1. Jackie Zolotsky Bridges, RN, MSN, CRNP, CSN Parkland School District Certified School Nurse Voices of School Health Conference August 16 & 17, 2016

2.  Describe the purpose of a focused neurological exam in the school setting  Decide what components of the student’s history are necessary in a neurological exam  How to evaluate the student’s Mental Status  How to assess the function of the student’s Cranial Nerves  How to assess the student’s Motor Function  How to assess the student’s Sensory Function, Reflexes, Gait & Coordination  How to reach a conclusion about the student’s overall status based on the neurological exam

4. “A systematic examination of the nervous system, including an assessment of mental status, of the function of each of the cranial nerves, of sensory and neuromuscular function, of the reflexes, and of proprioception and other cerebellar functions.” (Mosby)

5. It surveys the functioning of nerves delivering sensory information to the brain and carrying motor commands (peripheral nervous system) and impulses back to the brain for processing and coordinating (central nervous system).

6.  1. MENTAL STATUS: assessing normal orientation to person, place and time, space, and speech  2. CRANIAL NERVES (12): Checking the eyes with an ophthalmoscope and also assessing facial muscles strength and functioning  3. MOTOR FUNCTION: checking for tone, drift, and heel and toe walking

7.  4. SENSORY FUNCTION: cold and vibration testing  5. DEEP TENDON REFLEXES: using a reflex hammer (or other instrument) on an area above a nerve to emit a reflex (usually movement of muscle groups)  6. COORDINATION AND GAIT: finger to nose testing and observing the patient walk

8.  After an injury, particularly a head injury – the neurological exam can provide clues to possible neurological dysfunction.  Depending on what part of the neurological exam is abnormal – it can help the CSN determine whether or not the injury is life threatening, urgent – or can be evaluated after school.  The CSN is the first medical professional to evaluate the injured student. The more information the CSN can obtain in her evaluation, the better informed decision she can make as to the type of care the student requires.

9.  Good old vital signs are imperative in a neurological evaluation.  Should be done every 15 minutes for a conscious student – every 5 minutes for an unconscious student.  Gives the CSN an initial observation into the severity of the situation.

10.  Intracranial pressure (ICP) can result from head trauma.  ICP produces a specific set of changes known as Cushing's triad. Cushing's triad consists of: increasing systolic blood pressure with a widening pulse pressure, decreased pulse and decreased respirations.  Cushing's triad is a late sign of increased ICP. Once this pattern of vital signs occurs, brain stem herniation is already in progress and it may be too late to reverse it.  To detect increasing ICP before it reaches this point, the CSN should look for subtle changes in blood pressure, respirations, change in level of consciousness or uneven/unreactive pupils.

11.  Headache  Nausea  Vomiting  Lethargy  Diplopia  Blurred Vision  Memory Problems  Declining cognitive functioning

12.  It is important to get as much information from the student as possible.  They history should be detailed and chronological. It should contain information pertaining to events that occurred prior to, during and after the injury that occurred.  While taking the history – note the behavior of the student. Are they thinking, acting and speaking appropriately?. Are they coherent? Does the information they give make sense? If the answer is “NO” to any of these questions – you will need to perform a more detailed mental status exam.

13.  The student’s mental status and level of consciousness provide critical information about their neurological functioning.  The Mini Mental Status exam is a quick and reliable screening tool to evaluate the student’s mental status.  The Glasgow Coma Scale is also used in many medical settings as part of the routine Neuro Exam – not truly necessary in the school setting.

15.  A set of 12 nerves that relay messages between the brain and the head and neck and control motor and sensory functions, including vision, smell, and movement of the tongue and vocal cords.  An abnormality found during Cranial Nerve testing can give helpful information in determining where the dysfunction is in the brain.

17.  Cranial Nerve I - Olfactory (sensory)–smell ◦ TEST: Close eyes and smell (this test is usually omitted )  Cranial Nerve II - Optic (sensory)–visual acuity, pupil size and reactivity to light, visual field ◦ TEST: Snellen, penlight from side of face to test pupils  Cranial Nerve III – Oculomotor (motor) – pupil constriction, raising eyelid and movement of eye ◦ Innervates extra ocular muscles affecting lateral/vertical movement of eye (inferior oblique, inferior rectus, superior rector, medial rectus) as well as top of eye rotating away from nose ◦ TEST: Use of penlight to test EOMI in 6 cardinal directions ◦ NOTE: A physical anisocoria (difference in pupillary size by about 20%) may be present – can be normal.

18.  Cranial Nerve IV – Trochlear (motor) – movement of eye ◦ Innervates Superior Oblique muscle for downward and inward movement of eye, and top of eye rotating in towards nose ◦ TEST: Use of penlight to test EOMI in 6 cardinal directions  Cranial Nerve V – Trigeminal (motor and sensory) – Sensation of face, chewing, corneal reflex ◦ Motor – innervates masseter and temporalis muscles Have student clench their mouth, move jaw side to side, palpate TMJ ◦ Sensory - Can student feel touch on cheek & forehead with eyes closed.  Cranial Nerve VI – Abducens (motor) – movement of eye ◦ Innervates lateral rectus muscle for lateral movement of eye (looking side to side) ◦ TEST: Use of penlight to test EOMI in 6 cardinal directions

19.  Cranial Nerve VII – Facial (motor and sensory) – facial movements and symmetry ◦ Innervates temporal and masseter muscles ◦ Have student smile, frown, puff cheeks, open/shut eyes, show teeth, raise eyebrows ◦ Bell’s palsy is peripheral CN7 dysfunction  Cranial Nerve VIII – Acoustic & Equilibrium (sensory) ◦ Carries sound impulses from cochlea to brain ◦ Whisper test ◦ Tuning fork for Weber Test  conductive hearing deficit, the Webber will lateralize to the affected ear. BC>AC  sensorineural deficit, the Webber will lateralize to the normal ear AC>BC  Cranial Nerve IX – Glossopharyngeal - (motor and sensory) ◦ Check for gag reflex ◦ Have student say “Ahhh”. Check uvula. Is it midline?

20.  Cranial Nerve X – Vagus (motor and sensory) – Swallow, voice, defecation ◦ Have student swallow  Cranial Nerve XI – Spinal Accessory (motor) - ◦ Have student shrug shoulders ◦ Have student turn cheek into your hand  Cranial Nerve XII – Hypoglossal (motor) tongue movement ◦ Have student move their tongue, is it midline?

21.  Purpose of these tests is to note any abnormality  If a test is abnormal – it denotes a possible problem with the specific cranial nerve.  Most often, these tests will be completely normal in the school setting.  Occasionally – you will see an “abnormality” (i.e. - anisocoria) that is NORMAL for the student.  CN testing still helpful in determining a possible injury or abnormality. ESPECIALLY pupillary reaction to light and pupillary size.

22.  Assess motor strength bilaterally – looking for variations from L to R– possibly indicating dysfunction  Observe: Major muscle groups for symmetry/atrophy  Tests: ◦ Flex and extend arm against your hand ◦ Squeeze your fingers ◦ Lifting their leg against your hand while you exert downward pressure on their thigh ◦ Pushing their leg down against your hand while you push up. ◦ Plantar flexion and dorsiflexion of foot against your hand

23. Grade strength on the following scale ◦ +5 - full ROM, full strength ◦ +4 - full ROM, less than normal strength ◦ +3 - can raise extremity but not against resistance ◦ +2 - can move extremity but not lift it ◦ +1 - slight movement ◦ 0 - no movement Other motor functioning test: Pronator Drift -Have student stand with palms facing ceiling and eyes closed. If hands/arms turn inward (pronation) or start to drift down, the limb is weak (possible nerve damage)

24.  Evaluates student’s ability to perceive and identify sensations with their eyes closed.  TEST ◦ Using a variety of sensations (sharp vs. dull/soft touch) – alternate between right and left sides of the body – working your way from face to feet.

25.  Proprioception ◦ Have student close eyes, move the big toe up or down and have student tell you which direction you are moving it in  Stereognosis ◦ Have student close eyes and place an object in their hand (key or money) and have them tell you what the object is  Vibration sense ◦ Place tuning fork on finger joint or on joint of toe – have them tell you when vibration stops.  May also test hot vs. cold sensation

26.  Not routinely assessed in the school setting.  Should be assessed if a spinal cord injury is a concern (however, would be calling 911)  Achilles (S1, S2)  Patellar (S3, S4)  Biceps (C5, C6)  Triceps (C7, C8)  Babinski reflex (great toe dorsiflexion and other toes fan out)  Graded on a scale 0-4 (0 being absent, 2+ is normal, 4 hyper reflexive)

27.  Examining overall balance and coordination  Testing ◦ Observe normal gait, toe, heel and tandem walking (tandem walk >5yr) ◦ Finger, nose, finger exam ◦ Rapid alternating movement ◦ Romberg test  Eyes open, feet together, hands at sides – no swaying  Eyes closed, feet together, hands at sides  If there is swaying – positive Romberg test

28.  Are the vital signs consistent and within normal limits, or are they beginning to change?  Is the student’s mental status impaired? Has it changed during the exam?  Based on observations and testing – does there seem to be any impairment or deficit?  Have you noticed any change at all in the overall evaluation of your student?  The neurological exam can assist in answering these questions.  While the CSN cannot diagnose – they can come up with differential diagnoses and determine the severity of the situation.

29.  Haslam, Robert H. A. "The Nervous System." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2004.  http://www.healthcommunities.com/brain-nerve-tests/what-is-a-neuro-exam.shtml zz4Gbw0G7Xs http://www.healthcommunities.com/brain-nerve-tests/what-is-a-neuro-exam.shtml zz4Gbw0G7Xs  http://www.healthofchildren.com/N-O/Neurologic-Exam.html#ix http://www.healthofchildren.com/N-O/Neurologic-Exam.html#ix  http://www.jems.com/articles/2008/10/brain-injury-basics-0.html http://www.jems.com/articles/2008/10/brain-injury-basics-0.html  http://www.modernmedicine.com/modern-medicine/content/neurological-assessment- refresher http://www.modernmedicine.com/modern-medicine/content/neurological-assessment- refresher  neurologic examination. (n.d.) Mosby's Medical Dictionary, 8th edition. (2009). Retrieved August 5 2016 from http://medical-dictionary.thefreedictionary.com/neurologic+examinationhttp://medical-dictionary.thefreedictionary.com/neurologic+examination  http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/The-Complete- Neurological-Examination.aspx http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/The-Complete- Neurological-Examination.aspx

30. Thank you!