1. The Neurological System

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

3. Mental Status Examination
Examination - ABCT
Appearance
Behavior
Cognition
Thought processes (thought content & perceptions)
Mini Mental State Exam
Glasgow Coma Scale

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

5. Glasgow Coma Scale

6. 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)

7. 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

8. 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

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

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

11. Sensory Function Tests: Sensory Exam: Vibration

12. Sensory Function Tests: Proprioception: Position sense

13. Sensory Function Tests: Stereognosis

14. Sensory Function Tests: Graphesthesia

15. Sensory Function Tests: Two-point discrimination

16. Sensory Function Tests: Dermatomes

17. 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

18. 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

19. 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

20. Cerebellar Function, con’t RAM

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

22. Cerebellar Function, con’t Heel to Shin

23. 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!

24. 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

25. Reflexes-Cont: PERRL/PERRLA

26. Reflexes-Cont:
Babinski’s Reflex (Adult)

27. Reflexes-Cont: Reflex Arc – Deep Tendon Reflex

28. 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

29. BICEPS BRACHIORADIALIS ACHILLES/PLANTAR TRICEPS PATELLAR
DEEP TENDON REFLEXES

30. Grading of DTRs 4+ very brisk 3+ brisker than average
2+ average, normal
1+ diminished, low normal
0 no response

31. 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

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

33. 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.