Student 2017 Assessment of Nervous System.pdf

Sensory- 3 both-4 motor- 5 Assessment of the Nervous System Chapter #15 General Health History Present Health History Any changes in your ability to move around or participate in your usual activities? Chronic Diseases? Diabetes, hypertension, any TIA ( warning stroke) Medications? - Allergies If th...

Sensory- 3 both-4 motor- 5 Assessment of the Nervous System Chapter #15 General Health History Present Health History Any changes in your ability to move around or participate in your usual activities? Chronic Diseases? Diabetes, hypertension, any TIA ( warning stroke) Medications? - Allergies If they do have a acute memory problem they can be confused, memory change may need to ask family members General Health History Past Health History Head or spinal cord injury? Neurosurgery? Stroke? Seizures? back surgery, concussion, auto immune diseases, any seizures what kind and how often, any meningitis infection of the brain General Health History Family History Stroke, seizures or tumors? or neuro disjunctive disorders (ALS, MS, Huntington's disease General Health History Personal & Psychosocial Hx Change in ability to do ADLs? Alcohol consumption Marijuana, cocaine, barbiturates, tranquilizers or other mood altering drugs? smoking is a big risk factor for strokes Seatbelt and helmet use 4/5 spinal and head injuries could be prevented if people were wearing seatbelts or helmets Problem Based History Onset Location Duration Characteristics Aggravating, Alleviating factors Related symptoms Treatment Severity Problem Based History Headaches What do they feel like? Where do you feel the pain? How long do they last? How often? Any recent spinal anesthesia or lumbar puncture? Problem Based History Dizziness spinning Dizziness or vertigo or light headed How often? What makes it worse? What makes it better? Sudden or gradual? vertigo is caused by inner ear problems Problem Based History Seizures How often? When was your last seizure? Do you become unconscious? Aura? disturbance of smell, or visual disturbance such as lights Describe seizure movements Incontinent? How do you feel after seizure? Aggravating Factors Wear any identification? What did they look like, did they pass urine or stools Problem Based History Loss of Consciousness When? Blackout, faint, not aware of your surroundings Sudden? What happened right before you lost consciousness? Other symptoms? Problem Based History Changes in Movement For how long? Continuous or intermittent? Tremors or shaking of hands? Weakness? Confined to one area or generalized? Coordination problems? Parkinson's can cause tremors, tumors in the brain, if balance is off it could be the inner ear Problem Based History Changes in Sensation Numbness or tingling? How does it feel? Associated with any activity? Problem Based History Dysphagia Means difficulty swallowing For how long? Liquids or solids? Excessive saliva or drooling? Cough or choke when you try to swallow? can be caused by in cognitive function Problem Based History is difficulty communications caused by Dysphasia & Aphasia Aphasias brain injury, stroke and impairs the ability to communicate such as writing, using words For how long? Difficulty forming words or finding the right words? Any difficulty understanding things? Physical Examination Assess mental status & LOC Change of LOC is the earliest and most sensitive indicator of alterations in cerebral function Can be assessed when evaluating motor and sensory function in a conscious client Two components: Awareness Arousal (wakefulness) Suttle changes are a indication of a problem , like mixed up, what day it is ask 3 simple question Person Place Time- could ask if its day or night , season, or year. If they don't know the date Physical Examination Assess mental status & LOC the degree of components a person is showing Components of awareness: Orientation Attention Recall Judgment " what would you do if there was a emergency" call 911 Abstraction desk, chair, book self what are these? furniture Memory Calculation count backwards, forwards Language name things, write things Insight "do you know what brought you here" main part just know the Person Place Time Physical Examination Assess mental status & LOC Arousal When client’s awareness can’t be assessed because of unconsciousness, arousal is assessed Modified assessment due to unconsciousness Include: Pupillary reaction & response Inspect respiratory pattern Smell breath Auditory Tactile Painful Pupillary Reaction & Response Hold eyelid open when shining light Inspect pupils for size, shape & reaction to light Small, reactive pupils- bilateral cerebral dysfunction Bilaterally dilated pupils- overdose of hallucinogenics or CNS stimulants; pressure in brainstem Unilateral fixed & dilated pupil- pressure on CN II ( One dilated fixed pupil) -You will document if it is brisk, absent or sluggish -Sometimes you will see pupils dilated more the 6mm and it is called Mydriasis( pupils are big) Constricted pupils less then 2 mm are called miosos (pupils are small) - Make sure it is not congenital Glasgow Coma Scale will hear alot A way of excessing how the brain functions as a whole Neurological scale Objective way of recording conscious state of a person For initial or continuing assessment Pt assessed against the criteria of the scale Assesses LOC using 15 point scale 3-deep unconsciousness 15-awake and oriented Less then 8 means they need to intubate less than 4 on the floor used on trauma pt, seizures, shaken baby, rugby and ATV accidents Glasgow Coma Scale deep unconscious state that you can not be aroused Assess for best response to: Eye opening Verbal response Motor response Glasgow Coma Scale Eye Response No eye opening--1 Eye opening in response to pain --2 Eye opening in response to speech--3 Eye opening spontaneously --4 (Pressing on nail bed, pressing on sternum or pressure on a muscle Glasgow Coma Scale Verbal Response No verbal response--1 Incomprehensible sounds --2 only making sounds Inappropriate words--3 Confused--4 can have a convo but confused Oriented x 3--5 Person, time , Place Glasgow Coma Scale Motor Response someone we are concerned of neuro status No motor response --1 Extension to pain --2 known as decerebrate Abnormal flexion to pain --3 known as decorticate posturing Flexion/withdrawal to pain --4 Localizes to pain --5 Obeys commands --6 Glasgow Coma Scale Motor Response Determine stimulation required to achieve a response ONLY TIME ACCEPTABLE TO INFLICT PAIN ON PT First shake pt’s shoulder or leg and shout If no response, start with painful stimulation Begin peripherally and then move centrally Apply until pt responds in some way or for 15-30sec Depressing nailbed at cuticle with your fingernail or pen; sternal rub Other way to inflict pressure or pain Traipses pinch where the neck and shoulders meet Glasgow Coma Scale Motor Response Extension to pain is a 2 decerebrate usually means a brain stem injury Internal rotation of shoulder Pronation of forearm Extension of wrists and arms Abnormal flexion to pain Is a 3 Posturing ,sometimes called the mummy pose Decorticate Adduction of arm Internal rotation of shoulder Pronation of forearm Flexion of wrist Glasgow Coma Scale Motor Response Flexion/Withdrawal Flexion of elbow Supination of forearm Pulls part of body away when nail bed pinched Localizes to pain Purposeful movement Obeys commands Physical Examination Evaluate Speech Articulation Voice quality Comprehension of verbal communication Appropriate response usually indicates understanding Red Flags -not responding -1 word answers -slurring speech -speech is oddly slow Physical Examination Observe Gait Look for balance and symmetry Upright posture Walk unaided Maintain balance Opposing arm swing Physical Examination Muscle Strength Expect: 5/5, bilaterally symmetric, full resistance to opposition Test: quadriceps, hamstrings, deltoid, biceps, triceps, finger grips Pg. 308 Table 14-2 Physical Examination Deep Tendon Reflexes Pg. 349 Box 15-2 for scoring of DTR Test: -evaluates balance -Deep Tendon Reflex means its deeply imbedded in the muscle Triceps Elbow should extend Biceps Elbow should flex Patellar Extension of lower leg Plantar (Babinski) Plantar flexion of toes -Abnormal reflex- figure if its on one side or both Scoring Deep Tendon Reflexes (p.328 Box 15-3) - means jerking may not be pathologic Positive Babinski not a deep reflex Dorsiflexion of the great toe with fanning of the other toes Normal in infants but should disappear with age If positive in older than 2: brain or spinal cord tumor/damage deep tendon reflex's can be normal if 1 or a 2 or a 3. be concerned if a 4 or 0 START OF NEXT CLASS Physical Examination Assess Cranial Nerve I Olfactory Ask person to smell a strong, but familiar substance Coffee, vanilla sensory neuron not often tested only if pt reports altered taste or smell test with eyes closed and introduce different odors Physical Examination Assess Cranial Nerve II Optic Visual acuity and peripheral vision sensory neuron Confrontation Test for Peripheral Vision- pg 150 Snellen Chart for Visual Acuity- pg 149 Physical Examination Assess Cranial Nerve III Oculomotor Nerve Observe for PERRLA – pg. 154 Pupils are Equal, Round and Reactive to Light and Accommodation Observe eyes for extraocular muscle movement Six Cardinal Fields of Gaze- pg 154 motor neuron Abnormal Oculomotor Nerve (CNIII) Eyelid droop Eye is down & out Physical Examination Assess Cranial Nerve IV Trochlear Observe for extraocular eye movement Six Cardinal Fields of Gaze cranial nerves 3,4,6 makes the eyes do tricks ! and motor neuron do 6 gaze for 3,4,6 Physical Examination Assess Cranial Nerve V Trigeminal Test motor function: sensory in nose, eye and skin of face both motor and sensory neuron Ability to open mouth and move jaw side to side Palpate temporal and masseter muscles for mass & strength Test sensory function: Lightly touch eyeball with cotton swab to check corneal reflex Omit if pt is awake and blinking normally Test light touch: wipe cotton lightly over different areas of face Test deep touch: blunt and sharp ends of paperclip get pt to clench teeth and palpate MJ and open mouth side to side , puff out cheeks and try and touch them back in for sensory use light and deep touch, ask if its sharp or light or dull and get them to close their eye and ask where you are touching Physical Examination Assess Cranial Nerve VI motor neuron Abducens Extraocular eye movement Six Cardinal Fields of Gaze in charge of moving eye laterally , ex try looking at your ear sends signal to muscle on outer side of your eyes, responsible for outward gaze and controls your eye movement laterally. Physical Examination Assess Cranial Nerve VII Facial movement and expression Test sensory function: Taste on anterior 2/3 of tongue (salty and sweet) Salt, sugar, lemon Test motor function: Raise eyebrows, smile, puff out cheeks, purse lips and blow out, show teeth, squeeze eyes shut while you try to open them produces tears and effects salvation and nasal pharynx Physical Examination Assess Cranial Nerve VIII Vestibulocochlear vestibulo means balance cochlear is hearing Test for hearing: Weber’s Test (pg. 166) Activated tuning fork placed on the midline of the skull Should hear the tone equally in both ears sensory neuron Physical Examination Assess Cranial Nerve VIII Test for hearing: Rinne Test (pg. 167) Activated tuning fork placed on mastoid process (bone behind ear) and time how many seconds pt can hear tone Quickly move fork in front of ear and time again Tone in front of ear should last twice as long as tone on bone AC> BC; 2:1 Rinne Test: Place on the bone behind the ear and ask the PT to tell you when the sound has stopped. Do the same to the side of the ear hold the open end towards the ear and do the same thing. Time how long you can hear it should hear 2x as long in the air rather than bone. Physical Examination Assess Cranial Nerve IX Glossopharyngeal both motor and sensory glosso- tongue pharyngeal- pharynx Test for sensory function: Taste on posterior 1/3 of tongue (bitter and sour) Test for motor function: Gag reflex, swallowing and coughing Physical Examination Assess Cranial Nerve X 10 Vagus Nerve REMEMBER-:agus- gagus vagus is Greek for the word wandering Test gag reflex, coughing and swallowing Say “ahhhh”- uvula should move bilaterally Longest and most complex runs from brain to thorax to abdomen and to the digestive tract. It has cardiac branches, bronchial and esopogeal. check throat, check uvula is in middle and intact, see if they can swallow , cough and gage motor and sensory nerve Physical Examination Assess Cranial Nerve XI 11 Spinal Accessory Check ability to rotate head and shrug shoulders against resistance motor nerve Ability to rotate haead and shrug shoulders Ask PT to shrug shoulders up and down while pushing on them hold side of face and get pt to try and resist Physical Examination Assess Cranial Nerve XII Hypoglossal Nerve motor only Hypo-below glossal- tounge Ask pt to protrude tongue and move toward nose, chin and side to side Note symmetry ask to push tongue against cheek on both side, and can use speech well Physical Examination Test Cerebellar Function General Observation Observe walking use 2 test from each area 1 area- balance 2 area- coordination Balance Romberg Test Eyes closed, stand on one foot Hop on one foot, than other Heel to toe walking Knee bends Walk on toes/heels Physical Examination Test Cerebellar Function Coordination of upper extremity Rapid pronation/supination of hands on thighs Alternatively touch nose with index fingers, eyes closed Touch each finger to thumb in rapid sequence Move index finger between nose and examiner finger Coordination of lower extremity Heel to shin of opposite leg Physical Examination Assess Peripheral Nerves Test for sensation on hands, lower arms, abdomen, lower legs and feet Light touch Cotton swab Sharp/dull Cotton swab , touch hand and ask where your touching and move to other parts of the body and ask if it sharp,dull Paper clip or broken tongue depressor Vibration Tuning fork on bony prominence Place tuning fork on bones and see if they can feel it Ataxic Gait Ataxia: “lack of order”; lack of voluntary coordination of muscles http://www.youtube.com/watch?v=FpiEprzObIU Signs of Meningeal Irritation Brudzinski’s Sign Client lies supine Flex neck If client passively flexes knee and reports pain in vertebral column positive  meningeal irritation meningitis is a brain infection Signs of Meningeal Irritation Kernig’s Sign Cllient lies supine Flex knee and hip, then extend knee If unable to extend leg and pain in vertebral column positive meningeal irritation K AND K - Kerning and Knee