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Presented by: Ms. Jeceli Alviola Nobleza, BSN-RN
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
• 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.
REVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE
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
• Functions: a. act as supportive tissue, nourishing and protecting the neurons b. maintain homeostasis in the interstitial fluid around the neurons and account for about 50 percent of the central nervous system (CNS) volume c. have the ability to regenerate and respond to injury by filling spaces left by damaged neurons.
• Functions: a. have the ability to produce action potentials or impulses (excitability or irritability) and b. to transmit impulses (conductivity).
Sensory (afferent) neuron
Cell body Nissl bodies Nodes of Ranvier
Motor (efferent) neuron
Synaptic vesicles Axon Myelin Presynaptic terminal Synaptic cleft
Receptors in skin
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.
The Human Brain
tex Som a cort tosens ory ex
Central fissure PARIETAL LOBE
Emotion Behavior Intellect
Hearing Smell Taste Memory
Visual perception Coordination Equilibrium Balance
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
• Pathways,either ascending or afferent,allow sensory data, such as the feeling of a burned hand, to become conscious perceptions.
Leg Knee Foot toes
Trunk, Arm, Hand, Fingers, Face, Lips, Tongue
Lateral spinothalamic tract Pain &temperature Anterior spinothalamic tract Crude touch & pressure
Posterior column Fine touch, proprioception and vibration
Posterior root of the spinal cord
Trunk, Arm, Hand, Leg Fingers, Face, Lips, Tongue Knee Foot toes
Anterior corticospinal (uncroosed pyramidal tract
Lateral corticospinal (crossed pyramidal tract
• Spinal reflexes do not depend on conscious perception and interpretation of stimuli, nor on deliberate action; in other words, they do not involve the brain. • They occur involuntarily, with lightning speed, and are identical in all healthy children and adults, although they are less developed • in infants.
Dorsal root ganglion
PERIPHERAL NERVOUS SYSTEM
• The peripheral nervous system consists of - the cranial - spinal nerves and the - peripheral autonomic nervous system.
The 12 pairs of cranial nerves originate from the brain and are called the peripheral nerves of the brain.
I-Olfactory nerve – Smell (S) II-Optic nerve - Vision (S) III-Oculomotor nerve (M) - Eye movement; pupil constriction IV-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) - 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
• 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 some overlap,each is responsible for innervation of a particular area of the body.
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 • Sensory Function
a. Light touch c. Vibration e. Streognosis g. Two-point discrimination i. Sensory Extinction
(12 cranial nerves)
b. Pain d. Kinesthetics f. Graphesthesia h. point localization
• Reflex Function
a. Deep tendon reflexes b. Superficial reflexes
Ensure proper hygiene before seeing a client Ensure all equipment is properly cleaned
- 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
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 offensive body odor
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
Normal: Verbal expressions match with the nonverbal behavior Mood is appropriate to the situation Standing in upright stance with parallel alignment of hips &shoulders
Abnormal: Lack of facial expression
- Possible psychological disorder (e.g., depression or schizophrenia) or neurologic impairment affecting cranial nerves.
- Parkinson’s disease.
- Depression if
psychological in origin; or stroke with hemiparesis if physiological in origin.
3. SPEECH/ COMMUNICATION a. Speech and Language Listen to patient’s rate and ease of speech, including enunciation. Abnormal: Normal: Speech flows ■ Hesitancy, stuttering, easily; patient stammering, unclear speech: - Lack of familiarity with language, enunciates deference or shyness, anxiety, clearly. neurologic disorder. Sophistication of ■ Dysphasia/aphasia: speech matches - Neurologic problems such as stroke. age, education, ■ Drugs and alcohol can also cause and fluency. slurred 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 speech intact.
■ Impaired spontaneous speech: - Cognitive impairment. Impaired motor speech (dysarthria): Problem with CN XII
c. Autonomic Speech Have patient say something that is committed to memory, such as days of week or months of year. Normal: ■ Automatic speech intact.
■ Impaired automatic speech: Cognitive impairment or memory problem.
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 be psychiatric in origin
Lathargic or somnolent Obtunded Stupor Coma
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 ■ Oriented . . . . . . . . . . . . . . . 5 ■ Confused . . . . . . . . . . . . . . . 4 ■ Inappropriate . . . . . . . . . . . . 3 ■ Incomprehensible . . . . . . . . 2 ■ Unresponsive. . . . . . . . . .. . . 1 ■ Obeys commands . . . . . . . .. 6 ■ Localizes pain. . . . . . . . . . . 5 ■ Withdraws from pain. . . . …. 4 ■ Abnormal flexion . . . . . . .. . . 3 ■ Abnormal extension . . . . . . . 2 ■ Unresponsive. . . . . . . . . . . . . 1 Findings
Best verbal response V
Best motor response M
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)
EYE RESPONSE 4 3 Eyelids open or opened, tracking or blinking to command 2 Eyelids open but not tracking 1 Eyelids closed but open to loud voice 0 Eyelids closed but open to pain Eyelids remain closed with pain MOTOR RESPONSE 4 3 2 1 0 BRAINSTEM REFLEXES 4 3 2 1 0 RESPIRATION 4 3 2 1 0
Four Score Coma Measurement Scale
Thumbs up, fist, or peace sign to command Localizing to pain Flexion response to pain Extensor posturing No response to pain or generalized myoclonus status epilepticus
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 Not intubated, regular breathing pattern Not intubated, Cheyne-Stokes breathing pattern Not intubated, irregular breathing pattern Breathes above ventilator rate Breathes at ventilator rate or apnea
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 person or event, such as the name of the previous president of the United States or the location of a natural disaster.
Normal: Immediate, recent, and remote memory intact.
Abnormal: 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
Abnormal: Temporary memory loss
- may occur after head trauma.
- for events just preceding illness injury. or
- 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 adding 4 x 4. If successful, proceed to more difficult calculation, such as 11 9. as
Normal: Abnormal: Mathematical/calculati Inability to calculate at ve ability intact and level appropriate to age, appropriate for education, and language patient’s age, ability requires evaluation educational level, and for neurologic impairment. language facility.
b. General Knowledge and Vocabulary
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 difficult ones. Remember to consider the patient’s age, educational level, and cultural background.
Normal: Thought process intact
Abnormal: Incoherent speech illogical or unrealistic ideas repetition of words and phrases repeatedly straying from topic suddenly losing train of thought
(examples of altered thought processes that indicate 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
Abnormal: Able to generalize from ■ Impaired ability to think specific example and abstractly:
apply statement to - Dementia, delirium, mental human behavior. retardation, psychoses. Children should be able to distinguish like from unlike as appropriate for theirage and language facility.
e. Judgment Observe patient’s response to current situation. Ask patient to respond to a situation or hypothetical situation. Normal: Abnormal: ■ Impaired judgment can be Judgment appropriate and associated with dementia, psychosis, or drug and alcohol intact. 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 close eyes. 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: Abnormal: ■ Patient is able to ■ Anosmia is loss of sense of identify substance. smell.
-May be inherited and nonpathological: chronic rhinitis, (Bear in mind that some substances may be sinusitis, heavy smoking, zinc unfamiliar, especially deficiency, or cocaine use. - It may also indicate cranial nerve to damage from facial fractures or children.) 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, Trochlear, and Abducens Nerves
a. Ask the client to read a printed material, observe the distance between the printed material and the client’s eyes. b. Use the snellen chart to check/ test: - distant vision - color Client 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 Eyes d. Convergens & Accomodation e. Pupillary Light Reflex - using direct and consensual pupillary reaction to light
Testing eye movements
Testing pupil accommodation
Normal: ■ Able to read without difficulty ■ Visual acuity intact 20/20, both eyes
Hippus phenomenon: - Brisk constriction of pupils in reaction to light, followed by dilation and constriction - may be normal or sign of early CN III compression.
Abnormal: ■ CN II deficits
- 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 more sluggish 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 against resistance 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:
- 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: - Gently touch cornea with cotton wisp. o Touching 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
Cont. CN V
Normal: Full range of motion (ROM) in jaw and 15 strength. Patient perceives light touch and superficial pain bilaterally.
Weak or absent contraction unilaterally:
- Lesion of nerve, cervical spine, or brainstem.
Inability to perceive light touch and superficial pain
- may indicate peripheral nerve damage.
■ Tic douloureux:
- Neuralgic pain of CN V caused by the pressure of degeneration of a nerve.
■ Corneal reflex test used in patients with decreased LOC
- to evaluate integrity 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 – motor function
b. Testing sensory function: - Test taste on anterior two-thirds of tongue for sweet, sour, salty.
Sweet: Tip of the tongue Sour: Sides of back half of tongue Salty: Anterior sides and tip of tongue Bitter: Back of tongue
Testing taste sensation
Normal: Facial nerve intact; able to make faces. Taste sensation on anterior tongue intact.
(Taste decreased in older adults.)
Abnormal: 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.
Watch tick test
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)
Normal: Hearing intact. Negative Romberg test.
Abnormal: Hearing loss, nystagmus, balance disturbance, dizziness/vertigo: - Acoustic nerve damage. ■ Nystagmus: - CN VIII, brainstem, or cerebellum problem or phenytoin (Dilantin) toxicity.
6. CNs IX and X—Glossopharyngeal and Vagus 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 function of CN X by stimulating gag reflex. - 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 hoarseness when speaking
Swallow and cough reflex intact. Speech clear. Elevation and constriction of pharyngeal musculature and tongue retraction indicate positive gag reflex.
- Contralateral nerve damage. - Damage to CNs IX and X also impairs swallowing.
■ 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: - 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 symmetrical, with patient moving against resistance without pain. ■ Full ROM of neck with +5/5 strength.
Abnormal: Asymmetrical 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 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 tongue medially. No atrophy, tumors, or lesions.
Abnormal: Asymmetrical/diminished/ absent movement/deviation from midline/protruded tongue: - Peripheral nerve CN XII damage. ■ Tongue paralysis results in dysarthria.
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. Abnormal: Normal:
Identifies areas stimulated by light -Peripheral nerve damage or damage to touch. posterior column of spinal cord.
- Peripheral neuropathies can also cause sensory deficits. ■ Hypesthesia: Increased sensitivity. ■ Paresthesia: Numbness and tingling. ■ Anesthesia: Loss of sensation.
Diminished/absent cutaneous perception:
- Stimulate skin lightly with sharp and dull ends of toothpick/ paper clip -Apply stimuli randomly and ask patient to identify whether 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 identify whether sensation is hot or cold.
Diminished or absent pain perception:
to lateral spinothalamic tract.
Identifies areas stimulated and type - Peripheral nerve damage or damage of stimulation. ■ Hyperalgia:
Increased pain sensation.
Decreased pain sensation. ■ Analgesia: No pain sensation.
■ Diminished/absent temperature perception:
- Peripheral nerve damage or damage to lateral spinothalamic tract
-Place a vibrating tuning fork over a finger joint, and then over a toe joint. -Ask patient to tell you when vibration is felt and when it stops. - If patient is unable to detect vibration, test proximal areas as well.
Vibratory sensation intact bilaterally in upper and lower extremities.
Diminished/absent vibration sense: - Peripheral nerve damage caused by alcoholism, diabetes, or damage 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, and have 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.
Position sensation intact bilaterally in upper and lower extremities.
■ Diminished or absent position sense:
- Peripheral nerve damage or damage to posterior column of spinal cord.
With patient’s eyes closed, place a familiar object, such as a coin or a button, in patient’s hand, and ask patient to identify it. ■ Test both hands using different objects.
Stereognosis intact bilaterally.
■ Abnormal findings suggest a lesion or other disorder involving sensory cortex or a disorder affecting posterior column.
- With patient’s eyes closed, use point of a closed pen to trace a number on patient’s hand - Ask patient to identify the number. Abnormal: Normal: ■ Abnormal findings suggest Graphesthesia lesion or other disorder involving intact bilaterally. sensory cortex or disorder affecting posterior column.
7. Two-Point Discrimination
Ability to differentiate between two points of simultaneous stimulation. - Using ends of two toothpicks/ paper clip, stimulate two points on fingertips simultaneously. - Gradually move toothpicks together, and assess smallest distance at which patient can still discriminate two points (minimal perceptible distance). - Document distance and location.
Discriminates between two points on fingertips no more than 0.5 cm apart and on hands no more than 2 cm apart.
■ Abnormal findings suggest lesion or other disorder involving sensory cortex or disorder affecting posterior column.
8. Point Localization
■ Ability to sense and locate area being stimulated. ■ With patient’s eyes closed, touch an area; then have patient point to where he or she was touched. ■ Test Normal:both sides and upper and lower extremities. Abnormal: Point localization Abnormal findings suggest lesion or other disorder involving sensory intact. cortex or disorder affecting posterior column.
9. Sensory Extinction
■ Simultaneously touch both sides of patient’s body at same point. ■ Ask patient to point to where she or he was touched. Normal: Abnormal: Extinction intact. Identification of stimulus on only one side suggests lesion or other disorder involving sensory cortical region in opposite hemisphere.
Documenting Reflex Findings • Use these grading scales to rate the strength of each 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
1. 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. ■ 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. ■ Strike tendon directly below patella..
■ Contraction of quadriceps with extension of knee. ■+2
d. Achilles Reflex
■ Have patient lie supine or sit with one knee flexed. ■ Holding patient’s foot slightly dorsiflexed, strike Achilles tendon.
■ Plantar flexion of foot. ■+2
e. Test for Ankle Clonus ■ If you get 4 reflexes while supporting leg and foot, quickly dorsiflex foot.
■ No contraction
Abnormal: ■ Absent/diminished DTRs: - 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 such as 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 gloved 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 bulbocavernous 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 Function
1. Balance tests
a. Gait Observe as the person walks 10-20 feet, turns, and returns to the starting point. Normal: Abnormal:
Person moves with a sense of freedom. Gait is smooth, rhythmic, and effortless Opposing arm swing is coordinated The turns are smooth Stiff, immobile posture. Staggering or reeling. Wide base of support Lack of arm swing or rigid arms Unequal rhythm of steps. Slapping of foot. Scraping of toe of shoe Ataxia – uncoordinated or unsteady gait.
Perform Tandem Walking - ask the person to walk a straight line in a heelto-toe fashion. This decreases the base of support and will accentuate any problem with coordination.
Person can walk straight and stay balanced
Crooked line walk Widens base to maintain balance Staggering, 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 or hop 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)
Negative Romberg test
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, alcohol intoxication) -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, lift up, turn hands over, and pat the knees with the backs of the hands. Then ask to do this faster. Abnormal: Normal:
done with equal turning and quick rhythmic pace 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.
Dysmetria Movement is - clumsy movement with smooth and accurate 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 nose with each index finger, alternating hands and increasing speed.
Misses nose. Done with accurate Worsening of coordination when and smooth the eyes are closed movement - occurs with cerebellar disease
• Dillon, Patricia. Nursing Health Assessment. 2nd 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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