NEUROLOGIC assessment

Joy N. Bautista, RN, MPH, DRDM, MAN

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Health History
CCx = headache, dizziness, faintness, confusion, impaired mental status, or balance or gait disturbances. PH = current health, memory and ability to concentrate as well as current medications. PMH = illness, accidents or injuries, surgeries, and allergies. FMH = neurologic disorders that may have a genetic component, such as seizures, and migraine headaches

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LOC
Whats your name? (orientation to person) Whats your mothers name? (orientation to other person) What year is it? (orientation to time) Where are you now? (orientation to place) How old are you? (memory) Where were you born? (remote memory) What did you have for breakfast? (recent memory) Whos currently the Indonesian president? (general knowledge) Can you count backward from 20 to 1? (calculation ability)
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LOC
Alertfollows commands and responses completely and appropriately to stimuli. Lethargicis drowsy; has delayed responses to verbal stimuli; may drift off to sleep during examination. Stuporousrequires vigorous stimulation for a response. Comatose does not respond appropriately to verbal or painful stimuli; cant follow commands or communicate verbally.

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Glasgow Coma Scale

Test Eye-opening response Spontaneously To speech To pain None Motor response Obeys Localizes Withdraws Abnormal flexion Abnormal extension None Verbal response Oriented Confused Inappropriate words Incomprehensive None Score 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 Patients response Opens eyes spontaneously Opens eyes when told to Opens eyes only in painful stimulus Doesnt open eyes in response to stimulus Shows two fingers when asked Reaches toward painful stimulus and tries to remove it Moves away from painful stimulus Assumes a decorticate posture Assumes a decerebrate posture No response; just lies flaccidan ominous sign Tells current date Tells incorrect year Replies randomly with incorrect word Moan or screams No response

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Cognitive Function
Memory, orientation, attention span, calculation ability use mental status questions Thought content clarity, cohesiveness of ideas, logical transitions, smooth flow Abstract thinking interpretation of a common proverb or saying Judgment and insight how the patient will respond to a hypothetical situation Emotional status mood, emotional lability or stability, appropriateness of emotional responses Observe the patients constructional ability (ability to perform simple tasks and use various objects).
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Cranial Nerve Function

Cranial nerve I (olfactory nerve) Have the patient identify at least two smells. Cranial nerve II (optic nerve) Test visual acuity and visual fields with confrontation Examine the fundus of the optic nerve. Cranial nerve III (oculomotor nerve, IV (trochlear nerve), and VI (abducent nerve) Test extraocular movement using the six cardinal positions of gaze.
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Cranial Nerve Function

Cranial nerve V (trigeminal nerve) Check the patients ability to feel light touch and pain perception over his face Have him clench his teeth to assess temporal and masseter muscles. Cranial nerve VII (facial nerve) Test taste perception Observe the patients face for symmetry at rest and when smiling, frowning, and raising eyebrows. Cranial nerve VIII (acoustic nerve) Test hearing and check balance.
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Cranial Nerve Function

Cranial nerves IX (glossopharyngeal nerve and X (vagus nerve) Cranial nerve XI (spCheck the gag reflex. inal accessory nerve) Check the strength of the sternocleidomastoid and trapezius muscles. Cranial nerve XII (hypoglossal nerve) Assess tongue position, movement, and strength; observe for tongue symmetry.

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Sensory Function
Test pain perception in all dermatomes with the sharp and dull ends of a safety pin. Test light touch sensation in all dermatomes using a wisp of cotton. Test vibratory sense with a tuning fork over bony prominences. Assess position sense by having the patient identify whether his toe or finger is positioned up or down as you move it

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Stereognosis and Graphestesia

Stereognosis = Ask the patient to close his eyes and open his hand. Then place common object, such as key, in his hand and ask him to identify it Graphestesia = Have the patient keep his eyes closed and hold out his hand while you draw a large number on the palm. Ask him to identify the number

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Localization
Point localization = have the patient close his eyes; then touch one of his limbs, and ask him where you touched him. 2-point discrimination = touch the patient simultaneously in two contralateral areas. He should be able to identify both touches.

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Coordination and Balance

Romberg test patient stands eyes open, then close eyes. + Romberg if patient falls to one side Nose-finger test rapidly touching nose and outstretched finger of nurse accurately and smoothly Finger opposition Palm on thigh test turn palms up and down Foot tapping test patients soles tap against the palm of the nurse

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Motor Function
Muscle tone = guide the shoulders and hips through passive ROM exercises. Muscle strength = have the patient move major muscles and muscle groups against resistance. Observe the patients coordination and general balance Test extremity coordination Have the patient perform rapid alternating movements.

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Reflexes: Grading
0 +1 +2 +3 absent impulses diminished impulses normal impulses increased impulses (may be normal) hyperactive impulses

+4

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Biceps Reflex
Position the patients arm so his elbow is flexed at a 45-degree angle and his arm is relaxed. Place you thumb or index finger over the biceps tendon and your remaining fingers loosely over the triceps muscle. Strike your finger with the pointed end of the reflex hammer, and watch and feel for the contraction of the biceps muscle and flexion of the forearm.

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Triceps Reflex
Have the patient adduct his arm and place his forearm across his chest. Strike the triceps tendon about 2 inches (5 cm) above the olecranon process on the extensor surface of the upper arm. Watch for contraction of the triceps muscle and extension of the forearm.

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Brachioradialis Reflex
Ask the patient to rest the ulnar surface of his hand on his abdomen or lap with the elbow partially flexed. Strike the radius, and watch for supination of the hand and flexion of the forearm at the elbow.

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Patellar Reflex
Have the patient sit with his legs dangling freely. If he cant sit up, flex his knee at a 45-degree angle and place your non-dominant hand behind it for support. Strike the patellar tendon just below the patella, and look for contraction of the quadriceps muscle in the thigh with extension of the leg.
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Achilles Reflex
Have the patient flex his foot. Then support the plantar surface. Strike the Achilles tendon, and watch for, plantar flexion of the foot at the ankle.

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Superficial Reflexes
Babinskis reflex - stroke the lateral side of the patients sole from the heel to the great toe plantar flexion of toes Cremasteric reflex (in males) - stimulate the inner thigh Abdominal reflexes - stroke both sides of the abdomen above and below the umbilicus moving form the periphery toward the midline umbilicus moves towards stimulus

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Primitive Reflexes
Grasp reflex gentle pressure to the patients palm with your fingers suspect cortical or remoter cortex damage Snout reflex lightly tap patients upper lip frontal lobe damage Sucking reflex sucking motion cortical damage. Glabella response repeatedly tap bridge of the nose abnormal response is persistent blinking diffuse cortical dysfunction.

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