Download MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE

MENNONITE COLLEGE OF NURSING
AT ILLINOIS STATE UNIVERSITY
Diagnostic Reasoning for Advanced Practice Nursing 431
MODULE: NEUROLOGICAL SYSTEM
OBJECTIVES:
Upon completion of this module, the student will be able to:
1. Describe the overall neurological assessment process, including mental status, cranial nerves,
sensory, motor, coordination, and reflexes.
2. Perform an appropriate neurological assessment on a client.
3. Incorporate appropriate aspects of the complete neurological assessment into the routine
examination of clients.
REQUIRED READINGS:
Read applicable sections of the course textbook.
EQUIPMENT NEEDED:
 Ophthalmoscope
 Penlight
 Reflex hammer
 Hand-held visual acuity card with 14” measure
 Cotton ball
 Tuning fork
 Safety pin or broken Q-tip
 Key, paper clip, coins
 Aromatic substance
MODULE: NEUROLOGIC SYSTEM STUDY QUESTIONS:
1. Define/Describe:
a. Aphasia
b. Athetosis
c. Ataxia
d. Clonus
e. Fasciculation
f. Graphesthesia
g. Hyperesthesia
h. Myoclonus
i. Proprioception
j.
k.
l.
m.
Romberg
Spasticity
Stereognosis
Tremor
2. List the cardinal symptoms of the neurologic system.
3. What are the five main components of the neurological examination?
4. Name the cranial nerves and describe the main function of each, including their motor and/or
sensory function.
5. Describe the sensory pathway from receptor to the sensory cortex for each of the following
sensory components:
a. Touch
b. Pain
c. Temperature
d. Vibration
e. Proprioception
6. Describe the pathway of the reflex arc.
7. Differentiate upper and lower motor neuron dysfunction.
8. Describe the function of the cerebellum. How would you test?
9. List the components of the Mental Status exam.
10. If you are screening for sensory intactness and using only two tests, why would vibration and
pain be good choices?
11. What is the appropriate method of testing pain sensation?
12. What does the recognition of dullness when testing for pain mean?
13. Define the grading system for deep tendon reflexes.
14. Describe a Babinski reflex and its clinical significance.
NEUROLOGICAL ASSESSMENT
I. History
A. Headaches: type of pain (quality), warning prodromal signs, location, radiation, factors that
worsen or improve the pain, duration and frequency of pain, associated symptoms (nausea,
vomiting, duration and frequency of paresthesias, weakness, seizures, muscle stiffness or
soreness, fever, weakness). Time of day of onset, age at previous onset, hospitalizations, drug
therapy and effects. Family history of similar type of headache. Medications: BCPs
B. Seizure: unpleasant odor or taste; focal numbness, pain, prickling; auditory whistling, ringing;
visual disturbances, shapes, colors, movements, hallucinations, repetitive movements of a body
part, muttering, crying; nonattention, generalized convulsions.
C. Transient neurological dysfunction: aphasia, unconsciousness, motor or sensory deficits,
weakness, tinnitus, vertigo, abnormal sensations
D. Pain: ask patient to outline the affected area using one finger. Quality, precipitating and
relieving factors, associated symptoms.
E. Weakness: focus on activities of daily living and involved body parts
1. Distal vs. proximal—lower extremities
a. Tripping over carpet or cords (distal)
b. Stepping up to a bus or getting up from a chair (proximal)
2. Distal vs. proximal -- Upper extremities
a. Writing, shaking hands (distal)
b. Lifting arms, combing hair (proximal)
F. Stroke: what was patient doing at onset; presenting symptoms, any of the following: altered
level of consciousness, aphasia, headache, stiff neck, cranial nerve symptoms (blindness,
tinnitus, vertigo), weakness numbness, paralysis, trouble with gait uncoordination, seizures
1. Associated symptoms: chest pain, dysrhythmia, valvular heart disease, MI, diabetes, BCPs
2. Course since onset
3. Functional capacity
II. Physical Assessment: Refer to course textbook for the particular of the neurologic exam. However,
a screening exam of the neuro system is outlined below—to be used for a general assessment on a
well physical examination
A. Assessment of mental status
B. Evaluation of cranial nerves—remember most of this can be done with HEENT exam
C. Assessment of motor function, including
1. Walking
2. Knee bends (if patient is able)
3. Hopping
4. Balance (Romberg)
5. Heel-toe walking
D. Evaluation of sensory function, including
1. Vibratory sensation in the hands and feet
2. Sharp and dull testing in the hands and feet
E. Assessment of coordination
1. Hand coordination
2. Position sense
F. Assessment of DTRs
G. Developmental status at appropriate ages
Neuromuscular Changes in the Elderly
Permanent neuronal loss occurs with aging: brain weight decreases by 5-17%. Reaction time also
decreases secondary to decreases in lens transparency, pupil size, and changes in the vitreous humor
and retina, decreased numbers of axons and slowed conduction at the synapse. Deep tendon reflexes
decrease as well as conduction velocities in peripheral nerves.
The hearing threshold deteriorates with age and there is a decrease in directional hearing. Neurological
findings in the elderly may include changes in mental status, weakness, abnormal reflexes, and
abnormal posture and gait.
NEUROLOGICAL: COMMON ABNORMALITIES
Assessment Findings
Impaired ability to remember words
Aphasia
Dysarthria
Concrete response to proverb
interpretation
Loss of sense of smell
Visual field defects
Pupillary reactions (dilation, constriction,
abnormal reactions to light)
Ptosis
Abnormal extraocular movements
Diplopia
Facial asymmetry
Incoordination
Unsteady, wide-based, slapping gait
Staggering, unsteady, wide-based gait with
difficulty turning
Gait with hip and knee flexion, short
shuffling steps, minimal arm swing
Steppage gait—with foot drop
Difficulty performing knee bends
Symmetrical distal sensory loss
Loss of discriminative sensation
Hyperactive reflexes
Causes
Causes include mental retardation, depression, dementia,
anxiety, thiamine deficiency, chronic alcoholism, head
injury
May be due to a stroke, diffuse cortical damage, or a
progressive lesion
Damage to the central or peripheral nervous system
Schizophrenia, organic brain syndrome, mental retardation
Head injuries or tumor
Lesions of the optic tract or occipital lobe, glaucoma,
temporal or parietal lobe lesion, pituitary tumor
Drug use, third nerve or optic nerve lesions
Damage or paralysis of the third nerve, tumor, aneurysm,
head trauma, vascular lesions, meningitis
Lesions of the 4th or 6th cranial nerves; causes include
increased intracranial pressure, pressure from a tumor or
aneurysm, syphilis, meningitis, vascular lesions, head
trauma
Multiple sclerosis, myasthenia gravis, cerebral atheroma
Bell’s palsy, upper motor neuron paralysis, flattened
nasolabial folds (hemiparesis), abnormal facial movement
Sensory loss, cerebellar lesions
Sensory ataxia
Cerebellar ataxia
Parkinson’s disease
Lower motor neuron disease
Proximal hip girdle weakness
Peripheral neuropathy
Lesion of the sensory cortex or posterior columns
Upper motor neuron disease
NEUROLOGICAL EXAMINATION: STUDENT VALIDATION
** Branching Exam Procedure
COMPONENT ACTIVITIES
MENTAL STATUS EXAM (Client Sitting)
1. Orientation - time, place, person
2. Memory - recent, remote
3. Intellectual Performance
4. Judgment
HEAD and NECK Cranial Nerves (Assess and Name)
1. CN I (Olfactory)
2. CN II (Optic)
a. Visual Acuity
b. Visual Fields
c. Fundoscopy
3. CN III (Oculomotor)
CN IV (Trochlear)
CN VI (Abducens)
a. Pupils (PERRLA)
b. EOM’s
4. CN V (Trigeminal)
a. Motor - temporal muscles
Evaluate TM (temporomandibular joint - masseter
muscles
b. Sensory - (pain and light touch) –
-forehead
-cheeks
-jaws
c. **Corneal reflex
5. CN VII (Facial)
a. Inspect - nasolabial folds, abnormal movement
b. Raise eyebrows
c. Frown
d. Eye muscle strength
e. Smile
f. Puff out cheeks
6. CN VIII (Auditory)
a. Assess hearing
7. CN IX (Glossopharyngeal), CN X (Vagus)
a. Quality of speech
b. Soft palate/uvula rise
8. CN XII (Hypoglossal)
9. CN XI (Spinal Accessory)
a. Trapezius
b. Sternocleidomastoid
DONE
NOT
DONE
COMMENTS
CEREBELLAR FUNCTION
Upper Extremities
1. Finger to nose
2. ** Finger-to-thumb, rapidly
3. ** Rapid alternating movements
DEEP TENDON REFLEXES
1. Biceps
2. Triceps
3. Brachioradialis
4. Patellar (L2, L3, L4)
5. Ankle (S1, S2)
6. Plantar Response
7. ** Ankle clonus
8. Reinforcement - Upper/lower extremities
CEREBELLAR FUNCTION
Lower Extremities
1. ** Heel-to-shin
2. Romberg
SENSORY SYSTEM (Client lying on back)
1. Assess light touch
2. Assess pain
3. Vibratory sense
4. ** Joint position sense
5. ** Temperature
6. ** Discriminative sensations
a. ** Stereognosis
b. ** Graphesthesia
c. ** Two-point discrimination
d. ** Point localization
e. ** Extinction
SUPERFICIAL REFLEXES
1. ** Abdominal
SPECIAL MANEUVERS
1.
Brudzinski’s sign (flex neck)
2.
Kernig’s sign (hip/knee flex & straighten knee)
CLIENT WALKING
1.
Gait- observe for abnormalities
2.
Heel walk
3.
Toe walk
4.
**Heel-to-toe walk, forward and backward