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

Assessing LOC: Glasgow Coma Scale Eye opening Verbal responsiveness Motor responsiveness

Glasgow Coma Scale

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)

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

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

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!

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)

Reflexes-Cont: Reflex Arc – Deep Tendon Reflex

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

BICEPS BRACHIORADIALIS ACHILLES/PLANTAR 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

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.