neurological assessment nurs 347 towson university
TRANSCRIPT
Neurological Assessment
NURS 347Towson University
Nervous SystemCentral Nervous
System (CNS)Peripheral Nervous
System (PNS)
0Brain0Spinal Cord
012 pair of cranial nerves
031 pair of spinal nerves
0Nerve branches
Central Nervous System0Cerebral Cortex: Outer layer of cerebrum0Gray Matter0Area of highest functioning: through, memory,
reasoning, sensation, and voluntary movement
0Cerebrum: Right and Left hemispheres0Left dominant in 95% of people: Right handed
0Four lobes per hemisphere:0 frontal parietal0 temporal occipital
Assessing the Cerebral Cortex
0Begin with subjective data and history.
Neurological System
Questions to ask the patient:1. Orientation: Person, Place, Time, Situation2. Headache3. Head Injury4. Dizziness/Vertigo5. Seizures6. Tremors7. Weakness8. Incoordination9. Numbness or tingling10. Difficulty swallowing (Dysphagia)11. Difficulty speaking (Dysphasia)12. Significant Past History13. Environmental or occupational hazards14. Review medications: anticonvulsants,
antitremors, antivertigos, and pain medications
Subjective Data
Level of Consciousness (LOC)0 Alert: Easily awakened with
minimal stimulation0 Lethargic: Drowsy, vigorous
stimulation necessary for brief, but appropriate response
0 Stupor: Sluggish response to aggressive verbal, visual, or painful stimuli
0 Comatose: Response of reflex motor activity only to painful stimuli
Sternal Rub: Painful Stimuli used with a stuporous or comatose patient
Glasgow Coma Scale (GCS)
The Glasgow Coma Scale (GCS) minimizes the ambiguity of level of consciousness assessments,
The GCS is a quantitative tool that standardizes patient’s responses with a numerical value
Peripheral Nervous System Function
0 Carries sensory messages TO the central nervous system’s sensory receptors
0 Transmits messages FROM the CNS to the muscles and glands throughout the body
Cranial Nerves
Neurological Assessment
0 Inspection:0 Symmetry of skull (normocephalic)0 Symmetry of face
0 observe palpebral fissures, nasolabial folds
0 Scalp: Mobility0 Neck: Range of Motion (ROM)
0Palpation:0Scalp: Lesions0Neck: Tenderness
Objective Data: Head & Neck
CN I: Olfactory Nerve
0 Do not test routinely0 Test among those who report
loss of smell or had experienced head trauma
0 Step I: Occlude one nostril at a time and ask the patient to sniff0 Establishes baseline
and patency0 Step II: With patient’s eyes
closed, present an aromatic substance that is easily identified beneath one nostril
0 Step III: Repeat on opposite side
CNV: Trigeminal Nerve
Both a sensory and motor nerve!0Motor:
0 Symmetrical jaw movement0Mastication (chewing)
0 Assess: 0 Palpate temporal and masseter muscles bilaterally as patient clenches
teeth. 0Attempt to push down on chin to separate jaws.
0Sensation:0Three nerve divisions:
0 1) Opthalmic, 2) Maxillary, 3) Mandibular
0Assess: Touch cotton wisp to bilateral areas of forehead, cheek, and chin and request patient to state when sensation is felt.
CN VII: Facial Nerve
0 Mixed Motor and Sensory Nerve0 MOTOR Assessed by observing
bilateral movement when a patient:0 Smiles!0 Frowns0 Closes eyes tightly0 Lifts eyebrows0 Shows teeth0 Puffs cheeks0 When you press puffed cheeks in, assess
for equal bilateral, evacuation of air
CN VII: Facial Nerve
0SENSORY nerve:0Assessed when facial
nerve injury is suspected0Apply a cotton applicator
that has been covered with a solution of sugar, salt, or lemon juice to patient’s tongue- ask patient to identify taste.
CN IX & X:Glossopharyngeal & Vagus
0Assess the nerves’ motor function by:0 Depress tongue with a tongue blade: watch for
pharyngeal movement as the patient says “ahh” or yawns:
0 Uvula and soft-palate should rise midline0 Tonsillar pillars should move medially
0 Touch the posterior pharyngeal walls with tongue blade:0Note positive gag reflex0 Voice clear, no evidence of straining
0Assess sensory motor:0 Posterior third of tongue: bitter taste
CN XI: Spinal Accessory
0Spinal accessory motor nerve transmits communication between the PNS and CNS.
0Prior to testing nerve, assess sternomastoid and trapezius muscles for equal, bilateral size
01. Ask patient to forcibly rotate head against resistance applied at chin, repeated on both sides.
02. Ask patient to shrug shoulders against bilateral resistance
0An intact CN XI should provide motor responses of equal, bilateral strength.
CN XII: Hypoglossal0 Inspect the tongue:
should be free from tremors or wasting
0Forward thrust of tongue should remain midline
0Listen for clear l, t, d sounds with speech of “light, tight, dynamite”
The Eye: Subjective Assessment
1. Vision difficulty (blurring, blind spots, decreased acuity)
2. Pain3. Strabismus, diplopia4. Redness, swelling5. Watering, discharge6. History of ocular problems7. Glaucoma8. Use of glasses or contact lenses9. Self-Care Behaviors10. Surgeries
The Eye: Objective Assessment
Prior to testing neurological reflexes, inspect anatomy of the
eye for:0 Symmetry, position, discharge0 External Structures:
0 Lid, lashes, and brow0 Color0 Conjunctive0 Sclera
0Anterior Structures:0 Cornea and Lens0 Iris and Pupils
Inspecting the Ocular Fundus
0 In a darkened room using an opthalmoscope:
0 Elicit Red Reflex0 Assess retinal vessels for
0 Nicking0 Hemorrhages0 Exudates
0 Visualize the optic disc for:0 Color0 Size0 Shape
CN II: The Optic NerveSnellen Acuity Test
(Distant)Confrontation Test
Visual Fields
Visual Acuity0 “Near Sighted”
0 Decreased visual acuity at a distance
0 Assessed via Snellen Chart0 “Far Sighted”
0 Decreased visual acuity in a close range.
0 Assessed via Jaeger card0Peripheral Vision
0 Assessed via Confrontation Test
CN III, IV & VI: Oculomotor, Trochlear & Abducens
0CN III: Responsible for the eye’s up and down movement, movement of the pupil
0CV IV: Superior and oblique eye movement0CN VI: Outward eye movement
0Assess for:0 Strabismus: Deviated gaze or limited movement0 Nystagmus: Involuntary back and forth or cyclical
movement
Corneal Light Reflex: Hirschberg Test
Cover/Uncover Test
PERRLA
0Assessment of the CN III, IV and VI via the PUPILS
0 Pupils0 Equal0 Round0 React to0 Light and0 Accommodation
The Ear:Subjective Assessment
1. Earaches2. Infections3. Discharge4. Hearing loss5. Environmental Noise6. Tinnitus7. Vertigo8. Self-Care Behaviors
The External Ear:Objective Assessment
0 INSPECTION0 Size and Shape: Equal size
bilaterally, free from swelling or thickness
0 Skin color of ears matches facial skin color, skin intact, free from lumps or lesions
0 External auditory meatus: Note opening size, any swelling, redness, or discharge
0 PALPATION0 Mastoid process0 Move pinna and push on tragus0 Palpation should reveal firm
structures that move without producing pain
Inspection of the Tympanic Membrane
Otoscope0 Otoscope size depends on the diameter of the
auditory meatus: choose the largest speculum that will fit comfortably in the ear canal
0 Have the patient tilt head away from you and towards opposite shoulder
0 With the adult patient, pull pinna up and back
0 Infant or child under 3 years old, pull pinna down
0 Holding the otoscope in a position that seems upside down helps you balance the otoscope during the exam, decreasing risk of injury to the tympanic membrane.
CN VIII: Vestibulocochlear Assessment
Begins with subjective assessment: How well does the patient hear conversational speech?
o Voice Testo Tuning Fork TestoWeber Testo Rinne Test
Voice Test
1. Test one ear at a time by muffling sound in one ear by placing finger over tragus and rapidly pushing it in and out of auditory meatus
2. Stand behind patient so lip-reading cannot occur3. In the other ear, with your hear 2-3” from patient’s
ear, slowly whisper two-syllable words and have patient repeat words; repeat on opposite ear• Ex. Tuesday, armchair, baseball, and fourteen
Tuning Fork Tests: Weber & Rinne
Hearing Loss0 Conductive: Mechanical dysfunction of the external or inner
ear resulting in partial hearing loss. May be caused by impacted cerumen, foreign bodies, or a perforated tympanic membrane; inner ear pus or serum, and otosclerosis.
0 Sensorineural: Pathology associated with inner ear, CNVIII, or cerebral cortex ; gradual nerve degeneration (presbycusis) caused by aging; ototoxic medications (Lasix) that affect cochlear hair cells.
0 Mixed: Combination of both conductive and sensorineural hearing loss in the same ear.
CN VIII: Romberg Test
0CN VIII is also a nerve with a “special sense.”0The inner ear provides information regarding your
body’s position in space (proprioception).0 If the inner ear is inflamed, incorrect information is
transmitted (via the PNS) to the brain (CNS), causing the sensation of vertigo and an unsteady gait.
0Equilibrium and vertigo can be assessed via the Romberg Test.
Romberg Test
Cerebellar Functioning Assessment
BALANCE:0 The Romberg Test (CN VIII) assesses
balance, an extension of the CNS and the functionality of the cerebellum.
0 Gait: Have the patient walk 10-20 feet, turn and walk back. Gait should be smooth, rhythmic, and effortless with coordinated swing in the opposing arm and 15” from heel to heel.
0 Tandem Walking: Walk in a straight line in a heel-to-toe fashion. If intact, the person will walk straight and maintain balance, even with a decreased support base.
Cerebellar Functioning
Coordination and Skilled Movements:0Rapid Altering Movements (RAM)0Finger-to-Finger Test0Finger-to-Nose Test0Heel-to-Shin Test
Finger-to-Finger Test &Rapid Alternating Movement
Heel-to-Shin Test
Sensation: Superficial Pain
0 Use a tongue blade with both a sharp and dull point, lightly apply the sharp and dull points to the patient’s body in random, unpredictable manner.
0 Provide a 2-second break between application to prevent summation, when a frequent but separate stimuli are perceived as one, strong stimulus.
Sensation: Light Touch
0 Apply a wisp of cotton to the skin and brush it over the patient’s body in a random order at irregular intervals. Asl the patient to report when the touch is felt by stating “now” or “yes.”
0 Compare symmetric points bilaterally.
Sensation: Vibration
0Use a low-pitch tuning fork and strike against the heel of your hand.
0Apply the base of the tuning fork to a body surface of the fingers or great toe.
0Ask patient to report when the vibration starts and stops.
0 If no vibration is felt in those locations, move proximally, testing the ulnar processes, ankles, patellae, and iliac crests.
0Compare findings bilaterally.
Motor Strength
0 Assess via inspection the muscle groups for symmetry and size; if asymmetric, measure each in centimeters and compare difference. Measurements greater than 1 centimeter is significant.
0 Assess strength by assessing bilaterally muscle groups in the extremities, neck, and trunk, continuing to compare bilateral findings in each group.
0 Tone is the normal degree of contraction at rest. Assessment involves inspection and observation. Watch for resistance of the muscles during passive range of motion, assess bilaterally and compare.
Deep Tendon Reflexes (DTR)
0 Use the reflex hammer and use a short, snapping flow to the muscle’s insertion tendon.
0 Do not rest the hammer on the tendon.
0 Use the pointed end for smaller targets; the flat end on wider targets or to prevent pain
0 Compare bilateral responses
Grading4+ Very brisk, hyperactive with clonus. Indicates presence of disease process3+ Brisker than average; may indicate need for further work-up2+ Average, normal1+ Diminished, low-normal0 No response
Upper Extremity DTR
0Biceps0Triceps0Brachioradialis
Abdominal Reflexes
Lower Extremity DTR
0Patellar0Achilles0Ankle Clonus
Plantar Assessment
Plantar ReflexBabinski Sign:
Normal only in infants
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