1. ASSESSMENT: Neurologic Examination Ma. Tosca Cybil A. Torres, RN, MAN

2. AN IMPORTANT ASPECT OF THE NEUROLOGIC ASSESSMENT IS THE HISTORY OF THE PRESENT ILLNESS

3. HEALTH HISTORY Should include: Onset Character Severity Location Duration Frequency of s/sx Associated complaints Precipitating and aggravating factors Progression, remission, and exacerbation Presence and absence of similar symptoms among family members Review of medical history History of falls or trauma Use of alcohol, medications and illicit drugs

4. Common Clinical Manifestations Pain (chronic or acute) Seizures Dizziness and vertigo Visual disturbances Weakness Abnormal sensation

5. Physical Examination A neurological assessment is divided into five components: Cerebral function Cranial nerves Motor system Sensory system Reflexes Follows a logical sequence and progresses from higher levels of cortical function (ex: abstract thinking) to lower levels of function (ex: determination of the integrity of the peripheral nerves)

6. I. Assessing cerebral function Interpretation and documentation of neurologic abnormalities, particularly mental status abnormalities, should be SPECIFICandNONJUDGMENTAL.

7. Mental Status Assessment begins by observing client’s appearance and behavior Posture Gestures Movements Facial expressions Motor activity Manner of speech LOC Orientation

8. State of Awareness

9. Intellectual function Serial 7s Interpretation of well-known proverbs/idioms Capacity to recognize similarities Judgement

11. Spontaneous

12. Natural

13. Clear

14. Relevant

15. Coherent

16. Check: Illusions Hallucinations preoccupations

18. Mood

20. Auditory

21. Tactile

23. Language Ability Aphasia- deficiency in language function Broca’s Aphasia (non-fluent aphasia)- speech output is severely reduced and is limited mainly to short utterances of less than four words. Wernicke’s Aphasia (fluent aphasia) -ability to grasp the meaning of spoken words is chiefly impaired, while the ease of producing connected speech is not much affected. Global aphasia- most severe form of aphasia, and is applied to patients who can produce few recognizable words and understand little or no spoken language. Global aphasics can neither read nor write.

24. Broca’s Aphasia

25. Wernicke’s Aphasia Ex: I called my mother on the television and did not understand the door. It was too breakfast, but they came from far to near. My mother is not too old for me to be young.

26. II. Examining the Cranial Nerves

28. III. Examining the Motor System Assess muscle size, tone, and strength, coordination, and balance Note for rigidity, spasticity and flaccidity

29. Muscle Strength Grading 0 – No contraction1 – Slight contraction, no movement2 – Full range of motion without gravity3 – Full range of motion with gravity4 – Full range of motion , some resistance5 – Full range of motion, full resistance

30. Balance and Coordination Rapid, alternating movements Point-to-point testing Ataxia- incoordination of voluntary muscle action Romberg test

31. IV. Examining the Reflexes Stretch or Deep Tendon Reflexes A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmental level, and grading of DTR's is listed below. Grading DTR's 0 – Absent1 – Decreased but present2 – Normal3 – Brisk and excessive4 – With clonus

32. Reflexes Biceps reflex Triceps reflex Brachioradialis reflex Patellar reflex Ankle reflex Superficial reflexes Corneal Abdominal reflexes Gag Cremasteric Plantar perianal

33. V. Sensory Examination The sensory examination is largely subjective and requires the cooperation of the patient.

34. Assessment of the sensory system involves: Tactile sensation Superficial pain Vibration Integration of sensation Proprioception Stereognosis

35. Diagnostic Evaluation CT scan

36. CT scan

37. MRI

38. Cerebral angiography

39. Myelography An x-ray of the spinal subarachnoid space after injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture

40. Post myelography care Head elevated to 30-45 degrees for 3H or as prescribed by the AP Encouraged to increase OFI Assess VS and ability to void Untoward signs------headache, fever, stiff neck, photophobia, and seizures

41. Electroencephalography (EEG)

42. Electromyography (EMG)

43. Lumbar Puncture

44. CSF analysis Queckenstedt’s test

45. End of discussion