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NEUROLOGICAL EXAMINATION

PURPOSES To determine the nervous system dysfunction To diagnose diseases of the nervous system To locate disease with in the nervous system Provides data base of critical information of

neurological functions Review areas of special considerations Potential nursing diagnoses may be suggested by

the dysfunction identified

NURSE’S ROLE

EQUIPMENTS

Ophthalmoscope Otoscope Tongue blade Turning forks Pin Tape measure Flash light Reflex hammer Wisp of cotton

APPROACH

Preceded by General physical examination and

HistoryConducted in a systematic, hierarchial,

stepwise approach from the highest level of functions to the lowest and from general integrated functions to very specific functions

HistoryChief complaints:

Onset and frequency,

Precipitating or exacerbating factors,

Associated symptoms

( head ache, dizziness or faintness, confusion or impaired mental status, balance and gait disturbances, LOC changes)

History……Current health history:

Haedache, dizziness, numbness, tingling, seizures,tremors, weakness or paralysis

Evaluate speech, comprehension, reading or writing skills

Identify interferences with ADLs Detects impairment of memory and concentration

History……Past health history

Previous major illnesses, recurrent major illness, accidents or injuries, surgical procedures and allergies

Health and dietary habits and drug use

History……Family history

Diabetes Cardiac or renal disease Hypertension or stroke Cancer Bleeding or mental disorders

History……Psychosocial history

Occupation, home environment, religion, and hobbies

Assessment of patient’s self image

GENERAL OBSERVATIONS

The appropriateness of appearance and behavior in relation to the settings.

Predominant attitude, mood and facial expressions

Flow of speech Thought processes, content and perceptions

TESTING COGNITIVE FUNCTIONS Orientations to time, place, and person Attention and concentration Memory Retention and immediate recall Calculations Abstract reasoning Similarities Judgment

SPECIAL CEREBRAL FUNCTIONS

Recognition- Agnosia. Ability to recognise familiar objects, sight, sound or

feeling.

Visual agnosia, auditory agnosia, tactile agnosia.

Autopagnosia is the inability to identify body parts or understanding the relationships of body parts

Anosognosia is lack of awareness of or a denial of a deficit in physical function ( seen in left hemispheric lesions)

Neurolog ica l exam…….Cortical motor integration- apraxia

Performing a skilled motor act.

Communication- Aphasia Inability to communicate

( expressive or broca’s aphasia, reactive or Wernicke’s global aphasia),

dysphasia, facial muscle paralysis, dysarthria, dysphonia

CRANIAL NERVE EXAMINATION

Olfactory nerve (I)

Sense of smell is tested Anosmia- inability to smell Suspected ant. fossa tumor Foster kennedy syndrome- caused by a tumor or

abscess at the base of the frontal lobe, s/s include ipsilateral blindness, anosmia, ipsilateral atrophy of olfactory and optic nerve and contra lateral papilledema

Optic nerve ( II)

Visual acuity

Snellen chart

Visual field

normally extends 60 degrees to the nasal side, 100 degrees on the temporal side and 130 degrees vertically ( deficit seen in lesions along the visual path way)

Ophthalmoscopic examination

Optic nerve…….

Visual field defects Blindness of right eye Bitemporal hemianopsia or loss of half the visual

field Left homonymous hemianopsia Left homonymous hemianopsia superior quadrant

Optic nerve………

Common visual defects Scotomas- abnormal blind spots on visual fields Amblyopia- dim vision Amaurosis- complete blindness in an eye Photophobia- sensitivity of the eyes to light Diplopia- double vision

Optic nerve exam…….

Abnormal findings

Visual field defect may signal stroke, head injury, or brain tumors

Occulomotor (III), Trochlear(IV) and Abducent nerves (VI)

Position of eye ball with in the head Eye movements Ophthalmoplegia

Dolls eye movement, oculovestibular reflex

Nystagmus – involuntary movement of the eyes

Ptosis

Extra ocular movements

Pupilary examination

For assessing occulomotor nerve Check pupil size, pupil shape and pupillary

response to light Pupil size may be affected by increased ICP, optic

or oculomotor nerve damage or anisocoria

Trigeminal nerve (V)

Sensory component Comparing each side with respect to sensation( light

and sharp touch) of the patient’s fore head, cheek and jaw

Motor component Evaluating the strength of masseter and temporal

muscles by palpating them when jaws are tightly clamped

Reflexes Corneal reflex and jaw reflex

Trigeminal nerve (V)…..

Abnormal findings Loss of sensation in forehead, cheek or jaw

Peripheral nerve damage Severe piercing or stabbing pain one or more facial

dermatomes

Trigeminal neuralgia Impaired sensory and motor function

Spinal cord lesion Absent corneal reflex

Peripheral nerve or brain stem damage

Facial nerve (VII)

Sensory component

Testing sense of taste on the ant. Two thirds of the tongue

Motor component

Observing the symmetry of face and facial movements

Facial nerve…..

Abnormal findings Unilateral facial weakness

Stroke Taste impairement

Damage to facial or glossopharyngeal nerve

Acoustic nerve (VIII)

Testing hearing ( Acoustic portion)

Weber test Rinne test

Nystagmus and disturbed balance(Vestibular portion)

Acoustic nerve (VIII)………….

Abnormal findings Total hearing loss in sensoryneural hearing loss Nystagmus and vertigo in disturbances of vestibular

centers

Glossopharyngeal(IX) and Vagus nerves(X)

Assessing voice and gag reflex The patient is asked to open his or her mouth and

say ‘ ah.’ The palate should elevate when the patient say ah… The uvula should be checked to see if it deviates to

one side or the other

Glossopharyngeal and Vagus…….

Abnormal findings Impaired swallowing, paroxysmal pain or loss of gag

reflex in glossopharyngeal neuralgia

Vagal damage affect involuntary vital functions

Spinal accessory nerve(XI) Tests patient’s ability to overcome resistance applied to

shoulders

Tests patient’s ability to overcome resistance applied to his neck while his head is turned

Abnormal findings Unilateral weakness, atrophy or paralysis of muscles

in peripheral nerve leision

Hypoglossal nerve (XII)

Patient’s tongue is elevated to check lateral deviation, atrophy, fasciculations or spasticity

Assessing the strength of tongue by tongue blade

Hypoglossal nerve……………..

Abnormal findings

Unilateral flaccid paralysis of tongue, atrophy of affected side and deviation in peripheral nerve lesion

Unilateral spastic paralysis produces dysarthria

Motor exaMination

Assessing

Muscle size - wasting. atrophy Muscle tone – palpating while on rest and on

movement, check for spasticity, rigidity, flacidity, decortication, decerebration

Muscle strength- upper and lower extremity

Motor examination…

Involuntary movement- tremors, tics, spasms, choreiform movements

Gait – walk back and forth , obseve posture, movements of body parts, and types of steps

Motor exam……..

Abnormal findings Uncontrollable tics, involuntary tremors, muscle

fasciculations Hemiparetic, ataxic or steppage gait- indicates

disorders of cerebellum, posterior columns, cortico spinal tract, basal ganglia and lower motor neurons

SenSory exaMination

Superficial sensation Touch, pain, sensitivity to hot and cold

Deep sensation Sensitivity to vibration, deep pressure pain, proprioception

Discriminative sensation Two-point discrimination, point discrimination, recognition of

shape and form. Texture discrimination, graphesthesia, extension phenomenon

Sensory sys tem……Abnormal findings

Reduced sensory acquity Sensory deficit Tingling or dysesthesia Loss of sense of light touch, vibration or position Impaired pain or temperature sensation Peripheral neuropathy Impaired discriminative sensation Impaired point localization

Cerebellar function

Evaluate patient’s balance and co-ordination Assess accuracy of action, a staggering gait,

uncordinated movements, tremors Cerebellar dysfunction produces a wide based,

unsteady gait

Cerebellar function…..

Romberg’s test

Observe patient’s balance as he stands with his eyes open, feet together, and arms at his sides. Then ask him to close his eyes.

Hold your arms out on either side of him to protect him if he sways. If he falls to one side the result of Romberg’s test is positive

Cerebellar function…..

Nose to finger test Test extremity coordination by asking the patient to

touch his nose and then touch your overstretched finger as you move it. Have him do this faster. His movements should be accurate and smooth

Cerebellar exam……

Assesses patient for rapid alternating movements which should be accurate and smooth

Reflexes

Involves testing deep tendon and superficial reflexes

Deep tendon reflexes Biceps reflex ; contraction of biceps

muscle & flexion of forearm Triceps reflex; contraction of triceps and

extension of fore arm Brachioradialis reflex: supination of hand

and flexion of forearm at elbow

Deep tendon reflexes…

Patellar reflex: contraction of quadriceps muscle in the thigh with extension of the leg

Achillis reflex: plantar flexion of foot at the ankle

Superficial reflexes

Stimulating the skin or mucous membrane Babinski’s reflexCremasteric reflexAbdominal reflexes

Primitive reflexes

Grasp reflex Snout reflex Sucking reflex Glabella reflexes

Pathological/ abnormal fidings

Increased/hyperactive reflexes Decreased/hypoactive/absent reflexes Plantar response, babinski’s sign, hoffmann’s

sign, grasp reflex, snout reflex, sucking reflex…

Babinski’s reflex

Stroking lateral side of patient’s sole from heel to great toe

The normal response is plantar flexion of the toes Upward movement of the great toe and fanning of

the little toes – called babinski’s reflex- is abnormal

Special neurological signs

Brudzinski’s sign Kernig’s sign Battle’s sign Racoon’s sign Sunset signs