THE NEUROLOGICAL EXAMINATION

Anuradha .Y

INTRODUCTION:

A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired.

Neurological Anatomy

• Nervous system- divided into 2 structural parts

• Central Nervous System (CNS)- brain & spinal cord

• Peripheral Nervous System – cranial nerves (carry impulses to and from brain) & spinal nerve (carry messages to and from spinal cord

ASSESSMENT OF THE NERVOUS SYSTEM

Interview to identify presence of: • headache • difficulty with speech (dysphasia)• inability to read or write • alteration in memory • altered consciousness • confusion or change in thinking • disorientation • decrease in sensation, tingling or pain • motor weakness or decreased strength • decreased sense of smell or taste • change in vision or diplopia • difficulty with Swallowing (dysphagia) • decreased hearing • altered gait or balance ,vertigo• dizziness ,syncope,• tremors, twitches or increased tone

Neurological Assessment

NEUROLOGICAL EXAM

• MENTAL STATUS

• CRANIAL NERVES

• REFLEXES

• MOTOR EXAM– STRENGTH– GAIT– CEREBELLAR

• SENSATION

• Assessment• Ask if the client has noted signs of reduced

sensation or weakness in extremities• Determine history of seizures or convulsion• Screen client for headache,

tremors ,numbness ,dizziness• Discuss with spouse family members or friends

any recent change in behavior• Assess client for history of change in vision

hearing smell taste or touch• Review past history for head or spinal cord injury

hypertension or psychiatric disorders

Equipment

• Wisps of cotton (light touch)

• Penlight

• Opposite tip of cotton swab or tongue blade(pain Sensation)

• Tuning fork

• Flavors (sugar ,salt, lemon juice,)

• Knee hammer

• Test tubes of hot and cold water (skin temp)

• Pins or Needles (Tactile discrimination)

NeuroExam Tools

Planning

• Explain the procedure to the patient or family

• Wash hands

• Arrange the equipment in the bedside

Implementation

MENTAL STATUS (LOC)

• Cognitive (Intellectual)

• Affective (Emotional)

Level of Consciousness

• Awake and alert

• Agitated

• Lethargic– Arousal with

• Voice

• Gentle stimulation

• Noxious stimulation

• Painful/vigorous stimulation

• Comatose

LANGUAGE Aphasia vs Dysarthria Receptive Language: lost ability to

understand written or spoken words.– Command Following

Expressive Language; loss of power to express– Fluency, Word Finding

Repetition– Screens for Receptive, Expressive, and

Conductive Aphasias

MEMORY

• IMMEDIATE: recall information happened within seconds(repeat series 7-4-3 digits) (average 5 to eight in sequence and four to six in reverse order)

• RECENT : recall information happened earlier in the day (Breakfast)

• REMOTE :recall past events from months or yrs. (childhood experience, marriage, schooling)

Historical or personal events

ORIENTATION

• PERSON: Ability to recognize other person

• PLACE: Where they are

• TIME: when (recognize day or night )

OTHER COGNITIVE FUNCTIONS

• CALCULATION, CONCENTRATION OR ATTENTION SPAN

• WORLD” backwards

Months of the Year Backwards)

SUBSTRACTION (serial 7 or 3)

• SIMILARITIES/DIFFERENCES

• JUDGEMENT

Assessing LOC

• Glasgow Coma Scale (GCS)– Three Categories:

• Eye opening

• Best motor response

• Best verbal response

– Scoring• Highest or best possible score 15

• A score of < 8 indicates coma

• Lowest or worst possible score 3

Glasgow coma scale

CRANIAL NERVES

Olfactory NerveCranial nerve I Distinguish Coffee from Cinnamon Smelling Salts irritate nasal mucosa and test . Disorders of Smell result from closed head injuries

DON’T USE A NOXIOUS STIMULUS

Optic Nerve

Cranial nerve II

– VISUAL ACUITY– VISUAL FIELDS– FUNDOSCOPIC EXAM

CNII: Fundo scopic exam

CN III Oculomotor: moves

eyes in all directions except

outward and down & in; opens

eyelid; constricts pupil

CN IV Trochlear:moves eyes

down and in…..

CNII & III: Pupillary function

• Normal pupils are equal in size and shape and are situated in center of iris

• •Pupillary size varies with intensity of ambient light, but at average intensity is

• 3-4 mm

• –Miosis < 2 mm

• –Mydriasis > 5 mm

• –Anisocoria = pupillary asymmetry

Check pupil size in lighted room, and reactivity to light in a darkened room.

Unequal pupil size can be a sign of a serious brain injury.

CN VI Abducens: moves eyes outward

EOM’s:

(extraoccular movement) assessment of eye

movement in all

directions ( III, IV VI)

Trochlear Nerve

c.n. IV

Oculomotor NerveCn III

Abducens NerveCn VI

Trigeminal Nerve – V

• sensation to the face,

cornea and scalp;

• opens jaw against

resistance

Masseter strength Jaw jerk

Facial Nerve-VII

•OBSERVE FOR FACIAL ASYMMETRY• FOREHEAD WRINKLING, EYELID CLOSURE, WHISTLE/PUCKER

Vestibulocochlear Nerve-VIII

Vestibulocochlear Nerve CN VIII

Hearing and Balance• Patients will complain of tinnitis, hearing loss, and/or

vertigo Weber and Renee Test

• Differentiates Conductive vs Sensorineural hearing loss

Glossopharyngeal and Vagus Nervesc.n.’s IX and X

CN IX Glossopharyngeal:

moves the pharynx (swallow, speech & gag)

CN X Vagus: voice quality

Spinal Accessory Nervec.n. XI

Trapezius strength

Sternocleido-Mastoid strength

CN XI Spinal Accessory:

turns head and elevates

shoulders

ShoulderShrug

Hypoglossal Nervec.n. XII

Hypoglossal Nerve

Protrudes the tongue to the opposite side

REFLEXES

MUSCLE STRETCH REFLEXES (DEEP TENDON

REFLEXES)

– 0 - ABSENT– 1 – MINIMAL ACTIVITY (hypoactive)– 2 - NORMAL– 3 – MORE ACTIVE THAN NORMAL– 4 – MAXIMAL ACTIVITY (hyperactive)

DTR• BICEPS

• BRACHIORADIALIS

• TRICEPS

• PATELLAR REFLEX(KNEE)

• ACHILLES REFLEX (ANKLE )

• Superficial reflex:

• PLANTAR REFLEX(BABINSKI) Negative in adults

Biceps Reflex • Test c5-c6• Partially flex the arm at

the client’s elbow. Rest forearm over thethigh,placingthe palm of the hand down.

• Place the thumb horizontally over biceps tendon

• Deliver a blow• Observe the normal slight flexion

of the Elbow and feel biceps contraction to your thumb.

TRICEPS REFLEX(C7- C8)

Flex the client’s arm at the elbow ,and support it in the palm of non dominant hand.

palpate the triceps tendon about 2 to 5cm above the elbow

Deliver a blow with the percussion hammer directly to the tendon

Observe the normal slight extension of the elbow.

Brachioradialis Test c5-c6

Rest the clients forearm in a relaxed position externally rotated on firm surface

Deliver a blow with the percussion hammer directly on the radius 2- 5cm above the wrist or the stylloid process

Observe the normal flexion and supination of the forearm fingers of the hand may extend slightly.

Patellar reflex(kneeJerk)TEST L-2 L3 L4

Ask the client to sit on the edge of the examining table ,legs hang freely

Locate patellar tendon directly below the patella (knee cap)

Deliver a blow with the percussion hammer directly to the tendon

Observe normal extension of the leg.

ACHILLES REFLEX

TESTS S1 ,S2

ask client to sit on the edge of table ,dorsiflex the clients client’s ankle slightly by supporting the ball of the foot lightly in the hand.

Deliver a blow with the percussion hammer directly to the achilles tendon just above the heel.

Observe and feel the normal plantar flexion of the foot.

PLANTAR REFLEX

The Plantar,or Babinski reflex is superficial it may be absent in adults without Pathlogy.

Plantar reflex

MOTOR EXAMINATION

Motor function• Walking gait

• Romberg test

• Standing on one foot with eyes closed

• Heel toe walking

• Finger to nose test

• Finger to nose and nurse’s finger

• Fingers to fingers

• Fingers to thumb

• Heel down opposite shin

Romberg Sign

• Ask the client to stand with feet together and arms resting at the sides first with eyes open and then closed. Be close with the client during this test. to prevent client from falling.

• If client can not maintain balance with eyes close (positive sign) indicates lack of coordination.

Motor function

Standing on one foot with eyes closedHeel toe walking

Ask the client to walk a straight line ,placing the heel of one foot directly in front of the toes of other foot.

Toe or heel walking:

Ask client to walk on toe or heel several steps.

Motor functionFinger to nose test:

Ask the client abduct and extend the hand at shoulder level and rapidly touch the nose with one index finger then other with eyes close

Finger to nose and to the nurses finger

Ask the client to touch the nose and then nurses index finger with distance of 18 inch.

Fingers to fingers

Ask the client to spread arms broadly at shoulder level and then bring the fingers together at midline.

Motor functionFingers to thumb

Ask client to touch each finger of one hand to the thumb of the same hand

Heel down opposite shin:

Ask the client to place the heel of one foot just below the opposite knee and run the heel down the shin to the foot .repeat with the other foot.

STRENGTHGraded 0 - 5

0 - Paralysis

1 -10%normal strength no movement

2 – 25% normal strength movement against gravity with support

3 – 50% normal strength movement against gravity

4 – 75% normal strength movement against minimal resistance

5 – 100 %normal strength. movement against full resistance and gravity.

SENSORY EXAMINATION

SENSORY EXAMLight touch sensation

Ask the client to close eyes respond yes or no whenever the client feels the cotton wisp touching skin. ask to point the spot.

Pain sensation

Ask client to close eyes and say sharp r dull pain sensation when broken tongue depressor is felt.

SENSORY EXAMTemperature sensation:

This test done when pain sensation is not normal. Touch skin areas with test tubes filled with hot and cold water.

Position or kinesthetic sensation

Move toe ask client position of the toes Tactile discrimination

SENSORY EXAM

One and two point discrimination

Stimulate skins with two pins simultaneously and with one pin. Ask client whether client feels one or two)

Stereognosis :ability to recognize objects by touching them)

Graphesthesia : ability to identify numbers, letters, or shapes drawn on the skin)

Extinction phenomenon

Stimulate two symmetric areas of the body simultaneously thighs, cheeks hands.

128-Hz tuning fork •Test toe & finger Count seconds still stops •Compare side to side •If impaired, move proximally

Vibration sense

Stereognosis & Graphesthesia

Documentation

• Document findings in the client record using forms or checklist.

• Describe any abnormal findings.

Evaluation

• Perform detailed follow-up examination of other systems based on findings

• Relate findings with previous data if available.

• Report significant findings to the Physician

Than Q