neuro diag
TRANSCRIPT
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NEUROLOGIC
EXAMINATION
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HEALTH HISTORY
History of Present Illness
Important aspect of neurologicassessment
Initial Interview
Provides an excellent opportunity tosystematically explore the patients currentcondition and related eventswhile observing the:
Overall appearance Mental status Posture Movement
Affect
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HEALTH HISTORY
Depending on the patients condition, the
nurse may rely on:
YES or NO answer
Review of Medical Records
Input from Family
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HEALTH HISTORY INCLUDES:
Onset, character, severity, location duration
and frequency of signs and symptoms. Complaints
Precipitating, aggravating and relieving
factors Progression, remission and exacerbation
Presence or absence of similar signs and
symptoms among family members History of genetic disease
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HEALTH HISTORY
Review of medical history including
the system-by-system evaluation ispart of the nursing history.
The nurse should be aware of historyof trauma or falls that may haveinvolved the head or spinal injury.
Questions about the use of alcohol,medications and illicit drugs are also
relevant.
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PHYSICAL ASSESSMENT
General Observation of the client:
a. Posture, gait, coordination: performRomberg test
b. Personal hygiene and grooming
c. Evaluate speech and ability tocommunicate1. Place of speech: rapid, slow, halting2. Clarity: slurred or distinct
3. Tone: high-pitched, rough4. Vocabulary: appropriate choice of words
*** Facial features may suggest specific
syndromes in children
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PHYSICAL ASSESSMENT
Mental Status
a. General appearance and behaviorb. Level of consciousness
1. Oriented to person, place and time2. Appropriate response to verbal and tactile
stimuli3. Memory, problem solving abilities.
c. Moodd. Thought content & intellectual
capacity
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PHYSICAL ASSESSMENT
Assess Pupillary Status and Eye movement
a. Size of pupils should be equalb. Reaction of pupilsa. Accommodation: pupillary constriction to
accommodate near vision
b. Direct light reflex: constriction of pupil when lightis shone directly into the eyec. Consensual reflex: constriction of the pupil in the
opposite eye when the direct light reflex istested.
c. Evaluate ability to move eyea. Note nystagmusb. Ability of eyes to move togetherc. Resting position of iris should be at mid-position
of the eye socketd. PERRLA
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Clinical Manifestation
The clinical manifestation of neurologic disease
are as varied as the disease processesthemselves. Symptoms may be:
Varied or intense
Fluctuating or permanent
Inconvenient or devastating
PAIN
SEIZURES
DIZZINESS a nd VERTIGO
VISUAL DISTURBANCES
WEAKNESS
ABNORMALSENSATION
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Clinical ManifestationsPAIN unpleasant sensory perception & emotional experience associated with actual or
potential tissue damage
- Subjective-Acute
> lasts shorter & remits as pathology
resolves> trigeminal neuralgia, spinal disk disease
- Chronic or persistent
> Lasts longer than 6 months> degenerative and chronic neurologic cond.
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Clinical Manifestations
SEIZURES- Are the result of abnormal paroxysmal
discharges in the cerebral cortex,
which manifests as alteration in
sensation, perception, movement or
consciousness
- May be long or short- The type of seizure activity is a direct
result of the brain affected.
- May be a first obvious sign of brainlesion
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Clinical Manifestations
DIZZINESS AND VERTIGO
- Dizziness is an abnormal sensation ofimbalance or movement.
- Variety of causes: viral syndrome, hot
weather, roller coaster rides, middle earinfections
- About 50% of patients with dizziness have
vertigo (illusion of movement usuallyrotation).
- Vertigo is a manifestation of vestibular
dysfunction
Cli i l M if t ti
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Clinical Manifestations
VISUAL DISTURBANCES
Visual defects that cause people to seekhealth care can range from decreased
visual acuity associated with aging to
sudden blindness caused by glaucoma
Normal vision depends on :
- functioning visual pathways thought theretina and optic chiasm
- radiations into the visual cortex in the
occipital lobes
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Clinical Manifestations
WEAKNESS- common manifestation of neurologic
disease (muscle weakness)
- Coexists with other symptoms and can
affect variety of muscles causing
disability- Can be sudden or permanent or
progressive
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Clinical Manifestations
ABNORMAL SENSATION- Numbness, loss of sensation or
abnormal sensation is a neurologic
manifestation of both cerebral andperipheral nervous system diseaseh
- Usually associated with pain or
weakness and is potentially disablingg- Both numbness and weakness can
significantly affect balance and
coordination
PHYSICAL EXAMINATION
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PHYSICAL EXAMINATION The brain and the spinal cord cannot be
examined directly as other body systems Neurologic examination is an indirectevaluation that assesses the function ofspecific body part controlled
f
5 COMPONTENTS OF
NEURO ASSESSMENT
(1) Cerebral function(2) Cranial Nerves
(3) Motor system
(4) Sensory System(5) Reflexes
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Assessing Cerebral Function
Cerebral abnormalities may cause:
- disturbance in mental status
- Intellectual function- Thought content
- Pattern of emotional behavior
- Alteration in perception, motor andlanguage ability
- Lifestyle change/s
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Assessing Cerebral Function
Should be specific and non-judgemental
Avoid using the terms
inappropriateordemented
Specific records on observations
regarding orientation, level ofconsciouness, emotional state or thought
content
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Assessing the Mental Status
Observe patients appearance & behavior
Note dress, grooming & personal hygiene
Posture, gesture, movements, facialexpression & motor activity
Assess manner of speech & level of
consciousness Assess orientation to time, place & person
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Intellectual Function
A person with an average IQ can:
a. Recite 5 digits backwards
b. Serial 7s (Subtract 7 from 100,then 7 from that, and so forth)
Interpret proverbs
Ability to recognize similarities Situational analysis
Th ht C t t
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Thought ContentDuring the interview, it is important to
assess the patients thought content. Are the patients thought
Spontaneous
Natural Clear
Relevant
Coherentf
Unusual thoughts likehallucinations, preoccupation with
death and morbid events, paranoidideation requires further evaluation
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Emotional Status
Is the patients affect natural or even?
Does his or her mood fluctuate
normally?
Are verbal communications consistent
with nonverbal cues?
P ti
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Perception
The examiner may consider more
specific areas of higher cortical function
Agnosia - inability to recognize objects
seen through the special senses a patient may see a pencil but knows not what to do with it
or what its called
Screening forvisualand tactile agnosiaprovides insight into the patients
cortical interpretation ability
Placing a familiar object (key) in the patients hand, have himidentify it with eyes closed
L Abilit
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Language Ability
A person with normal neurologic function
can understand and communicate inspoken and written language.
Aphasia is a deficiency in language
function
Type of Aphasia Brain area involved
Auditory-receptive Temporal LobeVisual-receptive Parietal-occipital lobe
Expressive speaking Inferior posterior frontal areas
Expressive writing Posterior frontal area
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Motor Ability
Ask the patient to perform a skilled act
(throw a ball, move a chair)
Performance requires
=>the ability to understand the activity
desired and normal motor strength
Failure signals cerebral dysfunction
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ASSESSING THE
CRANIAL NERVES
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CRANIAL NERVES
Oh
Oh
Oh
To
TouchA nd
Feel
AGirls
Vagina
So
Heavenly
Olfactory (I)
Optic (II)
Occulamotor (III)
Trochlear (IV)
Trigemenal (V)Abducens (VI)
Facial (VII)
Acoustic (VIII)Glossopharyngeal (IX)
Vagus (X)
Spinal Accessory (XI)
Hypoglossal (XII)
S
S
M
M
M/SM
M/S
SM/S
M/S
M
M
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C i l N I Olf t N
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Cranial Nerve I - Olfactory Nerve
Before testing nerve function, ensure
patency of each nostril by occluding inturn and asking patient to sniff
Once patency is established, ask patient
to close eyes Occlude one nostril and hold aromatic
substance (coffee) beneath nose
Ask patient to identify substance Repeat with other nostril
C i l N I Olf t
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Cranial Nerve I - Olfactory
Normal:
Patient is able toidentify substance.
(Bear in mind thatsome substances maybe unfamiliar,especially to children)
Abnormal:
Anosmia - loss of senseof smell.
May be inherited and non-pathological: chronic rhinitis,
sinusitis, heavy smoking,zinc deficiency, or cocaineuse.
It may also indicate cranialnerve damage from facialfractures or head injuries,disorders of base of frontallobe such as a tumor, orartherosclerotic changes.
Cranial Nerve II - Optic Nerve
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Cranial Nerve II - Optic Nerve
Use the snellen chart to check/test:
- distant vision- color
Client should be 20 feet distant from the chart
Use an object to occlude one eye
Evaluate the vision one eye at a time
Cranial Nerves III IV and VI
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Testing eyemovements
Testing pupil
accommodation
Cranial Nerves III, IV and VI
=> Test for ocular rotations,
conjugate movements, nystagmus
** Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis
- using direct & consensual pupillary reaction to light
Normal:Abnormal:
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Normal: Able to read without
difficulty
Visual acuity intact20/20, both eyes
Hippus phenomenon:
Brisk constriction of
pupils in reaction to
light, followed by
dilation and
constriction- may be normal or
sign of early CN III
compression.
CN II deficits
- can occur with stroke or
brain tumor.
Changes in pupillary
reactions
- can signal CN III deficits.
Increased ICP causes
changes in pupillary
reaction
As pressure increases,
response becomes more
sluggish until pupilsfinally become fixed and
CN V T i i l N
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CN V - Trigeminal Nerve
a. Testing motor function:
- Askpatient to move jaw from side to
side against resistance and then clench
jaw as you palpate contraction of
temporal and masseter muscles, or tobite down on a tongue blade.
CN V - Trigeminal Nerve
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Testing CN V
sensory function
CN V Trigeminal Nerve
b. Testing sensory function:
-Askpatient to close eyes- Touch the face with the wisp of cotton
- Instruct to tell you when he or she feels
sensation on the face.
- Repeat the test using sharp and dull
stimuli (toothpick or tongue blade)
- Instruct to say Sharp orDull
(Be random, dont establish a pattern)
Cranial Nerve V Trigeminal Nerve
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Testing corneal reflex
Cranial Nerve V - Trigeminal Nerve
c. Testing corneal reflex:
- Gently touch cornea with cotton wisp.
oTouching cornea can cause abrasions.
oAlternative approach is to:
> puff air across cornea with a needlesssyringe, or
> gently touch eyelash
and look for blink reflex
Cont. CN V
Abnormal:
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Normal: Full range of motion
(ROM) in jaw and15 strength.
Patient perceives
light touch and
superficial pain
bilaterally
Weak or absent contractionunilaterally:
- Lesion of nerve, cervical spine,
or brainstem
Inability to perceive light touchand superficial pain
- may indicate peripheral nervedamage.
Trigeminal Neuralgia:- Neuralgic pain of CN V caused
by the pressure of degenerationof a nerve
Corneal reflex test used inpatients with decreased LOC
- to evaluate integrity of brainstem.
Cranial Nerve VII - Facial Nerve
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Testing CN VII motor function
a. Testing motor function:
- Ask patient to perform these movements:smile, frown, raise eyebrows, show upper
teeth, show lower teeth, puff out cheeks,
purse lips,close eyes tightly while nurse
tries to open them.
- Observe face for
flaccid paralysis
Cranial Nerve VII - Facial Nerve
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Testing taste sensation
b. Testing sensory function:
- Test taste on anterior two-thirds of
tongue for sweet, sour, salty.F
Sweet: Tip of the tongueSour: Sides of back half of tongue
Salty: Anterior sides and tip of tongue
Bitter: Back of tongue
CN VII - Facial Nerve
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CN VII Facial Nerve
Normal:
Facial nerve intact
Able to make faces.
Taste sensation onanterior tongue intact.
(Taste decreased inolder adults.)
Abnormal:
Asymmetrical or impairedmovement:
- Nerve damage, such asthat caused by Bells
palsy or stroke.
Impaired taste/loss oftaste:
- Damage to facial nerve,chemotherapy orradiation therapy to headand neck.
Cranial Nerve VIII - Acoustic Nerve
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Watch tick test
a. Perform Weber and Rinne tests for hearing
b. Perform watch-tick test by holding watch closeto patients ear.
c. Perform Romberg test for balance
- Nurse at the back or side of the pt.
- Instruct client to stand straight, feet together,
hands at the side and eyes closed.
(Evaluates the balancing function of the CN VIII)
Cranial Nerve VIII - Acoustic Nerve
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Cranial Nerve VIII Acoustic Nerve
Normal: Hearing intact.
Negative
Romberg test.
Abnormal:
Hearing loss,nystagmus, balancedisturbance,dizziness/vertigo:
- Acoustic nervedamage.
Nystagmus:- CN VIII, brainstem, or
cerebellum problem orphenytoin (Dilantin)toxicity.
Cranial Nerves IX and X
Gl h l & V N
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Testing CN IX and
Xmotor function
Glossopharyngeal & Vagus Nerves
a. Observe ability to cough, swallow, andtalk.
b. Test motor function:
-Ask patient to open mouth and say ah
while you depress the tongue with a
tongue blade.
- Observe soft palate and uvula.
- Soft palate and uvula should rise medially.
CN IX and X
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c. Test sensory function of CN IXand motor
function of CN X bystimulating gag reflex. Tell patient that you are going to touch interior
throat
Then lightly touch tip of tongue blade to posterior
pharyngeal wall.
Observe the pharyngeal movement.
Ask the client to drink a small amount of water*Note the ease & difficulty of swallowing
*Note quality of the voice or hoarseness
when speaking
CN IX and X Ab l
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CN IX and X
Normal: Swallow and cough
reflex intact.
Speech clear.
Elevation andconstriction ofpharyngeal
musculature andtongue retractionindicate positive gagreflex
Abnormal:
Unilateral movement:
Contralateral nerve damage.- Damage to CNs IX and X also
impairs swallowing.
Changes in voice quality (e.g.,
hoarseness): CN X damage.
Diminished/absent gag reflex:
Nerve damage
- Risk for aspiration
Impaired taste on posterior
portion of tongue:
Problem with CN IX
CN XI - Spinal Accessory Nerve
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p y
a. Test motor function of shoulder and
neck muscles:
=> Ask patient to shrug shoulders upwardagainst your resistance. (Trapieze
muscle)
=> Then ask her or him to turn head from
side to side against your resistance.(Strenoclaidomastoid muscle)
**Observe for symmetry of contraction and
muscle strength.
Cranial Nerve XI
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Normal:
Movementsymmetrical, withpatient movingagainst resistance
without pain.
Full ROM of neckwith +5/5 strength.
Abnormal:
Asymmetrical Diminished
Absent movement
Pain unilateral or bilateral
weakness:
Peripheral nerve CN
XI damage.
CN XII - Hypoglossal Nerve
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Testing CN XII
motor function
yp g
a. Have patient say d, l, n, t or a phrase
containing these letters.- The ability to say these letters requiresuse of the tongue.
b. Ask the patient to protrude the tongue.Observe any deviation from midline, tumors,lesions, or atrophy.
c. Now ask the patient to move thetongue from side to side.
Normal: Abnormal:
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Can protrude
tongue medially. No atrophy,
tumors, or
lesions.
Asymmetrical/diminished/
absent movement/deviation
from midline/protruded
tongue: - Peripheral nerve
CN XII damage.
Tongue paralysis results in
dysarthria.
Examining the Motor System
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g y Assessing the patients ability to flex or
extend the extremities against resistancetests muscle strength.
g
The evaluation of muscle strength
compares the sides of the body with eachother
This way, subtle differences in muscle strengthcan easily be detected and described.
f
MUSCLE STRENGTH
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Muscle tone (tension present in a
muscle at rest) is evaluated by palpation Abnormalities in tone include:
Spasticity (increased muscle tone)
Rigidity (resistance to passive strength)
Flaccidity
British Medical Council
Method of Scoring
Balance and Coordination
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Cerebellar influence on the motor system is
reflected in balance and coordination.
Coordination of the hands and extremities is
tested by:
Rapid, alternating movements
POINT TO POINT TESTING
Balance and Coordiantion
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a. Rapid Alternating Movements (RAM)
Ask the person to pat the knees with both hands, lift
up, turn hands over, and pat the knees with the backs
of the hands.
Then ask to do this faster.
Normal:
done with equal turning
and quick rhythmic
pace
Abnormal:Lack of coordinationDysdiadochokinesia- Slow, clumsy, and sloppy response- occurs with cerebellar disease
The patient is asked to
pronate and supinate
the hands as rapid as
possible
b. Finger-to-Finger test
With th k th t h h i d
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With the persons eyes open, ask that he or she use index
finger to touch your finger, then his or her own nose.
After a few times move your finger to a different spot.
Normal: Movement is smooth
and accurate
Abnormal:Dysmetria
- clumsy movement withovershooting the mark
- occurs with cerebellar
disorder
Past-pointing- constant deviation to one
side
Balance and Coordination
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Coordination in the lower extremities is
tested by having the patient run heel downthe anterior surface of the tibia of the otherleg. Each leg is tested
Ataxia is incoordination of voluntarymuscle groups in action
Tremors are rhythmic, involuntarymovements
=>The presence of these movements suggestscerebellar disease
When abnormality is observed, a thorough
examination is indicated
Balance and Coordination
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The cerebellum is responsible for
balance and coordination.
Rombergs Test- screening test for balance
- the pt stands with feet togetherand arms at the side, first witheyes open and eyes closed for 20
to 30 secs
- slight sway is normal but loss ofbalance is abnormal and considered
(+) Romberg rest
Normal:
Negative Romberg
Abnormal:Sways falls widens base of
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Negative Romberg
test
Sways, falls, widens base of
feet to avoid falling
Positive Romberg sign
-Loss of balance that occurs
when closing the eyes.
-Occurs with cerebellar
ataxia (multiple sclerosis,
alcohol intoxication)
-Loss of proprioception, and
loss of vestibular function
Perform Tandem Walking
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- ask the person to walk a straight line in a heel-to-toe fashion.
- This decreases the base of support and will accentuate any
problem with coordination.
Normal:
Person can walk straight
& stay balanced
Abnormal:Crooked line walk
Widens base to maintain balance
Staggering, reeling, loss of balanceAn ataxia that did not appear now.
Inability to tandem walk is sensitive for
an upper motor neuron lesion, such asmultiple sclerosis.
Hopping in place, alternating knee bends(some individuals cannot hop owing to aging or obesity)
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(some individuals cannot hop owing to aging or obesity)
Examining the ReflexesM t fl i l t t ti f
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Motor reflex are involuntary contraction of
muscles or muscle groups in response toabrupt stretching near the site of muscle
insertion
Technique:A reflex hammer is used toelicit a deep tendon reflex.
The tendon is struck briskly, and the
response is compared with the oppositeside of the body (right and left)
The response should be equal
Examining the Reflexes
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GRADING the REFLEXES The absence of reflex is significant,
although ankle jerks (achilles reflex) may
be absent on older people.
Some uses the terms:
PRESENTABSENT
DIMINISHED
REFLEXESDocumenting Reflex Findings
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Use these grading scales to rate the strength of
each reflex in a deep tendon and superficial reflexassessment.
Deep tendon reflex grades
0 absent+ present but diminished
+ + normal
+ + + increased but not necessarily pathologic
+ + + + hyperactive or clonic (involuntary contraction
and relaxation of skeletal muscle)
Superficial reflex grades
0 absent
+ present
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Documentation of reflex finding
ASSESSING REFLEXESBiceps Reflex
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Biceps Reflex- is elicited by striking the biceps tendon of
the flexed elbow.- the examiner supports the forearm withone arm while placing the thumb againstthe tendon and striking the thumb with thereflex hammer.
Normal:
Flexion at the elbow andcontraction of the biceps
ASSESSING REFLEXESb T i R fl
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b. Triceps Reflex
- flex pts arm to 90 angle and
positioned in front of the chest
Abduct patients arm and flex it at the elbow.
Support the arm with your non-dominant hand. Identify triceps tendon by
palpating 2.5 to 5cm
(1-2 in) above the elbow
Normal: Contraction of triceps with
extension at elbow
ASSESSING REFLEXES
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c. Patellar Reflex
Have patient sit with legs dangling. Strike tendon directly below patella.
Normal: Contraction of
quadriceps with
extension of knee.
ASSESSING REFLEXESd A kl R fl
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d. Ankle Reflex
- Achilles reflex- foot is dorsiflexed at the ankle and
the hammer strikes the stretched
Achilles tendon
Normal:
Plantar flexion of foot.
ASSESSING REFLEXES
e Test for Clonus
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e. Test for Clonus
When reflexes are very hyperactive, aphenomenon called clonus may be elicited If a foot is abruptly dorsiflexed, it may
continue to beat two to three times before it
settles into a position of rest The presence of clonus always indicates the
presence of CNS disease and requiresfurther evaluation
Normal:No contraction
F. Superficial Reflexes
Abdominal Reflex
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Abdominal Reflex
Stroke patients abdomen diagonally fromupper and lower quadrants toward umbilicus.
Contraction of rectus abdominis. Umbilicus
moves toward stimulus.
Perianal Reflex
Gently stroke skin around anus with gloved finger.
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Normal:
Anus puckers.
Cremasteric Reflex
Gently stroke inner aspect of a males thigh.
Normal: Testes rise.
Bulbocavernosus Reflex Gently apply pressure over bulbocavernous
muscle on dorsal side of penis.
Normal:
Bulbocavernosus muscle contracts.
ASSESSING REFLEXES
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BABINSKI REFLEX
Stroke sole of patients foot in an arcfrom lateral heel to medial ball.
Fanning of toes when stroked laterally
Normal in newborn (found until 16 24 mos) Indicates CNS disease of motor system
Normal: Flexion of all toes.
SENSORY EXAMINATION Highly subjective & requires cooperation of the pt
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Highly subjective & requires cooperation of the pt
The examiner should be familiar with dermatomes Most sensory deficits results from peripheral
neuropathy and follow anatomic dermatomes
Assessment involves:
Tactile sensation
Superficial pain
Vibration Position sense
** during assessment, pt eyes are kept closed
SENSORY EXAMINATION
Tactile Sensation or Light Touch
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Tactile Sensation or Light Touch
- Brush a light stimulus such as a cotton wispover patients skin in several locations, including
torso and extremities.
Normal:
Identifies areas
stimulated by light
touch.
Abnormal:Hypesthesia: diminished capacity for
physical sensation (esp. skin)
Hyperesthesia: Increased sensitivity
Paresthesia: Numbness & tingling
Anesthesia: Loss of sensation.
PAIN and TEMPERATURE- Stimulate skin lightly with sharp and dull ends of
h i k/ li
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toothpick/ paper clip
- Apply stimuli randomly and ask patient to identifywhether sensation is sharp or dull.
- Touch patients skin with test tubes filled with hot or
cold water.
- Apply stimuli randomly, and ask patient to identifywhether sensation is hot or cold.
Sensory ExaminationVIBRATION and PROPRIOCEPTION
Pl ib ti t i f k fi
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- Place a vibrating tuning fork over a finger
joint, and then over a toe joint.- Ask patient to tell you when vibration is felt
and when it stops.
- If patient is unable to detect vibration, testproximal areas as well.
Sensory Examination
l Abnormal:
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Normal:
Vibratorysensation intactbilaterally in upper
and lowerextremities.
Abnormal:
Diminished/absentvibration sense:
- Peripheral nerve
damage caused by
alcoholism,
diabetes, or damage
to posterior columnof spinal cord.
StereognosisWith patients eyes closed, place a familiar
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object, such as a coin or a button, in patients
hand, and ask patient to identify it. Test both hands using different objects.
Normal: Stereognosis
intact bilaterally.
Abnormal:Abnormal findings suggest alesion or other disorder
involving sensory cortex or adisorder affecting posterior
column.
Sensory Extinction Simultaneously touch both sides of patients
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body at same point.
Ask patient to point to where she or he wastouched.
Normal:
Extinction intact.
Abnormal:
Identification of stimulus ononly one side suggests lesion
or other disorder involving
sensory cortical region inopposite hemisphere.
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Assessing
Level of Consciousness
Level of Consciousness (LOC)
arousal; awareness of self or environmentd
Al t f ll k i t t t l d
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Alert fully awake; appropriate responses to external and
internal stimuli; oriented to person, place and timesLethargic somnolent, drowsy, listless, indifferent tosurroundings, very sleepy, can be aroused from sleep butwhen stimulation ceases, falls back to sleep; may be
oriented or confusedd
Stuporous unconscious most of the time but makesspontaneous movements and response is evoked only by astrong, continuous, noxious stimuli; loud noises or sounds,bright light, pressure to sternum, response is usually apurposeful attempt to remove the stimulusf
Comatose absence of voluntary response to stimuli
including painful stimuli; no response, no eye openingscore of 7 or less on GCS
Glasgow Coma Scale- A standardized objective assessment that
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j
defines the LOC by giving it a numeric value.- Most often after brain surgery
- Document as E_V_M_; for example, E4V5M6.
The three numbers are added; the total score reflects the
brain functional level.
A fully awake person = 15
Coma = 7 or less
The GCS assesses the functional state of the brain as a
whole, not of any particular site in the brain. (Juarez and Lyon,1995)
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Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)
ASSESSING LEVEL OFCONSCIOUSNESS
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a. Test orientation to time, place, and person
Normal:
Awake, alert, andoriented to time,place, and person(AAO x 3)
Responds to
external stimuli
Abnormal: Disorientation may be
physical in origin Disorientation can also
be psychiatric in origin(schizophrenia)
Lathargic or somnolent Obtunded
Stupor Coma
Abnormal FindingsAbnormalities in Muscle Movement
Paralysis
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Paralysis
Loss or impairment of the ability to move a body part,usually as a result of damage to its nerve supply.
Loss of sensation over a region of the body.
Hemiplegiaparalysis of one side of the body
Paraplegiaparalysis of both lower limbs due to
spinal disease or injury
Quadriplegiaparalysis of all four limbs or of the entire
body below the neckParesis
partial motor paralysis
Abnormal Findings
Abnormalities in Muscle Movement
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Abnormalities in Muscle Movement
Fasciculations
Rapid, continuous twitching of resting
muscle
Abnormal Findings
Abnormalities in Muscle Movement
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Abnormalities in Muscle Movement
Tic
Repetitive twitching of a muscle group
Abnormal Findings
Abnormalities in Muscle Movement
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Abnormalities in Muscle Movement
Myoclonus
Rapid, sudden jerk at a fairly regular
intervals
Abnormal Findings
Abnormalities in Muscle Movement
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Abnormalities in Muscle Movement
Tremor
Involuntary contraction of opposing muscle
groups
Rest tremor
Intention tremor
Abnormal Findings
Abnormalities in Muscle Movement
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Abnormalities in Muscle Movement
Chorea
Sudden, rapid, jerky,
purposelessmovement involving
limbs, trunk, or face
Abnormal Findings
Abnormalities in Muscle Movement
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Abnormalities in Muscle Movement
Athetosis
Slow, twisting,
writhing,continuousmovement,
resembling asnake or worm
Neurologic Exam: Meningeal signsBrudzinskis sign- neck stiffness
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neck stiffness
- involuntary flexion of hips and kneeswhen flexing neck is positive sign for
meningeal irritation
Neurologic Exam: Meningeal signsPositive Kernigs sign
-excessive pain in the lower back
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excessive pain in the lower back
when examiner attempts to straightenknees with client supine and knees
and hips flexed
Neurologic Exam: Meningeal
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Decorticate posturing (up)
Decorticate posturing (down)
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DIAGNOSTIC
EVALUATION
Computed Tomography Scan
Makes use of narrow x-ray beam to scan body partin successive layers
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in successive layers Images provide cross-sectional views of the brain
displayed on an oscilloscope or TV monitor and isphotographed and stored digitally
Non-invasive and painless and has high degree indetecting brain lesions
Nursing Intervention:
Teach patient about the need to lie quietlythroughout the entire procedure Assess for iodine/shellfish allergy Monitor for side effect of IV or inhalation contrast
agents: flushing, nausea, vomiting
CT SCAN
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Positron Emission Tomography (PET)
- Computer based nuclear imaging that produces
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images of actual organ functioning.- Radioactive gas or substance is inhaled orinjected that emits positively charged particles.
- It permits measurement of blood flow, tissue
composition, brain metabolism thus evaluatesbrain function.
- Useful in showing metabolic changes in thebrain (Alzheimers disease), locating lesions(tumor, epiliptogenic lesions), identifyingblood flow and oxygen metabolism in stroke ptand new therapies for brain tumor.
Positron Emission Tomography (PET)
Key nursing interventions include patient
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preparation, which involves explaining the test andteaching the patient about inhalation techniques and
the sensations (dizziness, light-headedness,
headache) may occur.
IV injection of radioactive substance produces
similar side effects.
Relaxation exercises may reduce anxiety during the
test.
PET Scan
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Single Photon Emission ComputedTomography (SPECT)
3D imaging technique that uses radionuclides
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g g q
and instruments to detect single photons.
Perfusion study that captures cerebral blood
flow at time of injection of radionuclide.
SPECT is useful in detecting extent &location of perfused areas of the brain,
allowing detection, localization and sizing ofstroke, detecting tumor progression andevaluation of perfusion before and after
neurosurgical procedures.
Single Photon Emission ComputedTomography (SPECT)
Nursing Intervention
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g
Preparation and monitoring
Observe for allegeric reaction.
Pregnancy and breastfeeding are
contraindications.
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Magnetic Resonance Imaging(MRI)
Uses a powerful magnetic
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Uses a powerful magneticfield to obtain images ofdifferent areas of thebody
Can identify cerebralabnormality earlier andmore clearly than anyother diagnostic tests
Useful in monitoringtumors response totreatment, Dx of MS
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Nursing Intervention: MRI
Relaxation techniques
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Advise pt that she can speak with the staff bymeans of a microphone inside the scanner
ALL metal objects and magnetic cards areremoved (aneurysm clips, ortho-hardware,
pacemakers, artificial heart valves, IUD) Medication patches removed (cause burns)
Sedation for claustrophobic pt
Scanning process is painless, but the patienthears loud thumping of magnetic coils asmagnetic field is being pulsed.
Myelography Myelogram is an Xray of spinal subarachnoid space
taken with contrast agent (through Lumbar Tap)
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g ( g p)
Shows distortion of spinal cord or spinal dural sac
caused by tumors, cysts, herniated vertebral disks
Nursing Intervention Meal before procedure is omited
After myelography, patient to lie in bed with head
elevated up to 45 and remain in bed for 3hrs
Encourage increased fluid intake
Monitor VS
Myelography
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CEREBRAL ANGIOGRAPHY
X-ray study of the cerebral circulation with
contrast agent injected to selected artery.
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g j y
Performed by threading a catheter through the
femoral artery in the groin and up to the desired
vessel.
Uses: Vascular disease, aneurysms, AVM
Digital Subtraction Angiography- X-ray images of areas in question are taken before and
after injection of contrast agent (peripheral vein) and then
compared
CEREBRAL ANGIOGRAM
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Nursing Intervention: CEREBRAL ANGIOGRAPHYNURSING CARE PRE-TEST
1.) Check allergy to iodine
2.) Keep NPO after midnight or offer clear liquid breakfast only
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3.) Explain that the client may have warm, flushed feeling and salty taste inmouth during procedure
4.) Take baseline vital signs and neuro check
5.) Administer sedation if ordered
NURSING CARE POST-TEST1.) Maintain pressure dressing over site if femoral or brachial artery used;
apply ice as ordered
2.) Maintain bed rest until next morning as ordered
3.) Monitor vital signs, neuro checks frequently; report any changes
immediately4.) Check site frequently for bleeding or hematoma; if carotid artery used;
assess for swelling of neck, difficulty swallowing or breathing
5.) Check pulse, color, and temperature of extremity distal to site used.
6.) Keep extremity extended and avoid flexion
Non-invasive Carotid Flow Studies
Uses ultrasound and doppler measurements of
arterial blood flow to evaluate carotid and deep
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orbital circulation. The graph produced indicates blood velocity.
( velocity = stenosis or partial obstruction)
Carotid doppler permits evaluation of
Carotid ultrasonography arterial blood flow and
Oculoplethysmography detection of atrialOpthalmodensinometry stenosis, occlusion and
plaques
Transcranial Doppler
Uses the same noninvasive techniques as
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Carotid flow studies except it records bloodflow velocities of intracranial vessels
Flow velocity is measured through thin area
of temporal and occipital bones of the skull. A hand-held doppler probe emits a pulsed
beam; the signal is reflected by a moving
RBC within the blood vessel Helpful in assessing vasospasm, altered cerebral
blood flow in occlusive vascular dse or stroke
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Electroencephalography (EEG)
Represents a record of electricalactivity generated by the brain
h h l d li d h
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through electrodes applied on thescalp
Used to diagnose seizure
disorders, coma Tumors, brain abscess, blood
clots may cause abnormalpatterns in electrical activity
Used in making a determinationof BRAIN DEATH
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Electroencephalography (EEG)
Nursing Intervention
Withhold medications that may interfere with the results-
ti l t d ti d ti l t
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anticonvulsants, sedatives and stimulants Wash hair thoroughly before procedure
Instruct adult client to sleep no more than 5 hrs the night
before.
Coffee, tea, chocolate and cola drinks are omitted Meal itself is not omitted because an altered glucose level
alters brain wave patterns
It takes 45min-1hour; 12 hours for sleep EEG
Standard EEG - water-soluble lubricant
Sleep EEG - collodion glue for electrode contact (acetone
for removal)
Diagnostic EvaluationElectromyography (EMG)- obtained by inserting needle electrode into the skeletal
l t h i th l t i l t ti l f th
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muscle to measure changes in the electrical potential of themuscles and the nerves leading to them.Determine presence of neuromuscular disorders & myopathies.
Nerve Conduction Studies
-A peripheral nerve is stimulated at several points along
its course and recording the muscle action potential or
sensory action potential.Useful in studying peripheral neuropathies.
Lumbar Puncture and CSF examination
Spinal tap - a needle is inserted into the subarachnoidspace through the 3rd and 4th or 4th and 5th
l b i t f t ithd i l fl id
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lumbar interface to withdraw spinal fluidhPURPOSES1. Measures CSF pressure
(normal opening pressure 60-150mmH2O)
2. Obtain specimens for lab analysis, cytology, C&S(protein - normally not present, sugar - normally present)
3. Check color of CSF (normally clear) and check forblood
4. Inject air, dye, or drugs into the spinal canal
- CSF pressure in lateral recumbent position is70-200mm H20
Lumbar Puncture and CSF examination
CONTRAINDICATION
INCREASED ICP
COAGULOPATHY & DECREASED PLATELETS
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COAGULOPATHY & DECREASED PLATELETS SPINAL DEFORMITIES ( SCOLIOSIS, KYPHOSIS)
Lumbar Puncture GuidelinesNURSING CARE PRE-TEST
1.) Have client empty bladder
2 ) Position client in a lateral recumbent position with head
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2.) Position client in a lateral recumbent position with headand neck flexed onto the chest and knees pulled up.
3.) Explain the need to remain still during the procedure
NURSING CARE POST-TEST
1.) Ensure labeling of CSF specimens in proper sequence
2.) Keep client flat for 12-24 hours as ordered
3.) Force fluids
4.) Check puncture site for bleeding, leakage of CSF
5.) Assess sensation and movement in lower extremities
6.) Monitor vital signs
7.) Administer analgesics for headache as ordered
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Queckenstendts Test lumbar manometric test
performed by compressing jugular veins during Spinal
tap
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tap in pressure caused by compression is noted; then
released and read every 10secs interval.
a slow rise and fall in pressure indicated a partial blockdue to lesion compressing the spinal subarachnoid path.
no pressure change => complete block is indicated.
Contraindicated: if intracranial lesion is suspected.
CSF Analysis CSF should be clear and colorless
Pink, blood-tinged, or glossy bloody CSF
indicates cerebral contusion laceration or
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indicates cerebral contusion, laceration or
subarachnoid hemorrhage
Specimens are obtained for: cell count,
culture and glucose and protein testing
Post Lumbar Headache Mild to severe, may occur few hours to several
days after the procedure.
i h bbi bif l i i l h d h
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It is throbbing bifrontal or occipital headache,
dull or deep in character
Cause:leak at puncture site, fluid continues toescape into the tissues by way of the needle
track from the spinal canal
May be avoided if small-gauged needle is used
and if pt remains prone
after the procedure.
sources Dillon, Patricia. Nursing Health Assessment. 2nd
Ed. F.A. Davis. 2007
J i C l Ph i l E i ti d H lth
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Jarvis, Carolyn. Physical Examination and Health
Assessment. 3rd ed. New York: W.B. Saunder
Company.2000
Bickley. Lyn and Hoekenan, Robert. Bates Guide
to Physical Examination and History Taking. 7th
ed. New York: Lippincott Williams and Wilkins.
1999
Estes, Mary Ellen Zator. Health Assessment &
Physical Examination. 3rd ed. Delmar Learning.
2006
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THANK YOU!!!