1. The Neurological System

2. Neurological Exam 5 Components
Mental status
Cranial nerves
Reflexes
Motor- includes Cerebellar function
Sensory

3. Mental Status Examination
Examination - ABCT
Appearance
Behavior
Cognition
Thought processes (thought content & perceptions)
Mini Mental State Exam
Glasgow Coma Scale
Appearance – posture, position, dress, grooming and hygeine
Behavior – level of consciousness, facial expression, speech, mood and affect
Cognitive functions – orientation x4
Attentions span, recent and remote memory, judgement
Thougt processes - Thought process should be realistic and cosistent with reality
thought content – should be consistent and logiceal
perceptions – should be consistent with reality (how he thinks people treat him, hearing name called when alone etc)
Screen for suicidal thoughts
MMSE – screening exam assesses judgement, calculation, abstraction, memory etc. –get a score
STANDARD SET OF 11 QUESTIONS (5-10 MINUTES)
CAN BE USED AT INTERVALS TO SEE PROGRESS OR DETERIORATION OF CONDITION
GLASGOW – ASSESSES LOC

4. Assessing LOC: Glasgow Coma Scale
Eye opening
Verbal responsiveness
Motor responsiveness
Glasgow Coma Scale (p.732, Jarvis)
Used to describe level of consciousness by given a quantitative value
Best eye response: spontaneous  no response (4-1)
Best motor: obeys  no response (6-1)
Best verbal: oriented x3  no response (5-1)
Fully alert: total score of 15
Coma: total score of 3

5. Glasgow Coma Scale Eyes 4 Spontaneous 3 To speech 2 To pain
1 No response

6. Levels of Consciousness
Physical Examination
Levels of Consciousness
Alert- awake or easily aroused
Lethargic- not fully alert, drifts off when not stimulated
Obtunded- sleeps most times, difficult to arouse (loud noise, vigorous shaking or pain)
Stupor- need persistent loud noise or pain for arousal; responds to stimuli
Coma- no response
(Jarvis CH 2)
Order of deterioration of LOC
A & O alters: first to time, then place, then familiar persons, last to self
lose ability obey simple commands
then responses deteriorate from purposeful to purposeless responses to pain
then absence of response to pain
then loss of corneal and gag reflexes

7. Cranial Nerves
“ On old Olympus’ Towering Tops a Finn and German Viewed some hops.”
I – Olfactory VII - Facial
II – Optic VIII – Auditory (V-C)
III – Occulomotor IX - Glossopharyngeal
IV – Trochlear X - Vagus
V – Trigeminal XI – Spinal Accessory
VI – Abducens XII - Hypoglossal

8. Neurological: Physical Examination Sensory System Function
With eyes closed
Interpret sensations
Discriminate side to side
Examine in detail if:
Reduced sensation
Numbness or pain
Motor or reflex abnormal
Skin changes
Be specific: “tell me where I touch”
Check both sides

9. Physical Examination Sensory Function Tests: Touch Vibration
Light touch 1st then Pain & Temperature
Vibration
Proprioception: Position sense
Stereognosis
Graphesthesia
2-point discrimination

10. Sensory Function Tests: Sensory Exam: Light Touch
Light touch – assessing the trigeminal nerve CN V

11. Sensory Function Tests: Sensory Exam: Vibration

12. Sensory Function Tests: Proprioception: Position sense

13. Sensory Function Tests: Stereognosis
Cortical
Stereognosis
Identify familiar object in hand
Two-point discrimination
One point or two points simultaneously touched
At what point cant discriminate between two points
Graphesthesia
Draw letter or number in palm of client’s hand
Test other hand with different figure

14. Sensory Function Tests: Graphesthesia

15. Sensory Function Tests: Two-point discrimination

16. Sensory Function Tests: Dermatomes

17. Motor Examination Symmetry, size, and presence f involuntary movements
Full ROM of joints
Check strength against resistance
Neuro patients: Assess hand grips and foot pushes if bedridden
Muscle bulk, strength and tone
C1-4: Neck and shoulder
C5-8, T1: Arm, hand, fingers
L1-5: Hip and leg
L4-5, S1-2: Foot and toe
S2-4: Anus/rectum

18. Heel to toe in straight line Walking on toes and heels Hop on one foot
Cerebellar Function
1. Gait and posture
Heel to toe in straight line
Walking on toes and heels
Hop on one foot
Note width of gait
Ex: traffic school – show videos of sobriety test – walk in straight line, finger to nose

19. Cerebellar Function, con’t
2. Coordination of hands and legs
RAM
nose to examiner’s finger
heel to shin coordination
Note smoothness of motion
Perform bilaterally

20. Cerebellar Function, con’t RAM

21. Cerebellar Function, con’t Nose –to - Finger Test
Ex sobriety test

22. Cerebellar Function, con’t Heel to Shin

23. Cerebellar con’t Romberg:
Stand upright, place feet together, then close eyes
loss of balance means + Romberg test
Be prepared to protect client from falling!
pronator drift—test for proprioception
+ means loss of balance (in ataxia)
Eyes open and fall—cerebellar disorder
Eyes closed and fall—posterior column disorder / altered proprioception

24. 4 types of Reflexes Superficial (abdominal reflex, Cremasteric reflex)
Visceral (pupillary response to light) PERRL
Pathologic
+ Babinski in adults
DTRs (e.g. knee)
Cremastic Reflex

25. Reflexes-Cont: PERRL/PERRLA

26. Reflexes-Cont: Babinski’s Reflex (Adult)
If assessing a comatose patient for deterioration, check for Babinski response
Babinski sign- dorsiflexion of big toe and fanning of other toes is abnormal (Positive); (should curl in adults)
in infancy this is normal

27. Reflexes-Cont: Reflex Arc – Deep Tendon Reflex
Helps maintain muscle tone
Permits quick response to bad stimuli
components needed for DTR response:
Intact sensory nerve (afferent)
A functional synapse in the cord
An intact motor nerve fiber (efferent)
The neuromuscular joint
A competent muscle

28. Reflexes-Cont: Deep Tendon Reflexes
Technique
Position limb so muscle is slightly stretched
Reflex hammer should strike tendon briskly to stretch tendon
Get patient to relax
Assesses receptor organ, relay nerves, cord
Deep Tendon Reflexes
With client relaxed in supine or sitting position
Position extremity with slight tension on the tendon to be tested
Distract client by having them contract another muscle group
Palpate the tendon then briskly tap tendon with reflex hammer using a flicking motion
Watch for muscle contraction
Evaluate each tendon bilaterally
Score the reflex from 0 (no response) to 4+ (hyperactive with intermittent clonus)

29. BICEPS BRACHIORADIALIS ACHILLES/PLANTAR TRICEPS PATELLAR
Flex the client’s arm to a 45 degree angle
Rest forearm in your arm with client’s hand slightly pronated
Strike tendon at about 1 – 2 inches from wrist with reflex hammer
Should cause pronation of the forearm and flexion of the elbow
Biceps:
Flex arm at elbow with forearm on thigh, palm up. Place thumb firmly on the biceps tendon in the antecubital fossa then strike thumb with hammer. Elbow and foream should flex and biceps muscle should contract.
Triceps
Flex elbow at 90 degrees angle palm down. Support wrist as you strike your thumb with hammer. The elbow and the forearm should flex and the biceps muscle should contract.
Patellar:
Sit on edge of table, legs relaxed and hanging down, freely swinging. Strike the patellar tendon just below the knee and above the tibial tuberosity. Check for quadriceps contraction and knee extension.
Achilles (Plantar Response)
Knee slightly flexed and foot dorsiflexed. Support foot with your palm, then strike the achilles tendon, observing for or feeling plantar flexion
TRICEPS
PATELLAR
DEEP TENDON REFLEXES

30. Grading of DTRs 4+ very brisk 3+ brisker than average
2+ average, normal
1+ diminished, low normal
0 no response
Know grading of dtr’s

33. Assessment Guide: Neurological
LOC: alert, comatose, lethargic, obtunded
GCS
Eye opening: spontaneously, to speech, to pain
Verbal Response: oriented, confused, inappropriate, incomprehensible
Motor Response: obeys, command, localizes pain, withdraws, flexion, extension

34. Assessment Guide : cont..
Seizure
Describe: tonic clonic, absence, status epilepticus
Timing: once at 10 am; 2 pm and 2:45 pm

35. Altered mental status: yes, no Aphasia: present, none
Intelllectual functioning: intact; short attention span, dementia, memory loss
Itnerventions in use:
Seizure precautions: side rails padded, oral airway at bedside
Med List: Klonopin, Aricept, Neurontin, Dilantin, etc.

40. Documentation
Appearance: Posture is erect, body movement is symmetrical and smooth, dress appropriate for setting; is clean and well groomed.
Behavior: alert, in good spirits, speech clear
Cognition: oriented x4, attentive, recent and remote recall intact
Thought processes and perceptions - appropriate

41. Documentation – cont.
Cerebellar function: Gait is balanced, good gross motor coordination (heel to toe walking), negative Romberg test
Coordination and skilled movements: RAM, Finger to finger, finger to nose, and heel to shin test smooth, and accurate
Spinothalamic tract: sensation to light touch intact

42. Documentation – cont.
Posterior column tract: vibration, position sense, stereognosis, graphesthesia, and point location intact.
DTRs: all DTRs intact, 2+ bilaterally.