Download Neurological Assessment

Nervous System
Central Nervous
System (CNS)
0 Brain
0 Spinal Cord
Peripheral Nervous
System (PNS)
0 12 pair of
cranial nerves
0 31 pair of spinal
nerves
0 Nerve branches
Central Nervous System
0 Cerebral Cortex: Outer layer of cerebrum
0 Gray Matter
0 Area of highest functioning: through, memory,
reasoning, sensation, and voluntary movement
0 Cerebrum: Right and Left hemispheres
0 Left dominant in 95% of people: Right handed
0 Four lobes per hemisphere:
0 frontal
0 temporal
parietal
occipital
Assessing the Cerebral Cortex
0 Begin with subjective
data and history.
Neurological System
Subjective Data
Questions to ask the patient:
1. Orientation: Person, Place, Time,
Situation
2. Headache
3. Head Injury
4. Dizziness/Vertigo
5. Seizures
6. Tremors
7. Weakness
8. Incoordination
9. Numbness or tingling
10. Difficulty swallowing (Dysphagia)
11. Difficulty speaking (Dysphasia)
12. Significant Past History
13. Environmental or occupational
hazards
14. Review medications: anticonvulsants,
antitremors, antivertigos, and pain
medications
Level of Consciousness (LOC)
0 Alert: Easily awakened with
minimal stimulation
0 Lethargic: Drowsy, vigorous
stimulation necessary for
brief, but appropriate
response
0 Stupor: Sluggish response to
aggressive verbal, visual, or
painful stimuli
0 Comatose: Response of reflex
motor activity only to painful
stimuli
Sternal Rub: Painful Stimuli used with a
stuporous or comatose patient
Glasgow Coma Scale (GCS)
The Glasgow Coma Scale
(GCS) minimizes the
ambiguity of level of
consciousness assessments,
The GCS is a quantitative tool
that standardizes patient’s
responses with a numerical
value
Peripheral Nervous System
Function
0 Carries sensory messages TO the
central nervous system’s sensory
receptors
0 Transmits messages FROM the CNS to
the muscles and glands throughout the
body
Cranial Nerves
0 Inspection:
0 Symmetry of skull (normocephalic)
0 Symmetry of face
Neurological
Assessment
Objective Data:
Head & Neck
0 observe palpebral fissures, nasolabial folds
0 Scalp: Mobility
0 Neck: Range of Motion (ROM)
0 Palpation:
0 Scalp: Lesions
0 Neck: Tenderness
CN I: Olfactory Nerve
0 Do not test routinely
0 Test among those who report
loss of smell or had
experienced head trauma
0 Step I: Occlude one nostril at a
time and ask the patient to sniff
0
Establishes baseline and
patency
0 Step II: With patient’s eyes
closed, present an aromatic
substance that is easily
identified beneath one nostril
0 Step III: Repeat on opposite
side
CNV: Trigeminal Nerve
Both a sensory and motor nerve!
0 Motor:
0 Symmetrical jaw movement
0 Mastication (chewing)
0 Assess:
0 Palpate temporal and masseter muscles bilaterally as patient
clenches teeth.
0 Attempt to push down on chin to separate jaws.
0 Sensation:
0 Three nerve divisions:
0 1) Opthalmic, 2) Maxillary, 3) Mandibular
0 Assess: Touch cotton wisp to bilateral areas of forehead, cheek,
and chin and request patient to state when sensation is felt.
CN VII: Facial Nerve
0 Mixed Motor and Sensory Nerve
0 MOTOR Assessed by observing
bilateral movement when a patient:
0
0
0
0
0
0
0
Smiles!
Frowns
Closes eyes tightly
Lifts eyebrows
Shows teeth
Puffs cheeks
When you press puffed cheeks in,
assess for equal bilateral, evacuation
of air
CN VII: Facial Nerve
0 SENSORY nerve:
0 Assessed when facial
nerve injury is
suspected
0 Apply a cotton
applicator that has been
covered with a solution
of sugar, salt, or lemon
juice to patient’s tongueask patient to identify
taste.
CN IX & X:
Glossopharyngeal & Vagus
0 Assess the nerves’ motor function by:
0 Depress tongue with a tongue blade: watch for
pharyngeal movement as the patient says “ahh” or
yawns:
0 Uvula and soft-palate should rise midline
0 Tonsillar pillars should move medially
0 Touch the posterior pharyngeal walls with tongue blade:
0 Note positive gag reflex
0 Voice clear, no evidence of straining
0 Assess sensory motor:
0 Posterior third of tongue: bitter taste
CN XI: Spinal Accessory
0 Spinal accessory motor nerve transmits
communication between the PNS and CNS.
0 Prior to testing nerve, assess sternomastoid and
trapezius muscles for equal, bilateral size
0 1.
Ask patient to forcibly rotate head against
resistance applied at chin, repeated on both sides.
0 2.
Ask patient to shrug shoulders against bilateral
resistance
0 An intact CN XI should provide motor responses of equal,
bilateral strength.
CN XII: Hypoglossal
0 Inspect the tongue:
should be free from
tremors or wasting
0 Forward thrust of
tongue should remain
midline
0 Listen for clear l, t, d
sounds with speech of
“light, tight, dynamite”
1. Vision difficulty (blurring,
The Eye:
Subjective Assessment
blind spots, decreased acuity)
2. Pain
3. Strabismus, diplopia
4. Redness, swelling
5. Watering, discharge
6. History of ocular problems
7. Glaucoma
8. Use of glasses or contact lenses
9. Self-Care Behaviors
10. Surgeries
The Eye:
Objective Assessment
Prior to testing neurological
reflexes, inspect anatomy of the
eye for:
0 Symmetry, position, discharge
0 External Structures:
0 Lid, lashes, and brow
0 Color
0 Conjunctive
0 Sclera
0 Anterior Structures:
0 Cornea and Lens
0 Iris and Pupils
Inspecting the Ocular Fundus
0 In a darkened room using
an opthalmoscope:
0 Elicit Red Reflex
0 Assess retinal vessels for
0 Nicking
0 Hemorrhages
0 Exudates
0 Visualize the optic disc for:
0 Color
0 Size
0 Shape
CN II: The Optic Nerve
Snellen Acuity Test
(Distant)
Confrontation Test
Visual Fields
Visual Acuity
0 “Near Sighted”
0 Decreased visual acuity at
a distance
0 Assessed via Snellen
Chart
0 “Far Sighted”
0 Decreased visual acuity in
a close range.
0 Assessed via Jaeger card
0 Peripheral Vision
0 Assessed via
Confrontation Test
CN III, IV & VI:
Oculomotor, Trochlear & Abducens
0 CN III: Responsible for the eye’s up and down
movement, movement of the pupil
0 CV IV: Superior and oblique eye movement
0 CN VI: Outward eye movement
0 Assess for:
0 Strabismus: Deviated gaze or limited movement
0 Nystagmus: Involuntary back and forth or cyclical
movement
Corneal Light Reflex:
Hirschberg Test
Cover/Uncover Test
PERRLA
0 Assessment of the CN III,
IV and VI via the PUPILS
0 Pupils
0 Equal
0 Round
0 React to
0 Light and
0 Accommodation
1. Earaches
2. Infections
The Ear:
Subjective Assessment
3. Discharge
4. Hearing loss
5. Environmental Noise
6. Tinnitus
7. Vertigo
8. Self-Care Behaviors
The
External
Ear:
Objective Assessment
0 INSPECTION
0 Size and Shape: Equal size
bilaterally, free from swelling or
thickness
0 Skin color of ears matches facial
skin color, skin intact, free from
lumps or lesions
0 External auditory meatus: Note
opening size, any swelling, redness,
or discharge
0 PALPATION
0 Mastoid process
0 Move pinna and push on tragus
0 Palpation should reveal firm
structures that move without
producing pain
Inspection of the Tympanic
Membrane
Otoscope
0 Otoscope size depends on the diameter of
the auditory meatus: choose the largest
speculum that will fit comfortably in the
ear canal
0 Have the patient tilt head away from you
and towards opposite shoulder
0 With the adult patient, pull pinna up and
back
0 Infant or child under 3 years old, pull
pinna down
0 Holding the otoscope in a position that
seems upside down helps you balance the
otoscope during the exam, decreasing risk
of injury to the tympanic membrane.
CN VIII: Vestibulocochlear
Assessment
Begins with subjective assessment: How well does the
patient hear conversational speech?
o Voice Test
o Tuning Fork Test
o Weber Test
o Rinne Test
Voice Test
1. Test one ear at a time by muffling sound in one ear
by placing finger over tragus and rapidly pushing it
in and out of auditory meatus
2. Stand behind patient so lip-reading cannot occur
3. In the other ear, with your hear 2-3” from patient’s
ear, slowly whisper two-syllable words and have
patient repeat words; repeat on opposite ear
•
Ex. Tuesday, armchair, baseball, and fourteen
Tuning Fork Tests:
Weber & Rinne
Hearing Loss
0 Conductive: Mechanical dysfunction of the external or
inner ear resulting in partial hearing loss. May be caused
by impacted cerumen, foreign bodies, or a perforated
tympanic membrane; inner ear pus or serum, and
otosclerosis.
0 Sensorineural: Pathology associated with inner ear,
CNVIII, or cerebral cortex ; gradual nerve degeneration
(presbycusis) caused by aging; ototoxic medications (Lasix)
that affect cochlear hair cells.
0 Mixed: Combination of both conductive and sensorineural
hearing loss in the same ear.
CN VIII: Romberg Test
0 CN VIII is also a nerve with a “special sense.”
0 The inner ear provides information regarding your
body’s position in space (proprioception).
0 If the inner ear is inflamed, incorrect information is
transmitted (via the PNS) to the brain (CNS), causing
the sensation of vertigo and an unsteady gait.
0 Equilibrium and vertigo can be assessed via the
Romberg Test.
Romberg Test
Cerebellar Functioning
Assessment
BALANCE:
0 The Romberg Test (CN VIII) assesses
balance, an extension of the CNS and the
functionality of the cerebellum.
0 Gait: Have the patient walk 10-20 feet,
turn and walk back. Gait should be
smooth, rhythmic, and effortless with
coordinated swing in the opposing arm
and 15” from heel to heel.
0 Tandem Walking: Walk in a straight
line in a heel-to-toe fashion. If intact, the
person will walk straight and maintain
balance, even with a decreased support
base.
Cerebellar Functioning
Coordination and Skilled Movements:
0 Rapid Altering Movements (RAM)
0 Finger-to-Finger Test
0 Finger-to-Nose Test
0 Heel-to-Shin Test
Finger-to-Finger Test &
Rapid Alternating Movement
Heel-to-Shin Test
Sensation: Superficial Pain
0 Use a tongue blade with both a sharp and dull point,
lightly apply the sharp and dull points to the patient’s
body in random, unpredictable manner.
0 Provide a 2-second break between application to
prevent summation, when a frequent but separate
stimuli are perceived as one, strong stimulus.
Sensation: Light Touch
0 Apply a wisp of cotton to the skin and brush it over the
patient’s body in a random order at irregular intervals.
Asl the patient to report when the touch is felt by stating
“now” or “yes.”
0 Compare symmetric points bilaterally.
Sensation: Vibration
0 Use a low-pitch tuning fork and strike against the heel
of your hand.
0 Apply the base of the tuning fork to a body surface of
the fingers or great toe.
0 Ask patient to report when the vibration starts and
stops.
0 If no vibration is felt in those locations, move
proximally, testing the ulnar processes, ankles,
patellae, and iliac crests.
0 Compare findings bilaterally.
Motor Strength
0 Assess via inspection the muscle groups for symmetry and
size; if asymmetric, measure each in centimeters and
compare difference. Measurements greater than 1
centimeter is significant.
0 Assess strength by assessing bilaterally muscle groups in
the extremities, neck, and trunk, continuing to compare
bilateral findings in each group.
0 Tone is the normal degree of contraction at rest.
Assessment involves inspection and observation. Watch for
resistance of the muscles during passive range of motion,
assess bilaterally and compare.
Deep Tendon Reflexes (DTR)
0 Use the reflex hammer and
use a short, snapping flow to
the muscle’s insertion tendon.
0 Do not rest the hammer on
the tendon.
0 Use the pointed end for
smaller targets; the flat end
on wider targets or to prevent
pain
0 Compare bilateral responses
Grading
4+ Very brisk, hyperactive
with clonus. Indicates
presence of disease process
3+ Brisker than average;
may indicate need for
further work-up
2+ Average, normal
1+ Diminished, low-normal
0 No response
Upper Extremity DTR
0 Biceps
0 Triceps
0 Brachioradialis
Abdominal Reflexes
Lower Extremity DTR
0 Patellar
0 Achilles
0 Ankle Clonus
Plantar Assessment
Babinski Sign:
Plantar Reflex
Normal only in infants
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