamination.

1.5 Language ability
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 Language is the communication of thought and idea from
one person to another through sign and symbol
 Functions of language
 Comprehension
 Reading
 Writing
 speech

1.5 Language ability
 The person with normal neurologic function can
understand and communicate in spoken and written
language.
 Does the patient answer questions appropriately?
 Can he or she read a sentence from a newspaper and
explain its meaning?
 Can the patient write his or her name or copy a simple
figure that the examiner has drawn?
 A deficiency in language function is called aphasia.
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Language ability…
Aphasia: inability to express oneself or to understand
language
 Expressive aphasia: inability to express oneself; often
associated with damage to the left frontal lobe area
 Receptive aphasia: inability to understand what someone
else is saying; often associated with damage to the
temporal lobe area
 Global aphasia-loss of all functions of language
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2. Cranial Nerves Assessment
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2. Cranial Nerves Assessment
o The examination of the cranial nerves (often abbreviated as CN) can be
summarized as follows:
Cranial Nerves Function
I Smell
II Visual acuity, visual fields, and ocular fundi
II, III Pupillary reactions
III, IV, VI Extraocular movements
V Corneal reflexes, facial sensation, and jaw movements
VII Facial movements
VIII Hearing
IX, X Swallowing and rise of the palate, gag reflex
V, VII, X, XII Voice and speech
XI Shoulder and neck movements
XII Tongue symmetry and position
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Cranial nerve examination
Olfactory:
Test the sense of smell by presenting the patient with
familiar and nonirritating odors
First check the passage of the nose
The patient should then close both eyes
Occlude one nostril and test smell in the other with such
substances as cloves, coffee, soap
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Optic nerve:
Examine visual acuity
Visualize the fundi with the ophthalmoscope
 Screen the visual fields by confrontation
Optic and Oculomoter nerve:
Inspect the size and shape of the pupils, and compare one
side with the other.
Test the pupillary reactions to light
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Visual flied by confrontation
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Oculomotor, Trochlear, and Abducens:
Test the extraocular movements in the six cardinal
directions of gaze
look for loss of conjugate movements in any of the six
directions.
Look for ptosis (drooping of the upper eyelids).
63

Cardinal Directions of Gaze
64

Trigeminal:
Motor: palpate the temporal and masseter muscles in
turn, ask the patient to clench his or her teeth.
Note the strength of muscle contraction.
Sensory:
 After explaining what you plan to do, test the
forehead, cheeks, and jaw on each side for pain
sensation.
The patient’s eyes should be closed.
Use a safety pin or other suitable sharp object
65

Trigeminal…..
 Ask the patient to report whether it is “sharp” or “dull” and to
compare sides.
 Two test tubes, filled with hot and ice-cold water, are the
traditional stimuli.
 Dry it before use. Touch the skin and ask the patient to identify
“hot” or “cold.”
 Test for light touch, using a fine wisp of cotton
 Test the corneal reflex. Ask the patient to look up and away from
you.
66

Assess the Muscles of Mastication by Palpating
the Temporal and Masseter Muscles
67

Test Light Touch Sensation by Touching a Cotton
Wisp to these Designated Areas on Person's Face:
Forehead, Cheeks, and Chin.
68

With the Person Looking Forward,
Bring a Wisp of Cotton in from
the Side (to Minimize Defensive
Blinking) and
Lightly Touch the Cornea—Not
the Conjunctiva.
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Facial:
Inspect the face, both at rest and during conversation with
the patient
Note any asymmetry
70

3
Note Mobility and Facial Symmetry
71

Acoustic:
 Assess hearing. If hearing loss is present:
 test for lateralization
 compare air and bone conduction
73

Lateralization(Weber test)
-Hearing loss can be:-
A. Conductive Loss
B. Sensorneural Loss
C. Mixed
74

Pathways of Hearing
Vibrations of sound pass through the air of the external
ear and are transmitted through the eardrum and ossicles
of the middle ear to the cochlea, a part of the inner ear.
The cochlea senses and codes the vibrations, and nerve
impulses are sent to the brain through the cochlear nerve.
75

Pathways of Hearing…………..
The first part of this pathway—from the external ear
through the middle ear—is known as the conductive
phase, and a disorder here causes conductive hearing
loss.
 The second part of the pathway, involving the cochlea
and the cochlear nerve, is called the sensorineural
phase; a disorder here causes sensorineural hearing
loss.
76

Pathways of Hearing…………..
Air conduction describes the normal first phase in the
hearing pathway.
An alternate pathway known as bone conduction by
passes the external and middle ear and it is used fro
testing purposes.
A Vibrating tuning fork, placed on the head, sets the bone
of the skull into vibration and stimulates the cochlea
directly.
In normal person air conduction is more sensitive.
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A. Conduction loss
Interruption of sound waves as they travel from the outer
ear to the Cochlea.
Due to pathology of external or middle ear.
B. Sensorneural Loss:-
Results from damage from the inner ear, Cochlea or CN
VIII.
78

How we perform Weber test
Prepare quite room and tunning fork.
Place lightly vibrating tunning fork (bass)firmly on the
mid head or forehead.
Ask the patient on which ear he/she hears better.
Normally the vibration is heard equally on both ears
/will be heard centrally.
o Conductive hearing loss:- the tone lateralize to the
affected side.
o Sensorneural hearing loss:- the sound localizes to the
intact or least affected.
79

The Rinne Test(comparing air conduction and bone
conduction)
 Place lightly vibrating tunning fork (on the bone) on the
mastoid process firmly.
 Ask the patient to tell when he/she no longer hears a sound.
 Then move the “U’’ part of the tunning fork near the ear
canal quickly and ask the patient whether he/she can hear the
sound or not.
 Normally AC>BC (Rinne Positive)
 With conductive hearing loss BC>AC recorded as Rinne
Negative .
 In Sensorneural loss AC>BC
80

Glossopharyngeal and Vagus:
 Listen to the patient’s voice
movements of the soft palate and the pharynx
soft palate normally rises symmetrically, the uvula remains
in the midline.
test the gag reflex by stimulate the back of the throat.
Unilateral absence of this reflex suggests a lesion of CN
IX, perhaps CN X.
81

Gag reflex
Ask to say “ah” or to yawn
as you watch the movements
of the soft palate and the
pharynx.
The soft palate normally
rises symmetrically, the
uvula remains in the
midline.
Stimulate the back of the
throat lightly on each side in
turn and note the gag reﬂex.
It may be symmetrically
diminished or absent in
some normal people.
Gag reflex
82

Spinal Accessory
From behind, look for atrophy or fasciculations in the
trapezius muscles, and compare one side with the other.
Ask the patient to shrug both shoulders upward against
your hands.
Note the strength and contraction of the trapezii
Hypoglossal:
 Listen to the articulation of the patient’s words.
 This depends on Cranial Nerves V, VII, and X as well as
XII.
Inspect the patient’s tongue as it lies on the floor of the
mouth.
83

Ask the Person to Shrug the
Shoulders Against Resistance
84

Test flexion (C5, C6—biceps) and extension (C6, C7,
C8—triceps) at the elbow by having the patient pull and
push against your hand.
Test extension at the wrist (C6, C7, C8, radial nerve) by
asking the patient to make a fist and resist your pulling it
down.
Weakness of extension is seen in peripheral nerve
disease (e.g., radial nerve damage) and
 in central nervous system disease producing hemiplegia
(e.g., stroke or multiple sclerosis).
85

Test the grip (C7, C8, T1).
 Ask the patient to squeeze two of your fingers as hard as
possible and not let them go.
A weak grip may be due to either central or peripheral
nervous system disease.
Test finger abduction (C8, T1, ulnar nerve). Position the
patient’s hand with palm down and fingers spread.
Instructing the patient not to let you move the fingers, try
to force them together.
Weak finger abduction in ulnar nerve disorders
86

Flexion, extension, and lateral bending of the spine
Test flexion at the hip (L2, L3, L4—iliopsoas) by placing
your hand on the patient’s thigh and asking the patient to
raise the leg against your hand
Test adduction at the hips (L2, L3, L4—adductors).
Test abduction at the hips (L4, L5, S1—gluteus medius and
minimus).
Test extension at the hips (S1—gluteus maximus). Have the
patient push the posterior thigh down against your hand.
87

Test extension at the knee (L2, L3, L4 quadriceps).
Support the knee in flexion and ask the patient to
straighten the leg against your hand.
Test flexion at the knee (L4, L5, S1,S2)hamstrings)
Test dorsiflexion (mainly L4, L5) and plantar flexion
(mainly S1) at the ankle by asking the patient to pull up
and push down against your hand
88

3. Motor System Examination
3.1 Balance tests
1. Gait
Observe the person while walks, turns and returns.
Normally the gait is smooth, rhythmic and effortless.
Ask the person to walk straight line in a heel-to-toe
fashion (tandem walking).
Normally the person can walk straight and stay balanced.
Abnormalities such as staggering or loss of balance can
be detected
89

Balance tests …
2. Romberg Test
 Ask the person to stand up with feet together and hands
at sides.
 Once in a stable position, ask the person to close his eyes
and hold the position.
 Wait about 20 seconds.
 Normally posture and balance are maintained.
90

Balance tests …
Positive Romberg’s sign is loss of balance with closing of
eyes that occur with cerebellar ataxia and loss of
vestibular function.
Ask the person to hop first on one leg, and then on the
other.
This demonstrates muscle strength and cerebellar
function.
91

3.2 Coordination & Skilled Mov’t
1. Rapid alternating movement (RAM)
 Ask the person to pat knees with both hands, lift up, turn
hands over and pat the knees with backs of hands.
 Then ask the person to do this faster.
 Normally, this is done with equal turning and a quick
rhythmic pace.
93

Coordination & Skilled Mov’t …
Alternatively, ask the person to touch the thumb to each
finger on the same hands, starting with index finger, then
reverse the direction.
Normally, this can be done quickly and accurately
Abnormally, lack of coordination can be detected with
cerebellar disease.
Failure to do this rapid movement is known as
Dysdiadochokinesia.
94

2. Finger-to-finger test
With the persons eyes open, ask the person to touch your
index finger with his index finger, and then his own nose
with the same index finger.
After some time move your finger to a different spot.
Normally, the person’s mov’t should be smooth and
accurate.
Abnormally, the person misses.
95

3. Finger-to-nose test
Ask the person to close his eyes and to stretch out his
arms.
Ask the person to touch the tip of his/her nose with each
index finger, alternating hands and increasing speed.
Normally, it is done with accurate and smooth movement.
Abnormally, the person misses nose.
96

4. Heel-to-shin test
Test the coordination of lower extremity by asking the
person, who is in a supine position, to place the heel on
the opposite knee and run it down the shin from the knee
to ankle.
Normally, moves the heel in straight line down the shin.
Abnormally, lack of coordination or heel falls off shin.
97

Stance…
Test for pronator drift: The patient should stand for 20 to
30 seconds with both arms straight forward, palms up, and
with eyes closed.
instructing the patient to keep the arms up and eyes shut,
as shown above, tap the arms briskly downward. The arms
normally return smoothly to the horizontal position.
99

Con’t…..
Check muscle strength
Instruct the patient to do the following
(a) Ask him to grip your hands and squeeze
(b) Have the patient push against your palm with his foot.
Compare the strength of his muscles on each side of his body
(c) Have the patient extend and flex his neck, elbows, wrists,
fingers, toes, hips, and knees
(d) Instruct him to extend his spine
(e) Ask the patient to contract and relax his abdominal
muscles.
(f) Have him rotate his shoulders
(g) Instruct the patient to walk on his toes, then to walk on his
heels
100

• Muscle strength of the
upper trunk:
- Test flexion ( biceps) and
extension (triceps) at the
elbow:
101

• Test extension atthe
wrist (radial nerve):
• Test the grip:
Test Grip
102

• Test finger abduction( ulnar nerve)
Finger abduction
103

• Test opposition of the thumb ( median nerve):
Opposition of thump
104

• Muscle strength of the lower trunk:
- flexion, extension, lateral bending of the spine
- Thoracic expansion, diaphragmatic excursion
during respiration
- Test flexion at the hip:
45
105

• Test dorsiflexion and planterflexion at the
ankle
dosiflexion
Plantar flexion
106

Muscle strength Abnormality
 Impaired strength is called weakness or paresis.
 Absence of strength is called paralysis or plegia.
 Hemiparesis refers to weakness of one half of the body
 Hemiplegia is paralysis of one half of the body
 Paraplegia means paralysis of the legs
 Quadriplegia is paralysis of all four limbs
108

4. Sensory Assessment
1. Pain and temperature (spinothalamic tracts)
2. Position and vibration (posterior columns)
3. Light touch (both of these pathways)
4. Discriminative sensations, which depend on some of
the above sensations but also involve the cortex
109

Pain: Use a sharp safety pin or other suitable tool.
Occasionally, substitute the blunt end for the point.
Temperature: Use two test tubes, filled with hot and cold
water, or a tuning fork heated or cooled by water. Touch
the skin and ask the patient to identify “hot” or “cold.”
Light Touch: With a fine wisp of cotton, touch the skin
lightly, avoiding pressure. Ask the patient to respond
whenever a touch is felt, and to compare one area with
another.
110

Vibration: Tap it on the heel of your hand and place it
firmly over a distal interphalangeal joint of the patient’s
finger, then over the interphalangeal joint of the big toe.
Discriminative Sensations:
Stereognosis: it refers to the ability to identify an object by
feeling it. Place in the patient’s hand a familiar object such
as a coin, paper clip, key, pencil.
Astereognosis refers to the inability to recognize objects
placed in the hand.
111

Number identification (graphesthesia). When motor
impairment, arthritis.
Two-point discrimination
Point localization. Briefly touch a point on the patient’s
skin.
Extinction. Simultaneously stimulate corresponding areas
on both sides of the body. Ask where the patient feels your
touch.
In general: Lesions of the sensory cortex can affect the
above tests.
112

Graphesthesi
a
Pain; Sharp-dull
Vibration
position
113

5. Reflexes assessment
Reflexes are movements produced in body parts when
hammering a tendon in a body.
Ask the patient to relax, position the limbs properly and
symmetrically, and strike the tendon briskly, using a rapid
wrist movement.
Your strike should be quick and direct, not glancing.
114

Reflexes …
Hold the reflex hammer between your thumb and index
finger so that it swings freely within the limits set by
your palm and other fingers.
Note the speed, force, and amplitude of the reflex
response.
Always compare one side with the other.
Reflexes are usually graded on a 0 to 4+ scale:
115

Reflexes …
4+ Very brisk, hyperactive, with clonus (rhythmic
oscillations between flexion and extension)
3+ Brisker than average; possibly but not
 necessarily indicative of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response
116

Reflexes …
Hyperactive reflexes suggest central nervous system
disease. Sustained clonus confirms it.
Reflexes may be diminished or absent when sensation is
lost, when the relevant spinal segments are damaged, or
when the peripheral nerves are damaged.
Diseases of muscles and neuromuscular junctions may also
decrease reflexes.
117

The Biceps Reflex (C5, C6)
The patient’s arm should be partially flexed at the elbow
with palm down.
Place your thumb or finger firmly on the biceps tendon.
Strike with the reflex hammer so that the blow is aimed
directly through your digit toward the biceps tendon.
Observe flexion at the elbow, and watch for and feel the
contraction of the biceps muscle.
118

The Biceps Reflex (C5, C6)
119

The Triceps Reflex (C6, C7)
Flex the patient’s arm at the elbow, with palm toward the
body, and pull it slightly across the chest.
Strike the triceps tendon above the elbow.
Use a direct blow from directly behind it.
Watch for contraction of the triceps muscle and extension
at the elbow.
120

The Triceps Reflex (C6, C7)
122

The Supinator or Brachioradialis Reflex
(C5, C6)
 The patient’s hand should rest on the abdomen or the lap,
with the forearm partly pronated.
 Strike the radius about 1 to 2 inches above the wrist.
 Watch for flexion and supination of the forearm.
123

The Supinator or Brachioradialis Reflex (C5,
C6)
124

The Abdominal Reflexes
Test the abdominal reflexes by lightly but briskly
stroking each side of the abdomen, above (T8, T9, T10)
and below (T10, T11, T12) the umbilicus
Use a key, the wooden end of a cotton tipped applicator,
or a tongue blade twisted and split longitudinally.
125

The Abdominal Reflexes …
Note the contraction of the abdominal muscles and
deviation of the umbilicus toward the stimulus.
Obesity may mask an abdominal reflex.
In this situation, use your finger to retract the patient’s
umbilicus away from the side to be stimulated.
Feel with your retracting finger for the muscular
contraction.
Abdominal reflexes may be absent in both central and
peripheral nervous system disorders.
126

The Knee Reflex (L2, L3, L4)
The patient may be either sitting or lying down as long
as the knee is flexed.
Briskly tap patellar tendon just below patella.
Note contraction of the quadriceps with extension at the
knee.
A hand on the patient’s anterior thigh lets you feel this
reflex.
When examining the supine patient, rest your supporting
arm under the patient’s leg.
Some patients find it easier to relax with this method.
128

The Knee (Patelar) Reflex (L2, L3, L4)
129

The Ankle (Achilles) Reflex
(primarily S1)
If the patient is sitting, dorsiflex the foot at the ankle.
Persuade the patient to relax.
Strike the Achilles tendon.
Watch and feel for plantar flexion at the ankle.
Note also the speed of relaxation after muscular
contraction.
When the patient is lying down, flex one leg at both hip
and knee and rotate it externally so that the lower leg
rests across the opposite shin.
Then dorsiflex the foot at the ankle and strike the
Achilles tendon.
130

The Plantar Response (L5, S1)
With an object such as a key or the wooden end of an
applicator stick, stroke the lateral aspect of the sole from
the heel to the ball of the foot, curving medially across
the ball.
Use the lightest stimulus that will provoke a response, but
be increasingly firm if necessary.
Note movement of the toes, normally flexion.
132

133

Dorsiflexion of the big toe, often accompanied by
fanning of the other toes, constitutes a Babinski response.
It often indicates a central nervous system lesion in the
corticospinal tract.
A Babinski response may also be seen in unconscious
states due to drug or alcohol intoxication or in the
postictal period following a seizure.
134

Babinski Response
Babinski
135

Meningeal Signs
Testing for these signs is important if you suspect
meningitis or subarachnoid hemorrhage.
Neck Mobility: First make sure there is no injury to the
cervical vertebrae or cervical cord.
Put the patient in supine position place your hands behind
the patient’s head and flex the neck forward, until the chin
touches the chest if possible.
Pain in the neck and resistance to flexion can arise from
meningeal inflammation, arthritis, or neck injury.
136

Brudzinski’s Sign: As you flex the neck, watch the hips and
knees in reaction to your maneuver.
Flexion of the hips and knees is a positive Brudzinski’s sign
and suggests meningeal inflammation.
Kernig’s Sign: Flex the patient’s leg at both the hip and the
knee, and then straighten the knee.
Pain and increased resistance to extending the knee are a
positive Kernig’s sign. When bilateral, it suggests meningeal
irritation.
137

Diagnostic Modalities
Computed Tomography(CT) Scanning
Magnetic Resonance Imaging(MRI)
Electroencephalography(EEG)
Cerebrospinal Fluid(CSF) analysis
Positron Emission Tomography
Single-Photon Emission Computed Tomography
Cerebral Angiography
Myelography
Noninvasive Carotid Flow Studies
139

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