The Neurological System

Neurological Exam 5 Components Mental status Cranial nerves Reflexes Motor- includes Cerebellar function Sensory

Mental Status Examination Examination - ABCT Appearance Behavior Cognition Thought processes (thought content & perceptions) Mini Mental State Exam Glasgow Coma Scale Appearance – posture, position, dress, grooming and hygeine Behavior – level of consciousness, facial expression, speech, mood and affect Cognitive functions – orientation x4 Attentions span, recent and remote memory, judgement Thougt processes - Thought process should be realistic and cosistent with reality thought content – should be consistent and logiceal perceptions – should be consistent with reality (how he thinks people treat him, hearing name called when alone etc) Screen for suicidal thoughts MMSE – screening exam assesses judgement, calculation, abstraction, memory etc. –get a score STANDARD SET OF 11 QUESTIONS (5-10 MINUTES) CAN BE USED AT INTERVALS TO SEE PROGRESS OR DETERIORATION OF CONDITION GLASGOW – ASSESSES LOC

Assessing LOC: Glasgow Coma Scale Eye opening Verbal responsiveness Motor responsiveness Glasgow Coma Scale (p.732, Jarvis) Used to describe level of consciousness by given a quantitative value Best eye response: spontaneous  no response (4-1) Best motor: obeys  no response (6-1) Best verbal: oriented x3  no response (5-1) Fully alert: total score of 15 Coma: total score of 3

Glasgow Coma Scale Eyes 4 Spontaneous 3 To speech 2 To pain 1 No response

Levels of Consciousness Physical Examination Levels of Consciousness Alert- awake or easily aroused Lethargic- not fully alert, drifts off when not stimulated Obtunded- sleeps most times, difficult to arouse (loud noise, vigorous shaking or pain) Stupor- need persistent loud noise or pain for arousal; responds to stimuli Coma- no response (Jarvis CH 2) Order of deterioration of LOC A & O alters: first to time, then place, then familiar persons, last to self lose ability obey simple commands then responses deteriorate from purposeful to purposeless responses to pain then absence of response to pain then loss of corneal and gag reflexes

Cranial Nerves “ On old Olympus’ Towering Tops a Finn and German Viewed some hops.” I – Olfactory VII - Facial II – Optic VIII – Auditory (V-C) III – Occulomotor IX - Glossopharyngeal IV – Trochlear X - Vagus V – Trigeminal XI – Spinal Accessory VI – Abducens XII - Hypoglossal

Neurological: Physical Examination Sensory System Function With eyes closed Interpret sensations Discriminate side to side Examine in detail if: Reduced sensation Numbness or pain Motor or reflex abnormal Skin changes Be specific: “tell me where I touch” Check both sides

Physical Examination Sensory Function Tests: Touch Vibration Light touch 1st then Pain & Temperature Vibration Proprioception: Position sense Stereognosis Graphesthesia 2-point discrimination

Sensory Function Tests: Sensory Exam: Light Touch Light touch – assessing the trigeminal nerve CN V

Sensory Function Tests: Sensory Exam: Vibration

Sensory Function Tests: Proprioception: Position sense

Sensory Function Tests: Stereognosis Cortical Stereognosis Identify familiar object in hand Two-point discrimination One point or two points simultaneously touched At what point cant discriminate between two points Graphesthesia Draw letter or number in palm of client’s hand Test other hand with different figure

Sensory Function Tests: Graphesthesia

Sensory Function Tests: Two-point discrimination

Sensory Function Tests: Dermatomes

Motor Examination Symmetry, size, and presence f involuntary movements Full ROM of joints Check strength against resistance Neuro patients: Assess hand grips and foot pushes if bedridden Muscle bulk, strength and tone C1-4: Neck and shoulder C5-8, T1: Arm, hand, fingers L1-5: Hip and leg L4-5, S1-2: Foot and toe S2-4: Anus/rectum

Heel to toe in straight line Walking on toes and heels Hop on one foot Cerebellar Function 1. Gait and posture Heel to toe in straight line Walking on toes and heels Hop on one foot Note width of gait Ex: traffic school – show videos of sobriety test – walk in straight line, finger to nose

Cerebellar Function, con’t 2. Coordination of hands and legs RAM nose to examiner’s finger heel to shin coordination Note smoothness of motion Perform bilaterally

Cerebellar Function, con’t RAM

Cerebellar Function, con’t Nose –to - Finger Test Ex sobriety test

Cerebellar Function, con’t Heel to Shin

Cerebellar con’t Romberg: Stand upright, place feet together, then close eyes loss of balance means + Romberg test Be prepared to protect client from falling! pronator drift—test for proprioception + means loss of balance (in ataxia) Eyes open and fall—cerebellar disorder Eyes closed and fall—posterior column disorder / altered proprioception

4 types of Reflexes Superficial (abdominal reflex, Cremasteric reflex) Visceral (pupillary response to light) PERRL Pathologic + Babinski in adults DTRs (e.g. knee) Cremastic Reflex

Reflexes-Cont: PERRL/PERRLA

Reflexes-Cont: Babinski’s Reflex (Adult) If assessing a comatose patient for deterioration, check for Babinski response Babinski sign- dorsiflexion of big toe and fanning of other toes is abnormal (Positive); (should curl in adults) in infancy this is normal

Reflexes-Cont: Reflex Arc – Deep Tendon Reflex Helps maintain muscle tone Permits quick response to bad stimuli components needed for DTR response: Intact sensory nerve (afferent) A functional synapse in the cord An intact motor nerve fiber (efferent) The neuromuscular joint A competent muscle

Reflexes-Cont: Deep Tendon Reflexes Technique Position limb so muscle is slightly stretched Reflex hammer should strike tendon briskly to stretch tendon Get patient to relax Assesses receptor organ, relay nerves, cord Deep Tendon Reflexes With client relaxed in supine or sitting position Position extremity with slight tension on the tendon to be tested Distract client by having them contract another muscle group Palpate the tendon then briskly tap tendon with reflex hammer using a flicking motion Watch for muscle contraction Evaluate each tendon bilaterally Score the reflex from 0 (no response) to 4+ (hyperactive with intermittent clonus)

BICEPS BRACHIORADIALIS ACHILLES/PLANTAR TRICEPS PATELLAR Flex the client’s arm to a 45 degree angle Rest forearm in your arm with client’s hand slightly pronated Strike tendon at about 1 – 2 inches from wrist with reflex hammer Should cause pronation of the forearm and flexion of the elbow Biceps: Flex arm at elbow with forearm on thigh, palm up. Place thumb firmly on the biceps tendon in the antecubital fossa then strike thumb with hammer. Elbow and foream should flex and biceps muscle should contract. Triceps Flex elbow at 90 degrees angle palm down. Support wrist as you strike your thumb with hammer. The elbow and the forearm should flex and the biceps muscle should contract. Patellar: Sit on edge of table, legs relaxed and hanging down, freely swinging. Strike the patellar tendon just below the knee and above the tibial tuberosity. Check for quadriceps contraction and knee extension. Achilles (Plantar Response) Knee slightly flexed and foot dorsiflexed. Support foot with your palm, then strike the achilles tendon, observing for or feeling plantar flexion TRICEPS PATELLAR DEEP TENDON REFLEXES

Grading of DTRs 4+ very brisk 3+ brisker than average 2+ average, normal 1+ diminished, low normal 0 no response Know grading of dtr’s

Assessment Guide: Neurological LOC: alert, comatose, lethargic, obtunded GCS Eye opening: spontaneously, to speech, to pain Verbal Response: oriented, confused, inappropriate, incomprehensible Motor Response: obeys, command, localizes pain, withdraws, flexion, extension

Assessment Guide : cont.. Seizure Describe: tonic clonic, absence, status epilepticus Timing: once at 10 am; 2 pm and 2:45 pm

Altered mental status: yes, no Aphasia: present, none Intelllectual functioning: intact; short attention span, dementia, memory loss Itnerventions in use: Seizure precautions: side rails padded, oral airway at bedside Med List: Klonopin, Aricept, Neurontin, Dilantin, etc.

Documentation Appearance: Posture is erect, body movement is symmetrical and smooth, dress appropriate for setting; is clean and well groomed. Behavior: alert, in good spirits, speech clear Cognition: oriented x4, attentive, recent and remote recall intact Thought processes and perceptions - appropriate

Documentation – cont. Cerebellar function: Gait is balanced, good gross motor coordination (heel to toe walking), negative Romberg test Coordination and skilled movements: RAM, Finger to finger, finger to nose, and heel to shin test smooth, and accurate Spinothalamic tract: sensation to light touch intact

Documentation – cont. Posterior column tract: vibration, position sense, stereognosis, graphesthesia, and point location intact. DTRs: all DTRs intact, 2+ bilaterally.