ASSESSMENT
OF NEUROLOGICAL SYSTEM
Purposes of
neurological examination
·
Identify a neurological
database.
·
Establish the presence of
nervous system dysfunction.
·
Compare current data with
the previous data to determine the trends and need for change in interventions.
·
Provide a data base for
nursing diagnosis and plan of care.
·
To identify the potential
collaborative problems.
Equipment’s
required
·
Pen light
·
Tongue Blade
·
Sterile Needle
·
Tuning Forks 200-400 Hz
and 500 -100 Hz
·
Familiar Objects- Coins,
Keys, Paper Clip
·
Cotton wisp
·
Reflex Hammer
·
Vials of aromatic
substances – coffee, orange, peppermint extract oil or clove
·
Vials of solution –
glucose, salt, lemons or vinegar and quinine with applications
·
Test Tubes of hot and
cold water
Assessment of
neurological system includes
§ Mental
status including level of consciousness
§ The
cranial nerves
§ Reflexes
§ Motor
function
§ Sensory
function
Mental status
It reveals that the client’s general cerebral
function. These function includes intellectual, emotional functions.
Major areas of mental status assessment - language,
orientation, memory and attention span and calculation.
Mental status
examination
1)
Appearance
attitude and behaviour
ü Appearance-
Posture, clothing, grooming facial expression
ü Attitude-
Cooperative/ Noncooperative, Hostile/ defensive, Interested/ disinterested
ü Behaviour
and Motor activity- Slow / Excess motor
activity, Tics, Mannerisms, waxy flexibility
2)
Speech
ü Pressure,
tone, volume of speech. Flow of speech, slurring speech, circumstantiality,
tangentiality.
3)
Mood
and affect
ü Mood-
sustained emotional state ( euthymic euphoric, angry, anxious
or apathetic )
ü Affect
- the external and dynamic manifestations of a person's internal emotional
state. ( Appropriate inappropriate, congruent/ incongruent )
4)
Thought
process
ü Thought
broadcasting, Thought withdrawal. Do you feel like somebody inserting thoughts
into your mind? Do you feel like somebody is taking away thoughts from your
mind?
5)
Attention
span- Assessment: assess patient ability to
repeat a series of 5 or 6 digits backwards and forwards.
6)
Orientation:
Assessment: assess the patient ability to
correctly state his name, date including month, year and approximate time of
day and the name of place where he is in.
7)
Memory
·
Immediate- Digit
repetition. I will tell 5numbers you have to repeat it back. 10, 15,20,23,30.
·
Recent- Ask questions
about the past 24 hours. What you had for your lunch yesterday?
·
Recent Past- When you got
admitted here?
·
Remote- Ask the patient
his date of birth Date of marriage
8)
Perceptional
disturbances: Ask questions about to find out
whether the patient is having illusions and hallucinations. When you are alone
do you feel like any voices talking to you? Do you feel like seeing some
persons or images?
9) Abstract thinking: Ask
the similarities and difference between a set of objects Car/ Train. Table/
Chair
10)
Judgment:
Ask questions about to find out how the
person responds to a situation appropriately. Ask the patient what should you
do when u find a stamped addressed letter?
Mini mental status
examination
·
Orientation to time- what
is the date
·
Registration- say 3 words
and ask to repeat
·
Naming –what is this
·
Reading-read and do what
it says
Language:
Any defects in or loss of the power to express by oneself, by speech, writing,
or signs , or to comprehend to spoken or written language due to disease or
injury of the cerebral cortex, is called APHASIA.
It can be categorized as sensory and motor aphasia.
Sensory or receptive aphasia is the loss of ability to
comprehend written or spoken words.
Two types of sensory aphasia;
·
Auditory (acoustic)
aphasia
·
Visual aphasia.
Motor or expressive aphasia involves the loss of power
to express oneself by writing, making signs or speaking. Any defects in or loss of the power to express
oneself by speech, writing or signs or to comprehend spoken or written language
due to disease or head injury. If the client displays difficulty in speaking.
Point to common
objects, and ask the client to name them. Ask the client to read some words and
to match the printed and written words with pictures. Ask the client to respond
to simple verbal and written commands. E.g.; point to your toes or raise your
left arm.
Orientation: client’s
ability to recognize other persons, awareness of when and where they presently
are time and place), who they, themselves, are self).
Memory: Nurse
assess the client’s recall of information presented seconds previously (immediate
recall). Events or information from
earlier in the day or examination (recent memory). Knowledge recalled from months or years ago (remote or long term
memory).
To assess the immediate
recall ask the client to repeat a series of three digits E.g.; 7-4-3,
spoken slowly. Gradually increase the number of digits: e.g.; 7-4-3-5-6-7-2 until
the client fails to repeat the series correctly.
Recent memory:
Ask the client to recent events of the day, such as how the client got to the
clinic.
Remote memory:
previous illness or surgery, birthday or anniversary.
Attention span and
calculation: Client’s ability to focus on a mental
task that is expected to be able to be performed by persons of normal
intelligence Ask the client to count backward from 100. Test the ability to calculate by asking the client to subtract 7
or 3 progressively from 100. i.e.;
100, 93, 86, 79. Normally an adult
can complete serial sevens test in about 90 seconds with three or few errors.
Level of consciousness:
LOC can lie anywhere along a continuum
from a state alertness to coma. A
fully alert client responds to questions spontaneously. A comatose client may not respond to verbal stimuli.
LEVEL
|
PATIENT RESPONSE
|
ALERTNESS
|
• Patient is awake, responds immediately and
appropriately to all verbal stimuli
|
LETHARGY
|
• Patient is lethargic, drowsy and inattentive but
arouses easily.
|
STUPOROUS
|
• Patient spends much of time sleeping.
• He arouses with great difficulty and cooperates
minimally when stimulated.
|
SEMI COMATOSE
|
• Patient has lost his ability to respond to verbal
stimuli.
• When the patient is stimulated with pain non
purposeful motor activity is seen.
|
COMA
|
• When the patient is stimulated there is no response
to verbal or painful stimuli.
• No motor activity is seen.
|
Assessment of level of consciousness
–Glasgow coma scale
Glasgow Coma Scale, a system for describing the degree
of loss of consciousness in the severely ill. It is also used to predict the
length and result of coma, mostly in patients with head injuries.
Glasgow coma scale. It tests in three major areas:
·
Eye response
·
Motor response
·
Verbal response
An assessment of total 15 points indicates the client
is alert and completely oriented. A comatose client scores 7 or less.
Glasgow Coma Scale or GCS, developed in
Glasgow, Scotland in 1974 is widely used in the assessment of comatose
patients.
The range of possible score is from 3-15.
·
Score 15- Fully alert
oriented person.
·
Score 3- Deep coma
·
Score 8 - Unconsciousness
GLASGOW COMA SCALE
¨ Eye
opening
1. Spontaneous
2. To
Speech
3. To
pain
4. None
|
¨ Verbal response
1. None
2. Incomprehensible
3. Inappropriate
4. Confused
5. Oriented
|
¨ Motor response
1.Obeys command
2.Localized pain
3.Withdraws from pain
4.Abnormal flexion
5.Extension
6.None
|
REFLEXES:
A reflex is an automatic response of the body to a
stimulus. It is not voluntarily learned or conscious. It is tested by using a
percussion hammer. Biceps reflex, triceps reflex, brachioradialis reflex, patellar
reflex, Achilles reflex and Plantar (Babinski reflex) are tested during
physical examination.
Ask the history the following: Presence of pain in the
head, back, or extremities, as well as onset and aggravating and alleviating
factors, disorientation to time, place, or person, speech disorder, any history
of loss of consciousness, fainting, convulsions, trauma, tingling, any history
of loss of consciousness, limping, paralysis, loss of memory, mood swings,
problems with smell, taste, touch or hearing.
Test reflexes using a percussion hammer, comparing one
side of the body of another. The response as described as on a scale of 0 to +
4.
Reflexes:
Superficial and Deep tendon Reflexes
Superficial
Reflexes: With the patient supine, stroke each
quadrant of the abdomen with the end of a reflex hammer or tongue blade edge.
·
The upper abdominal
reflexes are elicited by stroking downward and toward the umbilicus
·
Lower abdominal reflexes are elicited by
stroking downward away from the umbilicus toward each area of stimulation
should be bilaterally equal.
Autonomic reflex,
any of a large number of normal reflexes that regulate the functions of the
body's organs. Autonomic reflexes control activities as blood pressure, heart
rate, intestinal activity, sweating, and urination.
Deep tendon reflex
(DTR), myotatic reflex, and tendon
reflex: A quick contraction of a muscle when its tendon is sharply tapped
by a finger or rubber hammer. Absence of the reflex may be caused by damage to
the muscle, the nerve, nerve roots, or the spinal cord. A violent reflex may be
caused by disease of the nervous system or by overactive thyroid gland. Reinforcement is accomplished by asking the
patient to clench their teeth, or if testing lower extremity reflexes, have the
patient hook together their flexed fingers and pull apart. This is known as the
Jendrassik maneuver
It
is key to compare the strength of reflexes elicited with each other. A finding
of 3+, brisk reflexes throughout all extremities is a much less significant
finding than that of a person with all 2+, normal reflexes, and a 1+,
diminished left ankle reflex suggesting a distinct lesion.
Biceps reflex: Have
the patient sit up on the edge of the examination bench with one hand on top of
the other, arms and legs relaxed. Instruct the patient to remain relaxed. The
biceps reflex is elicited by placing the examiners thumb on the biceps tendon
and striking the thumb with the reflex hammer and observing the arm movement.
Repeat and compare with the other arm.
Triceps reflex: These reflex tests
the spinal cord C-7, C-8. Flex the client’s
arm at the elbow, and support it in the palm of your non dominant hand. Palpate the triceps tendon about 2 to
5 cm above the elbow. A blow with a
hammer directly to the tendon. Normally slight extension of the elbow.
The
brachioradialis reflex: striking the
brachioradialis tendon directly with the hammer when the patient's arm is
resting. Strike the tendon roughly 3 inches above the wrist. Note the reflex
supination. Repeat and compare to the other arm. The biceps and brachioradialis
reflexes are mediated by the C5 and C6 nerve roots.
Patellar reflex,
Knee jerk or quadriceps reflex: It tests the
spinal cord: L-2, L-3, and L-4. Ask
the client to sit on the edge of the table. So that the legs hang freely. Locate the patellar tendon directly
below the patella. With a knee
hammer directly blow to the tendon. Normal
extension of the legs as the Quadriceps muscle contracts.
Insult to the cerebellum may lead to pendular
reflexes. Pendular reflexes are not brisk but involve less damping of the limb
movement than is usually observed when a deep tendon reflex is elicited. Patients with cerebellar injury may have a
knee jerk that swings forwards and backwards several times. A normal or brisk
knee jerk would have little more than one swing forward and one back. Pendular
reflexes are best observed when the patient's lower legs are allowed to hang
and swing freely off the end of an examining table.
Achilles reflex: It
tests the spinal cord level S-1, S-2. Position
same as patellar reflex. And
slightly dorsiflex the client’s ankle by supporting the foot lightly in the
hand. Directly percuss to the
Achilles tendon just above the heel. Normal:
plantar flexion of the foot. (Downward
jerk movement)
Plantar reflex (Babinski
reflex): It is absent in adults. Use a moderately sharp object, such as
key. Stroke the lateral border of
the sole of the client’s foot, starting at the heel, continuing to the ball of
the foot, then proceeding the across the ball of the foot toward the big toe. Normally all five toes bend downward;
this is –ve Babinski reflex. In an
abnormal response the toes spread outward and the big toe moves upward.
The Hoffman
response is elicited by holding the patient's
middle finger between the examiner’s thumb and index finger. Ask the patient to
relax their fingers completely. Once the patient is relaxed, using your thumbnail
press down on the patient's fingernail and move downward until your nail
"clicks" over the end of the patient's nail. Normally, nothing
occurs.
A positive Hoffman's response is when the other
fingers flex transiently after the "click". Repeat this manuever
multiple times on both hands. A positive Hoffman response is indicative of an
upper motor neuron lesion affecting the upper extremity in question.
Finally, test clonus if any of the reflexes
appeared hyperactive. Hold the relaxed lower leg in your hand, and sharply
dorsiflex the foot and hold it dorsiflexed. Feel for oscillations between
flexion and extension of the foot indicating clonus. Normally nothing is felt.
Grading of
reflexes
0: no response
1+: sluggish or diminished
2+: active or expected response
3+: more brisk than expected, slightly hyperactive
4+: brisk and hyperactive with intermittent or
transient clonus
Cranial nerve 1-
olfactory nerve:
To assess the sense of smell instruct the patient to close
the nose, Occlude one nostril. Identify the odour. Repeat using the opposite
nostril. Use substances such as cloves, lemon, soap, ginger, garlic etc.
Cranial nerve 2 -
optic nerve:
Controls visual activity and visual field. To assess
the visual field. To assess the visual acuity. Fundoscopic examination
Cranial nerve iii, iv, vi
– oculomotor, trochlear, abducens:
Oculomotor
controls pupillary reaction. Oculomotor,
trochlear and abducens controls the extra ocular movements
Assessing pupillary reaction: Instruct
the client to fix his eye on an object. Shine a beam of flashlight directly
into the each pupil. Note the size shape, and reaction of the pupils to
the light
PERRLA - Pupils Equal Round Reactive to Light and
Accommodation
Cranial nerve V –
trigeminal nerve:
Has got both sensory and motor components. It controls
jaw movements and facial sensation. Sensory Function. Ask the patient close the
eyes. Touch various parts of the body using a wisp of cotton. Patient is asked
to identify where the cotton is applied each time
Motor function: Tell the patient to clench the teeth
while palpating the temporal & masseter muscles of the jaws with the hands.
Temperature sensation:
Two test tubes, filled with hot and ice-cold water. Touch the skin and
ask the patient to identify “hot” or “cold.”
Test the corneal reflex: Ask the patient to look up
and away from you. Touch the cornea (not
just the conjunctiva) lightly with a fine wisp of cotton. If the patient is
apprehensive, however, first touching the conjunctiva may allay fear.
Cranial nerve vii
– facial nerve
Ask the patient to: Raise both eyebrows, Frown, Smile,
and Puff out both cheeks. Close both eyes tightly so that you cannot open them.
Test muscular strength by trying to open them. Note any weakness or asymmetry.
Cranial nerve viii
– auditory nerve
Controls hearing and sense of balance. Hearing: Use a
ticking watch one or two inches from the patient and ask the patient whether he can hear the
tickling
Weber test, Rinne test
Weber test
- Test for lateralization. Place the base of the lightly vibrating tuning fork
firmly on top of the patient’s head or on the mid forehead. Ask where the
patient hears it. Normally the sound is heard in the midline or equally in both
ears. In unilateral conductive hearing loss,
sound is heard in (lateralized to) the impaired ear.
In unilateral sensor neural hearing loss, sound is
heard in the good ear.
Rinne test
– Compare air conduction (AC) and bone conduction (BC). Place the base of a
lightly vibrating tuning fork on the mastoid bone, behind the ear and level
with the canal. When the patient can no longer hear the sound, quickly place
the fork close to the ear canal and ascertain whether the sound can be heard
again. Normally the sound is heard
longer through air than through bone (AC > BC). In conductive hearing loss,
sound is heard through bone as long as or longer than it is through air (BC =
AC or BC > AC).
Cranial nerve ix
and x – glossopharyngeal and vagus: Controls
swallowing, gag reflex, articulation and phonation. Instruct the patient to open his mouth & say ah. Normally the soft palate and uvula
elevate in midline, if there is paralysis the uvula deviates to one side. To assess gag, Use the back of a
tongue depressor, very gently stimulate the back of pharynx.
Glossopharyhgeal –taste sensation, give salt, sugar
ask to identify taste by closing eyes
Cranial nerve XI-
spinal accessory
Ask the patient to turn his or her head to each side
against your hand. Observe the contraction of the opposite sternocleidomastoid
and note the force of the movement against your hand.
Cranial nerve xii-
hypoglossal
Cerebellar
function –
a) Gait b) Co-ordination
a) Gait b) Co-ordination
Observe the barefooted patient walk around the
examination room or down a halfway; first with the eyes open and then closed. Observe the expected gait sequence, noting simultaneous
arm moments and upright posture. Note
any shuffling, widely placed feet, toe walking, foot flop, leg lag, scissoring,
and loss of arm swing, staggering or reeling. The gait should have a smooth, regular rhythm
and symmetric stride length.
Superficial Touch:
Touch the skin with your fingertip, Have the patient point to the area touched.
Superficial pain:
Alternating the point and hub of a sterile needle, touch the patient’s skin is
an unpredictable pattern. Ask the patient to identify the sensation as dull or
sharp.
Vibrations: Place the stem of a vibrating tuning fork
against several bony prominences.
Graphesthesia
– with a blunt pen or an application
stick, draw a letter or number on the palm of the patient’s hand. Ask the patient to identify
the figure.
Point location - Touch an area on the patient’s
skin and withdraw the stimulus. Ask the patient to point to the area touched.
Motor and balance
tests generally are;
Romberg test and other gross motor function and
balance tests are used.
Walking gait: ask the client to walk across the room
and back, and assess the client’s gait.
Romberg
test: Ask the client to stand with feet
together and arms resting at the sides, first with eyes open, then closed. Stand close during this test prevent
the client from falling
|
Normal findings:
Negative Romberg:
May sway slightly but is able to maintain upright
posture and foot stance.
|
Standing on one foot with eyes closed:
Ask the client close the eyes and stand on one foot
and then the other. Stand close to the client during this test.
|
Maintains stance for at least 5 seconds.
|
Heel-toe-
walking:
Ask the client to walk a straight line, placing the
heel of one foot directly in front of the toes of the other foot.
|
Maintain heel- toe- walking along a straight line.
|
Toe
or heel walking:
Ask the
client to walk several steps on the toes and then on the heels.
|
Able to walk several steps on toes or heels.
|
Fine
motor tests for the upper extremities
Finger-
to- nose-test:
Ask the client to abduct and extend the arms at
shoulder height and rapidly touch the nose alternately with one index finger
and then the other. The client repeats the test with the eyes closed if the
test is performed easily.
|
Repeatedly and rhythmically touches the nose.
|
Alternating
supination and pronation of hands on knees:
Ask the client to pat both knees with the palms of both
the and then with the alternatively at an ever increasing rate.
|
Can alternately supinate and pronate hands at rapid
pace.
|
Finger
to nose and to the nurse’s finger:
Ask the client to touch the nose and then your index
finger, held at a distance at about 45 cm, at a rapid and increasing rate.
|
Performs with co- ordination and rapidity.
|
Fingers To Fingers
Ask the client to spread the arms broadly at
shoulder height and then bring the fingers together at the midline, first
with the eyes open and then closed, first slowly and then rapidly.
|
|
Fingers to Thumb (Same
Hand)
Ask the client to touch each finger of one hand to
the thumb of the same hand as rapidly as possible.
|
|
Fine
motor tests for lower extremities;
Heel
down opposite shin:
Ask the client to place the heel of one foot just
below the opposite knee and run the heel down the shin to the foot. The
client may also use a sitting position for this test.
|
Demonstrates bilateral equal co- ordination.
|
Toe or Bail of Foot to
the Nurse's Finger
Ask the client to touch your finger with the large toe of each foot. |
|
Light-touch
sensation:
Compare the light- touch sensation of symmetric
areas of the body.
Ask the client to close the eyes and to respond by saying
“yes” or no”. Whenever the client feels the cotton wisp touching the skin.
With a wisp of cotton, lightly touch one specific
spot and then the same spot on the other side of the body.
Test areas on the forehead, cheek, abdomen, foot and
lower leg. Ask the client to point to the spot where the touch was felt.
This demonstrates whether the client is able to
determine tactile location, i.e.; can accurately perceive where the client
was touched.
|
Light tickling or touch sensation.
Light tickling or touch sensation.
If areas of sensory dysfunction are found, determine
the boundaries of sensation by testing responses about every 2.5 cm in the area.
Make a sketch of the sensory loss area of recording purposes.
|
Pain
sensation
Ask the client to close the eyes and to say “sharp”,
“dull”, or “don’t know” when the sharp or dull end of the broken tongue
depressor is felt.
Alternately use the sharp and dull end of a sterile
pin or needle to lightly prick designated
anatomic areas at random, e.g.; hand, forearm, foot, lower leg and abdomen. Allow
at least seconds between each test to prevent summation effects of stimuli. i.e.;
several successive stimuli perceived as one stimulus.
|
Able to discriminate “sharp” and “dull” sensations.
|
Temperature
sensation
Touch the skin areas with test tubes filled with hot
or cold water.
Have the client respond by saying “hot”, “cold” or
“don’t know”.
|
Able to discriminate between “hot” and “cold”
sensations.
|
Position
for kinesthetic sensation
Commonly the middle fingers and the large toes are
tested for the kinesthetic sensation.
To test the fingers, support the client’s arm with
one hand, and hold the client’s palm in the other.to test the toes place the
client’s heels on the examining table.
Ask the client close the eyes. Grasp a middle finger
or a big toe firmly between your thumb and index finger, and exert the same
pressure on both sides of the finger or toe while moving it.
Move the finger or toe until it up, down, or
straight out, and ask the client to identify the position.
Use a brisk up-and- down movements before bringing
the finger or toe suddenly to rest in one of the three positions.
|
Can readily determine the position of fingers and
toes.
|
Tactile
discrimination:
For all tests, the client’s eyes need to be closed.
One-and- two- point- discrimination:
Alternately stimulate the skin with two pins simultaneously
and then with one pin. Ask whether the client
feels one or two pinpricks
|
Perception varies widely in adults over different
parts of the body.
|
Stereognosis
(ability to recognize objects by
touching them)
Place familiar objects, such as key, pare, clip, or
coin in the client’s hand, and ask the client to identify them.
If the client has motor impairment of the hand and
is unable to manipulate an object, write a number on a client’s palm, using blunt
instrument, and ask the client to identify it.
|
Recognizes common objects.
Able to identify numbers or letters written on palm.
|
Extinction
phenomenon
Simultaneously stimulate two symmetric areas of the
body, such as thighs, the cheeks, or the hands.
|
Both points of stimulus are felt.
|
Document the findings in nurse’s record using forms or
checklists.
COMMENTS