neuro reprt

8/3/2019 NEURO REPRT

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NEUROLOGIC

ASSESSMENT

Presented by: Ms. Jeceli Alviola Nobleza, BSN-RN

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Learning Objectives:

After the presentation, we should be able to:

• Perform a physical assessment of the

neurologic system

• Document neurologic system findings

• Differentiate between normal and abnormal

findings



INTRODUCTION

• The human nervous system is a unique system that

allows the body to interact with the environment as

well as to maintain the activities of internal organs.

• The nervous system acts as the main “circuit board”

for every body system. Because the nervous system

works so closely with every other system, a

problem within another system or within the

nervous system itself can cause the nervous system

to “short-circuit.”

(Dillon,2007)



• A major goal of nursing is early detection to

prevent or slow the progression of disease.

• So it is important for nurses to accurately perform a

thorough neurologic assessment and to understand

the implications of subtle changes in assessment

findings. By doing so, we can initiate timely

interventions that can save lives.

(Dillon,2007)



REVIEW OF THEANATOMY AND PHYSIOLOGY

OF THE

NEUROLOGIC SYSTEM



Cont. Review of Ana and Physio

General functions of the neurologic system include:

• Cognition, emotion, and memory.

• Sensation, perception, and the integration of

sensoryperceptual experience.• Regulation of homeostasis, consciousness,

temperature, BP, and other bodily processes.



There are two types of nerve cells:(1) neuroglia and

(2) neurons



Neuroglia

• Functions: a. act as supportive tissue, nourishing and protecting

the neurons

b. maintain homeostasis in the interstitial fluid aroundthe neurons and account for about 50 percent of the

central nervous system (CNS) volume

c. have the ability to regenerate and respond to injuryby filling spaces left by damaged neurons.



Neurons

• Functions: a. have the ability to produce action potentials or

impulses (excitability or irritability) and

b. to transmit impulses (conductivity).

Sensory (afferent) neuron Motor (efferent) neuron



Sensory (afferent) neuron Motor (efferent) neuron

Nisslbodies

nucleus

Axon

Myelin

Cell body

Receptorsin skin

dendriteNodes ofRanvier

Schwanncell

synapse

Presynapticterminal

Postsynapticmembrene

Postsynapticreceptor

Neurotransmittersubstance

Synapticcleft

Synaptic

vesicles

Neuromuscular junction



Neurons band together into

- peripheral nerves,

- spinal nerves,- spinal cord, and

- tissues of the brain.

• These structures make up the neurologic system,which is divided into

- the CNS and

- the peripheral nervous system (PNS).



CENTRAL NERVOUS SYSTEM

• consists of the brain and spinal cord.

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The Human Brain

CoordinationEquilibriumBalance

Visualperception

sensation

EmotionBehaviorIntellect

MotorSpeech Hearing

SmellTasteMemory

Speechcompensation

TEMPORAL LOBE

Broca’s Area

FRONTAL LOBE

Lateral fissure Central fissure

PARIETAL LOBE

Wernicke’s area

OCCIPITAL LOBE

Cerebellum



The Spinal Cord

• The spinal cord descends through the foramen magnum (large aperture) of the occipital bone of the skull, through

the first cervical vertebra (C1), and through the remainder

of the vertebral column to the first or second lumbar

vertebra.• conducts sensory information from the peripheral nervous

system (both somatic and autonomic) to the brain

• conducts motor information from the brain to our various

effectors- skeletal muscles

- cardiac muscles

- smooth muscles

-glands• serves as a minor reflex center



S P th



Sensory Pathways

• Pathways,either ascending or afferent,allow sensory

data, such as the feeling of a burned hand, to becomeconscious perceptions.

Sensorycortex

Trunk, Arm,Hand, Fingers,Face, Lips,Tongue

Leg

KneeFoottoes

pons

medulla

Posterior rootof the spinal

cord

Posterior columnFine touch, proprioceptionand vibration

Spinal cord

Anterior spinothalamic tract

Crude touch & pressure

Lateral spinothalamic tract

Pain &temperature

M t P th



Motor Pathways• Motor pathways (descending or efferent) transmit

impulses from the brain to the musclesTrunk, Arm, Hand,Fingers, Face, Lips,

TongueLegKneeFoottoes

Motor Cortex

Skeletalmuscles

Lateral corticospinal(crossed pyramidal tract

Anterior corticospinal

(uncroosed pyramidal tract



Spinal Reflexes• Spinal reflexes do not depend on conscious

perception and interpretation of stimuli, nor ondeliberate action; in other words, they do not

involve the brain.

• They occur involuntarily, with lightning speed, andare identical in all healthy children and adults,

although they are less developed

• in infants.

Reflex arc

Dorsal root ganglion

Motor nerve

Sensory nerve



PERIPHERAL NERVOUS SYSTEM

• The peripheral nervous system consists of - the cranial

- spinal nerves and the

- peripheral autonomic nervous system.

Cranial Nerves



Cranial NervesThe 12 pairs of cranial nerves originate from the brainand are called the peripheral nerves of the brain.

I-Olfactory nerve – Smell (S)



I Olfactory nerve Smell (S)

II-Optic nerve - Vision (S)

III-Oculomotor nerve (M)

- Eye movement; pupil constrictionIV-Trochlear nerve (M)

- Eye movement

V-Trigeminal nerve (B)- Somatosensory information (touch, pain)

from the face and head; muscles for chewing.

VI-Abducens nerve - Eye movement (M)

VII-Facial nerve (B)

- Taste (anterior 2/3 of tongue); somatosensory

information from ear; controls muscles used

in facial expression.

VIII-Vestibulocochlear nerve/Auditory nerve (S)



VIII Vestibulocochlear nerve/Auditory nerve (S)

- Hearing; balance

IX-Glossopharyngeal nerve (B)

- Taste(posterior 1/3 of tongue);- Somatosensory information from tongue, tonsil,

pharynx;

- controls some muscles used in swallowing.X-Vagus nerve (B)

- Sensory, motor and autonomic functions of

viscera (glands, digestion, heart rate)

XI-Accessory nerve/Spinal accessory nerve (M)

- Controls muscles used in head movement.

XII-Hypoglossal nerve (M)

- Controls muscles of tongue

Spinal and Peripheral Nerves



Spinal and Peripheral Nerves• Branching from the spinal cord are 31 pairs of spinal

nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,and 1 coccygeal

• The spinal nerves contain both ascending and

descending fibers, and although there is someoverlap,each is responsible for innervation of a

particular area of the body.



Dermatomes are regions of the body innervated by the



Dermatomes - are regions of the body innervated by the

cutaneous branch of a single spinal nerve.



Components of

Neurologic Exam

• Mental Status



a. Appearance/ Hygiene/ Grooming/ Odor

b. Behavior

c. Speech/ Communication

d. Level of Consciousness

e. Memory

f. Cognitive function

• Cranial Nerve Function (12 cranial nerves)

• Sensory Functiona. Light touch b. Pain

c. Vibration d. Kinesthetics

e. Streognosis f. Graphesthesia

g. Two-point discrimination h. point localizationi. Sensory Extinction

• Reflex Function

a. Deep tendon reflexes

b. Superficial reflexes

Ensure proper hygiene before seeing a client



p p yg g

Ensure all equipment is properly cleaned

Equipment Needed:- BP cuff - Tuning fork (128 or 256 Hz)

- Penlight - Nonsterile gloves

- Wisp of cotton - Tongue blade

- Reflex hammer

- Sharp object such as toothpick or sterile needle

- Objects to touch: coin, button, key or paperclip

- Something fragrant: rubbing alcohol or coffee- Something to taste: such as lemon juice, sugar or salt

- Two taste tubes or other vials

- Ophthalmoscope

Introduce self to the client.

Assessing the Mental Status



Assessing the Mental Status

1. APPEARANCE/ HYGIENE/ GROOMING/ ODOR

a. Begin the assessment as the patient approaches

you.

b. Observe the general appearance, hygiene,

grooming and the odor of the client.



Normal:

good grooming,

dress in appropriate to

temperature & weather,

no offensive or

unpleasant odor hair well kept or tied

Abnormal:

Poor hygiene

Unpleasant or offensivebody odor

2 BEHAVIOR



2. BEHAVIOR

a. Assess the client’s mood and emotions b. Observe body language and facial expression or

affect

c. Note his or her posture

Ab lNormal:



Abnormal:

Lack of facial expression

- Possible psychologicaldisorder (e.g., depression or

schizophrenia) or neurologic

impairment affecting cranial

nerves.

Masklike expression:

- Parkinson’s disease.

Slumped posture:- Depression if

psychological in origin; or stroke

with hemiparesis if physiological

in origin.

Normal:

Verbal expressions

match with thenonverbal behavior

Mood is appropriate to

the situation

Standing in upright

stance with parallel

alignment of hips

&shoulders

3 SPEECH/ COMMUNICATION



3. SPEECH/ COMMUNICATIONa. Speech and Language

Listen to patient’s rate and ease of speech,including enunciation.

Normal:

Speech flowseasily; patient

enunciates clearly.

Sophistication of

speech matches age,

education, and

fluency.

Abnormal:

■ Hesitancy, stuttering,

stammering, unclear speech:- Lack of familiarity with language,

deference or shyness, anxiety,

neurologic disorder.■ Dysphasia/aphasia:- Neurologic problems such as stroke.

■ Drugs and alcohol can also cause

slurred speech.

b Spontaneous Speech & Motor Speech



b. Spontaneous Speech & Motor Speech

- Show patient a picture and have him or her

describe what he or she sees.- Have patient repeat, “do, ray, me, fa, so, la, ti,

do.”

Normal:Spontaneous

speech intact.

Motor speechintact.

Abnormal:■ Impaired spontaneous speech:

- Cognitive impairment.

Impaired motor speech(dysarthria):

Problem with CN XII

c Autonomic Speech



c. Autonomic Speech

Have patient say something that is committed

to memory, such as days of week or months of year.

Normal:

■ Automaticspeech intact.

Abnormal:

■ Impaired automatic speech:Cognitive impairment or

memory problem.

4 LEVEL OF CONSCIOUSNESS



4. LEVEL OF CONSCIOUSNESS

a. Test orientation to time, place, and person

Normal:

Awake, alert, and

oriented to time,

place, and person

(AAO x 3)

Responds to

external stimuli

Abnormal:

Disorientation may be

physical in origin

Disorientation can also bepsychiatric in origin

(schizophrenia)

Lathargic or somnolentObtunded

Stupor

Coma

Glasgow Coma Scale



Glasgow Coma Scale

- A standardized objective assessment that

defines the LOC by giving it a numeric value.

- Most often after brain surgery

- Document as E_V_M_; for example, E4V5M6.

GLASGOW COMA SCALE



Eyes open

E

■ Spontaneously . . . . . . . . 4

■ To command . . . . . . . . . . 3

■ To pain . . . . . . . . . . . . . . . 2

■ Unresponsive. .. . . . . . . . . 1

Findings

Best verbal response

V

■ Oriented . . . . . . . . . . . . . . . 5

■ Confused . . . . . . . . . . . . . . . 4

■ Inappropriate . . . . . . . . . . . . 3

■ Incomprehensible . . . . . . . . 2■ Unresponsive. . . . . . . . . .. . . 1

Findings

Best motor response

M

■ Obeys commands . . . . . . . .. 6

■ Localizes pain. . . . . . . . . . . 5

■ Withdraws from pain. . . . …. 4

■ Abnormal flexion . . . . . . .. . . 3■ Abnormal extension . . . . . . . 2

■ Unresponsive. . . . . . . . . . . . . 1

Findings

Total______

From Wijdicks, et al, 2005, with permission.



• The three numbers are added; the total score

reflects the brain functional level.

• A fully awake person = 15

• Coma = 7 or less

• The GCS assesses the functional state of the brain

as a whole, not of any particular site in the brain.

(Juarez and Lyon,1995)

Four Score Coma Measurement Scale EYE



RESPONSE

4

3

2

10

Eyelids open or opened, tracking or blinking to command

Eyelids open but not tracking

Eyelids closed but open to loud voice

Eyelids closed but open to painEyelids remain closed with pain

MOTOR

RESPONSE

4

3

21

0

Thumbs up, fist, or peace sign to command

Localizing to pain

Flexion response to painExtensor posturing

No response to pain or generalized myoclonus status epilepticus

BRAINSTEM

REFLEXES

4

3

2

1

0

Pupil and corneal reflexes present

One pupil wide and fixed

Pupil or corneal reflexes absent

Pupil and corneal reflexes absent

Absent pupil, corneal, and cough reflex

RESPIRATION

4

3

21

0

Not intubated, regular breathing pattern

Not intubated, Cheyne-Stokes breathing pattern

Not intubated, irregular breathing patternBreathes above ventilator rate

Breathes at ventilator rate or apnea

5. MEMORY



5. MEMORY

a. Test immediate recall:

Ask patient to repeat three numbers, such as “4, 9, 1.” If patient can do so, ask her or him to repeat a series of five

digits.

b. Test recent memory:

Ask what patient had for breakfast.

c. Test long-term memory:

Ask patient to state his or her birthplace, recite his or her

Social Security number, or identify a culturally specific personor event, such as the name of the previous president of the

United States or the location of a natural disaster.

Normal:

I di

Abnormal:

Memory problems can be



Immediate, recent,

and remote

memory intact.

Memory problems can be

benign or signal a more

serious neurologic problem- such as Alzheimer’s disease.

Forgetfulness - especially for

immediate and recent events- often in older adults.

- With benign forgetfulness,

person can retrace or use memory

aids to help with recall.

Pathological memory loss

- as inAlzheimer’s disease

Cont Abnormal:



Cont . Abnormal:

Temporary memory loss

- may occur after head trauma.

Retrograde amnesia

- for events just preceding illness or

injury.

Postconcussion syndrome

- can occur 2 weeks to 2 months

after injury and may cause short-term memory deficits.

6. COGNITIVE FUNCTION



a. Mathematical and Calculative Ability

Ask patient to perform a simple calculation, such asadding 4 x 4. If successful, proceed to more difficult

calculation, such as 11 x 9.

Normal:Mathematical/calculativ

e ability intact and

appropriate for patient’sage, educational level,

and language facility.

Abnormal: Inability to calculate at

level appropriate to age,

education, and languageability requires evaluation

for neurologic impairment.

b. General Knowledge and Vocabulary



g y

Ask how many days in a week and months in a year.

c. Thought Process

Ask patient to define familiar words such as “apple,”

“earthquake,” and “chastise.”

Begin with easy words and proceed to more difficultones.

Remember to consider the patient’s age, educational

level, and cultural background.

Normal:Thought

Abnormal: Incoherent speech



Thought

process intact

Incoherent speech

illogical or unrealistic ideas

repetition of words and phrasesrepeatedly straying from topic

suddenly losing train of thought

(examples of altered thought processes thatindicate need for further evaluation)

Inability to define familiar words -

requires further evaluation

d. Abstract Thinking



Assess the client to think abstractly.

Quote a proverb and ask the client to explain it’s

meaning

Normal:

Able to generalize from

specific example and applystatement to human

behavior.

Children should be ableto distinguish like from

unlike as appropriate for

theirage and language

facility.

Abnormal:

■ Impaired ability to think

abstractly:

- Dementia, delirium, menta

retardation, psychoses.

e. Judgment

Ob ti t’ t t it ti



Observe patient’s response to current situation.

Ask patient to respond to a situation or

hypothetical situation.

Normal:

Judgment

appropriate and

intact.

Abnormal:

■ Impaired judgment can be

associated with dementia,

psychosis, or drug and alcohol

abuse.

Assessing the CRANIAL NERVES



1. CN I — Olfactory Nerve

a. Before testing nerve function, ensure patency of each nostril by occluding in turn and asking patient

to sniff.

b. Once patency is established, ask patient to closeeyes.

c. Occlude one nostril and hold aromatic substance

such as coffee beneath nose.

d. Ask patient to identify

substance.

e. Repeat with other nostril.

Normal:■ Patient is able to

Abnormal:■ Anosmia is loss of sense of



■ Patient is able to

identify substance.

(Bear in mind that

some substances may be

unfamiliar, especially to

children.)

■ Anosmia is loss of sense of

smell.

-May be inherited andnonpathological: chronic rhinitis,

sinusitis, heavy smoking, zinc

deficiency, or cocaine use.

- It may also indicate cranial nervedamage from facial fractures or

head injuries, disorders of base of

frontal lobe such as a tumor, or

artherosclerotic changes.

- Persons with anosmia usually also

have taste problems.

2. CNs II, III, IV, and VI — Optic, Oculomotor,

T hl d Abd N



Trochlear, and Abducens Nerves

a. Ask the client to read a printed material, observe thedistance between the printed material and the client’s eyes.

b. Use the snellen chart to check/ test:

- distant vision

- colorClient should be 20 feet distant from the chart

Use an object to occlude one eye

Evaluate the vision one eye at a time

c. Evaluate the Extra Ocular Movements of the Eyesd. Convergens & Accomodation



e. Pupillary Light Reflex

- using direct and consensual pupillary reaction to light

Testing eyemovements

Testing pupilaccommodation

Normal:■ Able to read without

Abnormal:■ CN II deficits



difficulty

■ Visual acuity intact20/20, both eyes Hippus phenomenon:

- Brisk constriction of

pupils in reaction to light,

followed by dilation and

constriction

- may be normal or signof early CN III

compression.

- can occur with stroke or brain

tumor.■ Changes in pupillary

reactions- can signal CN III deficits.

■ Increased ICP causes

changes in pupillary reaction.

As pressure increases,

response becomes moresluggish until pupils

finally become fixed and

dilated.

3. CN V — Trigeminal Nerve



a. Testing motor function:

- Ask patient to move jaw from side to side againstresistance and then clench jaw as you palpate

contraction of temporal and masseter muscles, or

to bite down on a tongue blade.

Testing CN V –

motor function

b. Testing sensory function:

A k ti t t l



- Ask patient to close eyes

- Touch the face with the wisp of cotton

- Instruct to tell you when he or she feels

sensation on the face.

- Repeat the test using sharp and dull stimuli

(toothpick)- Instruct to say “Sharp” or “Dull”

(Be random, don’t establish a pattern)

- Compare both bilaterally.

Testing CN V –

sensory function

c. Testing corneal reflex:

Gentl to ch cornea ith cotton isp



- Gently touch cornea with cotton wisp.

oTouching cornea can cause abrasions.

Alternative approach is to:

> puff air across cornea with a needless

syringe, or

> gently touch eyelash and look for blink reflex.

Testing corneal

reflex

Normal:

Full range of motion

Abnormal:Weak or absent contraction

Cont. CN V



Full range of motion

(ROM) in jaw and 15

strength.

Patient perceives

light touch and

superficial painbilaterally.

Weak or absent contraction

unilaterally:

- Lesion of nerve, cervical spine, orbrainstem.

Inability to perceive light touch

and superficial pain

- may indicate peripheral nerve

damage.

■ Tic douloureux:

- Neuralgic pain of CN V caused bythe pressure of degeneration of a

nerve.

■ Corneal reflex test used in

patients with decreased LOC- to evaluate inte rit of brainstem.

4. CN VII — Facial Nerve



a. Testing motor function:

- Ask patient to perform these movements: smile,frown, raise eyebrows, show upper teeth, show

lower teeth, puff out cheeks, purse lips, close eyes

tightly while nurse tries to open them.

Testing CN VII – motorfunction

b. Testing sensory function:

Test taste on anterior two thirds of tongue for



- Test taste on anterior two-thirds of tongue for

sweet, sour, salty.

Testing taste sensation

Sweet:

Tip of the tongue

Sour:

Sides of back half of

tongue

Salty:

Anterior sides and tip of

tongue Bitter: Back of tongue

Normal:

Facial nerve intact;

Abnormal:

Asymmetrical or impaired



Facial nerve intact;

able to make faces.

Taste sensation on

anterior tongue intact.

(Taste decreased inolder adults.)

Asymmetrical or impaired

movement:

- Nerve damage, such as that

caused by Bell’s palsy or stroke.

■ Impaired taste/loss of taste:

- Damage to facial nerve,chemotherapy or radiation

therapy to head and neck.

5. CN VIII — Acoustic Nerve



a. Perform Weber and Rinne tests for hearing

b. Perform watch-tick test by holding watch close to patient’s ear.

c. Perform Romberg test for balance

- Nurse at the back or side of the pt.

- Instruct client to stand straight, feet together,hands at the side and eyes closed.

(Evaluates the balancing function of the CN VIII)

Watch tick test

Normal:

Hearing intact

Abnormal:

Hearing loss nystagmus



Hearing intact.

Negative Romberg

test.

Hearing loss, nystagmus,

balance disturbance,

dizziness/vertigo:

- Acoustic nerve damage.

■ Nystagmus:

- CN VIII, brainstem, orcerebellum problem or

phenytoin (Dilantin)

toxicity.

6. CNs IX and X — Glossopharyngeal and Vagus

Nerves



Nerves a. Observe ability to cough, swallow, and talk.

b. Test motor function:- Ask patient to open mouth and say “ah”

while you depress the tongue with a tongue

blade.- Observe soft palate and uvula. Soft palate

and uvula should rise medially.

Testing CN IX and

X – motor function

c. Test sensory function of CN IX and motor functionof CN X by stimulating gag reflex.

T ll ti t th t i t t h i t i



- Tell patient that you are going to touch interior

throat- then lightly touch tip of tongue blade to

posterior pharyngeal wall.

- Observe the pharyngeal movement.

- Ask the client to drink a small amount of water

Note the ease & difficulty of swallowing

Note quality of the voice or hoarsenesswhen speaking

Normal:Swallow and cough

Abnormal:Unilateral movement:



g

reflex intact.

Speech clear.Elevation and

constriction of

pharyngealmusculature and

tongue retraction

indicate positive gag

reflex.

- Contralateral nerve damage.

- Damage to CNs IX and X also impairsswallowing.

■ Changes in voice quality (e.g.,

hoarseness): CN X damage.

- CN X damage may also affect vital

functions, causing arrhythmias because

vagus nerve innervates most of viscera

through parasympathetic system.

■ Diminished/absent gag reflex:

Nerve damage.- Evaluate further because patient is at

increased risk for aspiration.

■ Impaired taste on posterior portion

of tongue: Problem with CN IX.

7. CN XI — Accessory Nerve

a Test motor function of shoulder and neck muscles:



a. Test motor function of shoulder and neck muscles:

- Ask patient to shrug shoulders upward against

your resistance. (Trapieze muscle)

- Then ask her or him to turn head from side to

side against your resistance.

(Strenoclaidomastoid msucle)- Observe for symmetry of contraction and

muscle strength.

Normal:

Movement

Abnormal:

Asymmetrical



symmetrical, with

patient moving

against resistance

without pain.

■ Full ROM of neck with +5/5 strength.

y

Diminished

Absent movement

Pain

unilateral or bilateral

weakness:- Peripheral nerve CN XI

damage.

8. CN XII — Hypoglossal Nerve

a. Have patient say “d, l, n, t” or a phrase containing



a. Have patient say d, l, n, t or a phrase containing

these letters.

- The ability to say these letters requires use

of the tongue.

b. Ask the patient to protrude the tongue.

Observe any deviation from midline, tumors,lesions, or atrophy.

Now ask the patient to move the tongue from

side to side.

Testing CN XII – motor function

Normal:

Can protrude

Abnormal:

Asymmetrical/diminished/



Can protrude

tongue medially.

No atrophy,

tumors, or

lesions.

y

absent movement/deviation

from midline/protruded tongue:

- Peripheral nerve CN

XII damage.

■ Tongue paralysis results indysarthria.

Assessing Sensory Function



1. Light Touch

- Brush a light stimulus such as a cotton wisp over

patient’s skin in several locations, including torso and

extremities.

Normal: Identifies areas

stimulated by light

touch.

Abnormal:Diminished/absent cutaneous

perception:-Peripheral nerve damage or damage to

posterior column of spinal cord.

- Peripheral neuropathies can also cause

sensory deficits.

■ Hypesthesia: Increased sensitivity.

■ Paresthesia: Numbness and tingling.

■ Anesthesia: Loss of sensation.

2. Pain - Stimulate skin lightly with sharp and dull ends of

t th i k/ li



toothpick/ paper clip

-Apply stimuli randomly and ask patient to identifywhether sensation is sharp or dull.

-Touch patient’s skin with test tubes filled with hot or

cold water.

-Apply stimuli randomly, and ask patient to identifywhether sensation is hot or cold.

Normal:

Identifies areas

Abnormal:Diminished or absent pain

perception:



stimulated and type

of stimulation.

perception:

- Peripheral nerve damage or damageto lateral spinothalamic tract.

■ Hyperalgia:

Increased pain sensation.

■ Hypoalgesia:Decreased pain sensation.

■Analgesia: No pain sensation.

■ Diminished/absent temperature

perception:

- Peripheral nerve damage or damage

to lateral spinothalamic tract

3. Vibration -Place a vibrating tuning fork over a finger joint, and



then over a toe joint.

-Ask patient to tell you when vibration is felt andwhen it stops.

- If patient is unable to detect vibration, test proximal

areas as well.

Normal:

Vibratory

Abnormal:Diminished/absent vibration

sense:



sensation intact

bilaterally inupper and lower

extremities.

sense:

- Peripheral nerve damage causedby alcoholism, diabetes, or damag

to posterior column of spinal cord.

4. Kinesthetics (Position Sense) -Determine patient’s ability to perceive passive



movement of extremities.

- Hold fingers on sides and move up and down, andhave patient identify direction of movement.

-Flex and extend patient’s big toe, and ask patient to

describe movement as up or down. • Avoid moving the patient’s

finger by placing your finger on

top of the patient’s because the

patient may sense the pressure of your finger rather than a true

position change.

• If position sensation is intact

distally, it is intact

proximally.

Normal:

Position sensation

Abnormal:

■ Diminished or absent position



intact bilaterally in

upper and lowerextremities.

sense:

- Peripheral nerve damage or damageto posterior column of spinal cord.

5. Stereognosis

With patient’s eyes closed, place a familiar object,

h i b i i ’ h d d k



such as a coin or a button, in patient’s hand, and ask

patient to identify it.■ Test both hands using different objects.

Normal: Stereognosis

intact bilaterally.

Abnormal:■ Abnormal findings suggest a

lesion or other disorder involving

sensory cortex or a disorderaffecting posterior

column.

6. Graphesthesia

- With patient’s eyes closed, use point of a closed

b i ’ h d



pen to trace a number on patient’s hand

- Ask patient to identify the number.

Normal:

Graphesthesia

intact bilaterally.

Abnormal:

■ Abnormal findings suggest

lesion or other disorder involvingsensory cortex or disorder

affecting posterior

column.

7. Two-Point Discrimination

Ability to differentiate between two points of

i lt ti l ti



simultaneous stimulation.

- Using ends of two toothpicks/ paper clip,stimulate two points on fingertips

simultaneously.

- Gradually move toothpicks together, and assesssmallest distance at which patient can still

discriminate two points (minimal perceptible

distance).- Document distance and location.

Normal:

Discriminates

bet een t o points

Abnormal:

■ Abnormal findings suggest

l i h di d i l i



between two points

on fingertips nomore than 0.5 cm

apart and on hands no

more than 2 cm apart.

lesion or other disorder involvin

sensory cortex or disorder

affecting posterior

column.

8. Point Localization

■ Ability to sense and locate area being stimulated.

With ti t’ l d t h th h



■ With patient’s eyes closed, touch an area; then have

patient point to where he or she was touched.■ Test both sides and upper and lower extremities.

Normal:

Point localizationintact.

Abnormal:

Abnormal findings suggest lesioor other disorder involving sensor

cortex or disorder affecting

posterior column.

9. Sensory Extinction

■ Simultaneously touch both sides of patient’s body

at same point



at same point.

■ Ask patient to point to where she or he wastouched.

Normal:

Extinction intact.

Abnormal:

Identification of stimulus on onlyone side suggests lesion or other

disorder involving sensory cortical

region in opposite hemisphere.

REFLEXESDocumenting Reflex Findings

• Use these grading scales to rate the strength of each



g g g

reflex in a deep tendon and superficial reflex assessment.Deep tendon reflex grades

0 absent

+ present but diminished

+ + normal+ + + increased but not necessarily pathologic

+ + + + hyperactive or clonic (involuntary contraction

and relaxation of skeletal muscle)

Superficial reflex grades

0 absent

+ present



• Documentation of reflex finding

ASSESSING REFLEXES1. Deep Tendon Reflexes



a. Biceps Reflex■ Rest patient’s elbow in your nondominant hand,

with your thumb over biceps tendon.

■ Strike your thumbnail.

Normal:

■ Contraction of biceps with flexion of forearm.■ +2

b. Triceps Reflex

■ Abduct patient’s arm and flex it at the elbow.

S t th ith d i t h d



■ Support the arm with your nondominant hand.

■ Strike triceps tendon about 1 to 2 inches above

olecranon process, approaching it from directly

behind.

Normal:

■ Contraction of triceps with extension at elbow.

■ +2

c. Patellar Reflex

■ Have patient sit with legs dangling.

St ik t d di tl b l t ll



■ Strike tendon directly below patella..

Normal:

■ Contraction of quadriceps with extension of

knee.■ + 2

d. Achilles Reflex

■ Have patient lie supine or sit with one kneeflexed



flexed.■ Holding patient’s foot slightly dorsiflexed,strike Achilles tendon.

Normal:

■ Plantar flexion of foot.■ + 2

e. Test for Ankle Clonus

■ If you get 4 reflexes while supporting legand foot quickly dorsiflex foot



and foot, quickly dorsiflex foot.

Normal:

■ No contraction

Abnormal:

■ Absent/diminished DTRs:

Degenerative disease; damage to peripheral nerve



- Degenerative disease; damage to peripheral nerve

such as peripheral neuropathy; lower motor neuron

disorder, such as ALS and Guillain-Barré syndrome.

■ Hyperactive reflexes with clonus:

- Spinal cord injuries, upper motor neuron disease suchas MS.

■ Rhythmic contraction of leg muscles and foot is

positive sign of clonus- indicates upper motor neuron disorder.

2. Superficial Reflexes

a. Abdominal Reflex



■ Stroke patient’s abdomen diagonally from upper and lower quadrants toward umbilicus.

■ Contraction of rectus abdominis. Umbilicus

moves toward stimulus.

a. Abdominal Reflex

■ Gently stroke skin around anus with glovedfinger.



finger.

Normal: ■ Anus puckers.

b. Cremasteric Reflex

■ Gently stroke inner aspect of a male’s thigh.

Normal: ■ Testes rise.

c. Bulbocavernosus Reflex

■ Gently apply pressure over bulbocavernousmuscle on dorsal side of penis.



muscle on dorsal side of penis.

Normal: ■ Bulbocavernosus muscle contracts.

d. Plantar Reflex (Babinski’s Response)

■ Stroke sole of patient’s foot in an arc from

lateral heel to medial ball.

Normal:

■ Flexion of all toes.

Assessing the Cerebellar Function1. Balance tests



a. GaitObserve as the person walks 10-20 feet, turns,

and returns to the starting point.

Normal:

Person moves with a

sense of freedom.

Gait is smooth,

rhythmic, andeffortless

Opposing arm swing

is coordinated

The turns are smooth

Abnormal:Stiff, immobile posture. Staggering

or reeling. Wide base of support

Lack of arm swing or rigid arms

Unequal rhythm of steps. Slappingof foot. Scraping of toe of shoe

Ataxia – uncoordinated or unsteady

gait.

Perform Tandem Walking

- ask the person to walk a straight line in a heel-

to-toe fashion.



to toe fashion.

This decreases the base of support and will

accentuate any problem with coordination.

Normal:

Person can walk Abnormal:Crooked line walk



straight and staybalanced

Widens base to maintain balanceStaggering, reeling, loss of

balance

An ataxia that did not appear

now. Inability to tandem walk is

sensitive for an upper motor

neuron lesion, such as multiple

sclerosis.

b. The Romberg Test

(discussed previously)



• Ask the person to perform a shallow knee bend orhop in place, first on one leg, then the other.

- this demonstrates normal position sense, muscle

strength, and cerebellar function.(some individuals cannot hop owing to aging or

obesity)

Normal:

Negative Romberg

test

Abnormal:Sways, falls, widens base of feet

to avoid falling



Positive Romberg sign-Loss of balance that occurs

when closing the eyes.

-Occurs with cerebellar ataxia

(multiple sclerosis, alcoholintoxication)

-Loss of proprioception, and

loss of vestibular function

2. Coordination and Skilled Movements

a. Rapid Alternating Movements (RAM)

Ask the person to pat the knees with both hands,



p p ,

lift up, turn hands over, and pat the knees with the

backs of the hands.

Then ask to do this faster.

Normal: done with equal

turning and quick

rhythmic pace

Abnormal:Lack of coordination

Dysdiadochokinesia

- Slow, clumsy, and sloppy

response- occurs with cerebellar

disease

b. Finger-to-Finger test

With the persons eyes open, ask that he or she use

index finger to touch your finger, then his or her



own nose.After a few times move your finger to a different

spot.

Normal: Movement is

smooth and accurate

Abnormal: Dysmetria

- clumsy movement with

overshooting the mark

- occurs with cerebellar

disorder

Past-pointing

- constant deviation to one side

c. Finger-to-nose test

Ask the person to close the eyes and to stretch out

the arms.



Ask the person to touch the tip of his or her nosewith each index finger, alternating hands and

increasing speed.

Normal: Done with accurate

and smooth

movement

Abnormal:Misses nose.

Worsening of coordination when

the eyes are closed

- occurs with cerebellar disease

sources• Dillon, Patricia. Nursing Health Assessment. 2nd

Ed. F.A. Davis. 2007



Ed. F.A. Davis. 2007

• Jarvis, Carolyn. Physical Examination and Health

Assessment. 3rd ed. New York: W.B. Saunder

Company.2000

• Bickley. Lyn and Hoekenan, Robert. Bate’s Guide

to Physical Examination and History Taking. 7th

ed. New York: Lippincott Williams and Wilkins.

1999

• Estes, Mary Ellen Zator. Health Assessment &

Physical Examination. 3rd ed. Delmar Learning.

2006



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