1-1

Neurological ExaminationNeurological Examination

Prepared by Tesfa D. (B.Sc., M.Sc.)Prepared by Tesfa D. (B.Sc., M.Sc.)

March, 2012 March, 2012

1-2

Assess the 12 CN, motor and sensory system.Assess the 12 CN, motor and sensory system. Conduct mental status examination.Conduct mental status examination. Describe the components of mental status Describe the components of mental status

examination.examination. Identify equipment needed to conduct a Identify equipment needed to conduct a

neurological examination.neurological examination. Describe historical data related to the Describe historical data related to the

neurological system. neurological system.

Objective Objective 11

1-3

Describe the functions of major components of Describe the functions of major components of nerves system.nerves system.

Name the major division of nervous system.Name the major division of nervous system. Accurately record the assessment of the Accurately record the assessment of the

neurologic system.neurologic system.

Cont…dCont…d11

1-4

The NS can be divided in to two parts i.e. CNS The NS can be divided in to two parts i.e. CNS & PNS.& PNS.

The CNS includes the brain and spinal cord.The CNS includes the brain and spinal cord. The PNS includes the 12 pairs of CN, the 31 The PNS includes the 12 pairs of CN, the 31

pairs of spinal nerves, and all other branches.pairs of spinal nerves, and all other branches. The PNS carries message to CNS from the The PNS carries message to CNS from the

sensory receptors and from the CNS out to sensory receptors and from the CNS out to muscles and glands.muscles and glands.

Anatomy and PhysiologyAnatomy and Physiology11

1-5

Components of the CNSComponents of the CNS

1. Cerebral cortex: It is the cerebrums outer 1. Cerebral cortex: It is the cerebrums outer layer of nerve cell bodies, also called gray layer of nerve cell bodies, also called gray matter.matter.

The CC is the center for human’s highest The CC is the center for human’s highest function governing thought, memory, function governing thought, memory, reasoning, sensation and voluntary reasoning, sensation and voluntary movement.movement.

Cont…dCont…d11

1-6

The cerebrum is divided into two hemisphere The cerebrum is divided into two hemisphere with each hemisphere divided into four lobes: with each hemisphere divided into four lobes: FrontalFrontal ParietalParietal TemporalTemporal Occipital Occipital

Cont…dCont…d11

1-7

Cont…dCont…d

1-8

The FL is concerned with personality, The FL is concerned with personality, behavior, emotion and intellectual functions.behavior, emotion and intellectual functions.

The PL is the primary center for sensation.The PL is the primary center for sensation. The OL is the primary visual receptor center.The OL is the primary visual receptor center. The TL is the primary auditory reception The TL is the primary auditory reception

center.center.

Cont…dCont…d11

1-9

Damage to any of these specific cortical areas Damage to any of these specific cortical areas produces corresponding loss of function like produces corresponding loss of function like motor deficit, paralysis, loss of sensation or motor deficit, paralysis, loss of sensation or impaired ability to understand and process impaired ability to understand and process language.language.

2. Cerebellum: located under the occipital lobe 2. Cerebellum: located under the occipital lobe that’s is concerned with motor coordination of that’s is concerned with motor coordination of voluntary movements, equilibrium, and muscle voluntary movements, equilibrium, and muscle tone from cerebral cortex. E.g. coordination tone from cerebral cortex. E.g. coordination needed in playing the piano.needed in playing the piano.

Cont…dCont…d11

1-10

3. Brain stem: is the central core of brain 3. Brain stem: is the central core of brain consisting of midbrain, pons, and medulla. consisting of midbrain, pons, and medulla. Located b/n the cerebrum and spinal cord, it Located b/n the cerebrum and spinal cord, it connect pathways b/n the higher and lower connect pathways b/n the higher and lower structure.structure.

Midbrain: anterior part of brain stem that Midbrain: anterior part of brain stem that merges with the thalamus and hypothalamus. merges with the thalamus and hypothalamus. It contains many motor neurons and tracts.It contains many motor neurons and tracts.

Cont…dCont…d11

1-11

Pons: the enlarged area containing the Pons: the enlarged area containing the ascending and descending fiber tract.ascending and descending fiber tract.

Medulla: continuation of the spinal cord Medulla: continuation of the spinal cord connecting the brain and spinal cord. It has connecting the brain and spinal cord. It has vital autonomic centers (respiration, heart, and vital autonomic centers (respiration, heart, and GI function).GI function).

Cont…dCont…d11

1-12

Spinal cord: is the long cylindrical structure Spinal cord: is the long cylindrical structure that occupies the upper two third of vertebral that occupies the upper two third of vertebral canal (from medulla) till first or second lumbar canal (from medulla) till first or second lumbar vertebrae. It is the main high way for vertebrae. It is the main high way for ascending & descending fiber tracts that ascending & descending fiber tracts that connects the brain to the spinal nerves, it connects the brain to the spinal nerves, it mediates reflexes. It transmit impulse to and mediates reflexes. It transmit impulse to and from the brain.from the brain.

Cont…dCont…d11

1-13

Cont…dCont…d

1-14

Spinal nervesSpinal nerves The 31 pairs of spinal nerves arise from the The 31 pairs of spinal nerves arise from the

length of the spinal cord and supply the rest of length of the spinal cord and supply the rest of the body.the body.

They include 8 pairs of cervical, 12 pairs of They include 8 pairs of cervical, 12 pairs of thoracic, 5 pairs of lumbar, 5 pairs of sacral thoracic, 5 pairs of lumbar, 5 pairs of sacral and one pair of coccygeal. and one pair of coccygeal.

Cont…dCont…d11

1-15

Cont…dCont…d

They are mixed nerves containing both sensory They are mixed nerves containing both sensory and motor fibers. and motor fibers.

The nerves exit the spinal cord and innervate a The nerves exit the spinal cord and innervate a particular segment of the body.particular segment of the body.

1-16

Cont…dCont…d

Cranial nerveCranial nerve CN II through XII- CN II through XII-

diencephalon & brainstemdiencephalon & brainstem CN I and II- fiber tracts CN I and II- fiber tracts

emerging from the brain.emerging from the brain. Some are specialized, Some are specialized,

producing smell, vision, or producing smell, vision, or hearing (I, II, VIII).hearing (I, II, VIII).

1-17

Cont…dCont…d

1-18

Cont…dCont…d

1-19

Cont…dCont…d

1-20

Cont…dCont…d

Spinal reflexSpinal reflexDeep tendon reflex (mono synaptic, as few as two Deep tendon reflex (mono synaptic, as few as two

neuron) involves specific spinal segments.neuron) involves specific spinal segments. Ankle reflex- Sacral 1 primarily.Ankle reflex- Sacral 1 primarily. Knee reflex- Lumbar 2, 3, 4.Knee reflex- Lumbar 2, 3, 4. Supinator (brachioradialis) reflex- Cervical 5, 6.Supinator (brachioradialis) reflex- Cervical 5, 6.

1-21

Cont…dCont…d

Biceps reflex- Cervical 5, 6.Biceps reflex- Cervical 5, 6. Triceps reflex- Cervical 6, 7Triceps reflex- Cervical 6, 7 Abdominal reflexes—Abdominal reflexes—

Upper Thoracic 8, 9, 10.Upper Thoracic 8, 9, 10. Lower Thoracic 10, 11, 12.Lower Thoracic 10, 11, 12.

Plantar responses- Lumbar 5, Sacral 1.Plantar responses- Lumbar 5, Sacral 1.

1-22

Reflex arcReflex arc Reflexes are stimulus response activities of Reflexes are stimulus response activities of

the body. the body. They are fast , unlearned and involuntary They are fast , unlearned and involuntary

reaction to stimuli. reaction to stimuli. The reflex activity may be simple and take The reflex activity may be simple and take

place at the level of the spinal cord, with place at the level of the spinal cord, with interpretation at the cerebral level.interpretation at the cerebral level.

Cont…dCont…d11

1-23

If the tendon of the knee is sharply stimulated If the tendon of the knee is sharply stimulated with reflex hammer, the impulse follows the with reflex hammer, the impulse follows the different nerve fibers, a synapse occurs in the different nerve fibers, a synapse occurs in the spinal cord, the impulse is transmitted to the spinal cord, the impulse is transmitted to the efferent nerve fibers, leading to an additional efferent nerve fibers, leading to an additional synapse and stimulation of muscle fibers.synapse and stimulation of muscle fibers.

Cont…dCont…d11

1-24

As the muscle fibers contract, the lower leg As the muscle fibers contract, the lower leg moves , causing the knee jerk reaction.moves , causing the knee jerk reaction.

The individual is aware of the reflex after the The individual is aware of the reflex after the lower leg moves and the brain has interpreted lower leg moves and the brain has interpreted the activity. This is reflex arc. the activity. This is reflex arc.

Cont…dCont…d11

1-25

Cont…dCont…d

Motor PathwaysMotor PathwaysThe principal motor pathways are;The principal motor pathways are;

The corticospinal (pyramidal) tract.The corticospinal (pyramidal) tract.The basal ganglia system.The basal ganglia system.The cerebellar system.The cerebellar system.

1-26

Cont…dCont…d

1-27

Cont…dCont…d

Sensory PathwaysSensory Pathways Touch Touch PainPain TemperatureTemperature Position Position VibrationVibration

1-28

Cont…dCont…d

1-29

Cont…dCont…d

Dermatome Dermatome It is a circumscribed skin area that is supplied It is a circumscribed skin area that is supplied

mainly from one spinal cord segment through a mainly from one spinal cord segment through a particular spinal nerve.particular spinal nerve.

1-30

Cont…dCont…d

1-31

Cont…dCont…d

1-32

Ask for head ache, head injury, Ask for head ache, head injury, dizziness/vertigo, seizures, tremors, weakness dizziness/vertigo, seizures, tremors, weakness or incoordination, numbness or tingling, or incoordination, numbness or tingling, difficulty of swallowing, difficulty of speaking, difficulty of swallowing, difficulty of speaking, significant past history.significant past history.

Subjective DataSubjective Data11

1-33

Equipment needed: Penlight, tongue blade, Equipment needed: Penlight, tongue blade, sterile needle, cotton ball, tuning fork. sterile needle, cotton ball, tuning fork. percussion hammer, familiar aromatic percussion hammer, familiar aromatic substances (smell)substances (smell)

Objective DataObjective Data11

1-34

RememberRemember Perform a screening neurologic examination Perform a screening neurologic examination

on well persons who have no significant on well persons who have no significant subjective data findings from the history.subjective data findings from the history.

Perform a complete neurologic examination on Perform a complete neurologic examination on persons who have neurologic concerns or persons who have neurologic concerns or sings of neurologic dysfunction. sings of neurologic dysfunction.

Cont…dCont…d11

1-35

Perform a neurologic recheck on persons who Perform a neurologic recheck on persons who require periodic assessments.require periodic assessments.

Integrate the steps of the neurologic Integrate the steps of the neurologic examination with the examination of each examination with the examination of each particular part of the body. E.g. test CN while particular part of the body. E.g. test CN while assessing the head and neck. But record all assessing the head and neck. But record all neurologic data as a functional unit and record neurologic data as a functional unit and record them all together.them all together.

Cont…dCont…d11

1-36

For complete neurologic examination, use the For complete neurologic examination, use the following sequence.following sequence.

1.1. Mental status Mental status

2.2. Cranial nerves Cranial nerves

3.3. Motor systemMotor system

4.4. Sensory system Sensory system

5.5. ReflexesReflexes

Cont…dCont…d11

1-37

1. Mental health assessment1. Mental health assessment Mental status is a person’s emotional and Mental status is a person’s emotional and

cognitive functioning. Mental status cognitive functioning. Mental status assessment include appearance, behavior assessment include appearance, behavior cognition, and thought process. Or A, B, C, T.cognition, and thought process. Or A, B, C, T.

Method of ExaminationMethod of Examination11

1-38

I. AppearanceI. Appearance Posture is erect and position is relaxed.Posture is erect and position is relaxed. Body movements are voluntary, deliberate, Body movements are voluntary, deliberate,

coordinated, smooth and even. coordinated, smooth and even. Dressing is appropriate for setting, season, age, Dressing is appropriate for setting, season, age,

gender, social group.gender, social group. Grooming and hygiene should be noted. Clean Grooming and hygiene should be noted. Clean

and well groomed, hair is neat and clean. and well groomed, hair is neat and clean. Nail are clean.Nail are clean.

Cont…dCont…d11

1-39

II. Behavior:II. Behavior:

a. Level of consciousness- the person is awake, a. Level of consciousness- the person is awake, alert , and aware of stimuli from the env’t and alert , and aware of stimuli from the env’t and responds appropriate to stimuli.responds appropriate to stimuli.

b. Facial expression- look is appropriate to the b. Facial expression- look is appropriate to the situation and changes appropriately with the situation and changes appropriately with the topic.topic.

Cont…dCont…d11

1-40

Cont…dCont…d

c. Speech- pace of conversation is moderate, and c. Speech- pace of conversation is moderate, and stream of talking is fluent. Articulation is clear and stream of talking is fluent. Articulation is clear and understandable.understandable.

d. Mood and affect-judge this by body language, d. Mood and affect-judge this by body language, facial expression, and by talking directly, “how do facial expression, and by talking directly, “how do you feel today?”. The mood should be appropriate you feel today?”. The mood should be appropriate to the person’s place and condition and change to the person’s place and condition and change appropriately with topics. appropriately with topics.

1-41

III. Cognitive functionIII. Cognitive functiona. Orientation- assessa. Orientation- assess Time:-day of week, date, and year.Time:-day of week, date, and year. Place:-present location, name of city, zone. Place:-present location, name of city, zone. Person:-own name, age, type of work.Person:-own name, age, type of work.b. Attention:- (serial 7s) ask the person to begin b. Attention:- (serial 7s) ask the person to begin

with 100 and count backward by 7. Stop after 5 with 100 and count backward by 7. Stop after 5 subtraction and check correct answers.subtraction and check correct answers.

Cont…dCont…d11

1-42

Disorientation occurs with organic brain disorders. Disorientation occurs with organic brain disorders. Orientation is usually lost first to time, then to place, Orientation is usually lost first to time, then to place, and rarely to person.and rarely to person.

c. Recent memory- ask the 24 hour diet recall.c. Recent memory- ask the 24 hour diet recall.

d. Remote memory- ask the person verifiable d. Remote memory- ask the person verifiable past events. E.g. birth day, past health, past events. E.g. birth day, past health, historical events relevant for that person.historical events relevant for that person.

Cont…dCont…d11

1-43

e. New learning ability (give words)-say “ I am e. New learning ability (give words)-say “ I am going to say four words. I want you to going to say four words. I want you to remember them. In a few minutes I will ask remember them. In a few minutes I will ask you to recall them. Pick four words. E.g. fruit, you to recall them. Pick four words. E.g. fruit, glass, pen. Carrot.glass, pen. Carrot.

Normal response is an accurate four word recall Normal response is an accurate four word recall after a 10 minute delay, and at least three after a 10 minute delay, and at least three words remembered after 30 minutes.words remembered after 30 minutes.

Cont…dCont…d11

1-44

f. Higher intellectual functioningf. Higher intellectual functioning These tests measure problem solving and These tests measure problem solving and

reasoning abilities. reasoning abilities. Results are closely related to the person’s Results are closely related to the person’s

general intelligence and educational general intelligence and educational background must be considered. background must be considered.

Cont…dCont…d11

1-45

Information- how many days are there in a week? Information- how many days are there in a week?

what day is todaywhat day is today?? Judgement- to assess judgment, note what Judgement- to assess judgment, note what

the person says about job plans, social the person says about job plans, social obligation and plans for the future. It needs obligation and plans for the future. It needs to be realistic and rationale. E.g. what would to be realistic and rationale. E.g. what would you do if you find a stamped, addressed you do if you find a stamped, addressed envelope lying on street. envelope lying on street.

Cont…dCont…d11

1-46

IV. Thought process and perceptionsIV. Thought process and perceptionsa. Thought process: ask yourself, “ does this a. Thought process: ask yourself, “ does this

person make sense? Can I follow what the person make sense? Can I follow what the person is saying?” the way person thinks be person is saying?” the way person thinks be logical, goal directed, coherent, and relevant. logical, goal directed, coherent, and relevant. The person should complete a thought.The person should complete a thought.

Abnormal:- Illogical, unrealistic thought Abnormal:- Illogical, unrealistic thought process, evidence of blocking.process, evidence of blocking.

Cont…dCont…d11

1-47

b. Thought content-what the person says should b. Thought content-what the person says should be consistent and logical.be consistent and logical.

c. Perception-the person should consistently c. Perception-the person should consistently aware of reality and congruent with yours. Ask aware of reality and congruent with yours. Ask how do people treat you? Do other people talk how do people treat you? Do other people talk about you? Do you feel like you are being about you? Do you feel like you are being watched, or followed? How you heard your watched, or followed? How you heard your name when alone? Obsessions, compulsion name when alone? Obsessions, compulsion are abnormalities of thought content.are abnormalities of thought content.

Cont…dCont…d11

1-48

Illusions, hallucinations- abnormalities of Illusions, hallucinations- abnormalities of perception.perception.

Auditory and visual hallucinations occur with Auditory and visual hallucinations occur with psychiatric and organic brain diseases.psychiatric and organic brain diseases.

Tactile hallucinations occur with alcohol Tactile hallucinations occur with alcohol withdrawal.withdrawal.

Cont…dCont…d11

1-49

2. Motor system test2. Motor system test

Cerebral function: Balance tests.Cerebral function: Balance tests.o Gait- observe as the person walks, turns and Gait- observe as the person walks, turns and

returns. Normally the gait is smooth, rhythmic and returns. Normally the gait is smooth, rhythmic and effortless. Ask the person to walk a straight line in a effortless. Ask the person to walk a straight line in a heel to toe fashion (tandem walking). Normally, the heel to toe fashion (tandem walking). Normally, the person can walk straight and stay balanced. person can walk straight and stay balanced. Abnormal, staggering & loss of balance.Abnormal, staggering & loss of balance.

Cont…dCont…d11

1-50

Cont…dCont…d

1-51

Romberg test-Ask the person to stand up with Romberg test-Ask the person to stand up with feet together and arms at the sides. Once in a feet together and arms at the sides. Once in a stable position, ask the person to close the stable position, ask the person to close the eyes and to hold the position. Wait about 20 eyes and to hold the position. Wait about 20 second. Normal posture and balance are second. Normal posture and balance are maintained. maintained.

Cont…dCont…d11

1-52

Cont…dCont…d

Positive Romberg sign is loss of balance with Positive Romberg sign is loss of balance with closing of eyes that occurs with cerebellar ataxia closing of eyes that occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication), loss of (multiple sclerosis, alcohol intoxication), loss of vestibular function & loss of proprioception.vestibular function & loss of proprioception.

1-53

Ask the person to hop, first on one leg, then the Ask the person to hop, first on one leg, then the other. This demonstrate muscle strength, and other. This demonstrate muscle strength, and cerebral function.cerebral function.

Coordination and skilled movementsCoordination and skilled movements Rapid alternating movements (RAM)- ask the Rapid alternating movements (RAM)- ask the

person to pat the knees with both hands, lift up , person to pat the knees with both hands, lift up , turn hands over, and pat the knees with the turn hands over, and pat the knees with the backs of hands. Then ask the person to do backs of hands. Then ask the person to do faster. Normally, this is done with equal turning faster. Normally, this is done with equal turning and a quick turning and a quick rhythmic pace.and a quick turning and a quick rhythmic pace.

Cont…dCont…d11

1-54

Cont…dCont…d

1-55

Alternatively, ask the person to touch the Alternatively, ask the person to touch the thumb to each finger on the same hands, thumb to each finger on the same hands, starting with the index finger, then reverse starting with the index finger, then reverse direction, Normally, this can be done quickly direction, Normally, this can be done quickly and accurately. Abnormal lack of coordination and accurately. Abnormal lack of coordination with disease. with disease.

Cont…dCont…d11

1-56

Cont…dCont…d

1-57

Finger to finger test- with the person’s eyes Finger to finger test- with the person’s eyes open, ask to use the index finger to touch your open, ask to use the index finger to touch your finger, then the person’s own nose. After a few finger, then the person’s own nose. After a few times move your finger to a different spot. The times move your finger to a different spot. The person’s movement should be smooth and person’s movement should be smooth and accurate. accurate.

Cont…dCont…d11

1-58

Finger to nose test-Ask the person to close the Finger to nose test-Ask the person to close the eyes and to stretch out the arms. Ask the eyes and to stretch out the arms. Ask the person to touch the tip of his or her nose with person to touch the tip of his or her nose with each index finger, alternating hands and each index finger, alternating hands and increasing speed. Normally done with increasing speed. Normally done with accurate and smooth movement. Abnormal, accurate and smooth movement. Abnormal, misses nose.misses nose.

Cont…dCont…d11

1-59

Heel to shin test- test lower extremity Heel to shin test- test lower extremity coordination by asking the person, who is in a coordination by asking the person, who is in a supine position, to place the heel on the supine position, to place the heel on the opposite knee, and runs it down the shin from opposite knee, and runs it down the shin from the knee to ankle. Normally, moves the heel in the knee to ankle. Normally, moves the heel in a straight line down the shin. Abnormally, lack a straight line down the shin. Abnormally, lack of coordination; heel fall off shin.of coordination; heel fall off shin.

Cont…dCont…d11

1-60

3. Sensory system test3. Sensory system test Asking the person to identify various sensory Asking the person to identify various sensory

stimuli tests the intactness of the peripheral stimuli tests the intactness of the peripheral nerve fibers, the sensory tracts and higher nerve fibers, the sensory tracts and higher cortical discrimination.cortical discrimination.

Cont…dCont…d11

1-61

Pain- pain is tested by the person’s ability to Pain- pain is tested by the person’s ability to perceive a pin prick. Using a sterile needle, perceive a pin prick. Using a sterile needle, lightly apply the sharp point or the dull to the lightly apply the sharp point or the dull to the person’s body in a random and ask the person person’s body in a random and ask the person to say “sharp” or ”dull”; depending on the to say “sharp” or ”dull”; depending on the sensation felt. Abnormal, hypoalgesia, sensation felt. Abnormal, hypoalgesia, analgesia & hyperalgesia (increased pain analgesia & hyperalgesia (increased pain sensation).sensation).

Cont…dCont…d11

1-62

Light touch- apply a wisp of cotton to the skin Light touch- apply a wisp of cotton to the skin randomly. Include the arms, forearms, hands, randomly. Include the arms, forearms, hands, chest, legs. Ask the person to locate where chest, legs. Ask the person to locate where touched. Compare symmetric points.touched. Compare symmetric points. Calloused skin is normally relatively Calloused skin is normally relatively insensitive and should be avoided. Abnormal, insensitive and should be avoided. Abnormal, anesthesia (absence of touch sensation), anesthesia (absence of touch sensation), hypesthesia (decreased sensitivity), and hypesthesia (decreased sensitivity), and hyperesthesia (increased sensitivity).hyperesthesia (increased sensitivity).

Cont…dCont…d11

1-63

Vibration-test the person’s ability to feel Vibration-test the person’s ability to feel vibration of a tuning fork over boney vibration of a tuning fork over boney prominences. Strike on the heel of your hand, prominences. Strike on the heel of your hand, and hold the base on the bony surface of and hold the base on the bony surface of fingers and great toe. Ask the person to fingers and great toe. Ask the person to indicate when the vibration starts and stops. indicate when the vibration starts and stops. Loss of vibration sense occurs with peripheral Loss of vibration sense occurs with peripheral neuropathy. E.g. diabetes and alcohol. Often neuropathy. E.g. diabetes and alcohol. Often this is the first sensation lost.this is the first sensation lost.

Cont…dCont…d11

1-64

Cont…dCont…d

1-65

Stereogenesis-test the person ability to Stereogenesis-test the person ability to recognize objects by feeling their forms, size, recognize objects by feeling their forms, size, and weight. With the eyes closed, place a and weight. With the eyes closed, place a familiar objects (paper, clip, key, coin, cotton familiar objects (paper, clip, key, coin, cotton ball or pencil) in the person’s hand and ask the ball or pencil) in the person’s hand and ask the person to identify it. Normally will be explored person to identify it. Normally will be explored and identified. Astereogenesis, unable to and identified. Astereogenesis, unable to identify objects correctly that occurs in sensory identify objects correctly that occurs in sensory cortex lesion.cortex lesion.

Cont…dCont…d11

1-66

Cont…dCont…d

Number identification (graphesthesia)- With the Number identification (graphesthesia)- With the blunt end of a pen or pencil, draw a large number blunt end of a pen or pencil, draw a large number in the patient’s palm. Ask the person to report the in the patient’s palm. Ask the person to report the number written in his/her palm. A normal person number written in his/her palm. A normal person can identify most such numbers. Abnormal, can identify most such numbers. Abnormal, inability to recognize numbers, like astereognosis, inability to recognize numbers, like astereognosis, lesion in the sensory cortex.lesion in the sensory cortex.

1-67

Cont…dCont…d

1-68

Cont…dCont…d

Position-Position- Grasp the patient’s big toe, holding it by Grasp the patient’s big toe, holding it by its sides between your thumb and index finger. its sides between your thumb and index finger. Demonstrate “up” and “down” as you move the Demonstrate “up” and “down” as you move the patient’s toe clearly upward and downward. Then, patient’s toe clearly upward and downward. Then, with the patient’s eyes closed, ask for a response with the patient’s eyes closed, ask for a response of “up” or “down” when moving the toe in a small of “up” or “down” when moving the toe in a small arc.arc.

1-69

Cont…dCont…d

1-70

Cont…dCont…d

4. Cranial nerves test4. Cranial nerves test

1-71

CN I: olfactory nerveCN I: olfactory nerve Do not test routinely, test for those who report loss Do not test routinely, test for those who report loss

of smell. First, assess patency by occluding one of smell. First, assess patency by occluding one nostril at a time and asking the person to sniff. nostril at a time and asking the person to sniff. Then, with the person’s eyes closed, occlude one Then, with the person’s eyes closed, occlude one nostril and present an aromatic substance such as nostril and present an aromatic substance such as coffee, orange, soap. Any asymmetry in the sense coffee, orange, soap. Any asymmetry in the sense of smell is important.of smell is important.

Anosmia (a decrease or loss of smell).Anosmia (a decrease or loss of smell).

Cont…dCont…d11

1-72

CN II-Optic nerveCN II-Optic nerveTest visual acuity and test visual field by Test visual acuity and test visual field by confrontation test (peripheral vision)confrontation test (peripheral vision)

CN III, IV, and VI- Oculomotor, Trochlear, and CN III, IV, and VI- Oculomotor, Trochlear, and Abducens nerve.Abducens nerve.Palpebral fissure are usually equal in width. Palpebral fissure are usually equal in width. Check pupils for size, regularity, equality, light Check pupils for size, regularity, equality, light reaction, and accommodation. Assess extra reaction, and accommodation. Assess extra ocular movements by the cardinal position of ocular movements by the cardinal position of gaze. Abnormal, ptosis, limited movement. gaze. Abnormal, ptosis, limited movement.

Cont…dCont…d11

1-73

CN V- Trigeminal nerveCN V- Trigeminal nervea. Motor function: assess the muscles of a. Motor function: assess the muscles of

mastication by palpating the temporal and mastication by palpating the temporal and masseter muscle as the person clenches the masseter muscle as the person clenches the teeth. Muscle should feel equally strong on teeth. Muscle should feel equally strong on both sides. Try to separate the jaws by both sides. Try to separate the jaws by pushing down on the chin; normally you pushing down on the chin; normally you cannot. Abnormal, decreased strength on one cannot. Abnormal, decreased strength on one or both sides, asymmetry in jaw movement, or both sides, asymmetry in jaw movement, and pain.and pain.

Cont…dCont…d11

1-74

Cont…dCont…d

1-75

b. Sensory function: with the person’s eye b. Sensory function: with the person’s eye closed, test touch sensation by touching a closed, test touch sensation by touching a cotton wisp on forehead, cheeks and chin. Ask cotton wisp on forehead, cheeks and chin. Ask the person to say “ Now”, when ever the touch the person to say “ Now”, when ever the touch is felt. This test all the three division of nerve: is felt. This test all the three division of nerve: ophthalmic, maxillary, and mandibular. ophthalmic, maxillary, and mandibular.

Cont…dCont…d11

1-76

Cont…dCont…d

1-77

c. Corneal reflex: with the person looking for c. Corneal reflex: with the person looking for ward, bring a wisp of cotton in from the side ward, bring a wisp of cotton in from the side and lightly touch the cornea, not the and lightly touch the cornea, not the conjunctiva. Normally the person will blink conjunctiva. Normally the person will blink bilaterally. No blink, CN V lesion/paralysis.bilaterally. No blink, CN V lesion/paralysis.

Cont…dCont…d11

1-78

Cont…dCont…d

1-79

CN VII- Facial nerveCN VII- Facial nerve

a. Motor function: Note mobility and facial a. Motor function: Note mobility and facial symmetry as the person smile, frown, close symmetry as the person smile, frown, close eyes tightly, lift eyebrows, show teeth and puff eyes tightly, lift eyebrows, show teeth and puff checks. Press the puffed checks and air checks. Press the puffed checks and air should escape equally from both sides. should escape equally from both sides. Abnormal muscle weakness.Abnormal muscle weakness.

Cont…dCont…d11

1-80

1-81

b. Sensory function: Not routine, if indicated test b. Sensory function: Not routine, if indicated test sense of taste by applying to the tongue a sense of taste by applying to the tongue a cotton applicator covered a small amount of cotton applicator covered a small amount of sugar, salt or lemon juice solution. Ask the sugar, salt or lemon juice solution. Ask the person to identify the taste.person to identify the taste.

CN VIII- Acoustic nerveCN VIII- Acoustic nerve Test hearing acuity; voice test, tuning fork Test hearing acuity; voice test, tuning fork

tests, Webber and Rinne’s test.tests, Webber and Rinne’s test.

Cont…dCont…d11

1-82

CN IX and X- Glossopharyngeal and Vagus CN IX and X- Glossopharyngeal and Vagus nervenerve

a. Motor function: depress the tongue with a a. Motor function: depress the tongue with a tongue blade, and note pharyngeal tongue blade, and note pharyngeal movements as the person says “Ahhh”. movements as the person says “Ahhh”. Normally, uvula and soft palate rises in Normally, uvula and soft palate rises in midline. Abnormal, uvula deviates to side.midline. Abnormal, uvula deviates to side.

Cont…dCont…d11

1-83

CN XI- Spinal Accessory nerveCN XI- Spinal Accessory nerve Examine the sternomastoid and trapezius Examine the sternomastoid and trapezius

muscles for equal size and strength by asking muscles for equal size and strength by asking the person to rotate the head forcibly against the person to rotate the head forcibly against resistance applied to the side of chin and resistance applied to the side of chin and shrug shoulders against resistance. Should shrug shoulders against resistance. Should feel equally strong. Abnormal, atrophy, muscle feel equally strong. Abnormal, atrophy, muscle weakness or paralysis.weakness or paralysis.

Cont…dCont…d11

1-84

Cont…dCont…d

1-85

CN XII- Hypoglossal nerveCN XII- Hypoglossal nerve Inspect the tongue.Inspect the tongue. There should be no wasting or tremor. Note There should be no wasting or tremor. Note

midline position as the person protrudes the midline position as the person protrudes the tongue.tongue.

Lingual speech needs to be clear and distinct. Lingual speech needs to be clear and distinct.

Cont…dCont…d11

1-86

5. Reflex test5. Reflex test Reflex testing is usually the last part of the Reflex testing is usually the last part of the

neurologic assessment. The client is usually in neurologic assessment. The client is usually in a sitting position.a sitting position.

Hold the hand of the reflex hammer in your Hold the hand of the reflex hammer in your dominant hand b/n four thumb and index dominant hand b/n four thumb and index finger.finger.

Cont…dCont…d11

1-87

Use your wrist, and stimulate the reflex arc Use your wrist, and stimulate the reflex arc with a brisk tap to the tendon, not the muscle.with a brisk tap to the tendon, not the muscle.

Through continued practice and experience, Through continued practice and experience, you will learn the amount of forces to use.you will learn the amount of forces to use.

Strong force will cause pain, and too little force Strong force will cause pain, and too little force will not stimulate the arc.will not stimulate the arc.

After striking the tendon, remove the hammer After striking the tendon, remove the hammer immediately.immediately.

Cont…dCont…d11

1-88

Cont…dCont…d

1-89

Abnormal:-Abnormal:- Absent or diminished reflexes: Absent or diminished reflexes:

neuromuscular disease, spinal cord injury, neuromuscular disease, spinal cord injury, or lower motor neuron disease.or lower motor neuron disease.

Hyperactive reflexes: upper motor neuron Hyperactive reflexes: upper motor neuron disease.disease.

Cont…dCont…d11

1-90

Step-1: Assess the biceps reflex (C5, C6)Step-1: Assess the biceps reflex (C5, C6)Support the clients lower arm with your non-Support the clients lower arm with your non-dominant hand and arm. The arm needs to be dominant hand and arm. The arm needs to be slightly flexed at the elbow with palm up.slightly flexed at the elbow with palm up.Place the thumb of your non-dominant hand over Place the thumb of your non-dominant hand over the biceps tendon.the biceps tendon.Using the reflex hammer, briskly tap your thumb.Using the reflex hammer, briskly tap your thumb.Look for contraction of biceps muscle and slight Look for contraction of biceps muscle and slight flexion of the forearm.flexion of the forearm.

Cont…dCont…d11

1-91

Cont…dCont…d

1-92

Step-2: Assess the triceps reflex (C6, C7)Step-2: Assess the triceps reflex (C6, C7) Support the client’s elbow with your non-Support the client’s elbow with your non-

dominant hand.dominant hand. Sharply percuss the tendons just above the Sharply percuss the tendons just above the

olecranon process with the reflex hammer.olecranon process with the reflex hammer. Observe contraction of the triceps muscle with Observe contraction of the triceps muscle with

extension of the lower arm. extension of the lower arm.

Cont…dCont…d11

1-93

Cont…dCont…d

1-94

Step-3: Assess the brachioradialis reflex (C5, C6)Step-3: Assess the brachioradialis reflex (C5, C6) Position the client’s arm, so the elbow is flexed Position the client’s arm, so the elbow is flexed

and the hand is resting on the lap with palm and the hand is resting on the lap with palm down (pronation).down (pronation).

Using the reflex hammer, briskly strike the Using the reflex hammer, briskly strike the tendon toward the radius about 2-3 inches above tendon toward the radius about 2-3 inches above the wrist.the wrist.

Observe flexion of the lower arm and supination Observe flexion of the lower arm and supination of hand.of hand.

Cont…dCont…d11

1-95

Cont…dCont…d

1-96

Step-4: Assess the patellar (knee) reflex (L2, Step-4: Assess the patellar (knee) reflex (L2, L3, L4)L3, L4)

Flex the leg at the knee.Flex the leg at the knee. Palpate the patella to locate the patellar Palpate the patella to locate the patellar

tendon inferior to the patella.tendon inferior to the patella. Briskly strike the tendon with the reflex Briskly strike the tendon with the reflex

hammer.hammer. Note extension of lower leg and contraction of Note extension of lower leg and contraction of

the quadriceps muscles.the quadriceps muscles.

Cont…dCont…d11

1-97

Cont…dCont…d

1-98

Cont…dCont…d

1-99

Step-5: Assess the Achilles tendon (ankle) Step-5: Assess the Achilles tendon (ankle) reflex (S1)reflex (S1)

Flex the leg at the knee.Flex the leg at the knee. Dorsi flex the foot of the leg being examined.Dorsi flex the foot of the leg being examined. Hold the foot lightly in the non-dominant hand.Hold the foot lightly in the non-dominant hand. Strike the Achilles tendon with the reflex Strike the Achilles tendon with the reflex

hammer.hammer. Observe plantar flexion of the foot: the heel Observe plantar flexion of the foot: the heel

will “jump” from your hand.will “jump” from your hand.

Cont…dCont…d11

1-100

Cont…dCont…d

1-101

Cont…dCont…d

1-102

Step-6: Assess the plantar reflex (L5, S1)Step-6: Assess the plantar reflex (L5, S1) Position the leg with a slight degree of external Position the leg with a slight degree of external

rotation at the hip.rotation at the hip. Stimulate the sole of the foot from the heel to the ball Stimulate the sole of the foot from the heel to the ball

of the foot on the lateral aspect.of the foot on the lateral aspect. Continue the stimulation across the ball of the foot to Continue the stimulation across the ball of the foot to

the great toe.the great toe. Observe for plantar flexion, in which the toes curl Observe for plantar flexion, in which the toes curl

toward the sole of the foot. It may be necessary to toward the sole of the foot. It may be necessary to hold the ankle to prevent movement. hold the ankle to prevent movement.

Cont…dCont…d11

1-103

Cont…dCont…d

1-104

Babinski response is the framing of the toes Babinski response is the framing of the toes with the great toe pointing toward the dorsum with the great toe pointing toward the dorsum of the foot, called dorsiflexion of the toe. of the foot, called dorsiflexion of the toe. Abnormal in adult. May indicate upper motor Abnormal in adult. May indicate upper motor neuron disease (+ve Babinski sign). Normal neuron disease (+ve Babinski sign). Normal during infancy.during infancy.

Cont…dCont…d11

1-105

Meningeal assessmentMeningeal assessment Ask the client to flex the neck by bringing the Ask the client to flex the neck by bringing the

chin down to touch the chest.chin down to touch the chest. Observe the degree of range of motion and Observe the degree of range of motion and

the absence or presence of pain.the absence or presence of pain. The client should be able to flex the neck The client should be able to flex the neck

about 45about 45oo without pain. without pain.

Cont…dCont…d11

1-106

When the client complains of pain and has a When the client complains of pain and has a decrease in the flexion motion, you will decrease in the flexion motion, you will observe the Brudzinski sign.observe the Brudzinski sign.

With the client in a supine position, assist the With the client in a supine position, assist the client with neck flexion.client with neck flexion.

Observe the legs.Observe the legs. The sign is positive when neck flexion causes The sign is positive when neck flexion causes

flexion of the leg and thighs.flexion of the leg and thighs.

Cont…dCont…d11

1-107

Reflex incontinence related to cerebral Reflex incontinence related to cerebral loss as manifested by lack of awareness loss as manifested by lack of awareness of bladder filling.of bladder filling.

Impaired verbal communication related to Impaired verbal communication related to communication barrier as manifested by communication barrier as manifested by inability to name words.inability to name words.

Sensory perceptual alteration related to Sensory perceptual alteration related to neurological impairment as manifested by neurological impairment as manifested by stumbling. stumbling.

Nursing DiagnosisNursing Diagnosis11

1-108

Thank you for your attention!!!

Thank you for your attention!!!

11