neurologic assesment

Neurologic Assessment

Maria Carmela L. Domocmat, RN, MSN

Instructor, Nursing Health Assessment

School of Nursing

Northern Luzon Adventist College

Nervous System Anatomy: Review

6/26/2011

http://sciencecity.oupchina.com.hk/biology/student/glossary/img/peripheral_nervous_system.jpg

6/26/2011

� The right cerebral hemisphere controls movement of the left side of the body.

6/26/2011

� The cerebellum processes input from other areas of the brain, spinal cord and sensory receptors to provide precise timing for coordinated, smooth movements of the skeletal muscular system. A stroke affecting the cerebellum may cause dizziness, nausea, balance and coordination problems.

6/26/2011

9http://health.allrefer.com/pictures-images/cerebellum-function.html

6/26/2011

Neurologic Assessment:

OVERVIEW

Neurologic System Assessment

�Organized into 5 major areas:

1. Mental Status

2. Cranial Nerves2. Cranial Nerves

3. Sensory System

4. Motor System & Cerebellar

5. Reflexes

6/26/2011 13

Mental Status and Level of

Consciousness

�Observe the following:

• LOC

• posture and body movements

• dress, grooming and hygiene • dress, grooming and hygiene

• facial expression

• speech

• mood, feelings, and expressions

• thought processes and perceptions

• cognitive abilities 6/26/2011 14

Cranial Nerves

• I (olfactory)

• II (optic)

• III (oculomotor), IV (trochlear), VI (abducens)

• V (trigeminal)• V (trigeminal)

• VII (facial)

• VIII acoustic/vestibulocochlear)

• IX (glossopharyngeal), X (vagus)

• XI (spinal accessory)

• XII (hypoglossal) 6/26/2011 15

Motor and cerebellar systems

�assess condition and movement of muscles

�evaluate balance

�assess coordination

6/26/2011 16

Sensory Systems

• assess light touch, pain, and temperature

sensations

• test vibratory sensations

• sensitivity to position • sensitivity to position

• tactile discrimination (fine touch)

6/26/2011 17

Reflexes

• deep tendon

reflexes

o biceps

o brachioradialis

• superficial

reflexes

o plantar o brachioradialis

o triceps

o patellar

• Achilles

o plantar

o abdominal reflex

o cremasteric

reflex

6/26/2011 18

Tests for meningeal irritation or

inflammation

• Neck mobility

• Brudzinski’s sign

• Kernig’s sign

6/26/2011 19

MENTAL STATUS AND

LEVEL OF

CONSCIOUSNESS6/26/2011

Observe the following

• LOC

• posture and body movements

• dress, grooming and hygiene

• facial expression • facial expression

• speech

• mood, feelings, and expressions

• thought processes and perceptions

• cognitive abilities

6/26/2011

• Decorticate posture is

an abnormal posturing that

involves

• rigidity, flexion of the arms,

• clenched fists,

• Decerebrate posture is an

abnormal body posture that

involves

• arms and legs being held

straight out, • clenched fists,

• extended legs (held out

straight).

• arms are bent inward toward

the body

• wrists and fingers bent and

held on the chest.

straight out,

• toes being pointed

downward,

• head and neck being arched

backwards.

• muscles are tightened and

held rigidly.

6/26/2011

24http://www.nlm.nih.gov/medlineplus/ency/article/003300.htm

6/26/2011

25http://drugster.info/img/ail/938_943_1.png

6/26/2011

26http://loyaldavis.com/images/dec_1.jpg

For children under 5, the verbal response

criteria are adjusted as follow

SCORE 2 to 5 YRS 0 TO 23 Mos.

5 Appropriate words or phrases Smiles or coos appropriately

4 Inappropriate words Cries and consolable

3 Persistent cries and/or screamsPersistent inappropriate crying &/or screaming

2 Grunts Grunts or is agitated or restless

1 No response No response

6/26/2011

http://www.unc.edu/~rowlett/units/scales/glasgow.htm

CRANIAL NERVES

6/26/2011 28

I (olfactory)

o abnormal finding: � inability to smell : neurogenic anosmia, olfactory

tract lesion, tumor or lesion of frontal lobe� loss of smell: congenital, nasal dse, smoking, use � loss of smell: congenital, nasal dse, smoking, use

of cocaine

6/26/2011 29

CN II (optic)

o visual acuity – both far and near o confrontation test o asses retina using ophthalmoscope o OD – R eye; OS – L eye; OU - both eyes o OD – R eye; OS – L eye; OU - both eyes

6/26/2011 30

CN II (optic)

o normal finding: � round red reflex� optic disc – 1.5 mm; round or slightly oval; well-

defined margins,creamypink defined margins,creamypink � paler physiologic cup� retina – pink

6/26/2011 31

CN II (optic)

o abnormal finding: � blurred optic disc margins; dilated, pulsating veins

- Papilledema (swelling of optic nerve) – due to increased ICP from tumor or hemorrhageincreased ICP from tumor or hemorrhage

� optic atrophy – brain tumors

6/26/2011 32

III (oculomotor), IV (trochlear), VI (abducens)

o (a) inspect margin of eyelidso (b) extraocular muscles o (c) pupillary response to light

6/26/2011 33

CN III, IV, VI

o normal finding: � (a) eyelid covers abt 2 mm of iris � (b) eyes move smooth, coordinated motion in all

directions directions � (c) bilateral constriction

6/26/2011 34

CN III, IV, VI

o abnormal finding: � (a) ptosis (drooping of eyelids) – myasthenia

gravis � (b) abnormal eye movements� (b) abnormal eye movements

• nystagmus (rhythmic oscillation of the eyes) -cerebellar disorder

• limited eye movement – increased ICP• paralytic strabismus – paralysis of oculomotor, trochlear

or abducens nerves

6/26/2011 35

Nystagmus video

6/26/2011 Maria Carmela L. Domocmat, RN, MSN 36

CN III, IV, VI

� (c) dilated pupil (6-7 mm) – oculomotor nerve paralysis

� Argyll Robertson pupils – CNS syphilis, meningitis, brain tumor, alcoholism meningitis, brain tumor, alcoholism

6/26/2011 37

Argyll Robertson pupils

6/26/2011 38

CN III, IV, VI

� constricted, fixed pupils – narcotics abuse, damage to pons

� unilaterally dilated pupil unresponsive to light or accommodation – damage to CN IIIaccommodation – damage to CN III

� constricted pupil unresponsive to light or accommodation – lesions of the SNS (sympathetic nervous sys)

6/26/2011 39

CN V (trigeminal)

omotor function o sensory function :

6/26/2011 40

CN V (trigeminal)

omotor function � temporal and master muscles contraction � (Note: may be difficult to perform and evaluate

in client without teeth)in client without teeth)

6/26/2011 41

CN V (trigeminal)

o sensory function : � sharp or dull sensation and light touch on

forehead, chin and cheeks • safety pin, paper clip, or cut tongue depressor; wisp • safety pin, paper clip, or cut tongue depressor; wisp

of cotton

� corneal reflex (blinking reflex) � (Note: may be absent or reduced in clients who

wear contact lenses)

6/26/2011 42

Corneal refle

6/26/2011

o normal finding: � temporal and masseter muscles contract bilaterally � correctly identifies sharp or dull, light touch

6/26/2011 44

o abnormal finding: � inability to identify – lesions in trigeminal nerve,

lesions in spinothalamic tract or posterior columns � absent corneal reflex – lesions of CN V, lesions of � absent corneal reflex – lesions of CN V, lesions of

motor part of CN VII

6/26/2011 45

CN VII (facial)

o motor function

o sensory function

6/26/2011

CN VII (facial)

o motor function

� smile, frown, wrinkle forehead, show teeth, puff out

cheeks, purse lips, raise eyebrows, close eyes tightly

against resistance against resistance

6/26/2011

CN VII (facial)

o sensory function

� taste test – anterior 2/3 of tongue – salt, sugar, or

lemon juice

6/26/2011

CN VII

o abnormal finding:

� inability to close eyes, wrinkle forehead, or raise

forehead along with paralysis of lower part of face

on affected side – Bell’s palsy (peripheral injury to on affected side – Bell’s palsy (peripheral injury to

CN VII)

� paralysis of lower part of face on opposite side

affected - central lesions that affects the upper

motor neurons ex: CVA

6/26/2011

Bell’s palsy

CN VIII acoustic/vestibulocochlear)

o hearing: acoustic/ cochlear

� Whisper, Weber, Rinne tests

�balance: vestibular

6/26/2011

CN VIII

o abnormal finding:

� vibratory sound lateralizes to good ear –

sensorineural loss

� AC is greater than BC but not twice as long � AC is greater than BC but not twice as long

6/26/2011

CN IX (glossopharyngeal),

CN X (Vagus)

�uvula and soft palate

�gag reflex

�ability to swallow ability to swallow

6/26/2011

CN IX & X

o abnormal finding:

� soft palate does not rise – bilateral lesion of CN X

� unilateral rising of soft palate, deviation of uvula to

normal side –unilateral lesion CN Xnormal side –unilateral lesion CN X

� dysphagia or hoarseness – lesion CN IX or X

6/26/2011

CN XI (spinal accessory)

o trapezius muscle - shrug shoulders against

resistance

o sternocleidomuscle – turn head against

resistance resistance

6/26/2011

o abnormal finding:

� asymmetric, drooping of shoulders – paralysis or

muscle weakness due to neck injury or torticollis

� atrophy with fasciculations – peripheral nerve dse� atrophy with fasciculations – peripheral nerve dse

6/26/2011

Torticollis

6/26/2011

Atrophy with fasciculations

6/26/2011

CN XII (hypoglossal)

o strength and mobility tongue

o protrude tongue, move to side against resistance,

put back in mouth

6/26/2011

CN XII

o normal finding: symmetric and smooth, bilateral

strength

o abnormal finding:

� atrophy with fasciculations – peripheral nerve dse� atrophy with fasciculations – peripheral nerve dse

� deviation to affected side – unilateral lesion

6/26/2011

MOTOR AND

CEREBELLAR SYSTEMS

6/26/2011

Condition and movement of muscles

o size and symmetry muscle grps

o strength and tone

o note unusual involuntary movement (i.e,

fasciculations, tics, tremors)fasciculations, tics, tremors)

6/26/2011 62

o normal finding

� muscles- fully developed

� symmetric size (bilateral sides may vary 1 cm from

each other)

� relaxed muscles contract voluntarily; show mild, � relaxed muscles contract voluntarily; show mild,

smooth resistance to passive movement

� equally strong against resistance, without flaccidity,

spasticity, rigidity

� no fasciculations, tics, tremors

� elderly –hand tremor or dyskinesia (repetitive

movements of lips, jaw, tongue)6/26/2011 63

o abnormal finding

� muscle atrophy – dses of lower motor neurons or

muscle disorders

� soft, limp, flaccid muscles

� fasciculations - muscle twitching� fasciculations - muscle twitching

� tics – twitch of face, head or shoulders – stress,

neurologic disorder

� tremors – rhythmic, oscillating movements –

Parkinson’s dse, cerebellar dse, multiple sclerosis (with

movement), hyperthyroidism, anxiety

6/26/2011 64

Fasciculations

Tremors

o abnormal finding

� unusual bizarre face, tongue, jaw, lip

movements – chronic psychosis, long term

use of psychotropic drugs use of psychotropic drugs

� slow, twisting movements in extremities and

face – cerebral palsy

� brief, rapid, irregular, jerky movements (at

rest) - Huntington’s chorea

6/26/2011 68

Balance, Gait

o walk normally

o tandem walk – heel-to-toe walk

o romberg test

o hop with one foot o hop with one foot

o elderly – may be difficult to perform

6/26/2011 69

o normal finding:

� steady gait, opposite arms swing

� maintains balance with little difficulty

� elderly – may be very difficult � elderly – may be very difficult

� (-) Romberg test - erect with minimal swaying

� hops without losing balance

6/26/2011 70

o abnormal finding

� (+) Romberg test – swaying, moving feet apart to

prevent fall – dse of posterior columns, vestibular

dysfunction, cerebellar disorders dysfunction, cerebellar disorders

6/26/2011 71

Coordination

�Point-to-point

�Rapid Alternating Movements (RAM)

6/26/2011 72

o Point-to-point

� finger-to-nose test

� Finger- nose- to-finger

� heel-to-shin test � heel-to-shin test

� Note: dominant side may be more coordinated than

nondominant side

6/26/2011 73

6/26/2011

http://cloud.med.nyu.edu/modules/pub/neurosurgery/coordination.html

Rapid Alternating Movements

� Thumb to Fingers

� Hands on Lap

6/26/2011 77

6/26/2011

Rapid Alternating Movements

� normal finding:

• elderly – may be difficult – bcoz decreased reaction

time and flexibility

� abnormal finding: � abnormal finding: • inability to perform – cerebellar dse, upper motor neuron

weakness, extrapyramidal dse

• dysdiadochokinesia -

6/26/2011 79

�Dysdiadochokinesia

�impairment of the ability to make movements

exhibiting a rapid change of motion that is caused by

cerebellar dysfunctioncerebellar dysfunction

6/26/2011 80

SENSORY SYSTEM

6/26/2011

�Light Touch, Pain, and Temperature Sensations

�Vibratory sensations

�Proprioception (sensitivity to position)

�Tactile discrimination (fine touch)�Tactile discrimination (fine touch)

6/26/2011 82

Light Touch, Pain, and Temperature

Sensations�scatter stimuli – distal and proximal parts of all

extremities and trunk to cover most of dermatomes

6/26/2011 83

Dermatomes

6/26/2011 84

o abnormal finding

� anesthesia – absence of touch sensation

� hypesthesia – decreased sensitivity to touch

� hyperesthesia –increased sensitivity to touch

� analgesia – absence of pain sensation � analgesia – absence of pain sensation

� hypalgesia – decreased sensitivity to pain

� hyperalgesia – increased sensitivity to pain

6/26/2011 87

• Vibratory sensations

o tuning fork – bony surface fingers or big toe

o usually decreased by 70

6/26/2011 88

• Proprioception (sensitivity to position)

oNote: if position sense is intact distally, then it is

intact proximally

o normal findingo normal finding

� some – sense position of great toe may be reduced

o abnormal finding

� inability to identify directions – posterior column dse,

peripheral neuropathy (e.g., diabetes, chronic alcohol

abuse)

6/26/2011 89

Tactile discrimination (fine touch)

�Tests for lesions of the sensory cortex

�Stereognosis

�Point Locations

�Graphestesia �Graphestesia

�Two-Point Discrimination

�Extinction

6/26/2011 90

http://cloud.med.nyu.edu/modules/pub/neurosurgery/sensory.html

REFLEXES

6/26/2011

Deep tendon reflexes

o biceps

o brachioradialis

o triceps

o patellar o patellar

6/26/2011 94

Biceps reflex

�elicited by placing your thumb on the biceps tendon and striking your thumb with the reflex hammer and observing the arm movement.

�Repeat and compare with the other arm. �Repeat and compare with the other arm.

6/26/2011

Briceps reflex

6/26/2011

Brachioradialis reflex

�striking the brachioradialis tendon directly with the hammer when the patient's arm is resting.

�Strike the tendon roughly 3 inches above �Strike the tendon roughly 3 inches above the wrist.

�Note the reflex supination. Repeat and compare to the other arm.

�The biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve roots.

6/26/2011

Brachioradialis reflex

6/26/2011

http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig6.jpg

Triceps reflex

�strike the triceps tendon directly with the hammer while holding the patient's arm with your other hand.

�Repeat and compare to the other arm�Repeat and compare to the other arm

�.The triceps reflex is mediated by the C6 and C7 nerve roots, predominantly by C7.

6/26/2011

Triceps reflex

6/26/2011

Patellar reflex

� With the lower leg hanging freely off the edge of the bench, the knee jerk is tested by striking the quadriceps tendon directly with the reflex hammer. Repeat and compare to the other leg.The knee jerk reflex is mediated by the L3 and L4 nerve roots, mainly L4.Insult to the cerebellum may lead to pendular reflexes. Pendular reflexes are not brisk but involve less damping of the limb movement than is usually not brisk but involve less damping of the limb movement than is usually observed when a deep tendon reflex is elicited. Patients with cerebellar injury may have a knee jerk that swings forwards and backwards several times. A normal or brisk knee jerk would have little more than one swing forward and one back. Pendular reflexes are best observed when the patient's lower legs are allowed to hang and swing freelly off the end of an examining table.

6/26/2011

Patellar reflex

http://cloud.med.nyu.edu/modules/pub/neurosurgery/reflexes.html

http://www.brown.edu/Courses/Bio_160/Projects2000/Polio/Reflexcopy.jpg

Ankle reflex

�elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion. Compare to the other foot.The ankle jerk reflex is mediated the other foot.The ankle jerk reflex is mediated by the S1 nerve root.

6/26/2011

Plantar or Achilles

6/26/2011 104

http://www.beltina.org/pics/achilles_tendon.jpg

Rate the reflex with the following scale:

5+ Sustained clonus

4+ Very brisk, hyperreflexive, with clonus

3+ Brisker or more reflexive than normally.

6/26/2011

2+ Normal

1+ Low normal, diminished

0.5+ A reflex that is only elicited with reinforcement

0 No response

6/26/2011

http://www.wrongdiagnosis.com/bookimages/8/2546.png

deep tendon reflexes are graded as follows:0 = no response; always abnormal1+ = a slight but definitely present response; may or may not be normal

6/26/2011

2+ = a brisk response; normal3+ = a very brisk response; may or may not be normal4+ = a tap elicits a repeating reflex (clonus); always abnormal

Superficial reflexes

o Plantar reflex

o Abdominal reflex

o Cremasteric reflex

6/26/2011 108

Plantar reflex

�The plantar reflex (Babinski) is tested by coarsely running a key or the end of the reflex hammer up the lateral aspect of the foot from heel to big toe.

6/26/2011 109

�Normal finding : toe flexion.

�Abnormal finding:

�(+) Babinski's sign - toes extend and separate

� indicative of an upper motor neuron lesion affecting

the lower extremity in question.

Plantar reflex

6/26/2011 110

Abdominal reflex

6/26/2011 111

Abdominal reflex

6/26/2011 112

Cremasteric reflex

6/26/2011

Cremasteric reflex

6/26/2011

Other tests

Hoffman response

� elicited by holding the patient's middle finger between the

examiner's thumb and index finger.

� Ask the patient to relax their fingers completely. Once the

patient is relaxed, using your thumbnail press down on the

patient's fingernail and move downward until your nail "clicks" patient's fingernail and move downward until your nail "clicks"

over the end of the patient's nail.

� Repeat this maneuver multiple times on both hands.

� Normal finding: nothing occurs.

� Abnormal finding:

� (+) Hoffman's response - other fingers flex transiently after the "click".

� indicative of an upper motor neuron lesion affecting the upper extremity in question.

6/26/2011 116

Hoffman response

6/26/2011 117

� Hoffmann's sign, which is elicited by flicking the distal phalanx of the long finger.

� A negative response, as shown here, is no motion of the thumb.

� A positive response is flexion of the thumb at the interphalangeal joint.

6/26/2011

http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig6.jpg

Test of Clonus

�Test clonus if any of the reflexes appeared hyperactive. Hold the relaxed lower leg in your hand, and sharply dorsiflex the foot and hold it dorsiflexed. Feel for oscillations between flexion

6/26/2011 119

dorsiflexed. Feel for oscillations between flexion and extension of the foot indicating clonus. Normally nothing is felt.

Tonus video

6/26/2011

6/26/2011 121

neurologic assesment

Health & Medicine

Transcript of neurologic assesment

UBI - Neurologic Rehabiliation - Florida Institute for Neurologic

Neurologic Nursing

Neurologic examination

Pediatric neurologic

Neurologic Emergencies

Internet assesment

Neurologic Trauma

Neurologic Evaluation

Postoperative Neurologic Dysfunction Across the Lifespan · postoperative neurologic complications. Describe the pathophysiology related to various forms of postoperative neurologic

Neurologic Trauma.pptx

04 Neurologic

Neurologic Syndromes

NEUROLOGIC INVESTIGATIONS

Neuro-immunology AKA Neurologic manifestations of ... · Neurologic manifestations of autoimmune diseases ... • SPEP/UPEP * ... Neuro-immunology AKA Neurologic manifestations of

Risk assesment

Neurologic Assessment

Procedures assesment

Neurologic Studies

Neurologic Function

Assesment procedures