Neurological Assessment

1. Neurological Assessment NURS 347Towson University

2. Nervous System Peripheral Nervous System (PNS) Brain Spinal Cord 12 pair of cranial nerves 31 pair of spinal nerves Nerve branches Central Nervous System (CNS)

3. Central Nervous System • Cerebral Cortex: Outer layer of cerebrum • Gray Matter • Area of highest functioning: through, memory, reasoning, sensation, and voluntary movement • Cerebrum: Right and Left hemispheres • Left dominant in 95% of people: Right handed • Four lobes per hemisphere: • frontal parietal • temporal occipital

4. Assessing the Cerebral Cortex • Begin with subjective data and history.

5. Questions to ask the patient: • Orientation: Person, Place, Time, Situation • Headache • Head Injury • Dizziness/Vertigo • Seizures • Tremors • Weakness • Incoordination • Numbness or tingling • Difficulty swallowing (Dysphagia) • Difficulty speaking (Dysphasia) • Significant Past History • Environmental or occupational hazards • Review medications: anticonvulsants, antitremors, antivertigos, and pain medications Neurological System Subjective Data

6. Level of Consciousness (LOC) • Alert: Easily awakened with minimal stimulation • Lethargic: Drowsy, vigorous stimulation necessary for brief, but appropriate response • Stupor: Sluggish response to aggressive verbal, visual, or painful stimuli • Comatose: Response of reflex motor activity only to painful stimuli Sternal Rub: Painful Stimuli used with a stuporous or comatose patient

7. 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

8. Peripheral Nervous System Function • Carries sensory messages TO the central nervous system’s sensory receptors • Transmits messages FROM the CNS to the muscles and glands throughout the body

9. Cranial Nerves

10. Inspection: • Symmetry of skull (normocephalic) • Symmetry of face • observe palpebral fissures, nasolabial folds • Scalp: Mobility • Neck: Range of Motion (ROM) • Palpation: • Scalp: Lesions • Neck: Tenderness Neurological Assessment Objective Data: Head & Neck

11. CN I: Olfactory Nerve • Do not test routinely • Test among those who report loss of smell or had experienced head trauma • Step I: Occlude one nostril at a time and ask the patient to sniff • Establishes baseline and patency • Step II: With patient’s eyes closed, present an aromatic substance that is easily identified beneath one nostril • Step III: Repeat on opposite side

12. CNV: Trigeminal Nerve Both a sensory and motor nerve! • Motor: • Symmetrical jaw movement • Mastication (chewing) • Assess: • Palpate temporal and masseter muscles bilaterally as patient clenches teeth. • Attempt to push down on chin to separate jaws. • Sensation: • Three nerve divisions: • 1) Opthalmic, 2) Maxillary, 3) Mandibular • Assess: Touch cotton wisp to bilateral areas of forehead, cheek, and chin and request patient to state when sensation is felt.

13. CN VII: Facial Nerve • Mixed Motor and Sensory Nerve • MOTOR Assessed by observing bilateral movement when a patient: • Smiles! • Frowns • Closes eyes tightly • Lifts eyebrows • Shows teeth • Puffs cheeks • When you press puffed cheeks in, assess for equal bilateral, evacuation of air

14. CN VII: Facial Nerve • SENSORY nerve: • Assessed when facial nerve injury is suspected • Apply 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.

15. CN IX & X:Glossopharyngeal & Vagus • Assess the nerves’ motor function by: • Depress tongue with a tongue blade: watch for pharyngeal movement as the patient says “ahh” or yawns: • Uvula and soft-palate should rise midline • Tonsillar pillars should move medially • Touch the posterior pharyngeal walls with tongue blade: • Note positive gag reflex • Voice clear, no evidence of straining • Assess sensory motor: • Posterior third of tongue: bitter taste

16. CN XI: Spinal Accessory • Spinal accessory motor nerve transmits communication between the PNS and CNS. • Prior to testing nerve, assess sternomastoid and trapezius muscles for equal, bilateral size • 1. Ask patient to forcibly rotate head against resistance applied at chin, repeated on both sides. • 2. Ask patient to shrug shoulders against bilateral resistance • An intact CN XI should provide motor responses of equal, bilateral strength.

17. CN XII: Hypoglossal • Inspect the tongue: should be free from tremors or wasting • Forward thrust of tongue should remain midline • Listen for clear l, t, d sounds with speech of “light, tight, dynamite”

18. Vision difficulty (blurring, blind spots, decreased acuity) • Pain • Strabismus, diplopia • Redness, swelling • Watering, discharge • History of ocular problems • Glaucoma • Use of glasses or contact lenses • Self-Care Behaviors • Surgeries The Eye: Subjective Assessment

19. Prior to testing neurological reflexes, inspect anatomy of the eye for: • Symmetry, position, discharge • External Structures: • Lid, lashes, and brow • Color • Conjunctive • Sclera • Anterior Structures: • Cornea and Lens • Iris and Pupils The Eye: Objective Assessment

20. Inspecting the Ocular Fundus • In a darkened room using an opthalmoscope: • Elicit Red Reflex • Assess retinal vessels for • Nicking • Hemorrhages • Exudates • Visualize the optic disc for: • Color • Size • Shape

21. CN II: The Optic Nerve Confrontation Test Visual Fields Snellen Acuity Test (Distant)

22. Visual Acuity • “Near Sighted” • Decreased visual acuity at a distance • Assessed via Snellen Chart • “Far Sighted” • Decreased visual acuity in a close range. • Assessed via Jaeger card • Peripheral Vision • Assessed via Confrontation Test

23. CN III, IV & VI: Oculomotor, Trochlear & Abducens • CN III: Responsible for the eye’s up and down movement, movement of the pupil • CV IV: Superior and oblique eye movement • CN VI: Outward eye movement • Assess for: • Strabismus: Deviated gaze or limited movement • Nystagmus: Involuntary back and forth or cyclical movement

24. Corneal Light Reflex: Hirschberg Test

25. Cover/Uncover Test

26. PERRLA • Assessment of the CN III, IV and VI via the PUPILS • Pupils • Equal • Round • React to • Light and • Accommodation

27. Earaches • Infections • Discharge • Hearing loss • Environmental Noise • Tinnitus • Vertigo • Self-Care Behaviors The Ear:Subjective Assessment

28. INSPECTION • Size and Shape: Equal size bilaterally, free from swelling or thickness • Skin color of ears matches facial skin color, skin intact, free from lumps or lesions • External auditory meatus: Note opening size, any swelling, redness, or discharge • PALPATION • Mastoid process • Move pinna and push on tragus • Palpation should reveal firm structures that move without producing pain The External Ear:Objective Assessment

29. Inspection of the Tympanic Membrane

30. Otoscope • Otoscope size depends on the diameter of the auditory meatus: choose the largest speculum that will fit comfortably in the ear canal • Have the patient tilt head away from you and towards opposite shoulder • With the adult patient, pull pinna up and back • Infant or child under 3 years old, pull pinna down • 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.

31. CN VIII: Vestibulocochlear Assessment Begins with subjective assessment: How well does the patient hear conversational speech? • Voice Test • Tuning Fork Test • Weber Test • Rinne Test

32. Voice Test • 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 • Stand behind patient so lip-reading cannot occur • 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

33. Tuning Fork Tests: Weber & Rinne

34. Hearing Loss • 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. • 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. • Mixed: Combination of both conductive and sensorineural hearing loss in the same ear.

35. CN VIII: Romberg Test • CN VIII is also a nerve with a “special sense.” • The inner ear provides information regarding your body’s position in space (proprioception). • 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. • Equilibrium and vertigo can be assessed via the Romberg Test.

36. Romberg Test

37. Cerebellar Functioning Assessment BALANCE: • The Romberg Test (CN VIII) assesses balance, an extension of the CNS and the functionality of the cerebellum. • 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. • 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.

38. Cerebellar Functioning Coordination and Skilled Movements: • Rapid Altering Movements (RAM) • Finger-to-Finger Test • Finger-to-Nose Test • Heel-to-Shin Test

39. Finger-to-Finger Test &Rapid Alternating Movement

40. Heel-to-Shin Test

41. Sensation: Superficial Pain • 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. • Provide a 2-second break between application to prevent summation, when a frequent but separate stimuli are perceived as one, strong stimulus.

42. Sensation: Light Touch • 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.” • Compare symmetric points bilaterally.

43. Sensation: Vibration • Use a low-pitch tuning fork and strike against the heel of your hand. • Apply the base of the tuning fork to a body surface of the fingers or great toe. • Ask patient to report when the vibration starts and stops. • If no vibration is felt in those locations, move proximally, testing the ulnar processes, ankles, patellae, and iliac crests. • Compare findings bilaterally.

44. Motor Strength • 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. • Assess strength by assessing bilaterally muscle groups in the extremities, neck, and trunk, continuing to compare bilateral findings in each group. • 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.

45. Deep Tendon Reflexes (DTR) • Use the reflex hammer and use a short, snapping flow to the muscle’s insertion tendon. • Do not rest the hammer on the tendon. • Use the pointed end for smaller targets; the flat end on wider targets or to prevent pain • Compare bilateral responses Grading 4+ Very brisk, hyperactive with clonus. Indicates presence of disease process 3+ Brisker than average; may indicate need for further work-up 2+ Average, normal 1+ Diminished, low-normal 0 No response

46. Upper Extremity DTR • Biceps • Triceps • Brachioradialis

47. Abdominal Reflexes

48. Lower Extremity DTR • Patellar • Achilles • Ankle Clonus

49. Plantar Assessment Babinski Sign:Normal only in infants Plantar Reflex

50. For Fun…