Neurological assessment 3

MENNONITE COLLEGE OF NURSING

AT ILLINOIS STATE UNIVERSITY

Diagnostic Reasoning for Advanced Practice Nursing 431

Neurological Assessment

Quick A & P Review

Central nervous system: the brain and spinal cord

  The Brain

o  4 regions: cerebrum, diencephalon, brainstem, cerebellum

o  Contains interconnecting neurons (cell bodies and axons)

o  Gray matter: aggregations of neuronal cell bodies

o  White matter: neuronal axons coated with myelin

  The spinal cord

o  Extends from brainstem (medulla) to L1-L2 vertebrae

o  Contains motor and sensory pathways that exit and enter the cord via anterior and posterior nerve roots and spinal and peripheral nerves

o  5 segments: cervical (C1-8), thoracic (T1-12), lumbar (L1-5), sacral (S1-5), coccygeal

o  Note: Cauda equina at L1-2, where nerve roots fan out like a horse’s tail

Peripheral nervous system

  Cranial nerves

o  12 pairs of cranial nerves plus spinal and peripheral nerves

o  Govern motor, sensory, and specialized functions like smell, vision, and hearing

  Peripheral nerves

o  31 pairs of nerves that attach to the spinal cord: 8 cervical, 2 thoracic, 5 lumbar, 5 sacral, 1 coccygeal

o  Each nerve has an anterior (ventral) root containing motor fibers and a posterior (dorsal) root containing sensory fibers; the anterior and posterior roots merge to form a short (<5 mm) spinal nerve

o  Spinal nerve fibers commingle with similar fibers from other levels to form peripheral nerves

o  Motor and sensory pathways: descending motor and ascending sensory pathways

o  Dermatome: band of skin innervated by the sensory root of a single spinal nerve

Common neurological complaints or symptoms

  Headache (see Dains chapter 18)

  Dizziness or vertigo (see Dains chapter 12)

  Generalized, proximal, or distal weakness

  Numbness

  Abnormal or loss of sensations

  Loss of consciousness, syncope, or near-syncope

  Seizures (see Bickley, pages 718-719 for types) What history indicates an increased risk?

  Tremors or involuntary movements

  Weakness

  Memory problems

Health Promotion and Counseling

  Preventing stroke or TIA

  Reducing risk of peripheral neuropathy

  Detecting the “three Ds” – delirium, dementia, and depression

  In children, discuss achieved & anticipated developmental milestones

The Nervous System: Key Principles

  Objectives

o  Is there a problem involving the nervous system?

o  Localize the problem within the nervous system

o  Determine the etiology

o  Determine appropriate diagnosis and treatment

  As you examine the patient, remember three important questions:

o  Is mental status intact?

o  Are right- and left-sided findings the same, or symmetric?

o  If findings are asymmetric or otherwise abnormal, do the causative lesions lie in the central nervous system or the peripheral nervous system?

  Organize your thinking into 5 categories:

o  mental status, speech, and language

o  cranial nerves

o  motor system

o  reflexes

o  sensory system

Subjective Data: History is the most important factor in neuro assessment!!!

  Chief complaint

  HPI

o  Details about the symptoms

How would you describe the location of a headache when the patient points . . ?

o  Acute or chronic in nature?

o  Precipitating factors?

o  Improving or worsening?

o  Associated symptoms?

o  Any recent travel to foreign countries?

  Past Medical History

o  Previous similar symptoms

o  Other medical illnesses

o  Previous surgeries

o  Pregnancy or birth illness or injury

o  Allergies

o  Current medications – when last taken (for example Parkinson’s disease, tremors, seizures, dizziness, neuropathy, etc.)

  Family history

o  Huntington’s chorea, tics, etc.

  Social history

o  Employment – chemical exposures

o  drug or alcohol intake

o  home life – hobbies?

  ROS Ask about/document handedness---Why? What are you including in the Nervous system?

Objective Data; Physical Examination

  General Approach

o  Detail of exam depends on the data collected

o  Neuro exam can be integrated with other systems such as MSK, Behavior/Mental status.

o  What have you already done re: neuro?

o  Inspection, palpation, percussion (no auscultation)

o  Use head to toe approach, side-to-side (symmetry important!)

  Neuro exam: 5 parts

1.  Mental status (and speech)

2.  Cranial nerves

3.  Motor function

4.  Reflexes

5.  Sensory function

1.  Mental Status (Bickley, pages 145-157)

  Appearance and behavior

o  Level of consciousness – alert, lethargic, obtunded, stuporous, coma

o  Posture and motor behavior – walking, sitting, lying, comfortable, agitated, movements

o  Dress, grooming, hygiene

o  Facial expression – flat, asymmetrical

o  Manner, affect, relationship to people and things

  Speech & language

o  Quality, rate, volume

o  Articulation & Fluency

§  Language – receptive and expressive components

§  Dysarthrias (muscular control defect-Parkinson’s)

§  Dysphonias (aphasias) such as Wernicke’s (fluent receptive) & Broca’s (nonfluent expressive)

§  Aphasia testing How is this done?

  Mood – depressed, suicide

  Thoughts & perceptions – logical, relevant, organized, and coherent thoughts expressed during interview?

  Cognitive function

o  Orientation – person, place, time

o  Attention (Spell WORLD backwards)

o  Memory

§  Short-term (minutes to days; recall of 3 words at 3 minutes)

§  Long-term (months to years)

  Higher cognitive function

o  Information & Vocabulary (name last 4 presidents)

o  Calculation (simple math)

o  Abstract thinking (explain proverb)

o  Constructional (draw face of a clock with current time)

  RED FLAGS regarding mental status

o  Inaccurate or vague details about history

o  Jocularity

o  Change in observed grooming habits

o  Signs of change from previous behavior

o  MMSE – tool to screen for cognitive impairment not diagnose delirium or dementia

2. Cranial Nerves

  Sensory deficits are present when afferent fibers (A) are involved.

  Motor deficits are present when efferent fibers (E) are involved.

o  I Olfactory (A)

o  II Optic (A)

o  III Oculomotor (E)

o  IV Trochlear (E)

o  V Trigeminal (A, E)

o  VI Abducens (E)

o  VII Facial (A, E)

o  VIII Vestibulocochlear (Acoustic) (A)

o  IX Glossopharyngeal (A, E)

o  X Vagus (A, E)

o  XI Spinal Accessory (E)

o  XII Hypoglossal (E)

  Examination techniques

o  CNI-Olfactory; smell in each nostril separately

o  CN II-Optic; visual acuity chart, visual field confrontation, fundoscopic

o  CN III-Oculomotor, IV-Trochlear, VI-Abducens; PERRLA, accommodation, EOMs, convergence

o  CN V-Trigeminal; clinch jaw, palpate temporal/masseter muscles; light touch/sharp/dull

o  CN VI-Facial; asymmetry at rest, eyebrow raise, frown, tight closure of eyes, smile, puff cheeks

o  CN VIII; Acoustic; bilateral Whisper test

o  CN IX-Glossopharyngeal, CN X-Vagus; speech quality, say “Ah”

o  CN XII-Hypoglossal; stick tongue out and move side-to-side

o  CN XI-Spinal Accessory; shrug shoulders/turn head against resistance

3. Motor Function (trunk and limbs)

  Body position – shoulder height, neck position, etc.

  Involuntary movements – tremors, tics, fasciculations How do you describe these?

  Muscle bulk – contour, symmetry, atrophy

  Muscle tone – hypotonia, spasticity, cogwheel rigidity

o  Note tone & resistance during joint ROMs

  Muscle Strength:

o  Muscle group testing discussed in MSK

o  Grading

§  5/5 Normal Strength

§  4/5 Full ROM against gravity, with some effort at resistance

§  3/5 ROM against gravity

§  2/5 ROM without gravity

§  1/5 Trace joint or muscle contraction

§  0/5 No movement

  Coordination

o  Station and Gait

§  Walk across room and back (also not arm swing)

§  Walk heel to toe (tandem walking)

§  If has difficulty: Romberg, hop in place, shallow knee bend, walk on toes (plantar flexion”, walk on heels, dorsiflexion)

o  Cerebellar Function

§  Arms

·  Rapid rhythmic alternating movement

·  Point to point

§  Legs

·  Rapid rhythmic alternating movement

·  Point to point

4. Reflexes

  Technique

o  Relaxed client

o  Limb supported

o  Muscle mildly stretched

o  Strike tendon briskly

o  If reflexes are symmetrically diminished or absent, use isometrics-how is this done?

  Grading of Reflexes

o  0 Absent, no muscle contraction

o  1+ Hyporeflexia

o  2+ Normal

o  3+ Hyperreflexia

o  4+ Abnormal - strong contractions, with clonus

  Check these reflexes: What nerve roots do these test?

o  Biceps

o  Triceps

o  Brachioradialis

o  Patellar (knee)

o  Achilles (ankle)

o  Plantar response (formerly Babinski)

5. Sensory (dermatomes, fingers and toes)

  Pain & temperature (spinothalamic tract) – pinprick, tuning fork

  Position & vibration (posterior column) – hold side of digit, tuning fork on bone

  Light touch (both pathways) – cotton swab

  Discrimination

o  Stereognosis: object identification

o  Graphesthesia: number identification

o  Two point discrimination

o  Point localization

o  Extinction

Special Maneuvers:

  Meningeal signs

o  Brudzinski’s sign (flex neck, hips/knees flex)

o  Kernig’s sign (flex legs at hip and knee, resistance to straightening knees bilaterally)

  Lumbosacral radiculopathy - straight-leg raise

Examples of Nervous System notes

Normal screening neurological note

Mental status: alert, oriented x 3, appropriate responses in conversation.

Cranial nerves: PERRLA. EOMI. Visual acuity 20/20. Whispered voice test passed. Facial strength intact.

Motor: Bilateral strength 5/5 with shoulder abduction, elbow extension, wrist extension, finger abduction, hip flexion, knee flexion, ankle dorsiflexion. Casual and tandem gaits intact. Fine finger movement and finger-nose-finger intact.

Sensation: Sharp/dull intact in bilateral fingers and toes.

Reflexes: 2 at biceps, knees and ankles. Plantar responses flexor.

Focused normal neurological examination of lower extremities note

Motor: Bilateral muscle bulk and tone intact including extensor digitorum brevis, no fasciculations.

Bilateral strength 5/5 in hip flexors, knee extensors and flexors, knee abductors, ankle flexors and

extensors. Heel-to-shin intact. Casual, heel, toe, and tandem gaits intact. Romberg sign negative.

Reflexes: 2 at knees and ankles. No clonus. Plantar responses flexor.

Sensation: Bilaterally pinprick, vibratory, temperature and position sensations intact.

Normal detailed neurological examination note

Mental status: Alert, oriented x 3, logical and relevant responses in conversation. Recent and remote

memory, intellectual ability, fund of knowledge and judgment intact on screening.

Cranial nerves: Visual acuity 20/20. PERRLA. Disk margins sharp. Visual fields full. EOMI. Facial strength intact, symmetry at rest. Temporal and masseter strength intact. Whispered voice test passed. Uvula rose in the midline,

gag intact. Shoulder shrug symmetric, strength 5/5. Tongue protruded midline, symmetrical movement.

Motor: Good muscle bulk and tone bilaterally. Fine finger movements and finger-nose-finger intact.

Strength 5/5 throughout, no pronator drift. No tremors. Casual, heel, toe, and tandem gaits intact. Romberg sign

negative.

Sensation: Light touch, sharp/dull, and vibratory intact bilaterally.

Reflexes: 2 at biceps, triceps, brachioradialis, knees, and ankles. Plantar responses flexor.