RN.

coms Assessment Series: Focused Neurological Assessment

Presented by:

12400 High Bluff Drive San Diego, CA 92130

This course has been awarded two (2.0) contact hours. This course expires on October 5, 2008.
Copyright 2004 by RN.com. All Rights Reserved. Reproduction and distribution of these materials are prohibited without the express written authorization of RN.com. First Published: October 5, 2004 Revised: October 5, 2006

Acknowledgements ________________________________________________________3 Purpose & Objectives ______________________________________________________4 Introduction ______________________________________________________________5 Focused Neurological History _______________________________________________6 Adult Patient ____________________________________________________________6 Infant, Pediatric, and Aging Considerations __________________________________7 The Complete Neurologic Exam ______________________________________________8 Mental Status ___________________________________________________________8 12 Cranial Nerves ________________________________________________________8 Inspect and Palpate the Motor System______________________________________13 Check Cerebellar Function _______________________________________________14 Assess the Sensory System ______________________________________________15 Assess the Spinothalmic Tract ____________________________________________15 Assess Posterior Column Tract ___________________________________________16 Check the Reflexes ______________________________________________________17 The Neurological Recheck or Abbreviated Neuro Exam _________________________19 Motor Function _________________________________________________________19 Pupillary Response _____________________________________________________19 Glasgow Coma Scale ____________________________________________________20 Conclusion ______________________________________________________________21 References ______________________________________________________________22 Post Test Viewing Instructions______________________________________________23

Acknowledgements
RN.com acknowledges the valuable contributions of Lori Constantine MSN, RN, C-FNP, a nurse of nine years with a broad range of clinical experience. She has worked as a staff nurse, charge nurse and nurse preceptor on many different medical surgical units including vascular, neurology, neurosurgery, urology, gynecology, ENT, general medicine, geriatrics, oncology and blood and marrow transplantation. She received her Bachelors in Nursing in 1994 and a Masters in Nursing in 1998, both from West Virginia University. Additionally, in 1998, she was certified as a Family Nurse Practitioner. She has worked in staff development as a Nurse Clinician and Education Specialist since 1999 at West Virginia University Hospitals, Morgantown, WV.

Purpose & Objectives

When nurses perform a focused neurological assessment it is important to understand the fundamental processes of the brain and nervous system. If there is a disruption to any of these processes, the whole body suffers. This course will discuss specific neurological history questions and exam techniques for an adult patient. Physical exam techniques such as inspection, palpation, percussion, and auscultation will be highlighted. Additionally, throughout the course, you will learn how alterations in your neurological assessment findings could indicate potential nervous system abnormalities.

After successful completion of this course, the participant will be able to: 1. Outline a systematic approach to neurological assessment. 2. Discuss history questions which will help you focus your neurological assessment. 3. Describe abnormal neurological assessment findings associated with inspection, auscultation, percussion, and palpation.

Disclaimer RN.com strives to keep its content fair and unbiased. The author(s), planning committee, and reviewers have no conflicts of interest in relation to this course. There is no commercial support being used for this course. There is no "off label" usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or allencompassing. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients.

Introduction
The neurological history and exam allows the examiner to pinpoint various areas of the brain or nervous system that may be dysfunctional. Specific signs and symptoms manifested by your patient are associated with specific areas of the brain. Nurses observe for signs and symptoms that may be abnormal and link them to general areas of the nervous system that may be causing the disturbance. It is also important to recognize when further neurological injury is manifesting and intervene appropriately. Notifying the physician with your findings will most likely result in a change in plans for the patient. Integrate the process of obtaining the neurological history with the steps taken during the complete physical examination. It may not be necessary to perform the entire neurological exam on a patient with no suspicion of neurological disorders. You should perform a complete, baseline neurological examination on any patient that has verbalized neurological concerns in their history. Always perform the neuro exam at scheduled or periodic intervals with any patient that has a neurological deficit (Agone et al., 1997; Jarvis, 1996). Performing an exam and obtaining a history should be completed in an orderly, symmetrical fashion. This way, you will be certain that all areas are assessed. Each side of the body should be compared with the other side to detect any abnormalities. Also when completing your shift, it is beneficial to perform a brief exam with the oncoming nurse at the bedside. This process ensures that any subjective portion of your exam will not be misinterpreted by the next examiner. It allows for baseline neurological status to be ascertained at the beginning of each shift. Also, any changes in the patients neurological function will be more rapidly identified.

Neuro Most healthcare providers shorten the term neurologic or neurological to neuro. In this course neuro will also represent neurological or neurologic.

Focused Neurological History

If your patient is mentating normally, you can ask the patient the following history questions. If the patient is not alert and oriented, a family member or friend can provide some of this information. Past medical records may also provide some answers to the following questions as well.

Adult Patient
When assessing the nervous system with your adult patient, ASK the following: Any past history of head injury (location, loss of consciousness)? This question may give you clues to underlying neurological damage that may change your patients baseline. Do you have frequent or severe headaches (when, where, how often)? Pain is a neurologic phenomenon. Most patients do not complain of pain in the neurological history. Their complaints of pain are mentioned more in association with an extremity, back, or head assessment. Any dizziness or vertigo (frequency, precipitating factors, gradual or sudden)? Syncope is a sudden lack of strength, a sudden loss of consciousness usually due to a lack of cerebral blood flow. It is also known as fainting. Vertigo is experienced as a rotational spinning. It is usually due to neurological disorder or an inner ear disturbance.

Image courtesy of National Aeronautics and Space Administration (NASA) http://exploration.nasa.gov/articles/05feb_superconduc tor.html

Have you ever had/or do you have seizures (when did they start, frequency, course and duration, motor activity associated with, associated signs, post-ictal phase, precipitating factors, medications, coping strategies)? Seizures typically occur in disorders such as epilepsy. Often, the patient will describe an aura; an auditory, visual, or motor warning of the impending seizure. Any difficulty swallowing (solids or liquids, excessive saliva)? Difficult swallowing may clue you in to a possible abnormality with cranial nerves IX and X. Any difficulty speaking (forming words or actually saying what you intended)? If the patient answers yes to this question, then ask when it was first noticed and how long did it last. These questions may clue you in to potential transischemic attacks (TIAs), which may be a warning signal for impending stroke.

Do you have any coordination problems (describe)? affected by both peripheral and central abnormalities.

Muscle tone and strength may be

Do you have any numbness or tingling (describe)? Any abnormal sensations such as numbness or tingling may be referred to as parasthesias. Do you have any significant past neurologic history (CVA, spinal cord injuries, neurologic infections, congenital disorders)? Specific neurological infections include meningitis and encephalitis. Are you exposed to any environmental or occupational hazards? If so, explain type, length, and nature of exposure. Exposure to insecticides, lead, organic solvents, drugs, and alcohol may all manifest in neurological symptoms (Jarvis, 1996).

Infant, Pediatric, and Aging Considerations

To obtain the history of an infant or child, the nurse must rely on the parent or caregiver to provide most of the information. Questions you may wish to ask regarding your infant, pediatric, or aging patient are listed in the table below:

Additional History for Infants Did the mother have any health problems during pregnancy? Tell me about the babys birth? Premature or term? Birth weight? Apnea? APGAR Scores? Any congenital defects? Are sucking and swallowing coordinated? Does baby turn his head toward touch? Does baby startle with a loud noise?

Additional History for Children Does the child have any balance problems? Any unexplained falling? Muscle weakness? Difficulty getting up and down stairs? Does the child have any seizures? Describe the circumstances around which they occurred. Did motor and development milestones occur during the appropriate age range? Has your child had any environmental exposure to lead? Any learning problems in school? Any family history of neurological disorders? (Jarvis, 1996)

Additional History for Elderly Patients

Any problems with dizziness? If so when does it occur?

Any decrease in memory or change in mental functioning? Any tremors in your hands or face? Any sudden vision changes or sudden blindness? Any sudden weakness on one side of the body and not the other? Ever experience loss of consciousness?

The Complete Neurologic Exam

Not all Patients will require a complete neuro exam. Only patients that describe alterations in their neuro status or those with altered levels of consciousness will require the most thorough and complete neuro exam. When perfoming the complete neuro exam, EXAMINE the following:

Mental Status
The mental status portion of the examination is a series of detailed but simple questions designed to test cognitive ability. This includes: The patient's awareness and responsiveness to the environment The senses, appearance and general behavior, mood, content of thought Orientation with reference to time, place, and person

Most nurses will not find it necessary to perform a detailed mental status exam. Therefore, assessing key parts of cognitive ability will usually be sufficient to ascertain mental status and level of consciousness in their patients. Nurses should always establish if their patient is oriented to person, place, and time. Additionally, it is important to determine if your patient is alert. If not, how much stimulation is required - calling their name, light touch, vigorous touch, pain? Verbal response to your questions should also be assessed and noted. Nurses should be aware that many neurological diseases such as dementia can cause changes in intellectual status or emotional responsiveness as well as specific personality features. If other parts of the neurological exam are within normal limits and you still feel the patients neurological status is impaired, contacting the patients physician with details about the patients status and a suggestion for a neuro consult may be warranted.

12 Cranial Nerves
The cranial nerves arise directly from the central nervous system. Most often, a neurological problem is detected through the assessment of these nerves. The cranial nerves are composed of twelve pairs of nerves that stem from the nervous tissue of the brain. Some nerves have only a sensory component, some only a motor component, and some both. The motor components of cranial nerves transmit nerve impulses from the brain to target tissue outside of the brain. Sensory components transmit nerve impulses from sensory organs to the brain. A summary of the functions of the cranial nerves is listed in the table below.

Cranial Nerve Cranial Nerve I: Olfactory Cranial Nerve II: Optic Cranial Nerve III: Oculomotor

Cranial Nerve IV:

Trochlear

Cranial Nerve V:

Trigeminal

Cranial Nerve VI:

Abducens

Cranial Nerve VII:

Facial Vestibulocochle ar (auditory)

Major Functions Sensory Smell Sensory Vision Sensory and Motor Eyelid and eyeball Primarily Motor movement Innervates superior Sensory and Motor oblique eye muscle Primarily Motor Turns eye downward and laterally Chewing Sensory and Motor Face and mouth touch and pain Turns eye laterally Sensory and Motor Proprioception (sensory Primarily Motor awareness of part of the body) Controls most facial expressions Sensory and Motor Secretion of tears and saliva Sensory Hearing Equilibrium sensation Taste Senses carotid blood pressure Muscle sense proprioception, sensory awareness of the body Senses aortic blood pressure Slows heart rate Stimulates digestive organs Taste Controls trapezius and sternocleidomastoid controls swallowing movements Muscle sense proprioception Controls tongue movements Muscle sense proprioception

Cranial Nerve VIII:

Cranial Nerve IX:

Glossopharyng eal

Sensory and Motor

Cranial Nerve X:

Vagus

Sensory and Motor

Cranial Nerve XI:

Spinal Accessory

Sensory and Motor Primarily Motor

Cranial Nerve XII:

Hypoglossal

Sensory and Motor Primarily Motor

When testing the cranial nerves, follow the following guidelines for each cranial nerve.

Cranial Nerve I: Olfactory

Evaluate the patency of the nasal passages bilaterally by asking the patient to breathe in through their nose while the examiner occludes one nostril at a time. Once patency is established, ask the patient to close their eyes. Occlude one nostril, and place a small bar of soap or other familiar smell near the patent nostril and ask the patient to smell the object and report what it is. Make certain that the patient's eyes remain closed. Switch nostrils and repeat. Furthermore, ask the patient to compare the strength of the smell in each nostril. Very little localizing information can be obtained from testing the sense of smell. This part of the exam is often omitted unless there is a reported history suggesting head trauma or toxic inhalation.

Cranial Nerve II: Optic

Begin the exam by first testing visual acuity using a pocket visual acuity chart. Perform this part of the examination in a well lit room and make certain that if the patient wears glasses, they are wearing them during the exam. Hold the visual acuity chart 14 inches from the patient's face, and ask the patient to cover one of their eyes completely with one hand and read the lowest line on the chart as possible. Have them repeat the test covering the opposite eye. If the patient has difficulty reading a selected line, ask them to read the line above. Note the visual acuity for each eye.

Image courtesy of NASA http://exploration.nasa.gov/articles/22oct_cataracts.html

Next evaluate the visual fields via confrontation. Face the patient about one foot away, at eye level. Tell the patient to cover their right eye with their right hand and look the examiner in the eyes. Instruct the patient to remain looking you in the eyes and have the patient indicate when the examiner's fingers enter from out of sight, into their peripheral vision. Then, extend your arm and first two fingers out to the side as far as possible. Beginning with your hand and arm fully extended, slowly bring your outstretched fingers centrally, and notice when your fingers enter your field of vision. The patient should indicate seeing your fingers at the same time you see your fingers. Repeat this maneuver a total of eight times per eye, once for every 45 degrees out of the 360 degrees of peripheral vision. Repeat the same maneuver to test the other eye. If you are an advanced practice nurse, you may want to use an ophthalmoscope to observe the optic disc, physiological cup, retinal vessels, and fovea. Note the pulsations of the optic vessels, check for a blurring of the optic disc margin and a change in the optic disc's color from its normal yellowish orange.
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Cranial Nerves II & III:

Ask the patient to focus on any object in the distance. Observe the diameter of the pupils in a dimly lit room. Note the symmetry between the pupils. Next, shine a penlight or ophthalmoscope light into one eye at a time and check both the direct and consensual light responses in each pupil. Note the rate of these reflexes. If they are sluggish or absent, test for pupillary constriction via accommodation by asking the patient to focus on the light pen itself while the examiner moves it closer and closer to their nose. Normally, as the eyes accommodate to the near object the pupils will constrict. The test for accommodation should also be completed in a dimly lit room. Direct Light Response: When a light shines into one eye the pupil constricts. Consensual Light Response: When a light shines into one eye the other eyes pupil will also constrict.

Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, and Abducens
Instruct the patient to follow the penlight or ophthalmoscope with their eyes without moving their head. Move the penlight slowly at eye level, first to the left and then to the right. Repeat this horizontal sweep with the penlight at the level of the patient's forehead and then chin. Note extra-ocular muscle palsies and horizontal or vertical nystagmus, which would be abnormal. Eye movements should be coordinated and smooth.

Cranial Nerve V: Trigeminal

Begin by first palpating the masseter muscles (muscles of chewing or of the jaw) while you instruct the patient to bite down hard. Note via observation if there is any masseter muscle wasting. Next, ask the patient to open their mouth against resistance applied by the instructor at the base of the patient's chin. Palsy: Uncontrollable tremor or quivering Nystagmus: Rapid oscillation (movement) of the eye in any direction, but generally in a back-and-forth manner.

Next, test gross sensation of Cranial Nerve V. Tell the patient to close their eyes and say "sharp" or "dull" when they feel an object touch their face. Using a semi-sharp object and a dull object, randomly touch the patient's face with either object. Touch the patient above each temple, next to the nose and on each side of the chin, all bilaterally. Ask the patient to also compare the strength of the sensation of both sides. If the patient has difficulty distinguishing pinprick and light touch, then proceed to check the patients ability to sense temperature and vibration. Finally, test the corneal reflex using a large Q-tip with the cotton extended into a wisp. Ask the patient to look at a distant object and then approaching laterally, touch the cornea (not the sclera) and look for the eye to blink. Repeat this on the other eye. Often, the patient will blink before the object touches the cornea. This is also normal.
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Cranial Nerve VII: Facial Nerve

Inspect the face during conversation and rest noting any facial asymmetry including drooping, sagging or smoothing of normal facial creases. Ask the patient to raise their eyebrows, smile showing their teeth, frown and puff out both cheeks. Note asymmetry and difficulty performing these tasks. Ask the patient to close their eyes strongly and not let the examiner pull them open. When the patient closes their eyes, simultaneously attempt to pull them open with your fingertips. Normally the patient's eyes cannot be opened by the examiner. Once again, note asymmetry and weakness.
Facial nerves

Cranial Nerve VIII: Acoustic (Vestibulocochlear)

Assess hearing by instructing the patient to close their eyes and to say "left" or "right" when a sound is heard in the respective ear. Vigorously rub your fingers together very near to, yet not touching, each ear and wait for the patient to respond. After this test, ask the patient if the sound was the same in both ears, or louder in a specific ear. If lateralization (localization of a function or activity to one side of the body) or hearing abnormalities exist, and you are a nurse practitioner, perform the Rinne and Weber tests. (The Rinne and Weber tests are hearing tests performed using a vibrating tuning fork.)

Cranial Nerve IX & X: Glossopharyngeal and Vagus

Ask the patient to swallow and note any difficulty doing so. Note the quality and sound of the patient's voice. Is it hoarse or nasal? Ask the patient to open their mouth wide, protrude their tongue, and say "AHH." While the patient is performing this task, flash your penlight into the patient's mouth and observe the soft palate, uvula, and pharynx. The soft palate should rise symmetrically, the uvula should remain midline, and the pharynx should constrict medially like a curtain. Often the palate is not visualized well during this task. Ask the patient to yawn, which often provides a greater view of the elevated palate. Use a tongue depressor and the butt of a long Q-tip to test the gag reflex. Touch the pharynx with the instrument on both the left and then on the right side, observing the normal gag or cough.
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Image courtesy of http://training.seer.cancer.gov/module_anato my/unit10_3_dige_region1_mouth.html

Cranial Nerve XI: Spinal Accessory

Inspect for wasting of the trapezius muscles by observing the patient while standing behind them. Ask the patient to shrug their shoulders as strong as they can while the examiner resists this motion by pressing down on the patient's shoulders with their hands. Next, ask the patient to turn their head to the side as strongly as they possibly can while the examiner once again resists with their hand. Repeat this test on the opposite side. The patient should normally overcome the resistance. Note asymmetry.

Cranial Nerve XII: Hypoglossal

Have your patient "stick out their tongue" and move it side to side. Normally, the tongue will be protruded from the mouth and remain midline. Have the patient say light, tight, dynamite and note the clarity of each distinct word in pronunciation. Note deviations of the tongue from midline, a complete lack of ability to protrude the tongue, tongue atrophy, and fasciculation (muscle twitches) on the tongue.

Inspect and Palpate the Motor System Muscle Size

Does your patient have appropriate size muscles for body type, age, and gender? Atrophy is abnormally small muscles with a wasted appearance. This can occur with disuse, injury, motor neuron diseases, and muscle diseases. Hypertrophy occurs with athletes and body builders. It is characterized by increased size and strength of muscles.

Muscle Strength
Test muscle strength against resistance using a 0 5 scale, with 0 = no movement and 5 = strong muscle strength. Muscle strength should be equal bilaterally. When testing muscle strength in the arms ask your patient to do the following against resistance: Lift arms away from side Push arms towards side Pull forearm towards upper arm Push forearm away from upper arm Lift wrist up; push wrist down Squeeze examiners finger Pull fingers apart Squeeze fingers together

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When testing muscle strength in the legs ask your patient to do the following against resistance: Lift legs up Push legs down Pull legs apart Push legs together Pull lower leg towards upper leg Push lower leg away from upper leg Push feet away from legs Pull feet towards legs

Muscle Tone
Muscle tone can be described as the amount of resistance or tension in a muscle. Muscle tone enables us to move and affects posture. Abnormal findings can include: limited range of motion, pain on motion, flaccidity, decreased resistance, spasticity, or rigidity.

Involuntary Movements
Tics, tremors, and fasciculations (involuntary contraction of a muscle) are all examples of abnormal involuntary movements you may note on exam. Causes of involuntary movements may be related to serious disease conditions or damage to specific areas within the brain.

Check Cerebellar Function

Checking cerebellar functioning includes testing balance, coordination, and skilled movements.

Gait
Have the patient walk heel to toe in a straight line forwards and backwards. Assess for abnormalities such as stiff posture, staggering, wide base of support, lack of arm swing, unequal steps, dragging or slapping of foot, and presence of ataxia.

Rombergs Test
With eyes closed, have the patient stand with feet together and arms extended to the front, palms up. Your patient should be able to maintain their balance. Stay next to the patient when they are performing this test in particular, so if they begin to fall, you can catch them. Balance should be maintained.

Rapid Alternating Movements

Have your patient rapidly slap one hand on the palm of the other, alternating palm up and then palm down - test both sides. Abnormal findings might be lack of coordination, or slow, clumsy movements.
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Finger to Finger Test

Have your patient touch your index finger with their index finger, as you move your index finger in the space around them. Patients with normal cerebellar function should be able to do this without missing the mark. -algesia = sensation

Finger to Nose Test

Have your patient touch their nose with their index finger of each hand with eyes shut. Patients should be able to do this without missing the mark.

Heel to Shin Test

While standing, have your patient touch the heel of one foot to the knee of the opposite leg. While maintaining this contact, have the patient run the heel down the shin to the ankle. Test each leg. If your patient misses the mark, lower extremity coordination may be impaired.

Assess the Sensory System

Testing the sensory system checks the intactness of peripheral nerves, sensory tracts, and higher cortical discrimination. Have your patient close his eyes while checking sensory perception. Check the following bilaterally: Light Touch Sharp/Dull Can your patient feel light touch equally on both sides of the body? Can your patient distinguish between a sharp or dull object on both sides of the body? Can your patient distinguish between a hot or cold object on both sides of the body?

Hot/Cold

Sensory neuron

Assess the Spinothalmic Tract

To assess the spinothalmic tract, various sensory tests may be performed to test your patients ability to sense pain, temperature, and light touch.

Presence of Pain
Pain can be tested by a simple pin prick to the arms or legs while the patients eyes are closed. Abnormal findings would include hypalgesia, hyperalgesia, and analgesia.

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Temperature
Temperature tests should be performed only if the pain test is normal. To test for temperature sensation, hot and cold objects are placed on the patients skin at various locations bilaterally to test for temperature sensation.

Light touch
With a cotton ball or soft side of a Q-tip, touch the patients body bilaterally with their eyes closed. Ask them to indicate when you have touched them. Abnormal responses include hypesthesia, anesthesia, and hyperesthesia. -esthesia = sensitivity

Assess Posterior Column Tract

Assessing the posterior column tract may identify lesions of the sensory cortex or vertebral column.

Vibration
Test the patients ability to feel vibrations by placing a tuning fork over various boney locations on the patients toes and feet. If these areas are normal, then you may assume the proximal areas are also normal.

Position
Position or kinesthesia is tested by having the patient close their eyes and move their big toe up and down. The patient should be able to tell you which way there toes are moving.

Tactile discrimination
Tactile discrimination tests the discrimination ability of the sensory cortex. Stereognosis tests the patients ability to recognize objects by feeling them. You can place car keys, a spoon, a pencil, or other common object in your patients hand. They should be able to identify that object by feel only. Graphesthesia is the ability to identify a number gently etched to their palm.

Two point discrimination

Two point discrimination tests the brains ability to detect two distinct pin pricks on the skin. An increase in the distance it normally takes to identify two distinct pricks occurs with sensory cortex lesions (Jarvis, 1998; Shaw, 1998).

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Check the Reflexes

Reflexes are involuntary actions in response to a stimulus sent to the central nervous system. Alterations in reflexes are often the first sign of neurological dysfunction such as upper motor neuron disease, diseases of the pyramidal tract, or spinal cord injuries.

Stretch or Deep Tendon Reflexes

Deep tendon reflexes, also known as muscle stretch reflexes, are reflexes elicited in response to stimuli applied to tendons. Normally, when a specific area of the muscle tendon is tapped with a soft rubber hammer, the muscle fibers contract. Abnormal responses may indicate injury to the nervous system pathways that produce the deep tendon reflex. Deep tendon reflexes can be influenced by age, metabolic factors such as thyroid dysfunction or electrolyte abnormalities, and anxiety level of the patient. The main spinal nerve roots involved in testing the deep tendon reflexes are summarized in the following table:

Reflex Biceps Brachioradialis Triceps Patellar Achilles Tendon

Main Spinal Nerve Roots Involved C5, C6 C6 C7 L4 S1

Check the deep tendon reflexes with a reflex hammer to stretch the muscle and tendon. The limbs should be in a relaxed and symmetric position. Strike the reflex hammer across the selected tendon with a moderate tap. If you cannot elicit a reflex, you can sometimes bring it out by certain reinforcement procedures. For example, have the patient grit their teeth then try to elicit the reflex again. Or you may have them clench their fists together when checking lower extremity reflexes. When reflexes are very brisk, clonus is sometimes seen. This is a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch. Deep tendon reflexes are often rated according to the following scale: Rating 0 1+ 2+ 3+ 4+ 5+ Reflex Response absent reflex trace, or seen only with reinforcement normal brisk Non-sustained clonus (i.e., repetitive vibratory movements) sustained clonus
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Deep tendon reflexes are considered normal if they are 1+, 2+, or 3+. Reflexes that are asymmetric, or there is a large difference between the arms and legs, or are rated as 0, 4+, or 5+ abnormal (Jarvis, 1998).

Superficial Reflexes
The following reflexes are considered normal in adults. Upper Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side. Lower Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side. Cremasteric: Stroke inner thigh, elicits elevation of testes. Can you define Ipsilateral? It means on the same side or affecting the same side

The following reflexes are considered ABNORMAL in adults. Absence of superficial reflexes or unilateral suppression of superficial reflexes often results from upper motor lesions subsequent to a stroke. Presence of primitive reflexes in adults is often a sign of frontal lobe lesions. Reflex Name Babinski Sign Chaddock's Reflex Oppenheim's Sign Gordon's Sign Method to Elicit Stroking the bottom of the foot elicits fanning (eversion) of big toe. When the external malleolar skin area is irritated, extension of the great toe occurs in cases of organic disease of the corticospinal reflex paths. Scratching the inner side of leg elicits extension of toes. Sign of cerebral irritation. Squeeze the calf muscles and note the response of the great toe. Fanning or extension is considered abnormal. Flexion of the terminal phalanx of the thumb and of the second and third phalanges of one or more of the fingers when the palmar surface of the terminal phalanx of the fingers is flicked. Gently tapping or rubbing the upper lip elicits a reflexive sucking or puckering response. Stroking the patient's palm, causing him to grasp your fingers. A positive test occurs when the patient does not let go of your fingers. Rub the thenar eminence (area of palm just below the thumb) ------> elicit reflexive contraction of the muscles of the chin. (Agone et al., 1997; Jarvis, 1996)

Hoffman's Sign Suck Reflex Grasp Reflex Palmomental Sign

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The Neurological Recheck or Abbreviated Neuro Exam

Perform the neurological recheck exam at scheduled or periodic intervals with any patient that has a neuro deficit. This exam is also useful for your inpatient with a head injury or systemic disease process that may be manifesting as a neuro symptom. When performing this abbreviated exam, EXAMINE the following, in addition to any previously identified neurological deficits noted from the complete exam:

Level of Consciousness (Monitors for signs of increasing intracranial pressure)

Is your patient oriented to person, place, and time? Is your patient alert? If not, what does it take to get them alert - calling their name, light touch, vigorous touch, pain?

Motor Function
Ask your patient to squeeze your fingers with their hands and let go (tests for strength and symmetry of strength in the upper extremities). Ask your patient to push and pull their arms toward and away from you when their elbows are bent. Provide some resistance. (tests for strength and symmetry of strength in upper extremities). Ask your patient to dorsiflex and plantarflex their feet, while providing some resistance (tests for strength and symmetry of strength in lower extremities). Ask your patient to perform straight leg raises with and without resistance (tests for strength and symmetry of strength in lower extremities).

Pupillary Response
Size, shape, and symmetry of both pupils should be the same. Each pupil should constrict briskly when a light is shined into the eyes. Each pupil should have consensual light reflex.

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Glasgow Coma Scale

The Glasgow Coma Scale assesses how the brain functions as whole and not as individual parts (Teasdale, 1975). The scale assesses three major brain functions: eye opening, motor response, and verbal response. A completely normal person will score 15 on the scale overall. Scores of less than 7 reflect coma. Using the scale consistently in the healthcare setting allows healthcare providers to share a common language and monitor for trends across time (Jarvis, 1996).

Glasgow Coma Scale Best Eye Opening Response 1 = No response 2 = To pain 3 = To speech 4 = Spontaneously Best Motor Response 1 = No response 2 = Extension abnormal 3 = Flexion - abnormal 4 = Flexion withdrawal 5 = Localizes pain 6 = Obeys verbal commands Best Verbal Response 1 = No response 2 = Sounds - incomprehensible 3 = Speech - inappropriate 4 = Conversation - confused 5 = Oriented X 3

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Conclusion
Integrating the neurological health history and physical exam takes practice. It is not enough to simply ask the right questions and perform the physical exam. As the patients nurse, you must critically analyze all of the data you are obtaining, synthesize the data into relevant problem areas, and identify a plan of care for your patient based upon this synthesis. As the plan of care is being carried out, reassessments must occur on a periodic basis. How often these reassessments occur is unique to each patient and is based upon their physical disorder. Knowing when and how often to reassess is based on the specific patient, evidence presented, and facility policies, standards, and protocols.

Please Read: This publication is intended solely for the use of healthcare professionals taking this course, for credit, from RN.com It is designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com.

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References
Agone, K., Elder, A., Foley, M., Kraut, P., Michael, K., & Tscheschlog, B. (Eds.). (1997). Expert 10minute physical examinations. St. Louis: Mosby. American Association of Critical Care Nurses (1998). The Nervous System. In J. Alspach (Ed.), Core curriculum for critical care nursing (5th ed., Rev., pp. 399-459). Philadelphia: Saunders. Folin, S. (Ed.). (2004). Rapid Assessment: A flowchart guide to evaluating signs and symptoms. Springhouse, PA: Lippincott, Williams & Wilkins. Jarvis, C. (1996). Physical examination and health assessment. Philadelphia: W.B. Saunders. Shaw, M. (Ed.). (1998). Assessment made incredibly easy. Springhouse, PA: Springhouse. Teasdale, G. (1975). Acute impairment of brain function. Nursing Times, 71, 914-917.

Copyright 2004, AMN Healthcare, Inc.

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Post Test Viewing Instructions

In order to view the post test you may need to minimize this window and click TAKE TEST. You can then restore the window in order to review the course material if needed.

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