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Neurologic System Chapter 23 Assessment portion

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what subjective data should you obtain when performing a neurological exam?
you should ask questions about headache, head injury, dizziness/vertigo, tremors, seizures, weakness, falls, CVA, spinal cord injury, meningitis, medications, coordination problems, memory problems, tremors, numbness or tingling, difficulty swallowing, difficulty speaking, significant past history, and environmental/occupational hazards
When asking about HA during a neuro exam, what specific questions should you ask?
any unusuall frequent or sever headaches? when did this start? how often does it occur? where in your head do you feel the headache? do the headaches seem to be associated with anything?
When asking about head injury during a neuro exam, what specific questions should you ask?
ever had any head injury? please describe. what part of you head was hit? did you have a loss of consciousness? for how long?
When asking about dizziness/vertigo during a neuro exam, what specific questions should you ask?
ever feel lightheaded, a swimming sensation, like feeling faint? when have you noticed this? how often does it occur? does it occur with activity change in position? do you ever feel a sensation called vertigo, a rotational spinning sensation? do you feel as if the room spiins? or do you feel that you are spinning? did this come on suddenly or gradually?
When asking about seizures during a neuro exam, what specific questions should you ask?
ever had any convulsions? when did they start? how often do they occur? ask about course and duration, motor activity (where they begin, do they travel, one side or both, muscles seem tense or limp), color change in face or lips, loc, for how long, automatisms or incontinence, postictal phase (amt of time sleeping after, any confusion, weakness, HA, or muscle ache), precipitating factors, are you on any meds, how seizures affect daily life or occupation
when asking about tremors during a neuro exam, what specific questions should you ask?
any shakes or tremors in the hands or face? when did these start? do they seem to grow worse with anxiety, intention, or rest? are they relieved with rest, activity, etoh? do they affect daily activities?
when asking about weakness during a neuro exam, what specific questions should you ask?
any weakness or problem moving any body part? is this generalized or local? does it occur with anything?
When collecting objective date during a neuro exam, how should you organize the assessment?
integrate steps of neurologic examination with examination of particular part of body for example test cranial nerves while assessing the head an neck and superficial abdominal reflexes while assessing the abdomen
What sequence should you use for a complete neuro exam?
Mental status
Cranial nerves
Motor system
Sensory system
Reflexes
What equipment is need for a complete neuro exam?
penlight, tongue blade, cotton swab, cotton ball, tuning fork, percussion hammer, tuning fork, smelling scents, items to taste, brad, paperclip, penny, near vision pocket screener, eye cover, and cup of water
When do you test cranial nerve I? What is it?
when patient reports loss of smell, head trauma, or when presence of intracranial lesions is suspected; not tested routinely; Olefactory
How do you test cranial nerve I? What are the normal results?
check patency of nostrils then with person's eyes closed, occlude one nostril and present familiar aromatic substance, e.g., coffee, orange, vanilla, soap, or peppermint; normally the patient can identify an odor on each side of the nose
When do you test cranial nerve II? What is it?
always during a neuro assessment, optic nerve
How do you test cranial nerve II?
you perform the confrontation test to check visual fields and test visual acuity by using a near vision pocket screener then you use the ophthalmoscope and examine the ocular fundus to determine color, size, and shape of optic disc
When do you test cranial nerves III, IV, and VI? What are they?
always during a neuro assessment, occulomotor, trochlear, and abducens nerves
How do you test cn III, IV, and VI?
you assess the palpebral fissures first which should be equal in width, next you check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation as well as performing the cardinal fields of gaze test. end-point nystagmus is a normal find.
when do you test cn V? what is it?
during a normal neuro assessment you test sensory and motor fx but only perform the corneal reflex if the patient has abnormal facial sensations or abnormalities of facial movement and it is the trigeminal nerve
How do you test cn V?
to test the motor function you palpate temporal and masseter muscles as the pt clenches their teeth and it should be equally strong on both sides, next you try to separate the jaws by pushing down on the chin and normally you cannot. next you test the sensory function by having the patient close their eyes and test their light touch sensation by touching a cotton wisp to designated areas on their face: forehead, cheeks, and chin (ophthalmic, maxillary, and mandibular)
How do you perform the corneal reflex test? what cn are you assessing? when is it performed? what is it testing specifically?
you have the patient look forward and bring a wisp of cotton in from the side and lightly touch the cornea, not conjunctive and the patient should blink bilat.; you are assessing cn V, it's performed when the pt has an abnormal facial sensation or abnormality of facial movement; it tests sensory afferent in cranial nerve V and motor efferent in cranial nerve VII (muscles that close eye)
When do you test cn VII? what is it?
you test motor function routinely but only test sensory function if you suspect facial nerve injury; facial nerve
How do you test cn VII?
to test the motor function you first note mobility and facial symmetry as the pt responds to requests to smile, frown, close eyes tightly (against your attempt to open them) lift eyebrows, and show teeth, then have the pt puff cheeks and press on the cheeks to see that air escapes equally from both sides. to test sensory function you test the sense of taste by applying cotton applicator covered with solution of sugar, salt, or lemon juice to tongue and ask pt to identify the taste
When do you test cn VIII? what is it?
during a normal neuro exam; vestibulocochlear or accoustic nerve
How do you test cn VIII?
you test hearing acuity by ability to hear normal conversation and by whispered voice test
When do you test cn IX and X? What are they?
during a normal neuro exam you test motor fx but not the sensory function of cn IX which mediates taste on the posterior one third of the tongue because it is too difficult to test; glossopharyngeal and vagus nerves
How do you test cn IX and X?
you depress the tongue and note pharyngeal movement as the pt says ahhh or yawns, the uvula and soft palate should rise in midline then you touch the posterior pharyngeal wall with the tongue blade and note the gag reflex
When do you test cn XI? What is it?
during a normal neuro exam; the spinal accessory nerve
How do you test cn XI?
inspect the sternomastoid and trapezius muscles for equal size, next check equal strength by asking person to rotate head against resistance applied to side of chin, ask the pt to shrug their shoulders against resistance and these movements should feel equally strong on both sides
When do you test cn XII? what is it?
during a normal neuro exam; hypoglossal nerve
How do you test cn XII?
inspect the tongue, no tremors should be present, note forward thrust in midline as person protrudes tongue, asp pt to say light, tight, dynamite and note that lingual speech is clear and distinct
When assessing muscles during a neuro exam, what specifics are you noting?
size (all muscle groups), strength, tone, and involuntary movements
How do you inspect the muscles during a neuro exam?
compare the right side with the left, they should be symmetric bilat and if not measure in cm and record difference
Which muscles do you test for strength during a neuro exam?
muscle groups of the extremities, neck, and trunk
How do you test muscle tone during a neuro exam?
move extremities through passive rom having pt relax and move each extremity smoothly through a full rom support arm at elbow and leg at knee, you should note mild even resistance to movement
If involuntary muscle movements are noted during a neuro exam what do you document?
location, frequency, rate, and amplitude
What are you testing when assessing cerebellar function?
gait, romberg test, coordination and skilled movements
How do you assess the gait of a patient during a neuro exam?
observe them walk 10 to 20 feet, should be smooth, rhythmic, and effortless, opposing arm swing is coordinated, step length about 15 inches from heel to heel, next ask them to walk straight line in heel to toe fashion, if they cant walk straight or stay balanced they have a coordination problem
How do you perform the romberg test? what does it assess during a neuro exam?
have patient put feet together and arms at sides then have them close their eyes and hold position for about 20 seconds, normally they can maintain their posture and balance; it's used to assess cerebellar function
What tests do you perform to assess coordination and skilled movements during a neuro exam?
you check their rapid alternating movements by performing the finger to finger test, finger to nose test, and heel to shin test, also have them pat knees alternating front and back or have them touch thumb to each finger on same hand starting with the index finger
Explain the procedures for checking coordination and skilled movements during a neuro exam.
for the finger to finger test have the patient keep their eyes open, touch your finger with their index finger, then touch their nose and repeat more rapidly, for the finger to nose test ask pt to close eyes, stretch out arms and touch the tip of their nose with each index finger then increase speed, and for the heel to shin test have the pt lay supine and place heel on opposite knee then run it down the shin from the knee to the ankle
Name the routine screening procedures tested for assessment of the sensory system during a neuro exam.
superficial pain, light touch, vibration, and stereognosis
When testing the sensory system during a neuro exam how do you assess the patients pain response?
you test it by their ability to perceive a pinprick, break a tongue depressor and have them identify whether they feel a sharp sensation or dull sensation
WHen testing the sensory system during a neuro exam how do you assess the patients temperature detection?
it is only tested when pain sensation is abnormal and you place the flat side of the tuning fork on the skin then alternate with your hand
When testing the sensory system during a neuro exam, how do you assess the patients light touch response?
use a wisp of cotton and touch the skin in random order including the arms, forearms, hands, chest, thighs, and legs, have patient say now or yes when touch is felt
when testing the sensory system during a neuro exam, how do you assess the patients ability to sense vibration?
place a tuning fork over bony prominences of one finger on each hand and the big toe of each foot and have them tell you when the vibration starts and when it stops
When testing the sensory system during a neuro exam, how do you test kinesthesia?
you test their ability to perceive passive movements of extremities by moving a finger or big toe up and down and ask them to tell you whether it is going up or down
When testing the sensory system during a neuro exam, what tests do you perform in order to assess tactile discrimination?
stereognosis, graphesthesia, two-point discrimination, extinction, and point location
When assessing stereognosis during a neuro exam, what are checking the patient for?
their ability to recognize objects by feeling their forms sizes and weights
When assessing graphesthesia during a neuro exam, what are you checking the patient for?
their ability to read a number by having it traced on their skin
When assessing two-point discrimination during a neuro exam, what are you checking the patient for?
their ability to distinguish separation of two simultaneous pin points on their skin
When assessing extinction during a neuro exam, how do you perform this test?
simultaneously touch both sides of body at same point and normally both are felt.
When assessing point location during a neuro exam, how do you perform this test?
you touch skin and withdraw stimulus promptly then ask the pt to put their finger where you just touched
What does measurement of deep tendon reflexes reveal?
measurement of stretch reflexes reveals intactness of reflex arc at specific spinal levels
How do you test deep tendon reflexes?
have the limb relaxed then stimulate the reflex by directing short, snappy blows with the reflex hammer onto the muscle's insertion tendon and compare right and left sides, the responses should be equal
How do you document deep tendon reflexes?
with a graded 4-point scale: 4= very brisk, hyperactive, indicative of disease; 3= brisker than average, may indicate disease; 2=average, normal; 1= diminished, low normal, or occurs with reinforcement; 0= no response
What area does the biceps reflex check functioning and how do you test it?
c5 to c6; support the persons forearm on yours, place thumb on biceps tendon and strike a blow on your thumb, contraction of biceps muscle and flexion of forearm should be seen
what area does the triceps reflex check functioning and how do you test it?
c7 to c8; tell pt to let arm "just go dead' and strike triceps tendon directly just above the elbow and extension of the forearm should be se
what area does the brachioradialis reflex check functioning and how do you test it?
c5 to c6; hold pts thumbs to suspend forearms in relaxation and strike frearm directly, about 2 to 3 cm above radial styloid process, flexion and supination of forearm should be seen
what area does the quadriceps reflex check functioning and how do you test it?
L2 to L4; let lower legs dangle freely to flex knee and stretch tendons; strike tendon directly just below patella, extension of lower leg should be seen
what area does the achilles reflex check functioning and how do you test it?
L5 to S2; position pat with knee flexed hold foot in dorsiflexion and strike achilles tendon directly, plantar flexion should be seen
Name the superficial reflexes
cremasteric reflex and plantar reflex
What area does the cremasteric reflex check functioning and how do you test it?
L1 to L2; on male, lightly stroke inner aspect of thigh with reflex hammer or tongue blade and elevation of ipsilateral testicle should be seen
What area does the plantar reflex check fucntioning and how do you test it?
l4 to s2; position thigh with slight external rotation, with reflex hammer draw a light stroke up lateral side of sole of foot and inward across ball of foot like an upside down J, plantar flexion of toes and inversion and flexion of forefoot should be seen
When performing a neuro exam on an aging adult, what nerves aren't tested on them?
cranial nerves mediating taste and smell because they naturally decline in function with age
What are the special considerations for aging adults during a neuro exam?
look for senile tremors, dyskinesias, assess their gait, and their rapid alternating movements will be different
When assessing the rapid alternating movements of an aging adult during a neuro exam what should you consider?
that movements like pronating and supinating hands on the thigh may be difficult to perform
When collecting subective data during a neuro exam, what specific questions should you ask the patient about incoordination?
any problems with balance when walking? do you list to one side? any falling? which way? do your legs seem to give way? any clumsy movement?
When collecting subjective data during a neuro exam, what specific questions should you ask the patient about numbness or tingling?
does it feel like pins and needles? when did this start? where do you feel it? does it occur with activity?
When collecting subjective data during a neuro exam, what specific questions should you ask the patient aboutdifficulty swallowing?
does it occur with solids or liquids? have you experienced excessive saliva, drooling?
When collecting subjective data during a neuro exam, what specific questions should you ask the patient about difficulty speaking?
any problems forming words or with saying what you intended to say? when did you first notice this? how long did it last?
When collecting subjective data during a neuro exam, what specific questons should you ask the patient about significant past history?
is there any Hx of stroke, spinal cord injury, meningitis, encephalitis, congenital defect, or alcoholism?
When collecting subjective data during a neuro exam, what specific questions should you ask the patient about environmental/occupational hazards?
are you taking any meds now? how much alcohol do you drink? each week? each day? how about other mood altering drugs like marijuana, cocaine, barbiturates, tranquilizers? are you exposed to any insecticides, organic solvents, lead?
When do you perform a screening neurologic examination??
on seemingly well pts who have no significant subjective findings from the history
When do you perform a complete neurologic examination?
on pts who have neurologic concerns e.g. HA, weakness, loss of coordination. or who have shown signs of neurologic dysfunction
When do you perform a neurologic recheck?
on pts who have neuro deficits and require periodic assessments e.g. hospitalized pts or those in extended care
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