focused neurological assessment

7/31/2019 Focused Neurological Assessment

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Presented by:

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This course has been awarded two (2.0) contact hours.This course expires on October 5, 2008.

Copyright 2004 by RN.com.All Rights Reserved. Reproduction and distribution

of these materials are prohibited without theexpress written authorization of RN.com.

First Published: October 5, 2004 Revised: October 5, 2006

RN.coms Assessment Series:Focused Neurological

Assessment


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Acknowledgements ________________________________________________________3

Purpose & Objectives ______________________________________________________4

Introduction ______________________________________________________________5

Focused Neurological History _______________________________________________6

Adult Patient ____________________________________________________________6

Infant, Pediatric, and Aging Considerations __________________________________7

The Complete Neurologic Exam______________________________________________8

Mental Status ___________________________________________________________8

12 Cranial Nerves ________________________________________________________8

Inspect and Palpate the Motor System______________________________________13

Check Cerebellar Function _______________________________________________14

Assess the Sensory System ______________________________________________15

Assess the Spinothalmic Tract ____________________________________________15

Assess Posterior Column Tract ___________________________________________16

Check the Reflexes______________________________________________________17

The Neurological Recheck or Abbreviated Neuro Exam _________________________19

Motor Function _________________________________________________________19

Pupillary Response _____________________________________________________19

Glasgow Coma Scale ____________________________________________________20

Conclusion ______________________________________________________________21

References ______________________________________________________________22

Post Test Viewing Instructions______________________________________________23


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Acknowledgements

RN.com acknowledges the valuable contributions of

Lori Constantine MSN, RN, C-FNP, a nurse of nine years with a broad range of clinical

experience. She has worked as a staff nurse, charge nurse and nurse preceptor on manydifferent medical surgical units including vascular, neurology, neurosurgery, urology,gynecology, ENT, general medicine, geriatrics, oncology and blood and marrowtransplantation. She received her Bachelors in Nursing in 1994 and a Masters in Nursing in1998, both from West Virginia University. Additionally, in 1998, she was certified as a FamilyNurse Practitioner. She has worked in staff development as a Nurse Clinician and EducationSpecialist since 1999 at West Virginia University Hospitals, Morgantown, WV.


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Purpose & Objectives

When nurses perform a focused neurological assessment it is important to understand thefundamental processes of the brain and nervous system. If there is a disruption to any ofthese processes, the whole body suffers. This course will discuss specific neurological

history questions and exam techniques for an adult patient. Physical exam techniques suchas inspection, palpation, percussion, and auscultation will be highlighted. Additionally,throughout the course, you will learn how alterations in your neurological assessment findingscould indicate potential nervous system abnormalities.

After successful completion of this course, the participant will be able to:

1. Outline a systematic approach to neurological assessment.

2. Discuss history questions which will help you focus your neurological assessment.

3. Describe abnormal neurological assessment findings associated with inspection,auscultation, percussion, and palpation.

Disclaimer

RN.com strives to keep its content fair and unbiased.

The author(s), planning committee, and reviewers have no conflicts of interest inrelation to this course. There is no commercial support being used for this

course.

There is no "off label" usage of drugs or products discussed in this course.

You may find that both generic and trade names are used in courses producedby RN.com. The use of trade names does not indicate any preference of onetrade named agent or company over another. Trade names are provided to

enhance recognition of agents described in the course.

Note: All dosages given are for adults unless otherwise stated. The informationon medications contained in this course is not meant to be prescriptive or all-encompassing.

You are encouraged to consult with physicians and pharmacists about allmedication issues for your patients.


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Introduction

The neurological history and exam allows the examiner to pinpoint various areas of the brainor nervous system that may be dysfunctional. Specific signs and symptoms manifested byyour patient are associated with specific areas of the brain. Nurses observe for signs and

symptoms that may be abnormal and link them to general areas of the nervous system thatmay be causing the disturbance. It is also important to recognize when further neurologicalinjury is manifesting and intervene appropriately. Notifying the physician with your findingswill most likely result in a change in plans for the patient.

Integrate the process of obtaining the neurological history with the steps taken during thecomplete physical examination. It may not be necessary to perform the entire neurologicalexam on a patient with no suspicion of neurological disorders. You should perform acomplete, baseline neurological examination on any patient that has verbalized neurologicalconcerns in their history. Always perform the neuro exam at scheduled or periodic intervalswith any patient that has a neurological deficit (Agone et al., 1997; Jarvis, 1996).

Performing an exam and obtaining a history should becompleted in an orderly, symmetrical fashion. This way,you will be certain that all areas are assessed. Eachside of the body should be compared with the other sideto detect any abnormalities. Also when completing yourshift, it is beneficial to perform a brief exam with theoncoming nurse at the bedside. This process ensuresthat any subjective portion of your exam will not bemisinterpreted by the next examiner. It allows forbaseline neurological status to be ascertained at the

beginning of each shift. Also, any changes in thepatients neurological function will be more rapidlyidentified.

Neuro

Most healthcare providersshorten the term neurologic orneurological to neuro. In this

course neuro will alsorepresent neurological or

neurologic.


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Focused Neurological History

If your patient is mentating normally, you can ask the patient the following history questions.If the patient is not alert and oriented, a family member or friend can provide some of thisinformation. Past medical records may also provide some answers to the following questionsas well.

Adult Patient

When assessing the nervous system with your adult patient, ASK the following:

Any past history of head injury (location, loss of consciousness)? This question may give youclues to underlying neurological damage that may change your patients baseline.

Do you have frequent or severeheadaches (when, where, how often)?Pain is a neurologic phenomenon. Mostpatients do not complain of pain in theneurological history. Their complaints ofpain are mentioned more in associationwith an extremity, back, or headassessment.

Any dizziness or vertigo (frequency,precipitating factors, gradual or sudden)?Syncope is a sudden lack of strength, asudden loss of consciousness usually dueto a lack of cerebral blood flow. It is alsoknown as fainting. Vertigo is experiencedas a rotational spinning. It is usually dueto neurological disorder or an inner eardisturbance.

Have you ever had/or do you have seizures (when did they start, frequency, course andduration, motor activity associated with, associated signs, post-ictal phase, precipitatingfactors, medications, coping strategies)? Seizures typically occur in disorders such asepilepsy. Often, the patient will describe an aura; an auditory, visual, or motor warning of theimpending seizure.

Any difficulty swallowing (solids or liquids, excessive saliva)? Difficult swallowing may clueyou in to a possible abnormality with cranial nerves IX and X.

Any difficulty speaking (forming words or actually saying what you intended)? If the patientanswers yes to this question, then ask when it was first noticed and how long did it last.These questions may clue you in to potential transischemic attacks (TIAs), which may be awarning signal for impending stroke.

Image courtesy of National Aeronautics and SpaceAdministration (NASA)

http://exploration.nasa.gov/articles/05feb_superconductor.html


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Do you have any coordination problems (describe)? Muscle tone and strength may beaffected by both peripheral and central abnormalities.

Do you have any numbness or tingling (describe)? Any abnormal sensations such asnumbness or tingling may be referred to as parasthesias.

Do you have any significant past neurologic history (CVA, spinal cord injuries, neurologicinfections, congenital disorders)? Specific neurological infections include meningitis andencephalitis.

Are you exposed to any environmental or occupational hazards? If so, explain type, length,and nature of exposure. Exposure to insecticides, lead, organic solvents, drugs, and alcoholmay all manifest in neurological symptoms(Jarvis, 1996).

Infant, Pediatric, and Aging Considerations

To obtain the history of an infant or child, the nurse must rely on the parent or caregiver toprovide most of the information. Questions you may wish to ask regarding your infant,pediatric, or aging patient are listed in the table below:

Additional History forInfants

Additional History forChildren

Additional History forElderly Patients

Did the mother have anyhealth problems duringpregnancy?

Does the child have anybalance problems? Anyunexplained falling?Muscle weakness?Difficulty getting up anddown stairs?

Any problems with dizziness?If so when does it occur?

Tell me about the babysbirth? Premature or term?Birth weight? Apnea?

APGAR Scores?

Does the child have anyseizures? Describe thecircumstances aroundwhich they occurred.

Any decrease in memory orchange in mental functioning?

Any congenital defects?Did motor and developmentmilestones occur during theappropriate age range?

Any tremors in your hands orface?

Are sucking and swallowingcoordinated?

Has your child had anyenvironmental exposure to

lead?

Any sudden vision changes orsudden blindness?

Does baby turn his headtoward touch?

Any learning problems inschool?

Any sudden weakness on oneside of the body and not theother?

Does baby startle with aloud noise?

Any family history ofneurological disorders?

Ever experience loss ofconsciousness?

(Jarvis, 1996)


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The Complete Neurologic ExamNot all Patients will require a complete neuro exam. Only patients that describe alterations intheir neuro status or those with altered levels of consciousness will require the most thoroughand complete neuro exam.

When perfoming the complete neuro exam, EXAMINE the following:

Mental Status

The mental status portion of the examination is a series of detailed but simple questionsdesigned to test cognitive ability. This includes:

The patient's awareness and responsiveness to the environment

The senses, appearance and general behavior, mood, content of thought

Orientation with reference to time, place, and person

Most nurses will not find it necessary to perform a detailed mental status exam. Therefore,assessing key parts of cognitive ability will usually be sufficient to ascertain mental status and

level of consciousness in their patients. Nurses should always establish if their patient isoriented to person, place, and time. Additionally, it is important to determine if your patient isalert. If not, how much stimulation is required - calling their name, light touch, vigorous touch,pain? Verbal response to your questions should also be assessed and noted.

Nurses should be aware that many neurological diseases such as dementia can causechanges in intellectual status or emotional responsiveness as well as specific personalityfeatures. If other parts of the neurological exam are within normal limits and you still feel thepatients neurological status is impaired, contacting the patients physician with details aboutthe patients status and a suggestion for a neuro consult may be warranted.

12 Cranial Nerves

The cranial nerves arise directly from the centralnervous system. Most often, a neurological problemis detected through the assessment of these nerves.The cranial nerves are composed of twelve pairs ofnerves that stem from the nervous tissue of thebrain. Some nerves have only a sensorycomponent, some only a motor component, andsome both. The motor components of cranial nervestransmit nerve impulses from the brain to targettissue outside of the brain. Sensory componentstransmit nerve impulses from sensory organs to thebrain. A summary of the functions of the cranialnerves is listed in the table below.


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Cranial Nerve Major FunctionsCranial Nerve I: Olfactory Sensory Smell

Cranial Nerve II: Optic Sensory Vision

Cranial Nerve III: OculomotorSensory and Motor Primarily Motor

Eyelid and eyeballmovement

Cranial Nerve IV: TrochlearSensory and Motor Primarily Motor

Innervates superioroblique eye muscle

Turns eye downwardand laterally

Cranial Nerve V: Trigeminal Sensory and MotorChewing

Face and mouth touchand pain

Cranial Nerve VI: AbducensSensory and Motor Primarily Motor

Turns eye laterallyProprioception (sensoryawareness of part of the

body)

Cranial Nerve VII: Facial Sensory and Motor

Controls most facialexpressions

Secretion of tears andsaliva

Cranial Nerve VIII:Vestibulocochle

ar(auditory)

SensoryHearing

Equilibrium sensation

Cranial Nerve IX:Glossopharyng

ealSensory and Motor

TasteSenses carotid blood

pressureMuscle sense

proprioception, sensoryawareness of the body

Cranial Nerve X: Vagus Sensory and Motor

Senses aortic bloodpressure

Slows heart rateStimulates digestive

organsTaste

Cranial Nerve XI:

Spinal

Accessory

Sensory and Motor

Primarily Motor

Controls trapezius andsternocleidomastoidcontrols swallowing

movementsMuscle sense -proprioception

Cranial Nerve XII: HypoglossalSensory and Motor Primarily Motor

Controls tonguemovements

Muscle sense -proprioception


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When testing the cranial nerves, follow the following guidelines for each cranial nerve.

Cranial Nerve I: Olfactory

Evaluate the patency of the nasal passages bilaterally by asking the patient to breathe inthrough their nose while the examiner occludes one nostril at a time. Once patency is

established, ask the patient to close their eyes. Occlude one nostril, and place a small bar ofsoap or other familiar smell near the patent nostril and ask the patient to smell the object andreport what it is. Make certain that the patient's eyes remain closed. Switch nostrils andrepeat. Furthermore, ask the patient to compare the strength of the smell in each nostril.Very little localizing information can be obtained from testing the sense of smell. This part ofthe exam is often omitted unless there is a reported history suggesting head trauma or toxicinhalation.

Cranial Nerve II: Optic

Begin the exam by first testing visualacuity using a pocket visual acuity chart.Perform this part of the examination in awell lit room and make certain that if thepatient wears glasses, they are wearingthem during the exam. Hold the visualacuity chart 14 inches from the patient'sface, and ask the patient to cover one oftheir eyes completely with one hand andread the lowest line on the chart aspossible. Have them repeat the testcovering the opposite eye. If the patienthas difficulty reading a selected line, askthem to read the line above. Note thevisual acuity for each eye.

Next evaluate the visual fields via confrontation. Face the patient about one foot away, ateye level. Tell the patient to cover their right eye with their right hand and look the examinerin the eyes. Instruct the patient to remain looking you in the eyes and have the patientindicate when the examiner's fingers enter from out of sight, into their peripheral vision.Then, extend your arm and first two fingers out to the side as far as possible. Beginning withyour hand and arm fully extended, slowly bring your outstretched fingers centrally, and noticewhen your fingers enter your field of vision. The patient should indicate seeing your fingers atthe same time you see your fingers. Repeat this maneuver a total of eight times per eye,once for every 45 degrees out of the 360 degrees of peripheral vision. Repeat the samemaneuver to test the other eye.

If you are an advanced practice nurse, you may want to use an ophthalmoscope to observethe optic disc, physiological cup, retinal vessels, and fovea. Note the pulsations of the opticvessels, check for a blurring of the optic disc margin and a change in the optic disc's colorfrom its normal yellowish orange.

Image courtesy of NASA

http://exploration.nasa.gov/articles/22oct_cataracts.html


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Cranial Nerves II & III:

Ask the patient to focus on any object in the distance.Observe the diameter of the pupils in a dimly lit room.Note the symmetry between the pupils. Next, shine apenlight or ophthalmoscope light into one eye at a time

and check both the direct and consensual lightresponses in each pupil. Note the rate of these reflexes.If they are sluggish or absent, test for pupillaryconstriction via accommodation by asking the patient tofocus on the light pen itself while the examiner moves itcloser and closer to their nose. Normally, as the eyesaccommodate to the near object the pupils will constrict.The test for accommodation should also be completed ina dimly lit room.

Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, andAbducens

Instruct the patient to follow the penlight or ophthalmoscope with their eyes without movingtheir head. Move the penlight slowly at eye level, first to the left and then to the right. Repeatthis horizontal sweep with the penlight at the level of the patient's forehead and then chin.Note extra-ocular muscle palsies and horizontal or vertical nystagmus, which would beabnormal. Eye movements should be coordinated and smooth.

Cranial Nerve V: Trigeminal

Begin by first palpating the masseter muscles(muscles of chewing or of the jaw) while youinstruct the patient to bite down hard. Note viaobservation if there is any masseter musclewasting. Next, ask the patient to open theirmouth against resistance applied by the instructorat the base of the patient's chin.

Next, test gross sensation of Cranial Nerve V. Tell the patient to close their eyes and say"sharp" or "dull" when they feel an object touch their face. Using a semi-sharp object and adull object, randomly touch the patient's face with either object. Touch the patient above

each temple, next to the nose and on each side of the chin, all bilaterally. Ask the patient toalso compare the strength of the sensation of both sides. If the patient has difficultydistinguishing pinprick and light touch, then proceed to check the patients ability to sensetemperature and vibration.

Finally, test the corneal reflex using a large Q-tip with the cotton extended into a wisp. Askthe patient to look at a distant object and then approaching laterally, touch the cornea (not thesclera) and look for the eye to blink. Repeat this on the other eye. Often, the patient willblink before the object touches the cornea. This is also normal.

Direct Light Response:

When a light shines into one

eye the pupil constricts.

Consensual Light Response:

When a light shines into oneeye the other eyes pupil willalso constrict.

Palsy:Uncontrollable tremor or quivering

Nystagmus:Rapid oscillation (movement) of the

eye in any direction, but generally in aback-and-forth manner.


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Cranial Nerve VII: Facial Nerve

Inspect the face during conversation and rest noting anyfacial asymmetry including drooping, sagging or smoothing ofnormal facial creases. Ask the patient to raise theireyebrows, smile showing their teeth, frown and puff out both

cheeks. Note asymmetry and difficulty performing thesetasks. Ask the patient to close their eyes strongly and not letthe examiner pull them open. When the patient closes theireyes, simultaneously attempt to pull them open with yourfingertips. Normally the patient's eyes cannot be opened bythe examiner. Once again, note asymmetry and weakness.

Cranial Nerve VIII: Acoustic (Vestibulocochlear)

Assess hearing by instructing the patient to close their eyes andto say "left" or "right" when a sound is heard in the respectiveear. Vigorously rub your fingers together very near to, yet nottouching, each ear and wait for the patient to respond. After thistest, ask the patient if the sound was the same in both ears, orlouder in a specific ear. If lateralization (localization of a functionor activity to one side of the body) or hearing abnormalities exist,and you are a nurse practitioner, perform the Rinne and Webertests. (The Rinne and Weber tests are hearing tests performedusing a vibrating tuning fork.)

Cranial Nerve IX & X: Glossopharyngeal and Vagus

Ask the patient to swallow and note any difficultydoing so. Note the quality and sound of thepatient's voice. Is it hoarse or nasal? Ask thepatient to open their mouth wide, protrude theirtongue, and say "AHH." While the patient isperforming this task, flash your penlight into thepatient's mouth and observe the soft palate, uvula,and pharynx. The soft palate should rise

symmetrically, the uvula should remain midline, andthe pharynx should constrict medially like a curtain.Often the palate is not visualized well during thistask. Ask the patient to yawn, which often providesa greater view of the elevated palate. Use a tonguedepressor and the butt of a long Q-tip to test thegag reflex. Touch the pharynx with the instrumenton both the left and then on the right side,observing the normal gag or cough.

Image courtesy ofhttp://training.seer.cancer.gov/module_anato

my/unit10_3_dige_region1_mouth.html

Facial nerves


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Cranial Nerve XI: Spinal Accessory

Inspect for wasting of the trapezius muscles by observing the patient while standing behindthem. Ask the patient to shrug their shoulders as strong as they can while the examinerresists this motion by pressing down on the patient's shoulders with their hands. Next, askthe patient to turn their head to the side as strongly as they possibly can while the examiner

once again resists with their hand. Repeat this test on the opposite side. The patient shouldnormally overcome the resistance. Note asymmetry.

Cranial Nerve XII: Hypoglossal

Have your patient "stick out their tongue" and move it side to side. Normally, the tongue willbe protruded from the mouth and remain midline. Have the patient say light, tight, dynamiteand note the clarity of each distinct word in pronunciation. Note deviations of the tongue frommidline, a complete lack of ability to protrude the tongue, tongue atrophy, and fasciculation(muscle twitches) on the tongue.

Inspect and Palpate the Motor System

Muscle Size

Does your patient have appropriate size muscles for body type, age, and gender? Atrophy isabnormally small muscles with a wasted appearance. This can occur with disuse, injury,motor neuron diseases, and muscle diseases. Hypertrophy occurs with athletes and bodybuilders. It is characterized by increased size and strength of muscles.

Muscle Strength

Test muscle strength against resistance using a 0 5 scale, with 0 = no movement and 5 =strong muscle strength. Muscle strength should be equal bilaterally.

When testing muscle strength in the arms ask your patient to do the following againstresistance:

Lift arms away from side

Push arms towards side

Pull forearm towards upper arm

Push forearm away from upper arm Lift wrist up; push wrist down

Squeeze examiners finger

Pull fingers apart

Squeeze fingers together


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Finger to Finger Test

Have your patient touch your index finger with theirindex finger, as you move your index finger in the spacearound them. Patients with normal cerebellar functionshould be able to do this without missing the mark.

Finger to Nose Test

Have your patient touch their nose with their index finger of each hand with eyes shut.Patients should be able to do this without missing the mark.

Heel to Shin Test

While standing, have your patient touch the heel of one foot to the knee of the opposite leg.While maintaining this contact, have the patient run the heel down the shin to the ankle. Test

each leg. If your patient misses the mark, lower extremity coordination may be impaired.

Assess the Sensory System

Testing the sensory system checks the intactness ofperipheral nerves, sensory tracts, and higher corticaldiscrimination. Have your patient close his eyes whilechecking sensory perception. Check the following bilaterally:

Light Touch Can your patient feel light touch equallyon both sides of the body?

Sharp/Dull Can your patient distinguish between asharp or dull object on both sides of thebody?

Hot/Cold Can your patient distinguish between ahot or cold object on both sides of thebody?

Assess the Spinothalmic Tract

To assess the spinothalmic tract, various sensory tests may be performed to test your

patients ability to sense pain, temperature, and light touch.

Presence of Pain

Pain can be tested by a simple pin prick to the arms or legs while the patients eyes areclosed. Abnormal findings would include hypalgesia, hyperalgesia, and analgesia.

Sensory neuron

-algesia = sensation


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Temperature

Temperature tests should be performed only if the pain test is normal. To test fortemperature sensation, hot and cold objects are placed on the patients skin at variouslocations bilaterally to test for temperature sensation.

Light touch

With a cotton ball or soft side of a Q-tip, touch the patientsbody bilaterally with their eyes closed. Ask them to indicatewhen you have touched them. Abnormal responses includehypesthesia, anesthesia, and hyperesthesia.

Assess Posterior Column Tract

Assessing the posterior column tract may identify lesions of the sensory cortex or vertebral

column.

Vibration

Test the patients ability to feel vibrations by placing a tuning fork overvarious boney locations on the patients toes and feet. If these areasare normal, then you may assume the proximal areas are also normal.

Position

Position or kinesthesia is tested by having the patient close their eyes and move their big toeup and down. The patient should be able to tell you which way there toes are moving.

Tactile discrimination

Tactile discrimination tests the discrimination ability of the sensory cortex. Stereognosis teststhe patients ability to recognize objects by feeling them. You can place car keys, a spoon, apencil, or other common object in your patients hand. They should be able to identify thatobject by feel only. Graphesthesia is the ability to identify a number gently etched to theirpalm.

Two point discrimination

Two point discrimination tests the brains ability to detect two distinct pin pricks on the skin.An increase in the distance it normally takes to identify two distinct pricks occurs with sensorycortex lesions (Jarvis, 1998; Shaw, 1998).

-esthesia = sensitivity


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Check the Reflexes

Reflexes are involuntary actions in response to a stimulus sent to the centralnervous system. Alterations in reflexes are often the first sign of neurologicaldysfunction such as upper motor neuron disease, diseases of the pyramidal tract,or spinal cord injuries.

Stretch or Deep Tendon Reflexes

Deep tendon reflexes, also known as muscle stretch reflexes, arereflexes elicited in response to stimuli applied to tendons. Normally,when a specific area of the muscle tendon is tapped with a softrubber hammer, the muscle fibers contract. Abnormal responsesmay indicate injury to the nervous system pathways that produce thedeep tendon reflex. Deep tendon reflexes can be influenced by age,metabolic factors such as thyroid dysfunction or electrolyteabnormalities, and anxiety level of the patient. The main spinal

nerve roots involved in testing the deep tendon reflexes aresummarized in the following table:

Reflex Main Spinal Nerve Roots InvolvedBiceps C5, C6

Brachioradialis C6

Triceps C7

Patellar L4

Achilles Tendon S1

Check the deep tendon reflexes with a reflex hammer to stretch the muscle and tendon. Thelimbs should be in a relaxed and symmetric position. Strike the reflex hammer across theselected tendon with a moderate tap. If you cannot elicit a reflex, you can sometimes bring itout by certain reinforcement procedures. For example, have the patient grit their teeth thentry to elicit the reflex again. Or you may have them clench their fists together when checkinglower extremity reflexes. When reflexes are very brisk, clonus is sometimes seen. This is arepetitive vibratory contraction of the muscle that occurs in response to muscle and tendonstretch.

Deep tendon reflexes are often rated according to the following scale:

Rating Reflex Response0 absent reflex

1+ trace, or seen only with reinforcement

2+ normal

3+ brisk

4+ Non-sustained clonus (i.e., repetitive vibratory movements)

5+ sustained clonus


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Deep tendon reflexes are considered normal if they are 1+, 2+, or 3+. Reflexes that areasymmetric, or there is a large difference between the arms and legs, or are rated as 0, 4+,or 5+ abnormal (Jarvis, 1998).

Superficial Reflexes

The following reflexes are considered normal in adults.

Upper Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side.

Lower Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side. Cremasteric: Stroke inner thigh, elicits elevation of testes.

The following reflexes are considered ABNORMAL in adults. Absence of superficial reflexesor unilateral suppression of superficial reflexes often results from upper motor lesionssubsequent to a stroke. Presence of primitive reflexes in adults is often a sign of frontal lobelesions.

Reflex Name Method to Elicit

Babinski Sign Stroking the bottom of the foot elicits fanning (eversion) of big toe.

Chaddock's ReflexWhen the external malleolar skin area is irritated, extension of thegreat toe occurs in cases of organic disease of the corticospinal

reflex paths.Oppenheim's Sign

Scratching the inner side of leg elicits extension of toes. Sign ofcerebral irritation.

Gordon's SignSqueeze the calf muscles and note the response of the great toe.Fanning or extension is considered abnormal.

Hoffman's SignFlexion of the terminal phalanx of the thumb and of the second andthird phalanges of one or more of the fingers when the palmarsurface of the terminal phalanx of the fingers is flicked.

Suck ReflexGently tapping or rubbing the upper lip elicits a reflexive sucking orpuckering response.

Grasp Reflex Stroking the patient's palm, causing him to grasp your fingers. Apositive test occurs when the patient does not let go of your fingers.

Palmomental Sign Rub the thenar eminence (area of palm just below the thumb) ------>elicit reflexive contraction of the muscles of the chin.

(Agone et al., 1997; Jarvis, 1996)

Can you define Ipsilateral?

It means on the same side oraffecting the same side


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The Neurological Recheck or Abbreviated Neuro Exam

Perform the neurological recheck exam at scheduled or periodic intervals with any patientthat has a neuro deficit. This exam is also useful for your inpatient with a head injury orsystemic disease process that may be manifesting as a neuro symptom. When performing

this abbreviated exam, EXAMINE the following, in addition to any previously identifiedneurological deficits noted from the complete exam:

Level of Consciousness (Monitors for signs of increasing intracranial pressure)

Is your patient oriented to person, place, and time?

Is your patient alert? If not, what does it take to get them alert - calling their name, lighttouch, vigorous touch, pain?

Motor Function

Ask your patient to squeeze your fingers with their hands and let go (tests for strength andsymmetry of strength in the upper extremities).

Ask your patient to push and pull their arms toward and away from you when their elbowsare bent. Provide some resistance. (tests for strength and symmetry of strength in upperextremities).

Ask your patient to dorsiflex and plantarflex their feet, while providing some resistance(tests for strength and symmetry of strength in lower extremities).

Ask your patient to perform straight leg raises with and without resistance (tests forstrength and symmetry of strength in lower extremities).

Pupillary Response

Size, shape, and symmetry of both pupils should be the same.

Each pupil should constrict briskly when a light is shined into the eyes.

Each pupil should have consensual light reflex.


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Glasgow Coma Scale

The Glasgow Coma Scale assesses how the brain functions as whole and not as individualparts (Teasdale, 1975). The scale assesses three major brain functions: eye opening, motorresponse, and verbal response. A completely normal person will score 15 on the scale

overall. Scores of less than 7 reflect coma. Using the scale consistently in the healthcaresetting allows healthcare providers to share a common language and monitor for trendsacross time (Jarvis, 1996).

Glasgow Coma Scale

1 = No response

2 = To pain

3 = To speech

Best Eye Opening Response

4 = Spontaneously1 = No response

2 = Extension abnormal

3 = Flexion - abnormal

4 = Flexion withdrawal

5 = Localizes pain

Best Motor Response

6 = Obeys verbal commands

1 = No response

2 = Sounds - incomprehensible

3 = Speech - inappropriate

4 = Conversation - confused

Best Verbal Response

5 = Oriented X 3


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Conclusion

Integrating the neurological health history and physical exam takes practice. It is not enoughto simply ask the right questions and perform the physical exam. As the patients nurse, youmust critically analyze all of the data you are obtaining, synthesize the data into relevant

problem areas, and identify a plan of care for your patient based upon this synthesis. As theplan of care is being carried out, reassessments must occur on a periodic basis. How oftenthese reassessments occur is unique to each patient and is based upon their physicaldisorder. Knowing when and how often to reassess is based on the specific patient,evidence presented, and facility policies, standards, and protocols.

Please Read:This publication is intended solely for the use of healthcare professionals taking this course, for credit, fromRN.com It is designed to assist healthcare professionals, including nurses, in addressing many issuesassociated with healthcare. The guidance provided in this publication is general in nature, and is not designedto address any specific situation. This publication in no way absolves facilities of their responsibility for theappropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as apart of their own orientation processes should review the contents of this publication to ensure accuracy andcompliance before using this publication. Hospitals and facilities that use this publication agree to defend andindemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, andemployees from liability resulting from the use of this publication. The contents of this publication may not bereproduced without written permission from RN.com.


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References

Agone, K., Elder, A., Foley, M., Kraut, P., Michael, K., & Tscheschlog, B. (Eds.). (1997). Expert 10-minute physical examinations. St. Louis: Mosby.

American Association of Critical Care Nurses (1998). The Nervous System. In J. Alspach (Ed.), Core

curriculum for critical care nursing(5th ed., Rev., pp. 399-459). Philadelphia: Saunders.

Folin, S. (Ed.). (2004). Rapid Assessment: A flowchart guide to evaluating signs and symptoms.Springhouse, PA: Lippincott, Williams & Wilkins.

Jarvis, C. (1996). Physical examination and health assessment. Philadelphia: W.B. Saunders.

Shaw, M. (Ed.). (1998). Assessment made incredibly easy. Springhouse, PA: Springhouse.

Teasdale, G. (1975). Acute impairment of brain function. Nursing Times, 71, 914-917.

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