Neurological Assessment Health Assessment Objectives Describe the anatomy

Neurological Assessment Health Assessment

Objectives ◦ Describe the anatomy and physiology of the nervous system. ◦ Develop questions to be used when completing the focused interview. ◦ Describe the techniques required for assessment of the nervous system. ◦ Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Neurologic System ◦ Complex Integration, Coordination, and Regulation of Body Systems

Nervous System ◦ Central ◦ Peripheral

Central Nervous System ◦ Brain ◦ Spinal cord

Brain ◦ Cerebral cortex ◦ Frontal ◦ Parietal ◦ Occipital ◦ Temporal ◦ Diencephalon ◦ Thalamus ◦ Hypothalamus ◦ Epithalamus

Brain ◦ Cerebellum ◦ Brain stem ◦ Midbrain ◦ Pons ◦ Medulla oblongata

Regions of the brain

Spinal Cord ◦ Meninges ◦ Cerebrospinal fluid ◦ Vertebrae

Peripheral Nervous System ◦ Cranial nerves ◦ Spinal nerves

12 Pairs of Cranial Nerves ◦ Originate in the brain ◦ Control many activities in the body ◦ Take impulses to and from the brain

Cranial nerves and their target regions. (Sensory nerves are shown in blue; motor nerves, in red. )

Cranial Nerves

Spinal Cord ◦ 31 pairs of spinal nerves ◦ 8 pairs of cervical nerves ◦ 12 pairs of thoracic nerves ◦ 5 pairs of lumbar nerves ◦ 5 pairs of sacral nerves ◦ 1 pair of coccygeal nerves ◦ Dermatome

Spinal nerves

Focused Interview ◦ Specific questions ◦ Illness, infection, or injury ◦ Symptoms ◦ Pain ◦ Behaviors

Physical Assessment of the Neurologic System ◦ Techniques ◦ Inspection ◦ Palpation ◦ Auscultation of the carotid arteries ◦ Sensory and motor function ◦ Reflexes

Areas of the Neurologic System Assessment ◦ Observing mental status, speech, and language ◦ Observing sensorium, memory, calculation ability, abstract thinking ability, mood, emotional state, perceptions, thought processes, ability to make judgments

Tools for Assessment of Mental Status EBP

Cranial Nerves l. Olfactory: smell ll. Optic: vision lll. Oculomotor: moves eye constricts pupil, opens eyelid l. V. Trochlear: moves eye in and down

Cranial Nerves V. Trigeminal: sensation to face, scalp cornea Vl. Abducens: moves eye laterally Vll. Facial: moves face Vlll. Acoustic: hearing and balance

Cranial Nerves l. X. Glossopharyngeal: swallow & speech X. Vagus: voice quality Xl. Spinal Accessory: moves head & shoulders Xll. Hypoglossal: moves tongue

Cranial Nerves Assess together: Vl (EOMs) lll, l. V & Assess together: l. X, X & Xll (swallow, gag & dysarthria)

Areas of the Neurologic System Assessment ◦ Motor function ◦ Observation of gait and balance ◦ Administration of the Romberg test ◦ Administration of the finger-to-nose test ◦ Observation of rapid alternating action movements ◦ Administration of the heel-to-shin test

Evaluation of gait.

Heel-to-toe walk

Romberg’s test for balance

Finger-to-nose test

Alternative for pass point test

Testing rapid alternating movement, palms down.

Testing rapid alternating movement, palms up

Testing coordination using the finger-to-finger test.

Heel-to-shin test.

Areas of the Neurologic System Assessment ◦ Sensory function ◦ Observation of light touch identification ◦ Sharp, dull, temperature, and vibration determination ◦ Stereognosis ◦ Graphesthesia ◦ Two-point discrimination ◦ Topognosis ◦ Position sense

Evaluation of light touch

Testing the client’s ability to identify sharp sensations

Testing the client’s ability to identify dull sensations

Testing the client’s ability to feel vibrations, the toe

Testing the client’s ability to feel vibrations, the knee

Position sense of joint movement

Areas of the Neurologic System Assessment ◦ Reflexes ◦ Biceps ◦ Triceps ◦ Brachioradialsis ◦ Patellar ◦ Achilles ◦ Plantar ◦ Abdominal

Testing the biceps reflex

testing the triceps reflex

Testing the brachioradialis reflex.

Testing patellar reflex, client in a sitting position

Testing patellar reflex using a relaxation technique.

Testing the Achilles tendon reflex with client in a sitting position

Testing the Achilles tendon reflex with client in a supine position.

Testing the plantar reflex

Babinski response

Abdominal reflex testing pattern

Areas of the Neurologic System Assessment ◦ Additional assessments ◦ Carotid auscultation ◦ Meningeal assessment ◦ Glasgow Coma Scale

Glasgow Coma Scale

Neurosurgery Considerations ◦ Assess for increased intracranial pressure (ICP) ◦ Level of consciousness (LOC) ◦ Motor function ◦ Pupillary response ◦ Vital signs ◦ Following an ICU stay of several days, client will normally be confused about the date.

Pupils Assess for size, shape & reaction to light.

Pupils ◦ Controlled by: ◦ CN-III ◦ Brainstem ◦ Midbrain ◦ Pupillary Assessment ◦ Size N= 3 -5 mm ◦ Reaction ◦ Shape… ◦ N=Round ◦ Abn=oval – ICP (15 -20 mm. Hg) - post frontal / anterior temporal lesions - Contusions… Fixed Dilated= ICP, Prolonged diffuse hypoxia, Atropine Pinpoint pupil = Narcotics (Morphine, Demerol), Long Acting analgesia (Fentanyl)

Glossary ◦ analgesia The absence of pain sensation. ◦ anesthesia The inability to perceive the sense of touch. ◦ Babinski response The fanning of the toes with the great toe pointing toward the dorsum of the foot, considered an abnormal response in the adult that may indicate upper motor neuron disease. ◦ brainstem Located between the cerebrum and spinal cord, contains the midbrain, pons, and medulla oblongata and connects pathways between the higher and lower structures. ◦ central nervous system System of the body that consists of the brain and the spinal cord. ◦ cerebellum Located below the cerebrum and behind the brain stem, it coordinates stimuli from the cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements; also assists with maintaining equilibrium and muscle tone.

Glossary ◦ cerebrum The largest portion of the brain, responsible for all conscious behavior. ◦ clonus Rhythmically alternating flexion and extension, confirms upper motor neuron disease. ◦ coma Amore prolonged state of unconsciousness, with pronounced and persistent changes. ◦ dermatome An area of skin innervated by the cutaneous branch of one spinal nerve. ◦ diplopia Double vision. ◦ dysphagia Difficulty with swallowing. ◦ hypalgesia Decreased pain sensation. ◦ hyperesthesia An increased sensation.

Glossary ◦ meninges Three connective tissue membranes that cover, protect, and nourish the central nervous system. ◦ nuchal rigidity Stiffness of the neck as experienced when the meningeal membranes are irritated or inflamed. ◦ nystagmus The constant involuntary movement of the eyeball. ◦ peripheral nervous system System of the body that consists of the cranial nerves and spinal nerves. ◦ reflexes Stimulus-response activities of the body. ◦ Romberg test A test that assesses coordination and equilibrium. ◦ seizures Sudden, rapid, and excessive discharges of electrical energy in the brain. ◦ spinal cord A continuation of the medulla oblongata that has the ability to transmit impulses to and from the brain via the ascending and descending pathways. ◦ syncope Brief loss of consciousness, usually sudden.

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