Neuro Asses

7/27/2019 Neuro Asses

http://slidepdf.com/reader/full/neuro-asses 1/22

Presented by:

RN.com

12400 High Bluff Drive

San Diego, CA 92130

This course has been approved for two (2) contact hours.

This course expires on October 5, 2006.

Copyright © 2004 by RN.com.

All Rights Reserved. Reproduction and distribution

of these materials are prohibited without the

express written authorization of RN.com.

First Published: October 5, 2004

RN.com’s Assessment Series:

Focused Neurological

Assessment



1

Acknowledgements________________________________________________________________________ 2

Purpose & Objectives _____________________________________________________________________ 3

Introduction _____________________________________________________________________________ 4

Focused Neurological History _______________________________________________________________ 5

Adult Patient___________________________________________________________________________ 5

Infant, Pediatric, and Aging Considerations _________________________________________________ 6

The Complete Neurologic Exam_____________________________________________________________ 7

Mental Status __________________________________________________________________________ 7

12 Cranial Nerves_______________________________________________________________________ 8

Inspect and Palpate the Motor System_____________________________________________________ 11

Check Cerebellar Function ______________________________________________________________ 12

Assess the Sensory System_______________________________________________________________ 13

Assess the Spinothalmic Tract ___________________________________________________________ 13

Assess Posterior Column Tract___________________________________________________________ 14

Check the Reflexes _____________________________________________________________________ 14

The Neurological Recheck or Abbreviated Neuro Exam ________________________________________ 17

Motor Function________________________________________________________________________ 17

Pupillary Response_____________________________________________________________________ 17

Glasgow Coma Scale ___________________________________________________________________ 18

Conclusion______________________________________________________________________________ 19

References______________________________________________________________________________ 20

Post Test Viewing Instructions _____________________________________________________________ 21



2

ACKNOWLEDGEMENTS

RN.com acknowledges the valuable contributions of…

… Lori Constantine MSN, RN, C-FNP, a nurse of nine years with a broad range of clinical experience. She hasworked as a staff nurse, charge nurse and nurse preceptor on many different medical surgical units including

vascular, neurology, neurosurgery, urology, gynecology, ENT, general medicine, geriatrics, oncology and blood

and marrow transplantation. She received her Bachelors in Nursing in 1994 and a Masters in Nursing in 1998,

both from West Virginia University. Additionally, in 1998, she was certified as a Family Nurse Practitioner.

She has worked in staff development as a Nurse Clinician and Education Specialist since 1999 at West Virginia

University Hospitals, Morgantown, WV.



3

PURPOSE & OBJECTIVES

The fundamental processes of the brain and nervous system are key to understanding why nurses perform a

focused neurological assessment. If there is a disruption to any of these processes, the whole body suffers. This

course will discuss specific neurological history questions and exam techniques for your adult patient. Physicalexam techniques such as inspection, palpation, percussion, and auscultation will be highlighted. Additionally,

throughout the course, you will learn how alterations in your neurological assessment findings could indicate

potential nervous system abnormalities.

After successful completion of this course, the participant will be able to:

1. Outline a systematic approach to neurological assessment.

2. Discuss history questions which will help you focus your neurological assessment.

3. Describe abnormal neurological assessment findings associated with inspection, auscultation,

percussion, and palpation.



4

INTRODUCTION

The neurological history and exam allows the examiner to pinpoint various areas of the brain or nervous system

that may be dysfunctional. Specific signs and symptoms manifested by your patient are associated with specific

areas of the brain. Nurses observe for signs and symptoms that may be abnormal and link them to general areasof the nervous system that may be causing the disturbance. You must also recognize when further neurological

injury is manifesting, intervene appropriately, and notify the physician for a change in plans for the patient.

Integrate the steps of the neurological history with the steps taken during the complete physical examination. It

may not be necessary to perform the entire neurological exam on a patient with no suspicion of neurologicaldisorders. You should perform a complete, baseline neurological examination on any patient that has verbalized

neurological concerns in their history. Recheck the neuro exam at periodic intervals with any patient that has a

neurological deficit (Agone, et al., 1997; Jarvis, 1996).

The exam and history should be in an orderly, symmetrical

fashion. This way, you will be certain that all areas are

assessed. Each side of the body should be compared with the

other side to detect any abnormalities. When reporting off, it

is wise to perform a brief exam with the oncoming nurse at the

bedside. This ensures the subjectiveness of your exam is not

misinterpreted by the next examiner. It allows for baseline

neurological status to be ascertained at the beginning of each

shift. Also, when a change in neurological function is

experienced by the patient it is more easily identified.

Neuro

Most healthcare providersshorten the term neurologic or neurological to “neuro”. We

will do the same in this course.



5

FOCUSED NEUROLOGICAL HISTORY

When your patient is conscious, you can ask the patient the following history questions. If they are notconscious, sometimes a family member or friend can provide some of this information. Their past medicalrecords may also provide some answers to the following questions as well.

Adult Patient

When assessing the nervous system with your adult patient, ASK the following:

Any past history of head injury? (location, loss of consciousness) This

question may give you clues to underlying neurological damage that may

change your patient’s baseline.

Do you have frequent or severe headaches? (when, where, how often)Pain is a neurologic phenomenon. Most patients do not complain of

pain in the neurological history. Their complaints of pain are mentioned more in association with an extremity, back, or head assessment.

Any dizziness or vertigo? (frequency, precipitating factors, gradual or sudden) Syncope is a sudden lack of strength, a sudden loss of

consciousness usually due to a lack of cerebral blood flow. It is also

known as fainting. Vertigo is experienced as a rotational spinning. It is

usually due to neurological disorder or an inner ear disturbance.

Ever had/or do you have seizures? (when did they start, frequency, course and duration, motor activityassociated with, associated signs, post-ictal phase, precipitating factors, medications, coping strategies) Seizures

typically occur in disorders such as epilepsy. Often, the patient will describe an aura; an auditory, visual, or

motor warning of the impending seizure.

Any difficulty swallowing? (solids or liquids, excessive saliva) Difficult swallowing may clue you in to a

possible abnormality with cranial nerves IX and X.

Any difficulty speaking? (forming words or actually saying what you intended) If the patient answers yes to this

question, then ask when it was first noticed and how long did it last. These questions may clue you in to

potential transischemic attacks (TIA’s), which may be a warning signal for impending stroke.

Do you have any coordination problems? (describe) Muscle tone and strength may be affected by both

peripheral and central abnormalities.

Do you have any numbness or tingling? (describe) Any abnormal sensations such as numbness or tingling maybe referred to as parasthesias.

Any significant past neurologic history? (CVA, spinal cord injuries, neurologic infections, congenital disorders)

Specific neurological infections include meningitis and encephalitis.

Environmental or occupational hazards? (If so, explain type, length, and nature of exposure) Exposure to

insecticides, lead, organic solvents, drugs, and alcohol may all manifest in neurological symptoms.

(Jarvis, 1996).



6

Infant, Pediatric, and Aging Considerations

Additional history questions you may wish to ask regarding your infant, pediatric, or aging patients are listed inthe table below:

Additional History for Infants Additional History for

Children

Additional History for Elderly

Patients

Did the mother have any health problems during pregnancy?

Does the child have any balance problems? Any unexplained

falling? Muscle weakness?Difficulty getting up and downstairs?

Any problems with dizziness? If so when does it occur?

Tell me about the baby’s birth?Premature or term? Birth

weight? Apnea? APGAR Scores?

Does the child have any seizures?Describe the circumstances

around which they occurred.

Any decrease in memory or change in mental functioning?

Any congenital defects? Did motor and developmentmilestones occur during theappropriate age range?

Any tremors in your hands or face?

Are sucking and swallowingcoordinated?

Has your child had anyenvironmental exposure to lead?

Any sudden vision changes or sudden blindness?

Does baby turn his head toward touch?

Any learning problems in school? Any sudden weakness on oneside of the body and not theother?

Does baby startle with a loud

noise?

Any family history of

neurological disorders?

Ever experience loss of

consciousness?

(Jarvis, 1996)



7

THE COMPLETE NEUROLOGIC EXAM

Integrate the steps of the neurological history with the steps taken during the complete examination. It may not be necessary to perform the entire neuro exam on a patient with no suspicion of neuro disorders. You should perform a complete baseline neurological examination on any patient that has verbalized neuro concerns in their history. Recheck the neuro exam at periodic intervals with any patient that has a neuro deficit (Agone, et al.,1997; Jarvis, 1996).

When performing the complete neuro exam, EXAMINE the following:

Mental Status

The mental status portion of the examination is a series of detailed butsimple questions designed to test cognitive ability including: the

patient's awareness and responsiveness to the environment and the

senses, appearance and general behavior, mood, content of thought, and orientation with reference to time, place, and person.

Most nurses will not perform a detailed mental status exam. Therefore, assessing key parts of theaforementioned will be sufficient for most nurses to ascertain accurate mental status in their patients.

Specifically nurses should establish if their patient is oriented to person, place, and time. Additionally,determine if your patient is alert. If not, what does it take to get them alert - calling their name, light touch,vigorous touch, pain? Verbal response to your questions should also be noted.

Nurses should know that many neurological diseases, such as dementia, cause changes in intellectual status or

emotional responsiveness, and specific personality features. If other parts of the neurological exam are normal,and you still feel the patient’s neurological status is impaired, a neurological consult to complete a full mentalstatus exam may be warranted.



8

12 Cranial Nerves

The cranial nerves arise directly from the central nervous system. Most often, a neurological problem isdetected through the assessment of these nerves. The cranial nerves are composed of twelve pairs of nerves thatstem from the nervous tissue of the brain. Some nerves have only a sensory component, some only a motor

component, and some both. The motor components of cranial nerves transmit nerve impulses from the brain totarget tissue outside of the brain. Sensory components transmit nerve impulses from sensory organs to the brain.A summary of the functions of the cranial nerves is listed in the table below.

Cranial Nerve Major Functions

Cranial Nerve I: Olfactory Sensory Smell

Cranial Nerve II: Optic Sensory Vision

Cranial Nerve III: Oculomotor Sensory and Motor – Primarily Motor

Eyelid and eyeball movement

Cranial Nerve IV: Trochlear Sensory and Motor – Primarily Motor

Innervates superior obliqueeye muscleTurns eye downward and

laterallyCranial Nerve V: Trigeminal Sensory and Motor Chewing

Face and mouth touch and

pain

Cranial Nerve VI: Abducens Sensory and Motor – Primarily Motor

Turns eye laterallyProprioception (sensoryawareness of part of the body)

Cranial Nerve VII: Facial Sensory and Motor Controls most facialexpressions

Secretion of tears and saliva

Cranial Nerve VIII: Vestibulocochlear

(auditory)

Sensory Hearing

Equilibrium sensation

Cranial Nerve IX: Glossopharyngeal Sensory and Motor TasteSenses carotid blood pressure

Muscle sense – proprioception, sensoryawareness of the body

Cranial Nerve X: Vagus Sensory and Motor Senses aortic blood pressureSlows heart rate

Stimulates digestive organsTaste

Cranial Nerve XI: Spinal Accessory Sensory and Motor – Primarily Motor

Controls trapezius and sternocleidomastoid controls swallowing

movementsMuscle sense - proprioception

Cranial Nerve XII: Hypoglossal Sensory and Motor –

Primarily Motor

Controls tongue movements

Muscle sense - proprioception



9

When testing the cranial nerves, follow the following guidelines for each cranial nerve.

Cranial Nerve I: Olfactory

Evaluate the patency of the nasal passages bilaterally by asking the patient to breathe in through their nose whilethe examiner occludes one nostril at a time. Once patency is established, ask the patient to close their eyes.

Occlude one nostril, and place a small bar of soap or other familiar smell near the patent nostril and ask the patient to smell the object and report what it is. Making certain the patient's eyes remain closed. Switch nostrilsand repeat. Furthermore, ask the patient to compare the strength of the smell in each nostril. Very littlelocalizing information can be obtained from testing the sense of smell. This part of the exam is often omitted,unless there is a reported history suggesting head trauma or toxic inhalation.

Cranial Nerve II: Optic

First test visual acuity by using a pocket visual acuity chart. Perform this part of the examination in a well litroom and make certain that if the patient wears glasses, they are wearing them during the exam. Hold the chart

14 inches from the patient's face, and ask the patient to cover one of their eyes completely with their hand and

read the lowest line on the chart possible. Have them repeat the test covering the opposite eye. If the patient hasdifficulty reading a selected line, ask them to read the one above. Note the visual acuity for each eye.

Next evaluate the visual fields via confrontation. Face the patient about one foot away, at eye level. Tell the

patient to cover their right eye with their right hand and look the examiner in the eyes. Instruct the patient toremain looking you in the eyes and have the patient indicate when the examiner's fingers enter from out of sight,into their peripheral vision. Then, extend your arm and first two fingers out to the side as far as possible.Beginning with your hand and arm fully extended, slowly bring your outstretched fingers centrally, and noticewhen your fingers enter your field of vision. The patient should indicate seeing your fingers at the same time

you see your fingers. Repeat this maneuver a total of eight times per eye, once for every 45 degrees out of the360 degrees of peripheral vision. Repeat the same maneuver with the other eye.

If you are an advanced practice nurse, you may want to use an ophthalmoscope, observe the optic disc, physiological cup, retinal vessels, and fovea. Note the pulsations of the optic vessels, check for a blurring of the

optic disc margin and a change in the optic disc's color from its normal yellowish orange.

Cranial Nerves II & III:

Ask the patient to focus on any object in the distance.

Observe the diameter of the pupils in a dimly lit room. Note the symmetry between the pupils. Next, shine the penlight or ophthalmoscope light into one eye at a timeand check both the direct and consensual light responsesin each pupil. Note the rate of these reflexes. If they are

sluggish or absent, test for pupillary constriction viaaccommodation by asking the patient to focus on thelight pen itself while the examiner moves it closer and

closer to their nose. Normally, as the eyesaccommodate to the near object the pupils will constrict.The test for accommodation should also be completed ina dimly lit room.

Direct Light Response:

When a light shines into one eye the pupil constricts.

Consensual Light Response:

When a light shines into one eye the

other eye’s pupil will also constrict.



10

Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, and Abducens

Instruct the patient to follow the penlight or ophthalmoscope with their eyes without moving their head. Movethe penlight slowly at eye level, first to the left and then to the right. Then repeat this horizontal sweep with the

penlight at the level of the patient's forehead and then chin. Note extra-ocular muscle palsies and horizontal or vertical nystagmus, which would be abnormal. Eye movements should be coordinated and smooth.

Cranial Nerve V: Trigeminal

First, palpate the masseter muscles (muscles of chewing or of the jaw) while you instruct the patient to bite downhard. Note via observation if there is any masseter musclewasting. Next, ask the patient to open their mouth againstresistance applied by the instructor at the base of the

patient's chin.

Next, test gross sensation of Cranial Nerve V. Tell the patient to close their eyes and say "sharp" or "dull" when

they feel an object touch their face. Using a semi-sharpobject and a dull object, randomly touch the patient's facewith either object. Touch the patient above each temple, next to the nose and on each side of the chin, all

bilaterally. Ask the patient to also compare the strength of the sensation of both sides. If the patient has

difficulty distinguishing pinprick and light touch, then proceed to check temperature and vibration.

Finally, test the corneal reflex using a large Q-tip with the cotton extended into a wisp. Ask the patient to look at a distant object and then approaching laterally, touch the cornea (not the sclera) and look for the eye to blink.Repeat this on the other eye. Often, the patient will blink before the object touches the cornea. This is also

normal.

Cranial Nerve VII: Facial NerveInspect the face during conversation and rest noting any facial asymmetry including drooping, sagging or

smoothing of normal facial creases. Ask the patient to raise their eyebrows, smile showing their teeth, frownand puff out both cheeks. Note asymmetry and difficulty performing these tasks. Ask the patient to close their eyes strongly and not let the examiner pull them open. When the patient closes their eyes, simultaneouslyattempt to pull them open with your fingertips. Normally the patient's eyes cannot be opened by the examiner.Once again, note asymmetry and weakness.

Cranial Nerve VIII: Acoustic

(Vestibulocochlear)

Assess hearing by instructing the patient to close their eyes and to say "left" or "right" when a sound is heard in the respectiveear. Vigorously rub your fingers together very near to, yet nottouching, each ear and wait for the patient to respond. After thistest, ask the patient if the sound was the same in both ears, or

louder in a specific ear. If lateralization or hearingabnormalities exist, and you are a nurse practitioner, performthe Rinne and Weber tests. These will not be described in thisarticle.

Palsy:Uncontrolable tremor or quivering

Nystagmus:Rapid oscillation (movement) of the

eye in any direction, but generally in

a back-and-forth manner.

Lateralization:

Localization of a function or

activity to one side of the

body.



11

Cranial Nerve IX & X: Glossopharyngeal and Vagus

Ask the patient if they have difficulty swallowing and then ask them to swallow and note any difficulty doingso. Next, note the quality and sound of the patient's voice. Is it hoarse or nasal? Ask the patient to open their

mouth wide, protrude their tongue, and say "AHH". While the patient is performing this task, flash your penlight into the patient's mouth and observe the soft palate, uvula and pharynx. The soft palate should risesymmetrically, the uvula should remain midline and the pharynx should constrict medially like a curtain. Oftenthe palate is not visualized well during this task. One may also try telling the patient to yawn, which often

provides a greater view of the elevated palate. Also at this time, use a tongue depressor and the butt of a long Q-

tip to test the gag reflex. Perform this test by touching the pharynx with the instrument on both the left and thenon the right side, observing the normal gag or cough.

Cranial Nerve XI: Spinal Accessory

Inspect for wasting of the trapezius muscles by observing the patient from behind. Ask the patient to shrug their shoulders as strong as they can while the examiner resists this motion by pressing down on the patient'sshoulders with their hands. Next, ask the patient to turn their head to the side as strongly as they possibly canwhile the examiner once again resists with their hand. Repeat this test on the opposite side. The patient should

normally overcome the resistance. Note asymmetry.

Cranial Nerve XII: Hypoglossal

Have your patient "stick out their tongue" and move it side to side. Normally, the tongue will be protruded fromthe mouth and remain midline. Have the patient say “light, tight, dynamite” and note the clarity of each distinct

word in pronunciation. Note deviations of the tongue from midline, a complete lack of ability to protrude thetongue, tongue atrophy and fasciculation (muscle twitches) on the tongue.

Inspect and Palpate the Motor System

Muscle Size

Does your patient have appropriate size muscles for body type, age, and gender?Atrophy is abnormally small muscles with a wasted appearance. This can occur

with disuse, injury, motor neuron diseases, and muscle diseases. Hypertrophyoccurs with athletes and body builders. It is characterized by increased size and

strength of muscles.

Muscle Strength

Test muscle strength against resistance using a 0 – 5 scale, with 0 = no movement and 5 = strong muscle

strength. Muscle strength should be equal bilaterally.

When testing muscle strength in the arms ask your patient to do the following against resistance:

Lift arms away from side Push arms towards side Pull forearm towards upper arm Push forearm away from upper arm

Lift wrist up; push wrist down Squeeze examiners finger Pull fingers apart Squeeze fingers together



12

When testing muscle strength in the legs ask your patient to do the following against resistance:

Lift legs up Push legs down Pull legs apart Push legs together

Pull lower leg towards upper leg Push lower leg away from upper leg Push feet away from legs Pull feet towards legs

Muscle Tone

Abnormal findings can include: limited range of motion, pain on motion, flaccidity, decreased resistance,spasticity, or rigidity.

Involuntary Movements

Tics, tremors, and fasciculations (involuntary contraction of a muscle) are all examples of abnormal involuntarymovements you may note on exam.

Check Cerebellar FunctionChecking cerebellar functioning includes testing balance, coordination, and skilled movements.

Gait

Have the patient walk heel to toe in a straight line - forwards and backwards. Assessfor abnormalities such as stiff posture, staggering, wide base of support, lack of arm

swing, unequal steps, dragging or slapping of foot, and presence of ataxia.

Romberg’s Test

With eyes closed, have the patient stand with feet together and arms extended to thefront, palms up. Your patient should be able to maintain their balance. Stay next tothe patient when they are performing this test in particular, so if they begin to fall,

you can catch them. Balance should be maintained.

Rapid Alternating Movements

Have your patient rapidly slap one hand on the palm of the other, alternating palm up and then palm down - test both sides. Abnormal findings might be lack of coordination, or slow, clumsy movements.

Finger to Finger Test

Have your patient touch your index finger with their index finger, as you move your index finger in the spacearound them. Patients should be able to do this without missing the mark.



13

Finger to Nose Test

Have your patient touch their nose with their index finger of each hand with eyes shut. Patients should be ableto do this without missing the mark.

Heel to Shin Test

While standing, have your patient touch the heel of one foot to the knee of the opposite leg. While maintainingthis contact, have the patient run the heel down the shin to the ankle. Test each leg. If your patient misses the

mark, lower extremity coordination may be impaired.

Assess the Sensory System

Testing the sensory system checks the intactness of peripheral nerves, sensory tracts, and higher corticaldiscrimination. Have your patient close his eyes while checking sensory perception. Check the following

bilaterally:

Light Touch Can your patient feel light touch equally on both sides of the body?Sharp/Dull Can your patient distinguish between a sharp or dull object on both sides

of the body?Hot/Cold Can your patient distinguish between a hot or cold object on both sides of

the body?

Assess the Spinothalmic Tract

Checking the spinothalmic tract tests your patient’s ability to sense pain, temperature, and light touch.

Presence of PainPain can be tested by a simple pin prick with the patient’s eyes closed. Abnormalfindings would include hypalgesia, hyperalgesia, and analgesia.

Temperature

Temperature should be tested only if pain test is normal. Hot and cold objectsmay be placed on the patient’s skin at various locations bilaterally to test for temperature sensation.

Light touch

With a cotton ball or soft side of a Q-tip, touch the patient’s body bilaterally withtheir eyes closed. Ask them to indicate when you have touched them. Abnormalresponses include hypesthesia, anesthesia, and hyperesthesia.

“-algesia” =

sensation

“-esthesia” =

sensitivity



14

Assess Posterior Column Tract

Assessing the posterior column tract may identify lesions of the sensory cortex or vertebral column.

Vibration

Test the patient’s ability to feel vibrations by placing a tuning fork over various boneylocations on the patient’s toes and feet. If these areas are normal, then you may assume the

proximal areas are also normal.

Position

Position or kinesthesia is tested by having the patient close their eyes and move their big toe

up and down. The patient should be able to tell you which way there toes are moving.

Tactile discrimination

Tactile discrimination tests the discrimination ability of the sensory cortex. Stereognosis tests the patient’s

ability to recognize objects by feeling them. You can place car keys, a spoon, a pencil, or other common objectin your patient’s hand. They should be able to identify that object by feel only. Graphesthesia is the ability to

“read” a number “written” in your palm.

Two point discrimination

Two point discrimination tests the brain’s ability to detect two distinct pin

pricks on the skin. An increase in the distance it normally takes to identify twodistinct pricks occurs with sensory cortex lesions (Jarvis, 1998; Shaw, 1998).

Check the Reflexes

Reflexes are involuntary actions in response to a stimulus sent to the central nervous system. Alterations inreflexes are often the first sign of neurological dysfunction such as upper motor neuron disease, diseases of the

pyramidal tract, or spinal cord injuries.



15

Stretch or Deep Tendon Reflexes

Deep tendon reflexes, also known as muscle stretch reflexes, are reflexes elicited in response to stimuli totendons. Normally, when a specific area of the muscle tendon is tapped with a soft rubber hammer, the muscle

fibers contract. Abnormal responses may indicate injury to the nervous system pathways that produce the deeptendon reflex. Deep tendon reflexes can be influenced by age, metabolic factors such as thyroid dysfunction or electrolyte abnormalities, and anxiety level of the patient. The main spinal nerve roots involved in testing thedeep tendon reflexes are summarized in the following table:

Reflex Main Spinal Nerve Roots Involved

Biceps C5, C6

Brachioradialis C6

Triceps C7

Patellar L4

Achilles Tendon S1

Check the deep tendon reflexes with a reflex hammer to stretch the muscle and tendon. The limbs should be in arelaxed and symmetric position. Strike the reflex hammer across the selected tendon with a moderate tap. If

you cannot elicit a reflex, you can sometimes bring it out by certain reinforcement procedures. For example,have the patient grit their teeth then try to elicit the reflex again. Or you may have them clench their fiststogether when checking lower extremity reflexes. When reflexes are very brisk, clonus is sometimes seen. Thisis a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch.

Deep tendon reflexes are often rated according to the following scale:

Rating Reflex Response

0 absent reflex

1+ trace, or seen only with

reinforcement

2+ normal

3+ brisk

4+ Non-sustained clonus (i.e.,

repetitive vibratory movements)

5+ sustained clonus

Deep tendon reflexes are considered normal if they are 1+, 2+, or 3+. Reflexes that are asymmetric, or there is alarge difference between the arms and legs, or are rated as 0, 4+, or 5+ abnormal (Jarvis, 1998).

Superficial Reflexes

The following reflexes are considered normal in adults. Upper Abdominal: Ipsilateral contraction of abdominal

muscles on the stroked side. Lower Abdominal: Ipsilateral contraction of abdominal

muscles on the stroked side. Cremasteric: Stroke inner thigh, elicits elevation of testes.

Can you define Ipsilateral?

It means on the same side or

affecting the same side



16

The following reflexes are considered ABNORMAL in adults. Absence of superficial reflexes or unilateralsuppression of superficial reflexes often results from upper motor lesions subsequent to a stroke. Presence of

primitive reflexes in adults is often a sign of frontal lobe lesions.

Reflex Name Method to Elicit

Babinski Sign Stroking the bottom of the foot elicits fanning (eversion) of big toe.

Chaddock's ReflexWhen the external malleolar skin area is irritated, extension of the great toe

occurs in cases of organic disease of the corticospinal reflex paths.

Oppenheim's SignScratching the inner side of leg elicits extension of toes. Sign of cerebralirritation.

Gordon's SignSqueeze the calf muscles and note the response of the great toe. Fanning or extension is considered abnormal.

Hoffman's Sign

Flexion of the terminal phalanx of the thumb and of the second and third

phalanges of one or more of the fingers when the palmar surface of theterminal phalanx of the fingers is flicked.

Suck ReflexGently tapping or rubbing the upper lip elicits a reflexive sucking or

puckering response.

Grasp Reflex Stroking the patient's palm, causing him to grasp your fingers. A positive test

occurs when the patient does not let go of your fingers.

Palmomental Sign Rub the thenar eminence (area of palm just below the thumb) ------> elicit

reflexive contraction of the muscles of the chin.

(Agone, et al., 1997; Jarvis, 1996)



17

THE NEUROLOGICAL RECHECK OR ABBREVIATED

NEURO EXAM

Perform the neurological recheck exam at periodic intervals with any patient that has a neuro deficit. This exam

is also useful for your inpatient with a head injury or systemic disease process that may be manifesting as a

neuro symptom. When performing this abbreviated exam, EXAMINE the following, in addition to any previously identified neurological deficits noted from the complete exam:

Level of Consciousness (Monitors for signs of increasing intracranial pressure)

Is your patient oriented to person, place, and time? Is your patient alert? If not, what does it take to get them alert - calling their name, light touch,

vigorous touch, pain?

Motor Function

Ask your patient to squeeze your fingers with their hands and let go (tests for strength and symmetry of strength in the

upper extremities) Ask your patient to push and pull their arms toward and

away from you when their elbows are bent. Provide someresistance. (tests for strength and symmetry of strength in

upper extremities) Ask your patient to dorsiflex and plantarflex their feet, while

providing some resistance (tests for strength and symmetry of

strength in lower extremities) Ask your patient to perform straight leg raises with and

without resistance (tests for strength and symmetry of

strength in lower extremities)

Pupillary Response

Size, shape, and symmetry of both pupils should be thesame

Each pupil should constrict briskly when a light is shined into the eyes

Each pupil should have consensual light reflex



18

Glasgow Coma Scale

The Glasgow Coma Scale assesses how the brain functions as whole and not as individual parts (Teasdale,1975). The scale assesses three major brain functions: eye opening, motor response, and verbal response. Acompletely normal person will score 15 on the scale overall. Scores of less than 7 reflect coma. Using the scale

consistently in the healthcare setting allows healthcare providers to share a common language and monitor for trends across time (Jarvis, 1996).

Glasgow Coma Scale

1 = No response

2 = To pain

3 = To speech

Best Eye OpeningResponse

4 = Spontaneously

1 = No response

2 = Extension – abnormal

3 = Flexion - abnormal4 = Flexion – withdrawal

5 = Localizes pain

Best Motor Response

6 = Obeys verbal commands

1 = No response

2 = Sounds - incomprehensible

3 = Speech - inappropriate

4 = Conversation - confused

Best Verbal Response

5 = Oriented X 3



19

CONCLUSION

Integrating the neurological health history and physical exam takes practice. It is not enough to simply ask theright questions and perform the physical exam. As the patient’s nurse, you must critically analyze all of the datayou are obtaining, synthesize the data into relevant problem areas, and identify a plan of care for your patient

based upon this synthesis. As the plan of care is being carried out, reassessments must occur on a periodic basis.

How often these reassessments occur is unique to each patient and is based upon their physical disorder.Knowing when and how often to reassess is based on the specific patient, evidence presented, and facility

policies, standards, and protocols.

Please Read:

This publication is intended solely for the use of healthcare professionals taking this course, for credit, from RN.com It is

designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. Theguidance provided in this publication is general in nature, and is not designed to address any specific situation. This

publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals.Hospitals or other organizations using this publication as a part of their own orientation processes should review the

contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that

use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates,

officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication

may not be reproduced without written permission from RN.com.



20

REFERENCES

Agone, K., Elder, A., Foley, M., Kraut, P., Michael, K., & Tscheschlog, B. (Eds.). (1997). Expert 10-minute physical

examinations. St. Louis: Mosby.

American Association of Critical Care Nurses (1998). The Nervous System. In J. Alspach (Ed.), Core curriculum for critical care nursing (5th ed., Rev., pp. 399-459). Philadelphia: Saunders.

Folin, S. (Ed.). (2004). Rapid Assessment: A flowchart guide to evaluating signs and symptoms. Springhouse, PA:Lippincott, Williams & Wilkins.

Jarvis, C. (1996). Physical examination and health assessment. Philadelphia: W.B. Saunders.

Shaw, M. (Ed.). (1998). Assessment made incredibly easy. Springhouse, PA: Springhouse.

Teasdale, G. (1975). Acute impairment of brain function. Nursing Times, 71, 914-917.

© Copyright 2004, AMN Healthcare, Inc.



POST TEST VIEWING INSTRUCTIONS

In order to view the post test you may need to minimize this window and click “TAKE TEST”. You can thenrestore the window in order to review the course material if needed.

Neuro Asses

Documents

Transcript of Neuro Asses