2. NEUROLOGICAL ASSESSMENT

3. INTRODUCTION:
Neurological assessment was traditionally carried out to assess the extent of impairment to a particular skill and to attempt to determine the area of the brain which may have been damaged following brain injury or neurological illness.

4. DEFINITION
1) A neurological assessment looks at the functioning of the Brain and is conducted by a clinical psychologist. It is not a medical procedure and does not involve brain scans, blood tests, injections or other procedure. It forms one of a holistic assessment and treatment plans.
  According to Dictionary.

5. I. Level of consciousness I. Level of Consciousness:-
A person’s level of consciousness exists along a continuum from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli.

6. Cont...
Talk with the client, asking questions about events involving the clients or concerns about any health problem. A fully conscious client respond to question quickly and expression idea logically.

7. Cont...
- Alert
- lethargic
- Stuporus
- Semi-comatose
- Score Glasgow coma scale

8. Glasgow coma scale (GCS)
The Glasgow coma scale allow evaluation of the client’s neurological status over time.
The higher score, the better the client’s neurological functions.

9. Eye opening
Spontaneously - 4
To speech
To pain
None

10. Verbal response Confused - 4 Inappropriate word-3 Incomprehensible - 2
Oriented
Confused
Inappropriate word-3
Incomprehensible - 2
sounds
None

11. Motor response Localization pain - 5 Flexion withdrawal - 4
Obeys commands
Localization pain
Flexion withdrawal - 4
Abnormal flexion
Abnormal extension - 2
Flaccid

12. Mental status examination
General appearance
Speech
Thought process
Mood
Cognitive functions
- Attention and concentration
Serial 7
- Digit span – backward, forward
- Orientation
Time
Place
Person

13. Memory - Immediate - Recent Cont..... Abstract reasoninig Judgement
- Remote
General knowledge
Abstract reasoninig
Judgement
Insight.

14. BEHAVIOUR AND APPEARANCE
Behaviour, moods, hygiene, grooming, and choice of dress reveal pertinent information about mental Status.
Does the client respond appropriately to directions? Does the client’s mood vary with no apparent cause? Does the client show concern about appearance? Is the client’s hair clean and neatly groomed, and are the nails trim and clean?

15. Cont....
Avoid being judgmental, and focus assessment on the appropriateness of clothing for the weather.
Older adults sometimes neglect their appearance because of lack of energy, finances, or reduce vision.

16. Cerebral function

17. THERE ARE TWO TYPES OF CEREBREAL FUNCTIONS-
1) Special cerebral functions-
2)Cerebral functions -

18. Agnosia

19. Apraxia

20. Aphasia

21. Assessment of cerebral functions
Finger to finger test – normal/abnormal
Finger to nose test- normal/abnormal
Romberg test – normal /unable to perform
Tandem walking test- normal /unable to perform

22. Cont....
Finger to finger test – normal/abnormal

23. Finger to nose test-

24. Romberg test – normal /unable to perform.
Cont....
Romberg test – normal /unable to perform.

25. Cont....
Tandem walking test- normal /unable to perform

26. INTELLECTUAL FUNCTION:
Intellectual functions includes memory (recent, immediate, and past), knowledge, abstract thinking, association, and judgement.
Testing each aspect of function involves a specific technique. However, because cultural and educational background influences the ability to respond to test questions, do not ask questions related to concepts or ideas with which the client is unfamiliar.

27. Memory
Knowledge
Abstract thinking
Association
Judgement

28. MEMORY:
Assess immediate recall and recent and remote memory. Client demonstrate immediate recall by repeating a series of numbers in the order they are presented or in reverse order.
Clients normally recall a series of five to eight digits forward and four to six digit background.

29. KNOWLEDGE:-
Assess knowledge by asking how much the client knows about his or her illness or the reasons for seeking health care. By assessing a client’s knowledge, a client’s ability to learn or understand can be determined. If there is a an opportunity to teach, test the client’s mental status by asking for feedback during a follow-up visit.

30. ABSTRACT THINKING:
Interpreting abstract idea or concepts reflects the capacity for abstract thinking. For an individual to explain common phrases such as –
“ A stitch in time saves nine” “don’t count your chickens before they’re hatched” requires a higher level of intellectual function. Note whether the client’s explanations are relevant and concrete.  

31. Eg.- A dog is to be a beagle as a cat is to be a siamese.
ASSOCIATION -
Another higher level of intellectual functioning involves finding similarities or associations between concepts:-
Eg.- A dog is to be a beagle as a cat is to be a siamese.

32. JUDGMENT: -
Judgment requires a comparison and evaluation of facts and idea to understand their relationship and to form appropriate conclusions.
Attempt to measures the client ability to make logical decisions with questions such as-
“what would you do if you become ill at home ?” normally a client makes logical decisions.

33. IV. Cranial nerve examination: -
To assess cranial
Nerve function,
you may test
all 12 cranial nerves
or a single nerve
or related group
of nerves.

34. Olfactory nerve(sensory)
Cont...
Olfactory nerve(sensory)
:- sense of smell - present/ absent (ask client to identify different non-irritating aromas such as coffee and vanilla. )

35. 2. Optic nerve (sensory): visual acuity - Inspection of eye - inflammation/ cataract/ foreign bodies / any abnormalities - Visual acuity (Snellen’s chart) - Visual field examination – right eye, left eye. - Opthalmoscope examination - Color vision – present / absent

36. Snellen’s chart

37. Opthalmoscope examination
Also called fundoscopy.
- blood vessels.
- Retina
- Optic disk

38. Color vision

39. 3. Oculomotor(motor): - Extraocular eye movement
- Assess the direction of gaze.

40. Direction of gaze

41. Cont... 4. Trochlear (motor);- - pupil constriction and dilatation
- upward and downward movement of eyeball
(measure puppillary reaction to light reflex and accommodation and Assess the direction of gaze.)

42. Cont...
5. Trigeminal nerve (sensory and motor): Sensory nerve to skin of face -
- Corneal reflex – present/absent
- Facial sensory response- present/absent
- Mandibular strength- adequate / hypotonia

43. Trigeminal nerve -

44. Cont..
6.Abducent nerves(motor): [Motor nerve to muscles of jaw ] [Lateral movement of eye ball ] - Pupillary reaction to light – reacting /not reacting - Pupillary size – equal / unequal - Eye movement in six directions – (Lightly touch cornea with wisp of cotton. Assess corneal reflex. Measures sensation of light pain and touch across skin of face.)

45. Cont.... 7. Facial nerve (sensory and motor)
- facial expression – normal/ hypotonia
- Taste sensation – present / absent
(a client smiles, frowns, puffs out cheeks, and raises and lower eyebrows, looks for asymmetry.)

46. Cont... 8. Vestibule cochlear nerve (sensory) -Hearing
- Auditory acuity test
- air conduction
- bone conduction
(Assess ability to hear spoken word.)

47. Cont... 9.Glassocopharyngeal and Taste
- sensation of taste- present/ absent
- swallowing reflex - present/ absent
(ask the client to identify sour or sweet taste on back of tougue.)

48. 10.Vagus nerve (sensory and motor) Sensation of pharynx
Conti...
10.Vagus nerve (sensory and motor)
Sensation of pharynx
(ask the client to say “ah.” Observe movement of palate and pharynx.)

49. Cont.... 11.Spinal accessory nerve (motor)
-Movement of head and shoulders
- sternocleidomastoid muscle strength- normal/ hypotonia
- elevation of shoulders- adequate strength/ weakness
- turning of head- adequate/ inadequate
(ask the client to shrug shoulder and turn head against passive resistance.)

50. Cont... 12. Hypoglossal nerve (motor):Position of tongue
- tongue movement – normal/ abnormal
(ask the client to stick out tongue to midline and move it from side to side. )

51. Motor function assessment:
An assessment of motor function include measurements made during the musculoskeletal examination. In addition, you assess cerebellar functions. The cerebellar coordination muscular activity, maintains balance and equilibrium, and controls posture.

52. CONT.... -Muscle size -Muscle strength -Muscle tone
- Muscle co-ordination
-Gait
- Movement of all the joints
-Deformities
-Abnormal movements

53. Coordination:-
To assess fine motor functions, have the client extend the arms out to the sides and touch each forefinger alternately to the nose (first with eyes open, then with eye closed). Normally the client alternately touches the nose smoothly. Performing rapid, rhythmical, alternating movement demonstrates coordination in the upper extremities.
- While sitting, the client begins by patting the knees with both hands, then the clients alternatively turns up the palm and back of the hand while continuously patting the knees.

54. CONT....
-An additional maneuver for upper extremity coordination involves touching each finger with the thumb of the same hand in rapid sequence.
The client’s moves from the index finger to the little finger and back, with one hand tested at a time. The client’s dominant hand is slightly less awkward when performing this movement. Movement is smooth and in succession

55. Balance -
Have the client perform a Romberg’s test by standing with feet together, arm at the sides, both with eye open and eye closed.
a loss of balance (positive romberg) causes a client to fall to the side. Normally the client does break the stance.

56. REFLEXES: 1) Superficial reflexes- present / absent
Abdominal/planter/corneal/pharyngeal/ anal.
2) Deep tendon reflexes- present / absent
Biceps/triceps/brachioradial/patellar.
3) Any abnormal reflexes- present / absent.

58. Pharyngeal muscles

59. Biceps/Triceps

60. Brachioradialis

61. Sensory function assessment

62. SUMMARY

63. BIBLIOGRAPHY
1. Psychiatric Mental Health Nursing, Concept of care in evidence based practice, 6th edition, Mary C. Townsend.
2. Essentials of Mental Health and Psychiatric Nursing, K.P. Neerja, Jaypee, Vol. –One.
3. Essentials of Mental Health Nursing for B.Sc. and post B.B.Sc. Nursing Students Pawan Sharma, Jaypee Brother.
4. Psychiatric Mental Health Nursing, Katherine M. Fortinash Patricia A. Holgday worret, Mos by 3rd edition.
5. Sreevani R. “A guide to mental health and psychiatric nursing” second edition, jaypee publication .