Connie Barbour, MSN, RN. 1. Identify normal and abnormal findings in the neurological system. 2. Inspect and palpate the neurological system for variations.

Nursing Interventions in Performing a Neurological Exam

Connie Barbour, MSN, RN

Objectives

1. Identify normal and abnormal findings in the neurological system.

2. Inspect and palpate the neurological system for variations of normal.

3. Identify cranial nerves and their interpretation.

4. Demonstrate various methods of evaluating sensory function.

5. Evaluate motor function and muscle tone in clients.

6. Evaluate reflexes and be able to interpret findings.

Review of Anatomy & Physiology

Cerebrum – sensory/motor function

Frontal Lobe – voluntary motor activities, smell, memory, judgment, affect, personality

Parietal Lobe - speech, high level sensory function

Occipital Lobe – vision, memory

www.medical-look.com/.../organs/Cerebrum.html

Review of Anatomy & Physiology Cont.

Thalamus – Relays sensory input of taste, vision, and hearing to the cerebral cortex

Hypothalamus - Regulates temp., sleep, food & water consumption; ADH, TSH & growth hormone secretion

Brain Stem – origin of cranial nerves (pons, medulla oblongata, and midbrain)

Cerebellum – balance, voluntary movement and posture

http://upload.wikimedia.org/wikipedia/commons/a/a6/NIA_human_brain_drawing.jpg

General Goals of Assessment

Assessment of expected normal values

Establish baseline assessment Early identification of abnormal

finding

Preparation

Setting up the room Well lit environment Comfortable environment Provide privacy/draping

Setting up equipment Use of cue card Set up equipment in order of use Ensure equipment is in working order

Principles of Organization

Non-invasive to invasive

Head to toe

Front to back

Side to side

Important Points

Safety of Client

Need for Universal Precautions

Be aware of how culture may

influence exam

Gerontological adjustments

Introduction

Introduce self by Name & School

Call Client by respectful name

Explain purpose of exam

Make a statement about concerns/questions

Ask questions about client’s history of

complaints > COLDSPA

COLDSPA

Character

Onset

Location

Duration

Severity

Pattern

Associated Factors

Examination

General Survey

Central Nervous System

Cerebrum

Cerebellum

Peripheral Nervous System

Cranial Nerves

Subjective Data

Health History History of Present Illness (HPI)▪ Use COLDSPA

Past Health History▪ Surgery, trauma, illness

Family History▪ Some disease processes may be familial or

genetic Lifestyle and health practices▪ Diet, environmental exposures, work

Additional Questions?

difficulty swallowing

difficulty with head and neck

gait and balance

pain in lower back

muscle weakness or unusual muscle

activity

Objective Data / Assessment

Peripheral Nervous System Cranial Nerves (12) Spinal Nerves (31)

Autonomic Nervous System Sympathetic nervous system▪ “fight or flight”

Parasympathetic Nervous System▪ Rest and restore

Assessment

LOC & Use of Glasgow Coma Scale (p.86, Table 4-2)

Eye Opening Response Verbal Response Integral Motor Response

Annotated mini-mental state examination (p82, figure 4-5)Note general appearance, affect,

speech content, memory, logic, & speech patterns during the history & physical exam

GLASCOW

COMA

SCALE

Terms to Define Level of Consciousness

• Lethargy – drowsy, listless• Obtunded – decreased level of

consciousness, but responds to stimulation

• Stupor – senses are dulled to environment, senses dulled to all but deep painful stimulation

• Coma – a deep state of unconsciousness marked by the absence of spontaneous eye movement, no response to painful stimuli, no vocalization

Mini Mental State Exam

Thought Processes

Long Term Memory

Short Term Memory

Reality Orientation

Charting Example

Alert & Oriented X 3. Affect appropriate. Responds easily to questions. Able to follow directions. Speech clear without slur or stutter. Short & Long Term memory intact.

Cranial Nerves

www.pennhealth.com/.../images/cranial_nerves.jpg

1. Olfactory (sensory) 2. Optic (sensory) 3. Oculomotor (motor) 4. Troclear (motor) 5. Trigeminal (sensory/motor) 6. Abducens (motor) 7. Facial (sensory/motor) 8. Vestibulocochlear/Acoustic

(sensory) 9. Glossopharangeal

(sensory/motor) 10. Vagus (sensory/motor) 11. Spinal accessory (motor) 12. Hypoglossal (motor)

Cranial Nerve Article

Cranial Nerve Article with face diagram

Cranial Nerve (I) Olfactory

Sensory Carries smell impulses from nasal

mucous membrane to brain Have patient clear nose, close eyes

& occlude one nostril Have patient ID aroma: vanilla,

coffee or soap Repeat with other nostril

Cranial Nerve (II) Optic

Sensory controls central and peripheral vision

Assessed distant vision by using Snellen chart to determine visual acuity Normal = 20/20

Color Vision Near Vision tested by having patient

reading written material Normal – distance of 12-14 inches

Cranial Nerve II Optic

Abnormal

Amblyopia “lazy eye”

Myopia “near sighted”

Presbyopia – normal changes with age

Hyperopia “far-sighted”

Confrontation – to assess peripheral

vision/visual fields

Cranial Nerve (III) Oculomotor

Motor – tests also assess CN IV & VI (trochlear & abducens)!

Contracts eye lid, eye muscles & “pupil” Assess: absence of ptosis, pupillary

response Convergence Accommodation – PERRLA is the documentation

for a normal response in 2 tests. Distant to Near vision, and Indirect pupillary light reflex

[Corneal Light Reflex -In a person with normal ocular alignment the light lands on the center of both corneas

Pupillary Responses

Size of 2-6 mm = normal (ave 3.5

mm)

infancy quite small

childhood and early adult largest

25% of people have a slight

difference in size

Cranial Nerve III, IV & VI

6 Cardinal Fields of Gaze, Extraocular movement

Cardinal Fields of Gaze cont..

Cranial Nerves (III), (IV) & (VI) Normal Finding – able to follow

pointer without moving head Abnormal Finding – Unable to follow

pointer, or nystagmus

Cranial Nerve (V) Trigeminal

Sensory & Motor Carries sensory impulses of pain,

touch, and temperature from the face to the brain.

Influences clenching and lateral jaw movements (chewing and biting)

Assess: corneal reflex, clench teeth & move jaw (TMJ)

Corneal Reflex

Corneal reflex Should blink immediately

ASSESSMENT OF CN-5 TRIGEMINALTrigeminal Cranial Nerve Assessment (Temporal & Masseter muscles palpated with jaws clenched)

Cranial Nerve (VII) Facial

Motor/Sensory Innervates facial muscles

(expressions) Smile, frown, puffs cheeks, close eyes,

show teeth Contains senses for taste in the

anterior 2/3 of tongue, stimulates secretions and tears

Assess symmetry of face, taste Bell’s Palsy

ASSESSMENT CN-7 FACIALFacial CN (VII) Assessment

Assess: Smile Frown Puff out cheeks Wrinkle forehead Show teeth

Cranial Nerve (VIII) Acoustic Also called vestibulocochlear Sensory

Hearing & balance Assess by performing hearing tests

Whisper (p 310 - Mosby) Weber (p 311 - Mosby) – lateralization of

hearing Rinne (p 311 - Mosby) – Air to Bone

conduction▪ AC 2 x BC

Cranial Nerve (IX) Glossopharyngeal

Sensory Contains sensory fibers for taste on

posterior 1/3 of tongue Sensors for gag reflex Promotes swallowing movements Contains secretory fibers for parotid

glands ASSESSED TOGETHER WITH CN X

(VAGUS)

Cranial Nerve (X) Vagus

Sensory/Motor (S) Carries sensations from throat, larynx,

heart , lungs, bronchi, GI tract, and abdominal viscera

(M) Promotes swallowing, talking and production of digestive juices

ASSESS TOGETHER WITH CN IX Have patient say “ah”

(soft palate & uvula should elevate to midline) Patient able to talk without hoarseness Able to swallow Elicit “gag reflex”

Cranial Nerve (XI) Spinal Accessory

Motor Innervates neck muscles Movement of shoulders, head

rotation, and some larynx movement Assess:

Having patient shrug shoulders against resistance

Turn head against resistance▪ You are actually assessing muscle strength at

the same time which is part of the head and neck assessment

Cranial Nerve (XII) Hypoglossal

Motor Innervates tongue to assist with

movement of food and talking Assess:

stick out tongue midlinemove side to side

Sensory Function Superficial sensation

Touch (cotton) Pain (pin) (Heat/Cold = omitted if pain intact)

Deep sensation Vibration Position (proprioception)

Discriminative sensation 2-point discrimination (1point-2point) Stereognosis (familiar object) Graphesthesia (draw number)

Cerebellum

Assess balance and coordination by: Gait Walk the Line (Heel to toe), then heels, then toes. Romberg test▪ Arms by side, standing – will have very little movement even

with closed eyes for 20 seconds

Pronator drift▪ Standing with eyes closed—hold arms out in front of you with palms up.

Then tap the palms of the hands . If OK, Pt will hold balance. If not OK pt will be unable to hold their balance.

Tandem balance▪ 1 foot without losing balance (5 seconds) then hop x1

Finger to nose Rapid alternating movement/Finger-thumb

Motor Function Injury to almost any part of the

nervous system affects the patients ability to move in some way.

Changes give clues as to possible damage location.

System Assessment for Tone Strength

ASSESSMENT OF MOTOR SYSTEM

Examples of some coordination tests

Muscle Tone

Feel for muscle resistance increased (hyper > spasticity or

rigidity) or decreased (hypo > flaccidity)

Note whether upper or lower neurons Chapter 22, page 728

Muscle strength

Range

0 none/paralysis1+ no movement/flicker of contraction felt2+ full passive ROM only, severe weakness3+ full ROM against gravity only, can’t overcome resistance, moderately weak4+ slight weakness, full ROM against gravity & some resistance5+ normal/full ROM against gravity & resistance

Muscle Strength

(neck & shoulder already assessed with CN XI)

biceps (flexion) triceps (extension) hand grip quads - thigh lift shin kick (leg extension) plantar flexion & dorsiflexion (ankles)

Reflexes

Grading

0 no response 1+ diminished/sluggish/minimal 2+ average/expected/active/(normal) 3+ more brisk than expected or average 4+ very brisk and hyperactive with clonus

Reflex Assessment

BICEPS PATELLAR ACHILLES

EXAMPLES OF MAJOR DEEP TENDON REFLEXES

TRICEPS

BRACHIORADIALIS

Babinski reflex

POSITIVE RESPONSE

Dorsiflexion of great toe with fanning of remaining toes

The presence of this sign is normal in children under 2 years old

If positive in an adult it is a sign of damage to the central nervous system