Chapter 24: Neurological Assessment

Chapter 24: Neurological Assessment Urgent Assessment · acute change in mental status or LOC · seizure activity · change in pupil reactivity or eye deviation · progressive weakness or paralysis · changes in sensory ability or motor movement · significant changes in vital signs · Severe headache · changes in reflexes or asymmetry Focused Health History · headache/migraines · Weakness · involuntary movements or tremors · difficulty with balance, coordination, or gait · dizziness or vertigo · difficulty with expression or speech · change in intellectual abilities . numbness or loss of sensation · loss of consciousness or fainting · convulsions or seizures · sudden vision or hearing changes · sudden change in sensory function · LATERSNAPS Physical Assessment · initial survey · level of consciousness (LOC) ↳ Glasgow coma scale · Vital signs ↳ height, weight + cranial nerves · cognitive function · communication · gait (romberg test) · pronator drift · coordination · motor function · Sensory function · reflexes Initial Survey · general observations of the patient ↳ appearance: grooming, cleanliness, arrangement of clothing, use of prosthetics, visible evidence of trauma, and any unexpected findings Level of Consciousness (LOC) · Alert: Orientated to person, place, and time · Confused: slowed thinking, perhaps memory loss, not oriented · Delirious: restless or agitated and marked loss of attention · Drowsy > Lethargic: drifts off frequently, must be aroused (sedation?) > Obtunded: frequently asleep, difficult to arouse, incoherent speech · Stupor: responds only to pain, groans and mumbles · Coma: unconscious with little or no response to stimuli ↳ Use glascow coma scale * - - Vital Signs and Cognitive Function · Take the patients vital signs (HR, BP, RR etc. ) to establish baseline · Cognitive function ↳ orientated, attention, memory, vocabulary, abstract thinking etc. · Cranial Nerve Assessment ↳ check pupillary response then do the cranial nerve assessment mentioned before Gait, Posture, and Balance · ask patient to walk down corridor and observe smoothness of gait and position of feet · have them walk on tip-toes and heels · heel-to-toe tandem walk · Shallow knee bend · romberg standing test → tests vision, vestibular sense, and proprioception (NOT cerebellar!) · check for pronator and tremor Pronator Drift · patient extends arms with palms outward and holds the position for about 20 seconds with eyes open then closed · Forearm Pronates: contralateral pyramidal tract → muscle weakness · slow pronation with upward movement ↳ ipsilateral cerebellar (rebound test) ↳ ipsilateral dorsal column: more of a slow, searching movement · be sure to document presence, side, and direction of drift · Note: contralateral means opposite side of brain, and ipsilateral means same side - - Myotomes and Dermatomes · myotome: a group of muscles innervated by a single spinal nerve root · dermatome: an area of skin innervated by a specific cranial nerve · Sensory territory: the specific branches of nerves that innervate hands + feet etc. Coordination (Cerebellar Examination) · coordination of muscle movements requires interactions among motor, cerebellar, vestibular, and sensory · Point-to-point movements (dysmetria) ↳ finger to nose ↳ heel to skin · rapid alternating movements (dysdiadochokinesia) ↳ slap thigh with palm and back of hand as fast as possible ↳ tap each foot against examiners hand as fast as possible · axial stability and heel-toe walking · scanning speech (weird pulsing voice) (dysarthria) - - - - Motor Function · inspection, palpation, percussion, and reflex testing · inspect for asymmetry and palpate for muscle atrophy or fasciculation · tone ↳ atony: lack of normal tone or tension ↳ hypotonic: decreased muscle tone and increased flexibility "floppy baby syndrome" ↳ hypertonic: extremely tight muscles · strength and resistance ↳ push against patient's movements to test strength ↳ AHS Spinal signs (0-6) · coordination · involuntary movements · reflexes ↳ DTR: biceps, triceps, brachioradialis, patellar, and achilles ↳ Abdominal Reflex: graze skin with point of hammer and note contraction of muscles ↳ Superficial Babinski sign: draw up from the heel to the toes (baby's toes splay, adults should curl) Involuntary Movements Documenting reflexes: · Spasms · fasiculations · tremor Sensory Function · pain discrimination (sharp vs. dull) · temperature (hot vs. cold) · light touch: identify when being touched · two-point discrimination: move two objects together until they feel as one · proprioception: move finger and toes up and down · vibration (decreased in older adults): tuning fork on bony prominence of toe · Stereognosis: know what object is in hand · graphesthesia: "draw" number on patients hand · extinction: tap patients shoulders from behind and they say left or right Expected Findings: · LOC: patient is alert and opens eyes spontaneously · Orientation: patient is oriented to person, place and time · Speech: speech is clear and articulate · Cranial Nerves: CN I-XII intact and symmetric · Motor: muscle bulk without atrophy, passive tension during stretch. Strength in muscle group in arms and legs is 4 to 5+ · Coordination: point-to-point testing of arms smooth and accurate. Rapid alternating movements of hands performed smoothly and rapidly · Sensory: light touch over lower extremities. Pain sensation intact over extremities. Motion and position sense of extremities is intact, point localization is intact. Vibration sense is intact in the great toe. Stereognosis intact bilaterally. Graphesthesia intact bilaterally. · Reflexes: DTR are 2 + bilaterally