neurological assessment.ppt
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Health & Physical Assessment in Nursing, Second Edition
onita !A"ico # Colleen $arbarito
%eurological Assess"ent%eurological Assess"ent
&ecture '&ecture '
&ecture '&ecture '
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Health & Physical Assessment in Nursing, Second Edition
onita !A"ico # Colleen $arbarito
%ervous Syste"%ervous Syste"
Central Nervous System
•Brain
•Spinal cord
Peripheral Nervous System
•Cranial nerves
•Spinal nerves
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Health & Physical Assessment in Nursing, Second Edition
onita !A"ico # Colleen $arbarito
Central Nervous System-BrainCentral Nervous System-Brain
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Health & Physical Assessment in Nursing, Second Edition
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Central Nervous System-Spinal CordCentral Nervous System-Spinal Cord
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Peripheral Nervous System-12 Pairs of Cranial NervesPeripheral Nervous System-12 Pairs of Cranial Nerves
• Originate in the brain
• Control many activities in
the body
• Tae impulses to and from
the brain
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Figure 24.4 Cranial nerves and their target regions. (Sensory nerves are sho)n in blue* "otor nerves, in red.+
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able
2-.1Cranial
Nerves
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Peripheral Nervous System-Spinal nervesPeripheral Nervous System-Spinal nerves
• 1 pairs o/ spinal nerves
' pairs o/ cervical nerves
12 pairs o/ thoracic nerves
pairs o/ lu"bar nerves
pairs o/ sacral nerves
1 pair o/ coccygeal nerves
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Health & Physical Assessment in Nursing, Second Edition
onita !A"ico # Colleen $arbarito
Dermatome: band
o/ sin innervated bythe sensory root o/ asingle spinal nerve
SP!N"# N$%&$SSP!N"# N$%&$S
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Co""on or Concerning Sy"pto"sCo""on or Concerning Sy"pto"s
o/ the %ervous Syste"o/ the %ervous Syste"• Observing mental status' speech' and language
• Observing sensorium' memory' abstract thining ability' speech' mood'
emotional state' perceptions' thought processes' ability to mae (udgments
•
)eadache• *i++iness or vertigo
• ,eaness
• Numbness
•
#oss of sensations• #oss of consciousness
• Sei+ures
• Tremors or involuntary movements
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Health & Physical Assessment in Nursing, Second Edition
onita !A"ico # Colleen $arbarito
Physical Assess"ent o/ thePhysical Assess"ent o/ the
%eurologic Syste"%eurologic Syste"
• Testing cranial nerves
• Testing otor function
• Testing Sensory function
• Testing %efle.es
/"l0ays consider left to right symmetry
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Health & Physical Assessment in Nursing, Second Edition
onita !A"ico # Colleen $arbarito
Areas o/ the %eurologic Syste" Areas o/ the %eurologic Syste"
Assess"ent Assess"ent
• esting cranial nerves
I
II
III
I3
3
3I
3II
3III
I4 4
4I
4II
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onita !A"ico # Colleen $arbarito
l. Olfactory: smelll. Olfactory: smell
• Client both eyes and one naris are closed
• Place a strong smelling item under each nostril
individually and as the person to identify it
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onita !A"ico # Colleen $arbarito
ll. Optic: visionll. Optic: vision
• &isual acuity
-*istance3Central vision4 Snellen eye chart
-Near vision /hand-held card
• $.amine the Optic 5undi by using the Ophthalmoscope
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• 3isual acuity
6 *istance3Central vision4 Snellen eye chart7
position patient 28 feet /9 meters from the
charto Patients should 0ear glasses if needed
o Test one eye at a time
Eyes echni5ues o/ E6a"inationEyes echni5ues o/ E6a"ination
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Eyes echni5ues o/ E6a"inationEyes echni5ues o/ E6a"ination
• 3isual acuity
6 Near vision4 use /:aeger or
%osenbaum chart /hand-held card
6 can also use to test visual acuity at
the bedside
6 hold 1; inches /about
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lll Oculomotor lll Oculomotor
l& Trochlear l& Trochlear
&l "bducens&l "bducens
• Test $.traocular ovements
• Test direct and consensual pupillary reaction to light
• "ccommodation
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# $.traocular movements3si. cardinal directions of ga+e30agon
0heel method
# The client must eep the head still 0hile follo0ing a pen that you 0ill move in several
directions to form a star in front of the client=s eyes
# "l0ays return the pen to the center before changing direction
Eyes echni5ues o/ E6a"inationEyes echni5ues o/ E6a"ination
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# Acco""odation An ob7ect held about 10 c" /ro" the client!s nose
Eyes echni5ues o/ E6a"inationEyes echni5ues o/ E6a"ination
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V. TrigeminalV. Trigeminal
• Bilaterally palpate temporal and masseter muscles0hile patient clenches teeth
• /Sensation "s client to closed his eyes and test
forehead' each chee' and (a0 on each side for sharpor dull /use a cotton s0ab sensation *irect the client
to say >no0= every time the cotton is felt
• /%efle. ,ith the individual?s eyes open and looing
up0ard' the practitioner taes a strand of cotton'
approaches the cornea from the side' and touches it
0ith the cotton This should initiate a blin response
Both eyes should be tested independently
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Health & Physical Assessment in Nursing, Second Edition
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Vll. FacialVll. Facial
• "s the client to close both eyes and eep them closed Try to openthem by retracting the upper and lo0er lids simultaneously and
bilaterally
•
"s patient to raise eyebro0s' sho0 teeth' grimace' smile' puff bothchees /"ssess face for asymmetry' abnormal movements
• @se the s0eet' salty' sour and bitter items to test taste /Bet0een each
solution the mouth needs to be rinsed 0ith 0ater
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Health & Physical Assessment in Nursing, Second Edition
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Vlll. AcousticVlll. Acoustic
• ,eber Test /by using a tuning for
• %inne test4 to compares air and bone
conduction
• %omberg test4 "s the patient to remain
still and close their eyes /for about 28
seconds
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Ears 8earing acuityEars 8earing acuity
6 Rinne
o Compare time of air vs bone conduction
o Place the base of the tuning for on the
client=s mastoid process- and note the
number of seconds
o Then move the for in front the e.ternal
auditory meatus /1-2 cm
Air and bone conduction (AC and BC)
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lA lossopharyngeallA lossopharyngeal
A &agusA &agus
• "s the client to open the mouth' depress theclient=s tongue 0ith the tongue blade' as the client
to say ah @sually' the soft palate raises and the
uvula remains in the midline
• Observe the individual s0allo0ing
• Test gag refle.' 0arning patient first
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#A #OSSOP)"%DN$"##A #OSSOP)"%DN$"#
A &"@SA &"@S
"s the client to open the mouth' depress the client=s tongue 0ith the tongue blade'as the client to say ah @sually' the soft palate raises and the uvula remains in
the midline
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All )ypoglossalAll )ypoglossal
• Ask patient to protrude tongue and move it sideto side. Assess for symmetry, atrophy.
A / th % l i S tA / th % l i S t
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Areas o/ the %eurologic Syste" Areas o/ the %eurologic Syste"
Assess"ent Assess"ent
• 9otor /unction
:bservation o/ gait and balance
Ad"inistration o/ the ;o"berg test
Ad"inistration o/ the /inger
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:bservation o/ gait and balance
As the client to )al across the roo" and return
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;o"berg!s test /or balance.
As the patient to re"ain still and close their eyes (/or about 20 seconds+.
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=inger
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:bservation o/ rapid alternating action "ove"ents
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Health & Physical Assessment in Nursing, Second Edition
onita !A"ico # Colleen $arbarito
Areas o/ the %eurologic Syste" Areas o/ the %eurologic Syste"
Assess"ent Assess"ent
• Sensory /unction
:bservation o/ light touch identi/ication
Sharp, dull deter"ination
Stereognosis
>raphesthesia (%u"ber identi/ication+
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Health & Physical Assessment in Nursing, Second Edition
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onita !A"ico # Colleen $arbarito
esting the client!s ability to identi/y sharp sensations.
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Health & Physical Assessment in Nursing, Second Edition
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Health & Physical Assessment in Nursing, Second Edition
onita !A"ico # Colleen $arbarito
Areas o/ the %eurologic Syste" Areas o/ the %eurologic Syste"
Assess"ent Assess"ent
• ;e/le6es /Stimulus-response activities of the body/
$iceps
riceps
$rachioradialsis
Patellar (nee+
Achilles
Plantar ($abinsi+.
Abdo"inal
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esting the biceps re/le6.
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esting the triceps re/le6.
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esting the brachioradialis re/le6.
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esting patellar (nee+ re/le6, client in a sitting position.
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esting the plantar re/le6 ($abinsi+.
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Abdo"inal re/le6 testing pattern.
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REFE!E": "CAE F#R $RAD%N$REFE!E": "CAE F#R $RAD%N$
;e/le6es are usually graded on a 0 to - scale
- 3ery bris, hyperactive, )ith clonus (rhyth"ic oscillationsbet)een /le6ion and e6tension+
$riser than average* possibly but not necessarily indicative o/disease
2 Average* nor"al
1 So"e)hat di"inished* lo) nor"al
0 %o response
Areas o/ the %eurologic Syste"Areas o/ the %eurologic Syste"
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Areas o/ the %eurologic Syste" Areas o/ the %eurologic Syste"
Assess"ent
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