Neurological Assessment Health Assessment

Objectives Describe the anatomy and physiology of the nervous system. Develop questions to be used when completing the focused interview. Describe the techniques required for assessment of the nervous system. Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Neurologic System Complex Integration, Coordination, and Regulation of Body Systems

Nervous System Central Peripheral

Central Nervous System Brain Spinal cord

Brain Cerebral cortex Frontal Parietal Occipital Temporal Diencephalon Thalamus Hypothalamus Epithalamus

Brain Cerebellum Brain stem Midbrain Pons Medulla oblongata

Regions of the brain 8

Spinal Cord Meninges Cerebrospinal fluid Vertebrae

Peripheral Nervous System Cranial nerves Spinal nerves

12 Pairs of Cranial Nerves Originate in the brain Control many activities in the body Take impulses to and from the brain

Cranial nerves and their target regions Cranial nerves and their target regions. (Sensory nerves are shown in blue; motor nerves, in red.) 12

Cranial Nerves 13

Spinal Cord 31 pairs of spinal nerves 8 pairs of cervical nerves 12 pairs of thoracic nerves 5 pairs of lumbar nerves 5 pairs of sacral nerves 1 pair of coccygeal nerves Dermatome

Spinal nerves 15

Focused Interview Specific questions Illness, infection, or injury Symptoms Pain Behaviors

Physical Assessment of the Neurologic System Techniques Inspection Palpation Auscultation of the carotid arteries Sensory and motor function Reflexes

Areas of the Neurologic System Assessment Observing mental status, speech, and language Observing sensorium, memory, calculation ability, abstract thinking ability, mood, emotional state, perceptions, thought processes, ability to make judgments

Tools for Assessment of Mental Status EBP 19

Cranial Nerves l. Olfactory: smell ll. Optic: vision lll. Oculomotor: moves eye constricts pupil, opens eyelid lV. Trochlear: moves eye in and down

Cranial Nerves V. Trigeminal: sensation to face, scalp cornea Vl. Abducens: moves eye laterally Vll. Facial: moves face Vlll. Acoustic: hearing and balance

Cranial Nerves lX. Glossopharyngeal: swallow & speech X. Vagus: voice quality Xl. Spinal Accessory: moves head & shoulders Xll. Hypoglossal: moves tongue

Cranial Nerves Assess together: lll, lV & Vl (EOMs) Assess together: lX, X & Xll (swallow, gag & dysarthria)

Areas of the Neurologic System Assessment Motor function Observation of gait and balance Administration of the Romberg test Administration of the finger-to-nose test Observation of rapid alternating action movements Administration of the heel-to-shin test

Evaluation of gait. 25

Heel-to-toe walk 26

Romberg’s test for balance 27

Finger-to-nose test 28

Alternative for pass point test 29

Testing rapid alternating movement, palms down. 30

Testing rapid alternating movement, palms up 31

Testing coordination using the finger-to-finger test. 32

Heel-to-shin test. 33

Areas of the Neurologic System Assessment Sensory function Observation of light touch identification Sharp, dull, temperature, and vibration determination Stereognosis Graphesthesia Two-point discrimination Topognosis Position sense

Evaluation of light touch 35

Testing the client’s ability to identify sharp sensations 36

Testing the client’s ability to identify dull sensations 37

Testing the client’s ability to feel vibrations, the toe 38

Testing the client’s ability to feel vibrations, the knee 39

Position sense of joint movement 40

Areas of the Neurologic System Assessment Reflexes Biceps Triceps Brachioradialsis Patellar Achilles Plantar Abdominal

Testing the biceps reflex 42

testing the triceps reflex 43

Testing the brachioradialis reflex. 44

Testing patellar reflex, client in a sitting position 45

Testing patellar reflex using a relaxation technique. 46

Testing the Achilles tendon reflex with client in a sitting position 47

Testing the Achilles tendon reflex with client in a supine position. 48

Testing the plantar reflex 49

Babinski response 50

Abdominal reflex testing pattern 51

Areas of the Neurologic System Assessment Additional assessments Carotid auscultation Meningeal assessment Glasgow Coma Scale

Glasgow Coma Scale 53

Neurosurgery Considerations Assess for increased intracranial pressure (ICP) Level of consciousness (LOC) Motor function Pupillary response Vital signs Following an ICU stay of several days, client will normally be confused about the date.

Pupils Assess for size, shape & reaction to light.

Pupils Fixed Dilated=  ICP, Prolonged diffuse hypoxia, Atropine Controlled by: CN-III Brainstem Midbrain Pupillary Assessment Size N= 3-5mm Reaction Shape… N=Round Abn=oval –  ICP (15-20mmHg) post frontal / anterior temporal lesions Contusions… Fixed Dilated=  ICP, Prolonged diffuse hypoxia, Atropine Pinpoint pupil = Narcotics (Morphine, Demerol), Long Acting analgesia (Fentanyl)

Glossary analgesia The absence of pain sensation. anesthesia   The inability to perceive the sense of touch. Babinski response   The fanning of the toes with the great toe pointing toward the dorsum of the foot, considered an abnormal response in the adult that may indicate upper motor neuron disease. brainstem   Located between the cerebrum and spinal cord, contains the midbrain, pons, and medulla oblongata and connects pathways between the higher and lower structures. central nervous system   System of the body that consists of the brain and the spinal cord. cerebellum   Located below the cerebrum and behind the brain stem, it coordinates stimuli from the cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements; also assists with maintaining equilibrium and muscle tone.

Glossary cerebrum   The largest portion of the brain, responsible for all conscious behavior. clonus   Rhythmically alternating flexion and extension, confirms upper motor neuron disease. coma   Amore prolonged state of unconsciousness, with pronounced and persistent changes. dermatome   An area of skin innervated by the cutaneous branch of one spinal nerve. diplopia   Double vision. dysphagia   Difficulty with swallowing. hypalgesia   Decreased pain sensation. hyperesthesia   An increased sensation.

Glossary meninges   Three connective tissue membranes that cover, protect, and nourish the central nervous system. nuchal rigidity   Stiffness of the neck as experienced when the meningeal membranes are irritated or inflamed. nystagmus   The constant involuntary movement of the eyeball. peripheral nervous system  System of the body that consists of the cranial nerves and spinal nerves. reflexes   Stimulus-response activities of the body. Romberg test    A test that assesses coordination and equilibrium. seizures   Sudden, rapid, and excessive discharges of electrical energy in the brain. spinal cord   A continuation of the medulla oblongata that has the ability to transmit impulses to and from the brain via the ascending and descending pathways. syncope   Brief loss of consciousness, usually sudden.

THANK YOU FOR LISTENING ! The END ! ? Any questions GOOD DAY ! and THANK YOU FOR LISTENING !