Assessment of the Spinal Nerves (The Sensory and Motor Functions) & The Reflexes.pdf

Assessment of the Spinal Nerves (The Sensory and Motor Functions) & The Reflexes.pdf

1. ASSESSMENT OF THE PATIENT’S
NEUROLOGIC SYSTEM
Prepared by: Renz Victor T. Guangco, M.D.
PART IV: THE SPINAL NERVES: SENSORY AND MOTOR FUNCTIONS & THE REFLEXES

2. •The muscles are inspected and palpated while
at rest for size, consistency and atrophy.
•A tape measure is used to compare
corresponding parts of the muscles for size.
•The examiner should also note for symmetry
of posture, muscle contours and outlines.
ASSESSMENT OF THE MOTOR FUNCTION
MUSCLE SIZE

3. Measure the circumference in cm:
•For the ARM, 10 cm from the acromion
process
•For the FOREARM, 10 cm from the olecranon
process
•For the THIGH, 15 cm from the midinguinal
area
•For the LEG, 15 cm from the fibular head
ASSESSMENT OF THE MOTOR FUNCTION
MUSCLE SIZE

4. Muscles are tested for resistance to passive
movement. Look for abnormalities in tone.
a. Spasticity
b. Rigidity
c. Flaccidity
ASSESSMENT OF THE MOTOR FUNCTION
MUSCLE TONE

5. ASSESSMENT OF THE MOTOR FUNCTION
MUSCLE TONE

6. Inspect for any involuntary movements,
example:
• fasciculations, tremors, myoclonus, tics,
chorea, athetosis, dystonia or torsion spasm,
ballismus, motor seizures
ASSESSMENT OF THE MOTOR FUNCTION
ASSESSMENT OF INVOLUNTARY MOVEMENTS

7. ASSESSMENT OF THE MOTOR FUNCTION
ASSESSMENT OF INVOLUNTARY MOVEMENTS

8. •Upper extremities: with the patient
seated or supine, ask the patient to
close his eyes, raise his upper
extremities extended and supinated.
Observe for pronation drift.
ASSESSMENT OF THE MOTOR FUNCTION
MUSCLE STRENGTH: OBSERVE FOR LATENT PARALYSIS

9. •Lower extremities: in supine position with
eyes closed, ask the patient to bend the
hips and knees to 90 degrees. Note
whether the patient can keep both legs at
the same height.
ASSESSMENT OF THE MOTOR FUNCTION
MUSCLE STRENGTH: OBSERVE FOR LATENT PARALYSIS

10. •Flexion, extension and other movements
through the major joints are tested, first
without resistance and then with the examiner
offering resistance.
ASSESSMENT OF THE MOTOR FUNCTION
MUSCLE STRENGTH

11. The examiner compares corresponding muscles on each
side. The strength of the muscle is graded as follows:
•Grade 0: no visible muscle contraction
•Grade 1: minimal muscle contraction
•Grade 2: muscle movement with gravity eliminated
•Grade 3: muscle movement against gravity
•Grade 4: muscle movement against minimal to
moderate resistance
•Grade 5: muscle movement against full resistance
ASSESSMENT OF THE MOTOR FUNCTION
MUSCLE STRENGTH

12. ASSESSMENT OF THE MOTOR FUNCTION
INDIVIDUAL MUSCLE TESTING

13. ASSESSMENT OF THE MOTOR FUNCTION
INDIVIDUAL MUSCLE TESTING

14. 1.Ask the patient to close his eyes.
2.Note the patient's ability to perceive the sensation being tested.
3.Compare both sides of the body, corresponding extremities and
homologous areas.
4.Try to determine whether the sensory changes:
•Involve one side of the body
•Involve dermatomal in distribution
•Confined to the peripheral nerves.
ASSESSMENT OF THE SENSORY FUNCTION
ASSESSMENT OF THE GENERAL SENSATION

15. ASSESSMENT OF THE SENSORY FUNCTION
ASSESSMENT OF THE GENERAL SENSATION

16. ASSESSMENT OF THE SENSORY FUNCTION
FORMS OF SENSATION: THE PRIMARY FORMS

17. ASSESSMENT OF THE SENSORY FUNCTION
FORMS OF SENSATION: THE CORTICAL AND DISCRIMINATORY

18. •Lightly stroke the abdominal wall with a
tongue depressor. Observe the movement of
the umbilicus.
•Upper abdominal reflex (T7, 8 & 9) is
elicited by stroking the abdomen from the
lateral upper corner towards the umbilicus.
•Lower abdominal reflex (T11 & 12) is
elicited by stroking the abdomen from the
lateral lower abdomen towards the
umbilicus.
ASSESSMENT OF THE BODY REFLEXES
SUPERFICIAL REFLEXES (ABDOMINAL REFLEX)

19. •The normal response consists of diagonal
deviation of the umbilicus towards the origin of
the stimulus.
•These reflexes maybe masked in some obese
individuals, multiparous women and those
who have undergone abdominal surgery.
ASSESSMENT OF THE BODY REFLEXES
SUPERFICIAL REFLEXES (ABDOMINAL REFLEX)

20. •Stroke the anterior medial side of the upper thigh
area using a tongue depressor.
•The response is rapid elevation of the scrotum on
the side stimulated.
•Nerve segment ( L1, L2 ).
ASSESSMENT OF THE BODY REFLEXES
SUPERFICIAL REFLEXES (CREMASTERIC RELFEX)

21. •Gently stroke the skin around the anal margin
using a tongue depressor.
•The response is contraction of the anal
sphincter.
•Nerve segment (S2-S4).
ASSESSMENT OF THE BODY REFLEXES
SUPERFICIAL REFLEXES (ANAL RELFEX)

22. ASSESSMENT OF THE BODY REFLEXES
DEEP TENDON REFLEXES

23. STRETCH REFLEXES SHOULD BE GRADED
AS FOLLOWS:
0 = absent
1+ = diminished
2+ = normal
3+ = increased or hyperactive
4+ = hyperactive with clonus.
ASSESSMENT OF THE BODY REFLEXES
DEEP TENDON REFLEXES

24. •These are reflex responses present in the newborn
infant.
•These reflexes disappear with maturation of the central
nervous system but can reappear in degenerative
diseases associated with loss of inhibitory activity in the
brain or in FRONTAL LOBE lesions.
•SNOUT REFLEX - Gently tap the face between the
upper lip and the nose with the finger. There is
pursing of the lips in response to each stimulus.
•GRASP REFLEX - Stroke the palm of the patient
with a tongue depressor. The reflex is positive when
the patient's fingers flex and grasp the tongue
depressor.
ASSESSMENT OF THE BODY REFLEXES
THE PRIMITIVE REFLEXES

25. •Elicited by stroking the lateral aspect of the
sole of foot from the heel to the toes with a
blunt object.
•In pyramidal tract disease, an extension or
dorsiflexion of the big toe occurs in addition to
fanning of the small toes. (Positive Babinski)
ASSESSMENT OF THE BODY REFLEXES
THE PATHOLOGIC REFLEXES: BABINSKY

26. MODIFICATION OF BABINSKI
•CHADDOCK - Elicited by stroking the lateral
aspect of foot beneath the lateral malleolus
with a blunt object.
•OPPENHEIM - Elicited by stroking the
anteromedial surface the tibia with a blunt
object or knuckles of a closed fist.
•GORDON - Elicited by squeezing the calf
muscles firmly.
ASSESSMENT OF THE BODY REFLEXES
THE PATHOLOGIC REFLEXES: BABINSKY

27. ASSESSMENT OF THE BODY REFLEXES
THE PATHOLOGIC REFLEXES: BABINSKY

28. •The examiner supports the patient's hand,
dorsiflexed at the wrist, so that it is completely
relaxed and the fingers are partially flexed.
•The middle finger is partially extended and
either its middle or distal phalanx is grasped
firmly between the examiner's index and
thumb.
ASSESSMENT OF THE BODY REFLEXES
THE PATHOLOGIC REFLEXES: HOFFMAN

29. •With a sharp forcible flick of his other thumb,
the examiner nips or snaps nail of the patient's
middle finger causing a forcible increased
flexion of this finger followed by sudden
release.
•A POSITIVE HOFFMAN is flexion and
adduction of the thumb and flexion of the
index finger and sometimes flexion of the other
fingers as well. This implies lesion involving the
CORTICOSPINAL TRACT.
ASSESSMENT OF THE BODY REFLEXES
THE PATHOLOGIC REFLEXES: HOFFMAN

30. •With the patient supine, slightly flex the knees and
relax the leg, then briskly jerk the foot up and slightly
outward while continuously applying pressure with
your fingers against the sole of the patient's foot.
•Clonus is present when the foot oscillates between
flexion and extension for as long as the pressure is
applied.
•The presence of clonus indicates UPPER MOTOR
NEURON LESION.
ASSESSMENT OF THE BODY REFLEXES
THE PATHOLOGIC REFLEXES: CLONUS

31. •Ask the patient to touch his chest with his chin
(sitting) or the examiner passively flexes the head
on the chest (supine).
•Normally, the neck is supple and the patient can
easily bend the head and neck forward
SIGNS OF MENINGEAL IRRITATION
NUCHAL RIDGIDITY
In doing this, first make sure there is no injury to the cervical vertebrae or cervical cord.

32. •With the patient supine, flex his thigh at the hip level
and extend the leg.
•If Kernig's sign is positive, there will be back pain or
sciatic pain.
SIGNS OF MENINGEAL IRRITATION
BRUNDIZKY SIGN
In doing this, first make sure there is no injury to the cervical vertebrae or cervical cord.

33. END
•Reference: Health Assessment in Nursing, 7th Edition by Weber and Kelley
•Bates Guide to Physical Examination and History Taking, 13th Ed.