assessment of the neurologic system
Post on 14-Oct-2014
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Prepared by: Robert Adrian L. Peñaranda
The Neurologic System responsible for many functions including
initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought process, control of speech, and storage of memory
assessment of neurological function can be time consuming
a client’s LOC influences the ability to follow directions
The neurologic exam
A thorough neurologic exam takes about 2-3 hours; however, routine tests are done first. If the tests raised questions, more extensive neurologic exam is performed.
Three major considerations The client’s chief complains Client’s physical condition Client’s willingness to participate
Examination of the neurologic system includes assessment of: Mental status including the level of
consciousness The cranial nerves Reflexes Motor function Sensory function
Mental Status
Reveals the general Cerebral functions These functions include intellectual
(cognitive) as well as emotional (affective) functions
Major areas of mental status assessment includes language, orientation, memory, and attention span and calculation.
Language
AphasiaLoss of power to express oneself by speech,
writing or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex
Could be categorized as sensory or receptive and motor or expressive aphasia
Orientation
Determines the person’s ability to recognize familiar persons, awareness to where and when they presently are (time and place), and who they, themselves, are (self).
Memory
Assessment of recall of information presented seconds previously (immediate recall), events or information earlier in the day or examination (recent memory) and knowledge recalled from months or years ago (remote or long term memory)
Attention Span and Calculation Determines the client’s ability to focus
on a mental task that is expected to be performed by person of normal intelligence
Level of Consciousness
Anywhere along a continuum from a state of alertness to coma.
Level Description
Conscious Normal
ConfusedDisoriented; impaired thinking and responses
DeliriousDisoriented; restlessness, hallucinations, sometimes delusions
ObtundedDecreased alertness; slowed psychomotor responses
StuporousSleep-like state (not unconscious); little/no spontaneous activity
ComatoseCannot be aroused; no response to stimuli
The Glasgow Coma Scale
1 2 3 4 5 6
EyesDoes not open eyes
Opens eyes in response to painful stimuli
Opens eyes in response to voice
Opens eyes spontaneously
N/A N/A
VerbalMakes no sounds
Incomprehensible sounds
Utters inappropriate words
Confused, disoriented
Oriented, converses normally
N/A
MotorMakes no movements
Extension to painful stimuli(decerebrate)
Abnormal flexion to painful stimuli(decorticate)
Flexion / Withdrawal to painful stimuli
Localizes painful stimuli
Obeys Commands
Cranial Nerves
The nurse needs to know the specific functions and assessment methods of cranial nerves to detect abnormalities. In some cases, each nerve is assessed; in other cases only selected nerve functions are evaluated
Cranial nervesName Type Function Method
I Olfactory Sensory Sense of smell Ask client to identify different nonirritating aromas such as coffee & vanilla
II Optic Sensory Visual acuity Use Snellen Chart or ask client to read printed material while wearing glasses
III Oculomotor Motor Extraocular eye movement; Pupil constriction and dilation
Assess directions of gazeMeasure papillary reaction to light reflex and accommodation
IV Trochlear Motor Upward & downward movement of eyeball
Assess directions of gaze
V Trigeminal Sensory & Motor
Sensory nerve to skin of faceMotor nerve to muscles of jaw
Lightly touch cornea with wisp of cotton. Assess corneal reflex. Measure sensation of light pain & touch across skin of facePalpate temples as client clenches teeth
VI Abducens Motor Lateral movement of eyeballs Assess directions of gazeVII Facial Sensory
& MotorFacial expressionTaste
As client smiles, frowns, puffs out cheeks, & raises & lowers eyebrows, look for asymmetryHave client identify salty or sweet taste in front of tongue
VIII Auditory Sensory Hearing Assess ability to hear spoken wordIX Glossopharyngeal Sensory
& MotorTasteAbility to swallow
Ask client to identify sour or sweet taste on back of tongueUse tongue blade to elicit gag reflex
X Vagus Sensory & Motor
Sensation of pharynxMovement of vocal cords
Ask client to say “ah”. Observe movement of palate and pharynxAssess speech for hoarseness
XI Spinal Accessory Motor Movement of head & shoulders Ask client to shrug shoulders and turn head against passive resistance
XII Hypoglossal Motor Position of tongue Ask client to stick out tongue to midline and move it from side to side
Reflexes An automatic response of the body to a
stimulus. The deep tendon reflex (DTR) can be
activated by tapping the tendon and its associated muscles contract
Reflexes are tested using a percussion hammer.
Motor Function Evaluates proprioception and cerebellar
functions Proprioceptors are sensory nerve terminals
occurring chiefly on muscles, tendons, joints and the internal ear, that give information about movements and the position of the body
Cerebellar functions include posture control, coordination and smoothness of movements (work together with the cerebral cortex) and maintenance of the skeletal muscle equilibrium
Sensory Function
Includes touch, pain, temperature, position and tactile discrimination
Tests for sensory function include one- and two-point discrimination, stereognosis and extinction
Assessment Proper
LanguageIf the client displays difficulty speaking
○ Point to a common objects and ask the client to name them
○ Ask the client to read some words and match written words to pictures
○ Ask the client to respond to simple verbal commands like asking the client to point to his toes or raise an arm
Orientation Determine if the client is oriented to
person, place and time by asking tactful questions.
Ask the client his state or city of residence, time of the day, day of the week, duration of illness, and names of family members
If the client cannot answer the questions correctly, include questions about himself like his name for example
Memory
Listen for lapses in memory. Ask client about difficulty with memory. If problems are apparent, three categories of memory are tested: Immediate recall, recent memory and remote memory
To assess immediate recall: Ask the client to repeat series of three
digits. E.g. 7-4-3 spoken slowly Gradually increase the number of digits.
E.g. 7-4-3-4, 7-4-3-4-5, 7-4-3-4-5-6-7 Start again with a series of three digits,
but this time ask the client to repeat it backwards. An average person is able to repeat series of five to eight digits in sequence and four to six digits in reverse order
To assess recent memory Ask the client what happened earlier
such as how he got to the clinic. Ask the client to recall information given
earlier like the doctors name. Ask the client to remember three facts (a
color, an object or an address; or a three digit number) and ask the client to repeat all three facts later at the interview.
Remote memory
Ask the client to describe a previous illness or surgery. E.g. 5 years ago, or anniversary or birthday
Attention span and calculation Test the clients ability to concentrate or
maintain attention span by asking the client to recite the alphabet or to count backwards from 100.
Test the client’s ability to calculate by asking the client to subtract 7 or 3 progressively from 100.
Level of Consciousness
Apply the Glasgow Coma Scale A score of 15 indicates that the client is
alert and completely oriented. A comatose patient scores 7 or lower
Cranial NervesName Type Function Method
I Olfactory Sensory Sense of smell Ask client to identify different nonirritating aromas such as coffee & vanilla
II Optic Sensory Visual acuity Use Snellen Chart or ask client to read printed material while wearing glasses
III Oculomotor Motor Extraocular eye movement; Pupil constriction and dilation
Assess directions of gazeMeasure papillary reaction to light reflex and accommodation
IV Trochlear Motor Upward & downward movement of eyeball
Assess directions of gaze
V Trigeminal Sensory & Motor
Sensory nerve to skin of faceMotor nerve to muscles of jaw
Lightly touch cornea with wisp of cotton. Assess corneal reflex. Measure sensation of light pain & touch across skin of facePalpate temples as client clenches teeth
VI Abducens Motor Lateral movement of eyeballs Assess directions of gazeVII Facial Sensory
& MotorFacial expressionTaste
As client smiles, frowns, puffs out cheeks, & raises & lowers eyebrows, look for asymmetryHave client identify salty or sweet taste in front of tongue
VIII Auditory Sensory Hearing Assess ability to hear spoken wordIX Glossopharyngeal Sensory
& MotorTasteAbility to swallow
Ask client to identify sour or sweet taste on back of tongueUse tongue blade to elicit gag reflex
X Vagus Sensory & Motor
Sensation of pharynxMovement of vocal cords
Ask client to say “ah”. Observe movement of palate and pharynxAssess speech for hoarseness
XI Spinal Accessory Motor Movement of head & shoulders Ask client to shrug shoulders and turn head against passive resistance
XII Hypoglossal Motor Position of tongue Ask client to stick out tongue to midline and move it from side to side
Reflexes
Assess the reflexes using a percussion hammer
The grading for reflex are as follows:0 - no response1+ - Low normal with slight muscle contraction2+ - Normal with visible muscle twitch and
movement of the arm or leg3+ - Brisker than normal; may not indicate
disease4+ - Hyperactive and very brisk; often associated with spinal cord disorders
Biceps Reflex Tests the spinal cord level c5 and c6 Slightly flex the arm with the forearm
resting over the thumb with the palm of the hand down
Place your nondominant hand horizontally over the biceps tendon
Deliver a blow with the percussion hammer over your thumb
Observe for the slight flexion of the elbow and fell the biceps contract with your thumb
Triceps Reflex
Tests the spinal cord c7 and c8Flex the clients arm at the elbow, and
support it in the arm of your nondominant arm
Palpate the triceps tendon about 2-5cm (1 to 2in.) above the elbow
Deliver a blow with the percussion hammer directly to the tendon
Observe the slight extension of the elbow
Brachioradialis Reflex
Tests the spinal cord c5-c6Rest the client’s forearm in a relaxed
position externally rotated on a firm surfaceDeliver a blow directly on the radius 2 to
5cm (1 to 2 in.) above the wrist or the stylus process
Observe the normal flexion or supination of the forearm. The fingers of the hand may also extend slightly
Patellar Reflex Tests the spinal cord L2, L3 and L4
Ask the client to sit on the edge of the examining table so the legs would hang freely
Locate the patellar tendon directly below the patella
Deliver a blow with the percussion hammer directly to the tendon
Observe the normal extension or kicking out of the leg as the quadriceps muscle contracts
If no response occurs and you suspect that your client is not relaxed, ask the client to interlock the fingers and pull (Jendrassik’s maneuver)
Achilles Reflex
Tests the spinal cord S1 and S2With the client in the same position as in the
patellar reflex, slightly dorsiflex the client’s ankle by supporting the ball of the foot lightly in the hand
Deliver a blow with the percussion hammer directly to the Achilles tendon just above the heel
Observe the normal plantar flexion (downward jerk) of the foot
Plantar or Babinski Reflex The plantar or babinski reflex is
superficial and may be absent to adults without pathology or is overridden by voluntary control
Motor Function
Walking GaitAsk the client to walk across the room and
back. Observe for the client’s gait.Normally, the client stands in an upright
position with the arms swinging in opposite direction, walks unaided and maintains balance
Romberg Test Ask the client to stand with feet together
first with eyes open and then closed Negative Romberg: may sway a bit but
maintains upright posture and foot stance Positive Romberg: cannot maintain foot
stance, presence of ataxia or lack in the coordination of the voluntary muscles, and cerebellar ataxia or the inability to maintain stance with the eyes open or shut.
Standing on one foot with eyes shut Ask the client to close eyes and stand
with only one foot. Normally, the client should be able to
maintain stance at least for 5 seconds
Heel-Toe Walking
Ask the client to walk a straight line with the advancing foot’s heel touching the toes of the other foot.
A client assumes a larger foot gait to stay upright if she cannot perform this procedure
Toe or Heel Walking
Ask the client to walk several steps on the toes and then on the heels
Fine motor tests for the upper extremeties Finger-To-Nose test
Ask the client to abduct and extend the arms at shoulder height and then rapidly touch the nose alternatively with one index finger and then the outer. The client repeats the test with the eyes closed if the test is performed easily
Normally, the movements are coordinated and the finger do not miss the nose
Alternating Supination and Pronation of Hands on Knees Ask the client to pat both knees with the
palm of the hands and then with the backs of the hands alternatively at an ever-increasing rate
Assessment of the Nose and to the Nurse’s Finger Ask the client to touch the nose and
then your index finger, held at a distance about 45cm (18in.) at a rapid and increasing rate
Fingers to Fingers
Ask the client to spread the arms broadly at shoulder height and then bring the fingers together at the midline, first with the eyes open and then closed, first slowly, then rapidly
Fingers to Thumb (Same Hand) Ask the client to touch each finger of
one hand to the thumb of the same hand as rapidly as possible
Fine motor tests for the Lower extremities Heel Down Opposite Shin
Ask the client to place the heel of one foot just below the opposite knee and run the heel down the shin to the foot. Repeat with the other foot. The client may also sit for this test
Toe or Ball of Foot to the Nurse’s Finger Ask the client to touch your finger with
the large toe of each foot
Light-Touch Sensation
Compare the light-touch sensation of symmetric areas of the body
Ask the client to say “yes” or “now” whenever the client feels the cotton wisp touching the skin
Test areas in the forehead, cheek, hand, lower arm, abdomen, foot and lower leg.
Ask the client to point to the area where he felt the cotton wisp
Light-Touch Sensation
If areas of sensory dysfunction are found, determine the boundaries of sensation by testing responses about every 2.5cm (1 in.) in the area
Make a sketch of the sensory loss area for recording purposes
Pain Sensation Assess pain sensation by asking the client
to say “sharp”, “dull” or “don’t know” when the sharp or dull end of the tongue depressor is felt.
Alternately, use the sharp and dull end to slightly prick the designated anatomic areas at random, e.g. hand, forearm, lower leg, abdomen. The face is not tested in this manner
Give at least two seconds at each prick to prevent summation of stimuli
Temperature Sensation
If pain sensation is intact, temperature sensation tests are no longer performed. If there are pain sensation abnormalities, then the temperature sensation test is performed.
Touch skin with test tubes containing hot or cold water and ask the client to respond with “hot”, “cold” or “don’t know”
Position or Kinesthetic Sensation Commonly, the middle fingers and the
large toes are tested for kinesthetic sensation (sense of position)Support client’s arm and hand, or place the
client’s heel on the examining tableAsk client to close eyesGrasp the finger with your thumb and index
finger, and exert the same pressure on both sides of finger or toe while moving it
Move finger or toe until it is up, straight or down and ask the client to identify the position
Tactile Discrimination
For all tests, the clients eyes must be closed
Kinds of Tactile Discrimination TestsOne- and two- point discriminationStereognosisExtinction Phenomenon
One- and Two- Point Discrimination Alternatively stimulate the skin with two
pins simultaneously and then with one pin. Ask whether the client feels one or two pinsPerception varies widely in adults over different
parts of the body. The common sites for this test are:○ Fingertips, 2.8 mm○ Palms of the hands, 8-12 mm○ Chest, forearm, 40mm○ Back, 50-70 mm○ Upper arm, Thigh, 75 mm○ Toes, 3-8 mm
Stereognosis
Ability to recognize objects by touching themPlace familiar objects such as a key, paper
clip, or coin, in the client’s hand and ask the client to identify them
If the client cannot move the hands, write a number on the client’s palm using a blunt object and ask the client to identify it (graphesthesia)
Extinction Phenomenon
Simultaneously stimulate two symmetric areas of the body, such as the thighs, the cheeks or the hands
The client should be able to feel both stimulus
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