assessment of the nervous system_final (1) (1)
TRANSCRIPT
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A S S E S S M E N T O F T H EN E R V O U S S YS T E M
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OBJECTIVES After completion of this session the students should be able
: To learn a basic Nervous System Examination
To differentiate between normal and abnormal responsesrelated to the neurologic system
To apply findings to common clinical presentations
To document findings in a structured, systematic way
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Outlines Introduction
Review of anatomy and physiology
Nursing assessment
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Introduction The nervous system consists of the central
nervous system (CNS), the peripheral nervoussystem, and the autonomic nervous system.
Together these three components integrate allphysical, emotional, and intellectual activities.
The CNS includes the brain and spinal cord. These two structures collect and interpret
voluntary and involuntary sensory and motorsignals.
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Introduction The peripheral nervous system consists of the
12 pairs of cranial nerves and peripheralnerves. Most peripheral nerves contain both
motor and sensory fibers.
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Purposes of Neurologic
Assessment To collect baseline data to aid in establishing the
etiology, diagnosis and prognosis To evaluate the present state of psychological
functioning to evaluate changes in individuals emotional,
intellectual, motor, and perceptual responses To determine the guidelines of treatment plan To ascertain if some seemingly psychopathological
response, is in fact a disorder of the sensory organ(i.e., a deaf person appearing hostile)
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Three important questions govern
the neurologic examination:1) Is the metal status intact?
2) Are right-sided and left-sided findingssymmetric?
3) If the findings are asymmetric or otherwiseabnormal, does the causative lesion lie in theCNS or the peripheral nervous system?
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Components of a Neurologic
Assessment1.INTERVIEW
The patient/family interview will allow the nurse to:
gather data: both subjective and objective about the patient's
previous/present health state provide information to patient/family
clarify information
make appropriate referrals
develop a good working relationship with both the patient and
the family
initiate the development of a written plan of care which is
patient specific
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Components of a Neurological
Assessment1.Mental Status
2.Cerebellar Functions
3.Cranial Nerve Testing4.Sensory
5.Motor Function
6.Reflexes
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ToolsThe following tools will be used during
the neurological exam:Gloves
Reflex hammer (tomahawk
model)
Penlight
Tongue blade
Safety pin
Cotton swab
Ophthalmoscope
Eye chart
Tuning fork
Coffee
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I. The Mental Status
Appearance and behavior Speech and Language Moods and Thought perception Cognitive Functions
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General appearance, manner
and attitude A simple means of gathering a great deal of
information about the patient's neurological
system is to observe the patient walking,talking, seeing, and hearing. Watching thepatient enter the room is also important ingiving the examinerinformation.
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As the patient enters the room, check the following:
Posture and motor behavior, purposeful movements
and gestures
Dress, grooming, and personal hygiene.
Facial expression.
Speech manner, mood, and relation to persons and
things around him
General appearance, manner
and attitude
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L e v e l o f c o n s c i o u s n e s sThe single most valuable indicator of neurological function is
the individual's level of consciousness. You can legally describe the patient's condition in the nursing
notes by saying, "appears to be" alert or lethargic or so forth. Alert. The patient is awake and verbally and motorally
responsive. Confused. The patient may de disoriented to time, place and
person and has poor judgment and may not think clearly.
Lethargic. The patient is sleepy or drowsy and will awakenand respond appropriately to command.
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Obtundation. The patient is difficult to arouse and needs
constant stimulation to follow commands. He may respondwith a few words but will drift back to sleep when the
stimulus is removed Stupor. The patient becomes unconscious spontaneously
and is very hard to awaken. Semi coma. The patient is not awake but will respond
purposefully to deep pain. Coma. The patient is completely unresponsive.
***Consciousness is the most sensitive indicator of
neurological change**
L e v e l o f c o n s c i o u s n e s s
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Assessment of UnconsciousClient
GLASGOW COMA SCALE useful for
monitoring changes during the firstfew
days after acute injury or inunstable
comatose clients.
SCALE is divided into three (3) subscales
Eye Opening
Verbal Response
Motor Response
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GLASGOW COMA SCALE
Best Eye ResponseSpontaneously4
On command3
To Pain2
No response1
Best Verbal ResponseAlert & Oriented5Confused4
Inappropriate3
Incomprehensive2
No Response1
Best Motor Response
Follows Direction6
Localizes Pain5Withdraws from Pain4
Abnormal Flexions3
Abnormal Extensions2
NO Response1
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EYE OPENING (Max score 4) 4 Spontaneous eye opening. 3 Eye opening in response to speech - that is, any
speech or shout. 2 Eye opening in response to pain. 1 No eye opening. TOTAL SCORE ...... / 15 RECORD YOUR FINDINGS
You may record you findings on a specific CNS chart.
Otherwise record in the following fashion:
The Glasgow coma scale (GCS)
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ASSESS GRADES OF BEST VERBAL RESPONSE (Maxscore 5)
5 Oriented - patient knows who & where they are, and why,and the year, season & month.
4 Confused conversation - patient responds inconversational manner, with some disorientation andconfusion.
3 Inappropriate speech - random or exclamatory speech, noconversational exchange.
2 Incomprehensible speech - no words uttered, only
moaning. 1 No verbal response.
The Glasgow coma scale (GCS)
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The Glasgow coma scale (GCS)
ASSESS GRADES OF BEST MOTOR RESPONSE(Max score 6)
6 Carrying out request ('obeying command')
5 Localizing response to pain. 4 Withdrawal to pain - pulls limb away from painful
stimulus. 3 Flexor response to pain - pressure on nail bed
causes abnormal flexion of limbs 2 Extensor posturing to pain - stimulus causes limbextension
1 No response to pain.
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Speech and Language
Note the quality, rate, loudness, clarity, and
fluency of speech. If indicated, test for
aphasia
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TESTING FOR APHASIATEST FINDINGS
Word Comprehension Ask client to follow a one-stagecommand, such as Point to yournose. Try a two-stage command:
Point to your mount thenyour knee
Repetition Ask client to repeat a phrase of onesyllabus words ( the most difficultrepetition task)
NOTE: No ifs, ands or buts.Naming Ask client to name he parts of the
watch.
Reading comprehension
Writing
Asks client to read a paragraphaloud.
Ask client to write a sentence
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Thought and Perception
Assess coherency, logic and relevance-Where were you born?; What kind of work doyou do?
Ask about the patients spirits, if indicated,assess for suicide tendencies and depression.
Assess perception and reaction- How do youyourself now that you are in the hospital?
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Affect/Mood
During the physical part of the examination, note thepatient's mood and emotional expressions which you canobserve by his verbal and nonverbal behavior.
Notice if he has mood swings or behaves as though he isanxious or depressed.
Notice whether or not the patient's feelings areappropriate for the situation.
Disturbances in mood, affect, and feelings may be
indicated by a patient who exhibits unresponsiveness,hopelessness, agitation, euphoria, irritability, or widemood swings.
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Cognitive Functions
Assess reality orientation: time, place and
person- orderly progression of thoughts
based in reality.
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Cognitive Functions
Attention
Digit span-ability to repeat a series of
numbers forward and then backwardSpelling backward-five letter word such as
W-O-R-L-D
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Calculations in basic
mathematics
Serial 7s ability to subtract 7 repeatedly,
starting with 100
Ask the patient to do some simple arithmetic
problems without using paper and pencil. Forexample, ask him to add 7s or to subtract 3s
backwards.
It should take the patient of average intelligenceabout one minute to complete the calculations
with few errors.
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Memory (recent and remote(
Recent Memory(e.g. events of the day
Remote memory e.g., birthdays,
anniversaries, social security number,schools attended
New learning ability (recall) ability to
listen and respond with understanding orknowledge; ask the client to repeat a
phrase, or three of four words
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Higher Cognitive Functions
Knowledge (normal intellect(
Information and vocabulary
Calculating abilities
Abstract thinking
Constructional abilities
Ask the patient to name five large cities, major rivers, etc.Another way to test this area is to ask the patient to tell you the
meaning of proverb, or metaphor. For example, explain:
Too many cooks spoil the soup. A penny saved is a penny earned. A stitch in time saves nine
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II. The Cerebellar Functions These include tests for balance and coordination.
The cerebellum controls the skeletal muscles and
coordinates voluntary muscular movement.
Ask the patient to walk back and forth across theroom.
Observe for equality of arm swing , balance andrapidity and ease of turning.
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Cerebellar Functions1.Finger to finger test: have the patient touch
their index finger to your index finger (repeat
several times).
2.Finger to nose test: perform with eyes open
and then eyes closed.
3.Tandem walking: heel to toe on a straight line
4.Romberg test
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The Romberg Test
Instruct the patient to stand with his feettogether and his arms at his side.
Have the patient do this with his eyes openand then with his eyes closed. Stand closeto the patient to keep him upright if he startsto sway.(
Expect the patient to sway slightly but not fall.This is a test of balance.
If the patient begins to sway, have them opentheir eyes. If swaying continues, the test ispositive or suggestive of problem ofcerebellum
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Positioning
Usually tested only on the great toes butit can be tested on the fingers too.
Ask the patient to shut his eyes. Graspthe side of the toe between index fingerand thumb. This prevents movementfrom being felt as pressure up or down.
Move the digit up or down and ask thepatient to tell you the direction ofmovement
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Rapid alternating movements
test
Seat the patient. Instruct him to pat his knees
with his hands, palms down then palms up.
Have him alternate palms down and palms up
rapidly.
Watch the patient to notice if his movements
are stiff, slow, nonrhythmic, or jerky.
The movements should be smooth andrhythmic as he does the task faster.
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III. The Cranial NervesEvaluating the cranial nerves is an important
part of the neurological examination.
Taste and smell are usually not checkedunless a problem is suspected in thoseareas.
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Cranial Nerve I, TheOlfactory Nerve The olfactory nerve is not commonly tested during a
screening physical exam but can be performed if damagesecondary to trauma or intracranial mass is suspected.
Each nostril should first be evaluated for potency bycompressing one nostril and having the patient breaththrough the opposite.
Each nostril should then be tested separately with avolatile, non-irritating substance such as cloves, coffee orvanilla. The patient should close his eyes, occlude onenostril and identify the substance placed under the opennostril.
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Pupils:To examine cranial nerves II , III and mid-brain connectionsPUPILLARY ASSESSMENT
When assessing pupils (eyes) it is important to assess the
following:
size shape
reactivity to light
comparison of one pupil to the other
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Pupils: Reaction to LightTo examine cranial nerves II , III and mid-brain connections Have the patient look at a distant object Look at size, shape and symmetry ofpupils. Shine a light into each eye and observe constriction of pupil. Flash a light on one pupil and watch it contract briskly.
Flash the light again and watch the opposite pupil constrict(consensual reflex
Repeat this procedure on the opposite eye. Normal: Pupil size is 3-5 mm in diameter.
They react briskly to light. Both pupils constrict consensually.
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Pupils: SizeTo examine cranial nerves II , III and mid-brain connections
Pupils can be described according to their size (in mm) or by description:
Pinpoint: Seen with opiate overdose and pontine hemorrhage.
Small: Normal if the person is in a bright room.
May be seen with Horner's syndrome, pontine hemorrhage, ophthalmic drops,
metabolic coma etc.Midposition: Seen normally.
If pupils are midposition and nonreactive the cause is midbrain damage.
Large: Seen normally when the room is dark.
May be seen with some drugs and some orbital injuries.
Dilated: Always an abnormal finding.
Bilateral, fixed and dilated pupils are seen in the terminal stage of severe anoxia-
ischemia or at death.
Anti-cholinergic drugs can dilate pupils
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Vision: Visual AcuityTo examine cranial nerve II and ocularfunction Position yourself in front of the patient.
Test the patient's visual acuity, each eye separatelycoveringone at a time.
Snellen's chart is used by Ophthalmologists. Visual acuity isrecorded as a fraction. The numerator indicates the distance (infeet) from the chart which the subject can read the line.
The denominator indicates the distance at which a normal eye canread the line. Normal vision is 20/20.
A pocket screeneris used at the bedside. Hold the pocketscreenerat a distance of 12-14 inches. At this distance theletters are equivalent to those on Snellen's chart.
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Vision field By confrontation
Position yourself in front of the patient. The nose normally cuts off the medial field of vision. Hence, compare the patient's right eye to your left eye and vice
versa.
Instruct the patient to look straight at you and not to move their eyes. Compare your field of vision with the subject's. Bring your finger from the right field of vision until it is recognized. Test one quadrant at a time. Wiggle your fingers to see whether the patient can recognize the
movement. Some like to have the patient count fingers, i.e., 1, 2 or 5. Test all four quadrants in a similar fashion. When abnormality is detected , would require automated methods of
testing in the lab
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Extraocular MusclesTo examine cranial nerves III, IVand VI Inspect the eyes. Look for symmetry ofeyelids. Note the alignment of the eyes at rest. Ductions: Movement of one eye at a time
Versions: Both eye movement Have the patient follow an object into each of the nine
cardinal fields ofgaze. Note that both eyes move together into each field. Eye movements should be smooth and without jerking.
Eyelids should be gently lifted up by the examiner's fingerswhen testing downward gaze. Jerky, oscillatory eye movements (nystagmus) may be
abnormal, especially if sustained or asymmetrical.
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CN V: TrigeminalCorneal reflex: patient looks up and away.
Touch cotton wool to other side. Look for blink in both eyes, ask if can sense it.
Repeat other side [tests V sensory, VII motor].Facial sensation: sterile sharp item on forehead,
cheek, jaw. Repeat with dull object. Ask to report sharp or dull. If abnormal, then temperature [heated/ water-cooled
tuning fork], light touch [cotton].Motor: pt opens mouth, clenches teeth (pterygoids).
Palpate temporal, masseter muscles as they clench.
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Motor Function: FacialMusclesTo test cranial nerve VII Inspect the face. Look forasymmetry at rest,
during conversation and when testing variousmuscles.
Ask the patient to wrinkle his forehead or raisehis eyebrows, enabling you to test the upper face(frontalis)
Next, have the patient tightly close his eyes. Testthe strength of the orbicularis oculi by gentlytrying to pry open the patient's upper eyelid.
Instruct him to puff out both cheeks. Checktension by tapping his cheeks with your fingers.
Have the patient smile broadly and show histeeth, testing the lower face.
Normal: No facial asymmetry.
Wrinkling of the forehead and smiling are equaland symmetrical
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CNVIII: Hearing
With eyes closed, the patient should be instructed toacknowledge hearing the gentle rubbing of the examiner'sfingers approximately 3-4 inches away from his right andleft ear.
A watch, which the examiner can hear at a specificdistance from his ear, is placed next to the patient's ear.Ask him to note when the watch sound disappears. Notethat the examiner has to have normal hearing to do thisexam (in at least one ear(
Normal: In a quiet room, the patient should be able to hear the
physician's fingers rubbed lightly together 3-4 inches fromhis ear.
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CN IX and X
These tests will evaluatecertain structures in themouth.
The nurse ask the patient to
say "aah" and can detectabnormal positioning ofcertain structures such as thepalatel-uvula.
The examiner will also assess
the sensation capabilities ofthe pharynx, by stimulatingthe area with a wooden tonguedepressor, causing a gagreflex.
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CNXI
Inspect Trapezius andSternocleidomastoid muscles
Note muscle size (bulk). Look forasymmetry, atrophy and
fasciculation. Determine muscle powerby gently trying
to overpower contraction of each group ofmuscles.
Have patient shrug shoulder againstresistance and evaluate strength ofTrapezius muscle.
Have patient turn head to one side againstresistance and evaluate strength andobserve contracting sternomastoid muscle
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CNXII
This nerve tests the bulk
and power of the tongue.
The examiner looks fortongue protrusion and/or
abnormal movements
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IV. Sensory Function Testing for sensory function is the most difficult and
the least reliable part of the examination. Perform twotests.
(1) Test for pain. Perform this test using pin pricks in the
arms and legs. Ask the patient to say "sharp" or "dull"after each stimulus and to reply immediately.
This is a test of the patient's response to superficial pain.Usually, a sterile needle with a sharp point and dull hubon the other end is the instrument used. In a
nonpredictable pattern, touch the patient's skin with oneor the other end of the needle.
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Test for touch
Touch the skin with a cotton ball using light
strokes. Do not press down on the skin or
touch areas of the skin that have hair. Instructthe patient to point to the area you have
touched or tell you when he feels the
sensation of being touched. (Obviously, he will
not be watching you touch his skin.(
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Te s t f o r Te m p e r a tu r e Testing for temperature sensation is often
overlooked but it can be important. Tubes of hot and cold water may be used but
an easier and more practical approach is oftento touch the patient with a tuning fork as themetal feels cold.
First touch the patient where sensation isthought to be normal and say, "Does that feel
cold?" Then, when testing the limb, check thatthe patient is feeling the fork as cold and notjust as pressure
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V. The Motor SystemWhen assessing motor function, from a neurological
perspective, the assessment should focus on arm and
leg movement. You should consider the following:
1.muscle size2.muscle tone
3.muscle strength
4.involuntary movements
5.posture, gait
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Motor SystemInspectionStart by looking at the patient. Do
muscles look wasted? Is thereasymmetry? If the nurse strike the affected muscle
with a jerk hammer, it may induce
fasciculation.
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Motor Functions AssessmentTerm Common Meaning
Strong Normal Strength
Weak Not as strong as expected, moves against resistance but weak.
Unable to lift Cant bring limb off the bed, cant move against gravity
Withdraws Pulls back from pain source
Reflex Involves contraction of muscle in response to pain
Decorticate To painful stimuli: flexes arms, wrists with adduction of the upperextremities & extension, internal rotation & plantar flexion of
Lower extremities
Decerebrate To painful Stimuli : extends, abducts and hyperpronates arms &stiffly extends legs & plantar flexes feet.
Flaccid No response to pain, no muscle tone
Ataxia Incoordination of voluntary muscle groups.
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Note : Findings are recorded as afraction with 5 ( highest possible
Score) as the denomination
Ex: Normal ----------------- 5/5
Range of Motion
1.Flexion
2.Extension
3.Abduction4.Adduction
5.Rotation ( Internal & External)
Grading Reflexes
Hyperacative4+
Brisker than average3+
Average, NORMAL2+
Diminished, low N1+
No Response0+
Motor Functions Assessment
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Note : Findings are recorded as a
fraction with 5 ( highest possibleScore) as
the denomination
Ex: Normal ----------------- 5/5
Motor Functions Assessment
Grade Strength
5Full ROM against gravity and resistance; normal
muscle strength
4Full ROM against gravity and a moderate amount of
resistance; slight weakness3Full ROM against gravity only, moderate muscle
weakness
2Full range of motion when gravity is eliminated, severe
weakness1A weak muscle contraction is palpated, but no
movement is noted, very severe weakness
0Complete paralysis
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Motor SystemIn a conscious patient, the single best test to quickly
identify motor weakness is the drift test. Have thepatient hold their arms outward at 90 degrees fromthe body. With palms up, have the patient close theireyes and hold the arms for a couple of minutes.Drifting will occur if one side is weak.
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Abnormal posturing
Decorticate posturingLegs and feet extendedwith planter
flexion and arms rotatedand
flexed on chest
Decerebrate posturing
Arms stiffly extended and hands turned
outward and flexed,leg also extended
with planter flexion
Decorticate posture may progress todecerebrate posture, or the two may alternate.
The posturing may occur on one or both sides
of the body.
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VI. The Reflexes
A reflex is defined as an immediate and involuntaryresponse to a stimulus.
Superficial reflexes. Stroke the skin with a hard object such as an applicator
stick. What is felt is a superficial reflex 5 Ps Pain Pallor Pulses Paresthesia Paralysis
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Biceps--deep tendon reflex
1- Have the patient's elbow at about a 90angle of flexion with the arm slightly bentdown as shown in figure 2-6.
2- Grasp the elbow with your left hand so thefingers are behind the elbow and yourabductee thumb presses the bicepsbrachial tendon.
3- Strike your thumb a series of blows withthe rubber hammer, varying your thumb
pressure with each blow until the mostsatisfactory response is obtained.
4- Normal reflex is elbow flexion (bending(
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Triceps--deep tendon reflex
Grasp the patient's wrist withyour left hand and pull his arm
across his chest so the elbow isflexed about 90 and the
forearm is partially bent down.
Tap the triceps brachial tendondirectly above the olecranon
process. The normal response
is elbow extension.
Triceps reflex
Triceps jerk with arms folded
Triceps jerk with one arm
flexed
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Plantar (Babinski) reflex Lightly stimulate the outer margin of
the sole of the foot to get this reflex.Perform the reflex check in thismanner:
Grasp the ankle with your left hand. Use a blunt point and moderatepressure and stroke the sole of the footnear its lateral border.
Stroke from the heel toward the ball ofthe foot where the course should curve
across the ball of the foot to the medialside, following the bases of the toes.
A normal reflex is for the patient to haveplantar flexion of all his toes.
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Patellar reflex
(kneejerk)
Test the reflex in this manner
1 -Have the patient sit on a table orhigh bed to allow his legs to swingfreely.
2 -Tap the patellar tendon directly witha rubber hammer.
3 -Normally, the knee extends.
4 -Conduct the reflex check as shownin this figure if the patient must belying down. Put your hand under the
popliteal fossa and lift the patient'sknee from the table or bed. Tap thepatellar tendon directly.
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Achilles reflex (ankle jerk) Tap the Achilles tendon and the foot
should extend from the contraction of thegastrocnemius and soleus musclesresponding to that tap. Perform the reflextest in this manner:
Have the patient sit on a table or bed sothat his legs dangle. With your left hand, grasp the patient's
foot and pull it in dorsiflexion (upward).Find the degree of stretching upward ofthe Achilles tendon that produces the
optimal response. Tap the tendon directly. Normal response is contraction of the
gastrocnemius and plantar flexion of thefoot.
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Deep tendon reflexes should be
graded on a scale of 0-4
as follows:
= 0 absent despite reinforcement
= 1 present only with reinforcement= 2 normal
= 3 increased but normal
= 4 markedly hyperactive, with clonus
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Others: Vital Signs
Changes in vital signs are not consistent earlywarning signals.
Both respiratory and cardiac centres are located inthe brainstem.
Therefore, compression of the brainstem will causechanges in vital signs.
This is usually a late sign and impendingherniation/death will occur if the problem is notresolved.
Do not forget to compare findings to previousassessment
Others: CONVULSION SCORING
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CHART(Rhea et al.(Factors 0 1 2
Occurrence None in 24 hours Occur only instimulation
Occurspontaneously
Duration fleeting Last between 10-60sec.
Longer than1minute
Severity Mild twitching Moderate clonus Severe shaking
Frequency More than 60minutes apart
60-10 minutesapart
Less than 10minutes apart
Ventilation adquate impaired Impaired to thepoint of cyanosis
*Score is done every 4 hours
Interpretation:Score above 7 increase the dose of anticonvulsant
Score of 5-7 may be transitional. If it tends to increase from 5-7 during a 24-hour period,
convulsion potential is still high, but if reversed, patient is stable and improving
Score 2-4 are important to observe the trends, but there is less urgency. A stable score in
this range by the late 2nd or 3rd week, recovery is expected
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In Summary
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ASSESSMENT OF THENEUROLOGICAL SYSTEM:Establishing Nursing Data Base
a. Demographic Profile
b. Chief complains
c. Present Illness
c.1: Assess the circumstances of injury and admission
c.2: Assess Chief Complaint
A any associated Sx with cc
P - what provokes ( make worst) or (Makes better)
Q - Quality of Pain
R - Region and RadiationS - Severity of pain 1-10
T - Timing ( when did it start & stop, intermittent
or constant duration
d. Past and Family History
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2.Review of System
3.Comprehensive Physical Assessment including Vital signs
4.Comprehensive Neuro Assessment
3mportant Questions govern the Neurological Examination1.Is mental status intact?
2.Are Right sided & left sided findings symmetric?
3.If findings are asymmetric or otherwise abnormal, does the causative
lesion lie in the CNS or the Peripheral Nervous System?
ASSESSMENT OF THENEUROLOGICAL SYSTEM:
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Components of a Neurological
Assessment
1.Mental Status
2.Cerebellar Functions
3.Cranial Nerve Testing
4.Sensory
5.Motor Function
6.Reflexes
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