NEUROLOGIC ASSESSMENT

Presented by: Ms. Jeceli Alviola Nobleza, BSN-RN

Learning Objectives:

After the presentation, we should be able to:

• Perform a physical assessment of the neurologic system

• Document neurologic system findings

• Differentiate between normal and abnormal findings

INTRODUCTION

• The human nervous system is a unique system that allows the body to interact with the environment as well as to maintain the activities of internal organs.

• The nervous system acts as the main “circuit board” for every body system. Because the nervous system works so closely with every other system, a problem within another system or within the nervous system itself can cause the nervous system to “short-circuit.”

(Dillon,2007)

• A major goal of nursing is early detection to prevent or slow the progression of disease.

• So it is important for nurses to accurately perform a thorough neurologic assessment and to understand the implications of subtle changes in assessment findings. By doing so, we can initiate timely interventions that can save lives.

(Dillon,2007)

REVIEW OF THE ANATOMY AND PHYSIOLOGY

OF THE

NEUROLOGIC SYSTEM

Cont. Review of Ana and Physio

General functions of the neurologic system include:

• Cognition, emotion, and memory.

• Sensation, perception, and the integration of sensoryperceptual experience.

• Regulation of homeostasis, consciousness, temperature, BP, and other bodily processes.

 

There are two types of nerve cells:

(1) neuroglia and

(2) neurons

Neuroglia • Functions:

a. act as supportive tissue, nourishing and protecting the neurons

b. maintain homeostasis in the interstitial fluid around the neurons and account for about 50 percent of the central nervous system (CNS) volume

c. have the ability to regenerate and respond to injury by filling spaces left by damaged neurons.

Neurons

• Functions:

a. have the ability to produce action potentials or impulses (excitability or irritability) and

b. to transmit impulses (conductivity).

Sensory (afferent) neuron Motor (efferent) neuron

Nisslbodies

nucleus

Axon

Myelin

Cell body

Receptors in skin

dendriteNodes of Ranvier

Schwann cell

synapse

Presynaptic terminal

Postsynaptic membrene

Postsynapticreceptor

Neurotransmittersubstance

Synaptic cleft

Synapticvesicles

Neuromuscularjunction

Neurons band together into- peripheral nerves, - spinal nerves, - spinal cord, and - tissues of the brain.

• These structures make up the neurologic system, which is divided into

- the CNS and

- the peripheral nervous system (PNS).

CENTRAL NERVOUS SYSTEM

• consists of the brain and spinal cord.

The Human Brain

CoordinationEquilibriumBalance

Visualperception

sensation

So

mat

ose

nso

ryco

rtexMo

tor

cort

ex

Emotion BehaviorIntellect

MotorSpeech Hearing

SmellTasteMemory

Speechcompensation

TEMPORAL LOBE

Broca’s Area

FRONTAL LOBELateral fissure Central fissure

PARIETAL LOBE

Wernicke’s area

OCCIPITAL LOBE

Cerebellum

The Spinal Cord• The spinal cord descends through the foramen magnum

(large aperture) of the occipital bone of the skull, through the first cervical vertebra (C1), and through the remainder of the vertebral column to the first or second lumbar vertebra.

• conducts sensory information from the peripheral nervous system (both somatic and autonomic) to the brain

• conducts motor information from the brain to our various effectors - skeletal muscles- cardiac muscles- smooth muscles-glands

• serves as a minor reflex center

Sensory Pathways• Pathways,either ascending or afferent,allow sensory

data, such as the feeling of a burned hand, to become conscious perceptions.

Sensory cortex

Trunk, Arm, Hand, Fingers, Face, Lips, Tongue

LegKneeFoottoes

pons

medulla

Posterior root of the spinal cord

Posterior columnFine touch, proprioception and vibration

Spinal cord

Anterior spinothalamic tractCrude touch & pressure

Lateral spinothalamic tractPain &temperature

Motor Pathways• Motor pathways (descending or efferent) transmit

impulses from the brain to the muscles

Trunk, Arm, Hand, Fingers, Face, Lips,

Tongue LegKneeFoottoes

Motor Cortex

Skeletal muscles

Lateral corticospinal (crossed pyramidal tract

Anterior corticospinal(uncroosed pyramidal tract

Spinal Reflexes• Spinal reflexes do not depend on conscious

perception and interpretation of stimuli, nor on deliberate action; in other words, they do not involve the brain.

• They occur involuntarily, with lightning speed, and are identical in all healthy children and adults, although they are less developed

• in infants.

Reflex arc

Dorsal root ganglion

Motor nerve

Sensory nerve

PERIPHERAL NERVOUS SYSTEM• The peripheral nervous system consists of

- the cranial - spinal nerves and the

- peripheral autonomic nervous system.

Cranial NervesThe 12 pairs of cranial nerves originate from the brainand are called the peripheral nerves of the brain.

I-Olfactory nerve – Smell (S)II-Optic nerve - Vision (S)III-Oculomotor nerve (M)

- Eye movement; pupil constrictionIV-Trochlear nerve (M)

- Eye movementV-Trigeminal nerve (B)

- Somatosensory information (touch, pain) from the face and head; muscles for chewing.

VI-Abducens nerve - Eye movement (M)VII-Facial nerve (B)

- Taste (anterior 2/3 of tongue); somatosensory information from ear; controls muscles used in facial expression.

VIII-Vestibulocochlear nerve/Auditory nerve (S)- Hearing; balance

IX-Glossopharyngeal nerve (B)- Taste(posterior 1/3 of tongue); - Somatosensory information from tongue,

tonsil, pharynx;- controls some muscles used in swallowing.

X-Vagus nerve (B)- Sensory, motor and autonomic functions of

viscera (glands, digestion, heart rate)XI-Accessory nerve/Spinal accessory nerve (M)

- Controls muscles used in head movement.XII-Hypoglossal nerve (M)

- Controls muscles of tongue

Spinal and Peripheral Nerves• Branching from the spinal cord are 31 pairs of spinal

nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal

• The spinal nerves contain both ascending and descending fibers, and although there is some overlap,each is responsible for innervation of a particular area of the body.

Dermatomes - are regions of the body innervated by thecutaneous branch of a single spinal nerve.

Components of Neurologic Exam

• Mental Statusa. Appearance/ Hygiene/ Grooming/ Odorb. Behaviorc. Speech/ Communicationd. Level of Consciousnesse. Memoryf. Cognitive function

• Cranial Nerve Function (12 cranial nerves)• Sensory Function

a. Light touch b. Painc. Vibration d. Kinestheticse. Streognosis f. Graphesthesiag. Two-point discrimination h. point localizationi. Sensory Extinction

• Reflex Functiona. Deep tendon reflexesb. Superficial reflexes

Ensure proper hygiene before seeing a clientEnsure all equipment is properly cleaned

Equipment Needed:- BP cuff - Tuning fork (128 or 256 Hz)- Penlight - Nonsterile gloves

- Wisp of cotton - Tongue blade- Reflex hammer- Sharp object such as toothpick or sterile needle- Objects to touch: coin, button, key or paperclip- Something fragrant: rubbing alcohol or coffee- Something to taste: such as lemon juice, sugar or salt- Two taste tubes or other vials - Ophthalmoscope

Introduce self to the client.

Assessing the Mental Status

1. APPEARANCE/ HYGIENE/ GROOMING/ ODOR

a. Begin the assessment as the patient approaches you.

b. Observe the general appearance, hygiene, grooming and the odor of the client.

Normal: good grooming, dress in appropriate

to temperature & weather,

no offensive or unpleasant odor

hair well kept or tied

Abnormal:Poor hygieneUnpleasant or offensive body odor

2. BEHAVIOR

a. Assess the client’s mood and emotions

b. Observe body language and facial expression or affect

c. Note his or her posture

Abnormal:Lack of facial expression - Possible psychological disorder (e.g., depression or schizophrenia) or neurologic impairment affecting cranial nerves.Masklike expression: - Parkinson’s disease.Slumped posture:

- Depression if psychological in origin; or stroke with hemiparesis if physiological in origin.

Normal: Verbal expressions

match with the nonverbal behavior

Mood is appropriate to the situation

Standing in upright stance with parallel alignment of hips &shoulders

3. SPEECH/ COMMUNICATIONa. Speech and Language Listen to patient’s rate and ease of speech, including enunciation.

Normal: Speech flows

easily; patient enunciates clearly.

Sophistication of speech matches age, education, and fluency.

Abnormal:■ Hesitancy, stuttering, stammering, unclear speech: - Lack of familiarity with language, deference or shyness, anxiety, neurologic disorder.■ Dysphasia/aphasia: - Neurologic problems such as stroke.■ Drugs and alcohol can also cause slurred speech.

b. Spontaneous Speech & Motor Speech- Show patient a picture and have him or her

describe what he or she sees.- Have patient repeat, “do, ray, me, fa, so, la, ti,

do.”

Normal: Spontaneous

speech intact. Motor speech

intact.

Abnormal:■ Impaired spontaneous speech:

- Cognitive impairment.Impaired motor speech (dysarthria):

Problem with CN XII

c. Autonomic SpeechHave patient say something that is committed

to memory, such as days of week or months of year.

Normal:■ Automatic

speech intact.

Abnormal:■ Impaired automatic speech: Cognitive impairment or

memory problem.

4. LEVEL OF CONSCIOUSNESSa. Test orientation to time, place, and person

Normal: Awake, alert, and

oriented to time, place, and person (AAO x 3)

Responds to external stimuli

Abnormal:Disorientation may be physical in originDisorientation can also be psychiatric in origin (schizophrenia)Lathargic or somnolentObtundedStuporComa

Glasgow Coma Scale- A standardized objective assessment that

defines the LOC by giving it a numeric value.

- Most often after brain surgery

- Document as E_V_M_; for example, E4V5M6.

Eyes openE

■ Spontaneously . . . . . . . . 4■ To command . . . . . . . . . . 3■ To pain . . . . . . . . . . . . . . . 2■ Unresponsive. .. . . . . . . . . 1

Findings

Best verbal responseV

■ Oriented . . . . . . . . . . . . . . . 5■ Confused . . . . . . . . . . . . . . . 4■ Inappropriate . . . . . . . . . . . . 3■ Incomprehensible . . . . . . . . 2■ Unresponsive. . . . . . . . . .. . . 1

Findings

Best motor responseM

■ Obeys commands . . . . . . . .. 6■ Localizes pain. . . . . . . . . . . 5■ Withdraws from pain. . . . …. 4■ Abnormal flexion . . . . . . .. . . 3■ Abnormal extension . . . . . . . 2■ Unresponsive. . . . . . . . . . . . . 1

Findings

Total______

GLASGOW COMA SCALE

From Wijdicks, et al, 2005, with permission.

• The three numbers are added; the total score reflects the brain functional level.

• A fully awake person = 15

• Coma = 7 or less

• The GCS assesses the functional state of the brain as a whole, not of any particular site in the brain. (Juarez and Lyon,1995)

Four Score Coma Measurement ScaleEYE

RESPONSE43210

Eyelids open or opened, tracking or blinking to commandEyelids open but not trackingEyelids closed but open to loud voiceEyelids closed but open to painEyelids remain closed with pain

MOTORRESPONSE

43210

Thumbs up, fist, or peace sign to commandLocalizing to painFlexion response to painExtensor posturingNo response to pain or generalized myoclonus status epilepticus

BRAINSTEMREFLEXES

43210

Pupil and corneal reflexes presentOne pupil wide and fixedPupil or corneal reflexes absentPupil and corneal reflexes absentAbsent pupil, corneal, and cough reflex

RESPIRATION43210

Not intubated, regular breathing patternNot intubated, Cheyne-Stokes breathing patternNot intubated, irregular breathing patternBreathes above ventilator rateBreathes at ventilator rate or apnea

5. MEMORYa. Test immediate recall:

Ask patient to repeat three numbers, such as “4, 9, 1.” If patient can do so, ask her or him to repeat a series of five digits.

b. Test recent memory: Ask what patient had for breakfast.

c. Test long-term memory: Ask patient to state his or her birthplace, recite his or her Social Security number, or identify a culturally specific person or event, such as the name of the previous president of the United States or the location of a natural disaster.

Normal: Immediate, recent,

and remote memory intact.

Abnormal: Memory problems can be benign or signal a moreserious neurologic problem - such as Alzheimer’s disease.Forgetfulness - especially for immediate and recent events - often in older adults. - With benign forgetfulness, person can retrace or use memory aids to help with recall.Pathological memory loss - as inAlzheimer’s disease

Cont. Abnormal: Temporary memory loss

- may occur after head trauma.

Retrograde amnesia - for events just preceding illness

or injury.

Postconcussion syndrome

- can occur 2 weeks to 2 months after injury and may cause short- term memory deficits.

6. COGNITIVE FUNCTION

a. Mathematical and Calculative AbilityAsk patient to perform a simple calculation, such as

adding 4 x 4. If successful, proceed to more difficult calculation, such as 11 9.

Normal: Mathematical/

calculative ability intact and appropriate for patient’s age, educational level, and language facility.

Abnormal: Inability to calculate at level appropriate to age,education, and language ability requires evaluation for neurologic impairment.

b. General Knowledge and VocabularyAsk how many days in a week and months in a year.

c. Thought ProcessAsk patient to define familiar words such as “apple,”“earthquake,” and “chastise.” Begin with easy words and proceed to more difficult

ones. Remember to consider the patient’s age, educational

level, and cultural background.

Normal: Thought

process intact

Abnormal: Incoherent speech illogical or unrealistic ideasrepetition of words and phrasesrepeatedly straying from topicsuddenly losing train of thought (examples of altered thought processes that indicate need for further evaluation)

Inability to define familiar words - requires further evaluation

d. Abstract Thinking Assess the client to think abstractly.Quote a proverb and ask the client to explain it’s

meaning

Normal: Able to generalize from

specific example and apply statement to human behavior.

Children should be ableto distinguish like from

unlike as appropriate for theirage and language facility.

Abnormal:■ Impaired ability to think abstractly: - Dementia, delirium, mental retardation, psychoses.

e. JudgmentObserve patient’s response to current situation.Ask patient to respond to a situation or

hypothetical situation.

Normal: Judgment

appropriate and intact.

Abnormal:■ Impaired judgment can be associated with dementia,psychosis, or drug and alcohol abuse.

Assessing the CRANIAL NERVES1. CN I—Olfactory Nerve

a. Before testing nerve function, ensure patency of each nostril by occluding in turn and asking patient to sniff.b. Once patency is established, ask patient to closeeyes. c. Occlude one nostril and hold aromatic substancesuch as coffee beneath nose. d. Ask patient to identifysubstance.e. Repeat with other nostril.

Normal:■ Patient is able to

identify substance.

(Bear in mind thatsome substances may be

unfamiliar, especially to

children.)

Abnormal:■ Anosmia is loss of sense of smell. -May be inherited and nonpathological: chronic rhinitis, sinusitis, heavy smoking, zinc deficiency, or cocaine use. - It may also indicate cranial nerve damage from facial fractures or head injuries, disorders of base of frontal lobe such as a tumor, or artherosclerotic changes.- Persons with anosmia usually also have taste problems.

2. CNs II, III, IV, and VI—Optic, Oculomotor, Trochlear, and Abducens Nerves

a. Ask the client to read a printed material, observe the distance between the printed material and the client’s eyes.

b. Use the snellen chart to check/ test:- distant vision- color

Client should be 20 feet distant from the chartUse an object to occlude one eyeEvaluate the vision one eye at a time

c. Evaluate the Extra Ocular Movements of the Eyesd. Convergens & Accomodatione. Pupillary Light Reflex

- using direct and consensual pupillary reaction to light

Testing eye movements

Testing pupil accommodation

Normal:■ Able to read without

difficulty■ Visual acuity intact

20/20, both eyes Hippus

phenomenon: - Brisk constriction of pupils in reaction to light, followed by dilation and constriction

- may be normal or sign of early CN III compression.

Abnormal:■ CN II deficits - can occur with stroke or brain tumor.■ Changes in pupillary reactions - can signal CN III deficits. ■ Increased ICP causes changes in pupillary reaction.

As pressure increases, response becomes more sluggish until pupils finally become fixed and dilated.

3. CN V—Trigeminal Nerve

a. Testing motor function: - Ask patient to move jaw from side to side against resistance and then clench jaw as you palpate contraction of temporal and masseter muscles, or to bite down on a tongue blade.

Testing CN V – motor function

b. Testing sensory function: - Ask patient to close eyes- Touch the face with the wisp of cotton- Instruct to tell you when he or she feels

sensation on the face. - Repeat the test using sharp and dull stimuli

(toothpick)- Instruct to say “Sharp” or “Dull”

(Be random, don’t establish a pattern)- Compare both bilaterally.

Testing CN V – sensory function

c. Testing corneal reflex: - Gently touch cornea with cotton wisp.

o Touching cornea can cause abrasions. Alternative approach is to:

> puff air across cornea with a needlesssyringe, or

> gently touch eyelash and look for blink reflex.

Testing corneal reflex

Normal: Full range of

motion (ROM) in jaw and 15 strength.

Patient perceives light touch and superficial pain bilaterally.

Abnormal:Weak or absent contraction unilaterally: - Lesion of nerve, cervical spine, or brainstem.Inability to perceive light touch and superficial pain - may indicate peripheral nerve damage.■ Tic douloureux: - Neuralgic pain of CN V caused by the pressure of degeneration of a nerve.■ Corneal reflex test used in patients with decreased LOC - to evaluate integrity of brainstem.

Cont. CN V

4. CN VII—Facial Nerve

a. Testing motor function: - Ask patient to perform these movements: smile, frown, raise eyebrows, show upper teeth, show lower teeth, puff out cheeks, purse lips, close eyes tightly while nurse tries to open them.

Testing CN VII – motor function

b. Testing sensory function: - Test taste on anterior two-thirds of tongue for

sweet, sour, salty.

Testing taste sensation

Sweet: Tip of the tongueSour: Sides of back half of tongueSalty: Anterior sides and tip of tongueBitter: Back of tongue

Normal: Facial nerve intact;

able to make faces. Taste sensation on

anterior tongue intact.

(Taste decreased in older adults.)

Abnormal:Asymmetrical or impaired movement: - Nerve damage, such as that caused by Bell’s palsy or stroke.■ Impaired taste/loss of taste: - Damage to facial nerve, chemotherapy or radiation therapy to head and neck.

5. CN VIII—Acoustic Nerve

a. Perform Weber and Rinne tests for hearingb. Perform watch-tick test by holding watch close to

patient’s ear.

c. Perform Romberg test for balance- Nurse at the back or side of the pt.- Instruct client to stand straight, feet together, hands at the side and eyes closed.

(Evaluates the balancing function of the CN VIII)

Watch tick test

Normal: Hearing intact. Negative Romberg

test.

Abnormal:Hearing loss, nystagmus, balance disturbance, dizziness/vertigo:

- Acoustic nerve damage.■ Nystagmus:

- CN VIII, brainstem, or cerebellum problem or

phenytoin (Dilantin) toxicity.

6. CNs IX and X—Glossopharyngeal and Vagus Nervesa. Observe ability to cough, swallow, and talk.b. Test motor function:

- Ask patient to open mouth and say “ah” while you depress the tongue with a tongue

blade. - Observe soft palate and uvula. Soft palate

and uvula should rise medially.

Testing CN IX and X – motor function

c. Test sensory function of CN IX and motor function of CN X by stimulating gag reflex.

- Tell patient that you are going to touch interior throat

- then lightly touch tip of tongue blade to posterior pharyngeal wall.

- Observe the pharyngeal movement.

- Ask the client to drink a small amount of waterNote the ease & difficulty of swallowingNote quality of the voice or hoarseness

when speaking

Normal: Swallow and cough

reflex intact. Speech clear. Elevation and

constriction of pharyngeal musculature and tongue retraction indicate positive gag reflex.

Abnormal:Unilateral movement: - Contralateral nerve damage. - Damage to CNs IX and X also impairs swallowing.■ Changes in voice quality (e.g., hoarseness): CN X damage.- CN X damage may also affect vital functions, causing arrhythmias because vagus nerve innervates most of viscera through parasympathetic system.■ Diminished/absent gag reflex: Nerve damage. - Evaluate further because patient is at increased risk for aspiration.■ Impaired taste on posterior portion of tongue: Problem with CN IX.

7. CN XI—Accessory Nervea. Test motor function of shoulder and neck

muscles: - Ask patient to shrug shoulders upward against your resistance. (Trapieze muscle)- Then ask her or him to turn head from side to side against your resistance. (Strenoclaidomastoid msucle)- Observe for symmetry of contraction and muscle strength.

Normal: Movement

symmetrical, with patient moving against resistance without pain.

■ Full ROM of neck with +5/5 strength.

Abnormal:AsymmetricalDiminishedAbsent movementPainunilateral or bilateral weakness: - Peripheral nerve CN XIdamage.

8. CN XII—Hypoglossal Nervea. Have patient say “d, l, n, t” or a phrase containing these letters.

- The ability to say these letters requires use of the tongue.b. Ask the patient to protrude the tongue.

Observe any deviation from midline, tumors, lesions, or atrophy.

Now ask the patient to move the tongue fromside to side.

Testing CN XII – motor function

Normal: Can protrude

tongue medially. No atrophy,

tumors, or lesions.

Abnormal:Asymmetrical/diminished/absent movement/deviation from midline/protruded tongue:

- Peripheral nerve CNXII damage.

■ Tongue paralysis results in dysarthria.

Assessing Sensory Function1. Light Touch

- Brush a light stimulus such as a cotton wisp over patient’s skin in several locations, including torso and extremities.

Normal: Identifies areas

stimulated by light touch.

Abnormal:Diminished/absent cutaneous perception: -Peripheral nerve damage or damage to posterior column of spinal cord.- Peripheral neuropathies can also cause sensory deficits.■ Hypesthesia: Increased sensitivity.■ Paresthesia: Numbness and tingling.■ Anesthesia: Loss of sensation.

2. Pain- Stimulate skin lightly with sharp and dull ends of toothpick/ paper clip-Apply stimuli randomly and ask patient to identify whether sensation is sharp or dull.

-Touch patient’s skin with test tubes filled with hot or cold water.-Apply stimuli randomly, and ask patient to identify whether sensation is hot or cold.

Normal: Identifies areas

stimulated and type of stimulation.

Abnormal:Diminished or absent pain perception: - Peripheral nerve damage or damage to lateral spinothalamic tract.■ Hyperalgia:

Increased pain sensation.■ Hypoalgesia:

Decreased pain sensation.■ Analgesia: No pain sensation.■ Diminished/absent temperature perception: - Peripheral nerve damage or damage to lateral spinothalamic tract

3. Vibration-Place a vibrating tuning fork over a finger joint, and then over a toe joint.-Ask patient to tell you when vibration is felt and when it stops.- If patient is unable to detect vibration, test proximal areas as well.

Normal: Vibratory

sensation intact bilaterally in upper and lower extremities.

Abnormal:Diminished/absent vibration sense: - Peripheral nerve damage caused by alcoholism, diabetes, or damage to posterior column of spinal cord.

4. Kinesthetics (Position Sense)-Determine patient’s ability to perceive passive movement of extremities. - Hold fingers on sides and move up and down, and have patient identify direction of movement.-Flex and extend patient’s big toe, and ask patient to describe movement as up or down.

• Avoid moving the patient’s finger by placing your finger on top of the patient’s because thepatient may sense the pressure of your finger rather than a true position change.• If position sensation is intact distally, it is intactproximally.

Normal: Position sensation

intact bilaterally in upper and lower extremities.

Abnormal:■ Diminished or absent position sense: - Peripheral nerve damage or damage to posterior column of spinal cord.

5. StereognosisWith patient’s eyes closed, place a familiar object, such as a coin or a button, in patient’s hand, and ask patient to identify it.■ Test both hands using different objects.

Normal: Stereognosis

intact bilaterally.

Abnormal:■ Abnormal findings suggest a lesion or other disorder involving sensory cortex or a disorder affecting posteriorcolumn.

6. Graphesthesia- With patient’s eyes closed, use point of a closedpen to trace a number on patient’s hand- Ask patient to identify the number.

Normal: Graphesthesia

intact bilaterally.

Abnormal:■ Abnormal findings suggest lesion or other disorder involving sensory cortex or disorder affecting posteriorcolumn.

7. Two-Point DiscriminationAbility to differentiate between two points ofsimultaneous stimulation.

- Using ends of two toothpicks/ paper clip, stimulate two points on fingertips simultaneously.

- Gradually move toothpicks together, and assess

smallest distance at which patient can still discriminate two points (minimal perceptible distance).

- Document distance and location.

Normal: Discriminates

between two points on fingertips no

more than 0.5 cm apart and on hands no more than 2 cm apart.

Abnormal:■ Abnormal findings suggest lesion or other disorder involving sensory cortex or disorder affecting posteriorcolumn.

8. Point Localization■ Ability to sense and locate area being stimulated.■ With patient’s eyes closed, touch an area; then havepatient point to where he or she was touched.■ Test both sides and upper and lower extremities.Normal:

Point localization intact.

Abnormal:Abnormal findings suggest lesion or other disorder involving sensory cortex or disorder affecting posterior column.

9. Sensory Extinction■ Simultaneously touch both sides of patient’s bodyat same point.■ Ask patient to point to where she or he wastouched.

Normal: Extinction intact.

Abnormal:Identification of stimulus on only one side suggests lesion or other disorder involving sensory cortical region in opposite hemisphere.

REFLEXESDocumenting Reflex Findings

• Use these grading scales to rate the strength of each reflex in a deep tendon and superficial reflex assessment.

Deep tendon reflex grades0 absent+ present but diminished+ + normal+ + + increased but not necessarily pathologic+ + + + hyperactive or clonic (involuntary contractionand relaxation of skeletal muscle)

Deep tendon reflex grades0 absent+ present but diminished+ + normal+ + + increased but not necessarily pathologic+ + + + hyperactive or clonic (involuntary contractionand relaxation of skeletal muscle)

Superficial reflex grades0 absent+ present

Superficial reflex grades0 absent+ present

• Documentation of reflex finding

ASSESSING REFLEXES1. Deep Tendon Reflexes

a. Biceps Reflex■ Rest patient’s elbow in your nondominant hand,with your thumb over biceps tendon.■ Strike your thumbnail.

Normal:■ Contraction of biceps with flexion of forearm.■ +2

b. Triceps Reflex■ Abduct patient’s arm and flex it at the elbow.■ Support the arm with your nondominant hand.■ Strike triceps tendon about 1 to 2 inches above

olecranon process, approaching it from directly behind.

Normal:■ Contraction of triceps with extension at elbow.■ +2

c. Patellar Reflex■ Have patient sit with legs dangling.■ Strike tendon directly below patella..

Normal:■ Contraction of quadriceps with extension of

knee.■ + 2

d. Achilles Reflex■ Have patient lie supine or sit with one knee

flexed.■ Holding patient’s foot slightly dorsiflexed,

strike Achilles tendon.

Normal:■ Plantar flexion of foot.■ + 2

e. Test for Ankle Clonus■ If you get 4 reflexes while supporting leg and foot, quickly dorsiflex foot.

Normal:■ No contraction

Abnormal:■ Absent/diminished DTRs: - Degenerative disease; damage to peripheral nerve such as peripheral neuropathy; lower motor neuron disorder, such as ALS and Guillain-Barré syndrome.■ Hyperactive reflexes with clonus: - Spinal cord injuries, upper motor neuron disease such as MS.■ Rhythmic contraction of leg muscles and foot is positive sign of clonus

- indicates upper motor neuron disorder.

2. Superficial Reflexes

a. Abdominal Reflex■ Stroke patient’s abdomen diagonally from upper and lower quadrants toward umbilicus.■ Contraction of rectus abdominis. Umbilicus moves toward stimulus.

a. Abdominal Reflex■ Gently stroke skin around anus with gloved finger.

Normal:■ Anus puckers.

b. Cremasteric Reflex■ Gently stroke inner aspect of a male’s thigh.

Normal:■ Testes rise.

c. Bulbocavernosus Reflex■ Gently apply pressure over bulbocavernous muscle on dorsal side of penis.

Normal:■ Bulbocavernosus muscle contracts.

d. Plantar Reflex (Babinski’s Response)■ Stroke sole of patient’s foot in an arc from lateral heel to medial ball.

Normal:■ Flexion of all toes.

.

Assessing the Cerebellar Function1. Balance tests

a. GaitObserve as the person walks 10-20 feet, turns, and returns to the starting point.

Normal: Person moves with a

sense of freedom. Gait is smooth,

rhythmic, and effortless

Opposing arm swing is coordinated

The turns are smooth

Abnormal:Stiff, immobile posture. Staggering or reeling. Wide base of supportLack of arm swing or rigid armsUnequal rhythm of steps. Slapping of foot. Scraping of toe of shoeAtaxia – uncoordinated or unsteady gait.

Perform Tandem Walking

- ask the person to walk a straight line in a heel-to-toe fashion.

This decreases the base of support and will accentuate any problem with coordination.

Normal: Person can walk

straight and stay balanced

Abnormal:Crooked line walkWidens base to maintain balanceStaggering, reeling, loss of balanceAn ataxia that did not appear now. Inability to tandem walk is sensitive for an upper motor neuron lesion, such as multiple sclerosis.

b. The Romberg Test (discussed previously)

• Ask the person to perform a shallow knee bend or hop in place, first on one leg, then the other.- this demonstrates normal position sense, muscle strength, and cerebellar function.(some individuals cannot hop owing to aging or obesity)

Normal: Negative Romberg

test

Abnormal:Sways, falls, widens base of feet to avoid fallingPositive Romberg sign

-Loss of balance that occurs when closing the eyes.-Occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication)-Loss of proprioception, and loss of vestibular function

2. Coordination and Skilled Movementsa. Rapid Alternating Movements (RAM)

Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the knees with the backs of the hands.Then ask to do this faster.

Normal: done with equal

turning and quick rhythmic pace

Abnormal:Lack of coordinationDysdiadochokinesia

- Slow, clumsy, and sloppy response - occurs with cerebellar

disease

b. Finger-to-Finger testWith the persons eyes open, ask that he or she use index finger to touch your finger, then his or her own nose.After a few times move your finger to a different spot.

Normal: Movement is

smooth and accurate

Abnormal:Dysmetria

- clumsy movement with overshooting the mark

- occurs with cerebellar disorderPast-pointing

- constant deviation to one side

c. Finger-to-nose testAsk the person to close the eyes and to stretch out the arms.Ask the person to touch the tip of his or her nose with each index finger, alternating hands and increasing speed.

Normal: Done with accurate

and smooth movement

Abnormal:Misses nose.Worsening of coordination when the eyes are closed

- occurs with cerebellar disease

sources• Dillon, Patricia. Nursing Health Assessment. 2nd

Ed. F.A. Davis. 2007

• Jarvis, Carolyn. Physical Examination and Health Assessment. 3rd ed. New York: W.B. Saunder Company.2000

• Bickley. Lyn and Hoekenan, Robert. Bate’s Guide to Physical Examination and History Taking. 7th ed. New York: Lippincott Williams and Wilkins. 1999

• Estes, Mary Ellen Zator. Health Assessment & Physical Examination. 3rd ed. Delmar Learning. 2006

THANK YOU!!!