Neurological examination

Neurological Examination

1. NEUROLOGICAL EXAMINATION Mrs. D.Melba Sahaya Sweety Msc Nursing GIMSAR

2. INTRODUCTION The nervous system is very complex and controls many parts of the body. The nervous system consists of the brain, spinal cord, 12 nerves that come from the brain, and the nerves that come from the spinal cord. The circulation to the brain, arising from the arteries in the neck, is also frequently examined.  A neurological exam, also called a   neuro exam , is an evaluation of a person's nervous system The neurologic examination is typically divided into eight components: mental status; cranial nerves; motor examination; sensory examination; coordination; reflexes; and gait & station. The mental status is an extremely important part of the neurologic examination that is often overlooked.

3. A neurological examination is defined as the assessment of  Sensory neuron  and  motor  responses, especially  reflexes , to determine whether the  nervous system is impaired.    It is a systematic examination that surveys the functioning of nerves delivering sensory information to the brain and carrying motor commands (peripheral nervous system) and impulses back to the brain for processing and coordinating (central nervous system). DEFINITION

4. The purpose of neurological examination is to determine the presence or absence of disease in the nervous system. Identify which component of the neurological system are affected If possible, determine the precise location of the problem. Screening for the presence of discrete abnormalities in patients at risk for the development of neuro -psychiatric disorders PURPOSE

5. ARTICLES NEEDED FOR NEUROLOGICAL EXAMINATION Big tray with cover Sheet for cover patient Gloves Reflex Hammer [ 128 and 512 (or 1024] Hz Tuning Forks A Snellen Eye Chart or Pocket Vision Card Pen Light or Otoscope Fundoscope Cotton Swabs Bowl B P apperatus Stethoscope Steel kidney tray Test tube-2( one for cold water and one for hot water) Tourch Common pin or needle , coin,key Aesthesiometer Sugar , Salt , Coffee powder and Orange

6. ASPECTS OF NEUROLOGICAL EXAMINATION

7. 1.Levels of consciousness Assessment of levels of consciousness includes following categories : a. Alertness: Patient is awake, responds immediately & appropriately to all verbal stimuli. b. Lethargic: Patient is drowsy & inattentive but arouses easily, frequently off to sleep. c. Stuporous : He arouses with great difficulty & co-operates minimally when stimulated.

8. d. Semi-comatose: The patient has lost his ability to respond to verbal stimuli. There is some response to painful stimuli. Little motor function is seen. e. Comatose: When the patient isstimulated there is no response toverbal or painful stimuli, no motoractivity is seen. The Glasgow coma scale is widely used to measure the patient’s level of consciousness. 1.Levels of consciousness

9. The Glasgow Coma Scale Features Response Score EYE OPENING Spontaneous 4 To sound 3 To pressure 2 None 1

10. Features Response Score VERBAL RESPONSE Orientated 5 Confused 4 Words 3 Sounds 2 None 1 The Glasgow Coma Scale

11. Features Response Score MOTOR RESPONSE Obey commands 6 Localising 5 Normal flexion 4 Abnormal flexion 3 Extension 2 None 1 The Glasgow Coma Scale

12. The Glasgow Coma Scale Interpretation

13. • The components of mental status examination include the assessment for following categories; General appearance, speech, thought process, mood , cognitive functions, attention, concentration, orientation, memory, general knowledge, abstract reasoning, judgment & insight. 2. Mental Status Examination

14. Assess for agnosia , apraxia & aphasia. • Agnosia – inability to recognize common objects through the senses • Apraxia – patient cannot carry out skilled act in the absence of paralysis. • Aphasia – inability to communicate. 3. Special Cerebral Function

15. 4.Cranial nerve examination Cranial nerve (CN) examination provides information about the brainstem & related pathways. Olfactory nerve (CN I) Optic nerve (CN II) Oculomotor (CN III) Trochlear (CN IV) Trigeminal (CN V) Abducens (CN VI) Facial nerve (VII) Vestibulocochlear or Acoustic nerve (CN VIII) Glossopharyngeal (CN IX) Vagus (CN X) Spinal accessory nerve (CNXI) Hypoglossal nerve

16. Olfactory nerve (CN I) The sense of smell is tested by having the patient occlude one nostril and close his or her eyes. The examiner then takes a non irritating substance and places it near the non occluded nostril. patient is asked to identify familiar odours (coffee, tobacco). Each nostril is tested separately Repeat the process for the opposite side using a different scent. 4.Cranial nerve examination

17. Visual Field Assesses peripheral vision: Stand arm’s length from the patient. Cover your left eye, while the patient covers their right eye. Have the patient look at your nose (tell the patient NOT to look at your fingers) In the top and bottom of the visual field (test it with yours) hold up random numbers with your fingers and have the patient recite them back to you. Repeat again with the other eye (cover your right eye while the patient covers their left eye). Optic nerve (CN II) 4.Cranial nerve examination

18. 1.The optic nerve testing includes assessment of both visual acuity and visual fields. 2. Each eye is examined separately while the patient covers the other one. 3. Visual acuity is tested by having the patient read a snellen chart from 20 feet away 4. Have the patient start with one eye covered and read the lines from top to bottom (largest to smallest letters). 5. Record the lowest line that the patient can read with 50% accuracy. 4.Cranial nerve examination Optic nerve (CN II)

19. Visual Inattention Visual inattention can be tested by moving both fingers at the same time and checking the patient identifies this. Fundoscopy Finally  fundoscopy should be performed on both eyes. 4.Cranial nerve examination Optic nerve (CN II)

20. Test for eye movement toward the nose Inspect for conjugate movements and Evaluate papillary size and test for pupillary reactivity to light Inspect ability to open eyelids. Have the patient follow your pen light by moving it 12-14 inches from the patient’s face in the six cardinal fields of gaze (start in the midline) Watch for any  nystagmus  (involuntary movements of the eye) 4.Cranial nerve examination Oculomotor (CN III)

21.  • Trochlear - Test for upward eye movement inspect for conjugate movements and nystagmus 4.Cranial nerve examination Trochlear (CN IV)

22.   The trigeminal nerve is the largest of the cranial nerves The patient should have his or her eyes closed during the testing procedure. Touch cotton to forehead, cheeks, and jaw. Sensitivity to superficial pain is tested in these same three areas by using the sharp and dull ends of a broken tongue blade. Alternate between the sharp point and the dull end. Patient reports “sharp” or “dull” with each movement. If responses are incorrect, test for temperature sensation. 4.Cranial nerve examination Trigeminal (CN V)

23. The  corneal reflex  should also be examined as the sensory supply to the cornea is from this nerve. Do this by lightly touching the cornea with the cotton wool. This should cause the patient to shut their eyelids. Have patient clench and move the jaw from side to side. Palpate the masseter and temporal muscles, noting strength and equality . Trigeminal (CN V) 4.Cranial nerve examination

24. Motor Supply To test the motor supply, ask the patient to clench their teeth together, observing and feeling the bulk of the  masseter  and  temporalis  muscles. Ask the patient to then open their mouth against resistance. Finally perform the jaw jerk on the patient by placing your left index finger on their chin and striking it with a tendon hammer. This should cause slight protrusion of the jaw. Trigeminal (CN V) 4.Cranial nerve examination

25. • Abducens - Test for lateral eye movement • 3 cranial nerves are usually tested together because they control the function of the extra ocular eye muscles. • The functions include eyelid elevation, constriction of the pupils, and movement of the eye through the six cardinal directions. Make the lights normal and have patient look at a distant object to dilate pupils, and then have patient stare at pen light and slowly move it closer to the patient’s nose. Watch the pupil response: The pupils should  constrict and equally move to cross. 4.Cranial nerve examination Abducens (CN VI)

26. Motor : • Observe for facial tics. Then, ask the patient to perform the following movements: raise his or her eyebrows, close his or her eyelids tightly, puff out his or her cheeks, smile, and frown. Observe for weakness or asymmetry of muscle movement. • Abnormal findings of upper motor neuron lesion, lower motor neuron lesion, or a stroke can cause weakness or paralysis of the facial muscles. • Have the patient rinse his or her mouth with water between tests . 4.Cranial nerve examination Facial nerve (VII)

27. Sensory test • The facial nerve is also a mixed cranial nerve with both sensory and motor components. • The sensory component includes the sense of taste on the anterior two- thirds of the tongue. The testing of the sensory component is often deferred, unless changes are noted in the health history interview. • When tested, have the patient stick out his or her tongue and test each side separately. • The taste is sweet and pleasant, but different from the standard sweet taste. Test ability to discriminate between sugar and salt. 4.Cranial nerve examination Facial nerve (VII)

28.  The acoustic nerve has two divisions: cochlear and vestibular. 1. The cochlear division is involved in hearing- Do weber and rinnes test To carry out the Rinne test, place a sounding tuning fork on the patient’s mastoid process and then next to their ear and ask which is louder. A normal patient will find the second position louder. To carry out the Weber’s test, place the tuning fork base down in the centre of the patient’s forehead and ask if it is louder in either ear. Normally it should be heard equally in both ears. 4.Cranial nerve examination Vestibulocochlear or Acoustic nerve (CN VIII)

29. Assess patient’s ability to swallow and discriminate between sugar and salt on posterior third of the tongue.  It can be tested with the gag reflex or by touching the arches of the  pharynx . 4.Cranial nerve examination Glossopharyngeal (CN IX)

30. • The glosso pharyngeal and vagus nerves are usually tested together. In the pharynx, CN IX is primarily sensory, and CN X is mostly motor. • observe the patient as he or she swallows a small amount of water. Ask if he or she frequently chokes on food or has trouble swallowing . Dysphagia (difficulty swallowing ) can often be seen after neurosurgical procedures or CVA (stroke.) • Depress a tongue blade on posterior tongue, or stimulate posterior pharynx to elicit gag reflex. Note any hoarseness in voice. Check ability to swallow. Asking the patient to speak gives a good indication to the efficacy of the muscles. The uvula should be observed before and during the patient saying “ aah ”. Check that it lies centrally and does not deviate on movement. 4.Cranial nerve examination Vagus Nerve (CN X)

31.  SPINAL ACCESSORY • Assess the trapezius & sternocleidomastoid • Trapezius – examiner place the hands on patient shoulder, ask the patient TO shrug his /her shoulder. Observe strength • Sternocledoid - examiner place hands on one cheek and ask the patient to turn his/her head against hand as the movement is resisted • Repeat the test on opposite • Abnormality - CVA 4.Cranial nerve examination Accessory nerve (CNXI)

32. • The hypoglossal nerve is tested by asking the patient to open his or her mouth, stick out his or her tongue, and wiggle it side to side. • While patient protrudes the tongue, note any deviation or tremors. Test the strength of the tongue by having patient move the protruded tongue from side to side against a tongue depressor. • The tongue should be midline. Observe for asymmetry, atrophy, or fasciculations . Carotid endarterectomy is a common cause of dysfunction of CN XIII. 4.Cranial nerve examination Hypoglossal nerve (CNXII)

33. Motor function: Assessment of motor function involves assessing for muscle size, muscle strength, muscle tone, muscle co-ordination, gait & movement . Muscle size: Inspect all major muscle groups bilaterally for symmetry, hypertrophy, & atrophy . Muscle Strength: Assess the power in major muscle groups against resistance. Assess & rate muscle strength on a 5-pointscale in all four extremities, comparing one side with other. 5.Motor Function

34. Muscle tone : Assess muscle tone while moving each extremity through its range of passive motion. When tone is decreased ( hypotonicity ), the muscle are soft, flabby, or flaccid; when tone is increased ( hypertonicity ), the muscles are resistant to movement, rigid, or spastic. Note the presence of abnormal flexion or extension posture. Muscle coordination: Disorders related to coordination indicate Cerebellar or posterior column lesions. 5.Motor Function

35. Muscle Strength 5 -Point scale GRADE ABILITY TO MOVE Grade - 5 The muscle can move the joint it cross through a full range of motion, against gravity, and against full resistance applied by the examiner Grade - 4 The muscle can move the joint it cross through a full range of motion, against moderate resistance Grade - 3 The muscle can move the joint it cross through a full range of motion, against gravity, but without any resistance Grade -2 The muscle can move the joint it cross through a full range of motion, only if the part is properly positioned so that the force of gravity is eliminate. Grade -1 Muscle contraction is seen or identified with palpation, but it is insufficient to produce joint movement even with elimination of gravity Grade -0 No muscle contraction is seen or identified with palpation, Paralysis;

36. Gait & station: Assess gait station by having the patient stand still, walk & in tandem(one foot in front of the other in a straight line). Walking involves the functions of motor power, sensation & coordination. The ability to stand quietly with the feet together requires coordination & intact proprioception (sense of body position). Movement: Examine the muscles for fine &gross abnormal movements. Move all the points through a full range of passive motion. Abnormal findings include pain, joint contractures, & muscle resistance 5.Motor Function

37. • Sensory assessment involves testing for touch, pain, vibration & discrimination . • A complete sensory examination is possible only on a conscious & co-operative patient. • Always test sensation with patient’s eye closed. • Help the patient relax & keep warm . • Conduct sensory assessment systematically . • Test a particular area of the body, & then test the corresponding are on the other side. 6.Sensory Function

38. Exam in this order Superficial ( Exteroceptive ) sensation Proprioceptive (deep) sensation Combined cortical sensations . If the superficial sensation is impaired then some impairment is also seen in deep and combined sensations. Sensory tests are done from the distal to the proximal direction. [3] Diabetes mellitus, thiamine deficiency and neuro toxin damage (e.g. insecticides) are the most common causes of sensory disturbances 6.Sensory Function

39. Superficial Sensation Deep Sensation Combined Cortical Sensation Pain Perception Kinesthesia Awareness Stereognosis Perception Temperature Awareness Vibration Perception Tactile Localization Touch Awareness Two-Point Discrimination Pressure Perception Double Simultaneous Stimulation Graphesthesia Recognition of Texture Barognosis 6.Sensory Function

40. Pain Perception It is also known as sharp/dull discrimination. To test this sensation, the sharp and dull end of any objects like a safety pin, a reshaped paperclip, or neurological pin is used. The sharp and dull end is randomly applied perpendicular to the skin, should not be applied too close to each other or in a too rapid manner to avoid the summation of impulses. The patient is asked verbally to indicate sharp/dull when a stimulus is felt. All areas of the body should be tested. After testing the instrument should be sterilized or disposed. 6.Sensory Function

41. Temperature Awareness Two test tubes with stoppers are required for this examination; one should be filled with the cold water (between 5°C to 10°C) and warm water( 40°C to 45°C). It should be taken care that the temperature should remain within this range for accuracy. The test tubes are randomly placed in contact with the skin area to be tested. All skin surfaces should be tested. The patient is asked to respond hot and cold after each stimulus application. 6.Sensory Function

42. Touch Awareness A piece of cotton, camel-hair brush, or tissue is used to perceive the tactile touch input. Light touch or stroke is applied in the area to be tested. The patient is asked to indicate where he/she recognizes that a stimulus has been applied . 6.Sensory Function

43. Pressure Perception The therapist's fingertip or a double-tipped cotton swab is used to apply a firm pressure on the skin surface. This test can also be administered using the thumb and finger to squeeze the Achilles tendon. The patient is asked to indicate when an applied stimulus is recognized. 6.Sensory Function

44. Kinesthesia Awareness Awareness of movement is known as kinesthesia . The Therapist passively moves a joint through a relatively small range of motion and the patient is asked to describe the direction of movement. The patient can also respond by simultaneously duplicating the movement with the opposite extremity. 6.Sensory Function

45. Proprioception Awareness Proprioception includes position sense and awareness of joint at rest. The joint is moved through a range of motion and held in static position by the therapist, the patient is asked to describe the position either verbally or by demonstrating on another limb. 6.Sensory Function

46. Vibration Perception The perception of a vibratory stimulus is tested by placing the base of the vibrating tuning fork on the bony prominence( sternum, elbow, ankle). Generally, the tuning fork should be of 128Hz. If there is impairment patient will be unable to distinguish between a vibrating and non vibrating tuning fork. Therefore, there should be a random application of vibrating and non vibrating stimuli. 6.Sensory Function

47. Stereognosis Perception Tactile object recognition is determined in this test. A familiar object of different shape and size are required like keys, coins, combs, safety pins, pencils). A single object is placed in a hand and the patient manipulates it to identify the object and say it verbally. For speech impairment patients sensory testing shield can be used. 6.Sensory Function

48. Tactile Localization ( Topognosis ) The test checks the ability to localize touch sensation on the skin. This test is not performed in isolated manner rather it is done in combination with pressure perception or touch awareness. 6.Sensory Function

49. Two-Point Discrimination It determines the ability to perceive two points applied to the skin simultaneously. Aesthesiometer or the circular two-point discriminator are the devices to test. The two tips of the instrument are applied to the skin simultaneously with the tip spread apart. With each successive application, the two tips are gradually brought closer together until the stimuli are perceived as one. The smallest distance between the stimuli that is still perceived as two distinct points is measured. 6.Sensory Function

50. Double Simultaneous Stimulation(DSS) DSS examines the ability to perceive a simultaneous touch stimulus on opposite sides of the body; proximally and distally on a single extremity; or proximally and distally on one side of the body. 6.Sensory Function

51. Graphesthesia (Traced Figure Identification) The ability to recognize letters, numbers, or designs traced on the skin is examined using fingertip or the eraser end of the pencil. the patient is asked verbally the figures drawn on the skin. 6.Sensory Function

52. Recognition of Texture The test examine the ability to differentiate among various textures like cotton, wool, or silk. Barognosis ( Recognition of weight) For the test different weights are used. the therapist may choose to place a seres of different weights in the same hand one at a time, place a different weight in each hand simultaneously. 6.Sensory Function

53. • Astereognosis refers to the inability to recognize objects placed in the hand. Without a corresponding dorsal column system lesion, these abnormalities suggest a lesion in the sensory cortex of the parietal lobe. • Apraxias are problems with executing movements despite intact strength, coordination, position sense and comprehension. This finding is a defect in higher intellectual functioning and associated with cortical damage 6.Sensory Function

54. • For evaluation of balance & co-ordination the tests used are: a. Finger to finger test: It is performed by instructing the patient to place her index finger on the nurse’s index finder. He is asked to repeat this for several times in succession on both sides. 7.Cerebellar Function

55. b. Finger to nose test: Tell the patient to extend his index finger & then touch the tip of his nose several times in rapid succession. This test is done with patient’s eyes both open &closed 7.Cerebellar Function

56. c. Romberg test: Here the nurse instructs the patient to stand with his feet together with arms positioned at his sides. He is told to close his eyes. This position is maintained for 10 seconds. This test positive only if there is actual loss of balance. 7.Cerebellar Function

57. d. Tandom walking test: This is tested by having the patient assume a normal standing position. He is then instructed to walk over heel on a straight line. Any unsteadiness, lurching or broadening of the gait base is noted. 7.Cerebellar Function

58. A  reflex  is an involuntary and nearly instantaneous movement in response to a stimulus. The reflex is an automatic response to a stimulus that does not receive or need conscious thought as it occurs through a reflex arc. Reflex arcs act on an impulse before that impulse reaches the  brain 8.Reflex Activity

59. • Reflex testing evaluates the integrity of specific sensory & motor pathways. • Reflex activity assessment, always a part of neurologic assessment, provides information about the nature, location,& progression of neurologic disorders. • Normal reflexes: Two types of reflexes are normally present I. Superficial or cutaneous reflexes II. Deep tendon muscle-stretch reflexes 8.Reflex Activity

60. I. Superficial ( cutaneous ) reflexes: Abdominal reflex The abdomen is mentally divided into four quadrants, and the skin in each quadrant is gently stroked, on the diagonal, towards the  navel . The navel should twitch towards the stimulus. It can be helpful in determining the level of a  central nervous system (CNS)  lesion . 8.Reflex Activity

61. Plantar reflex The plantar reflex is a reflex elicited when the sole of the foot is stimulated with a blunt instrument. The reflex can take one of two forms. In healthy adults, the plantar reflex causes a downward response of the hallux (flexion). 8.Reflex Activity

62. Corneal reflex The corneal reflex, also known as the blink reflex, is an involuntary blinking of the eyelids elicited by stimulation of the cornea (such as by touching or by a foreign body), though could result from any peripheral stimulus. 8.Reflex Activity

63. Pharyngeal (Gag)reflex The gag reflex is a reflex contraction of the back of the throat, elicited by touching the posterior pharyngeal wall, tonsillar area, or the base of the tongue. 8.Reflex Activity

64. Cremasteric reflex The  cremasteric reflex is a superficial reflex found in human males that is elicited when the inner part of the thigh is stroked. Stroking of the skin causes the  cremaster  muscle to contract and pull up the ipsilateral testicle toward the inguinal canal. 8.Reflex Activity

65. Anal reflex The anal wink, anal reflex, perineal  reflex, or anocutaneous  reflex is the reflexive contraction of the external anal sphincter upon stroking of the skin around the anus. A noxious or tactile stimulus will cause a wink contraction of the anal sphincter muscles and also flexion. 8.Reflex Activity

66. Deep tendon (muscle-stretch) reflexes: A biceps jerk (fore arm flexion) The forearm should be supported, either resting on the patient's thighs or resting on the forearm of the examiner. The arm is midway between flexion and extension. Place your thumb firmly over the biceps tendon, with your fingers curling around the elbow, and tap briskly. The forearm will flex at the elbow. Biceps reflex is a reflex test that examines the function of the C5 reflex arc and the C6 reflex arc 8.Reflex Activity

67. A triceps jerk (fore arm extension ) Support the patient's forearm by cradling it with yours or by placing it on the thigh, with the arm midway between flexion and extension. Identify the triceps tendon at its insertion on the olecranon , and tap just above the insertion. There is extension of the forearm. 8.Reflex Activity

68. A brachioradial jerk The  brachioradialis reflex (also known as  supinator reflex  by striking the  brachioradialis tendon  (at its insertion at the base of the wrist into the radial styloid process (radial side of wrist around 4 inches proximal to base of thumb)) directly with a reflex hammer when the patient's arm is relaxing. This reflex is carried by the radial nerve (spinal level: C5, C6) The reflex should cause slight pronation or  supination [1]  and slight elbow flexion. 8.Reflex Activity

69. A knee jerk, quadricepsjerk or patellar reflex The patellar reflex or knee-jerk (in American English knee reflex) is a  stretch reflex  which tests the L2, L3, and L4 segments of the  spinal cord . Striking of the  patellar tendon  with a  reflex hammer  just below the  patella  stretches the  muscle spindle  in the  quadriceps muscle . This produces a signal which travels back to the spinal cord and synapses at the level of L3 or L4 in the spinal cord, and triggering contraction. This contraction, coordinated with the relaxation of the antagonistic flexor hamstring muscle causes the leg to kick. 8.Reflex Activity

70. Achilles reflex The ankle jerk reflex, also known as the Achilles reflex, occurs when the  Achilles tendon  is tapped while the foot is  dorsiflexed . It is a type of stretch reflex that tests the function of the  gastrocnemius  muscle and the nerve that supplies it. A positive result would be the jerking of the foot towards its  plantar surface 8.Reflex Activity

71. Babinski reflex   It is one of the normal reflexes in infants. Reflexes are responses that occur when the body receives a certain stimulus. The  Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out. ABNORMAL REFLEX 8.Reflex Activity

72. Snout reflex The Snout reflex or a "Pout" is a pouting or pursing of the lips that is elicited by light tapping of the closed lips near the midline. The contraction of the muscles causes the mouth to resemble a snout. This reflex is tested in a neurological exam and if present, is a sign of brain damage or dysfunction.  8.Reflex Activity ABNORMAL REFLEX

73. The jaw jerk reflex The jaw jerk reflex or the  masseter reflex is a stretch reflex used to test the status of a patient's  trigeminal nerve  ( cranial nerve  V) and to help distinguish an upper cervical cord compression from lesions that are above the  foramen magnum . The  mandible —or lower jaw—is tapped at a downward angle just below the lips at the chin while the mouth is held slightly open. In response, the  masseter muscles  will jerk the mandible upwards. Normally this reflex is absent or very slight. However, in individuals with  upper motor neuron   lesions  the jaw jerk reflex can be quite pronounced. 8.Reflex Activity ABNORMAL REFLEX

74. Palm-chin ( palmomental ) reflex The  thenar eminence  is stroked briskly with a thin stick, from proximal (edge of wrist) to distal (base of thumb) using moderate pressure. A positive response is considered if there is a single visible twitch of the ipsilateral   mentalis muscle  (chin muscle on the same side as the hand tested). A strong, sustained, and easily repeatable contraction of the mentalis muscle, which can be elicited by stimulation of areas other than the palm, is more likely to indicate cerebral damage. 8.Reflex Activity ABNORMAL REFLEX

75. Ankle Clonus Clonus  is a rhythmic, oscillating, stretch reflex, the cause of which is not totally known; however, it relates to lesions in upper motor neurons and therefore is generally accompanied by hyperreflexia . Clonus  at the ankle is tested by rapidly flexing the foot into dorsiflexion (upward), inducing a stretch to the gastrocnemius muscle. Subsequent beating of the foot will result, however only a sustained  clonus  (5 beats or more) is considered abnormal. 8.Reflex Activity ABNORMAL REFLEX

76. The  glabellar reflex  It is elicited by repeatedly tapping the patient between the eyebrows (the  glabella  area), causing them to blink. Normally, the adult patient habituates to the stimulus, and ceases blinking after a few taps. If blinking persists, it is abnormal in adults. Rooting reflexes It can be observed in adult patients with frontal lobe pathology. They often present with other primitive reflexes that are normally suppressed by the frontal lobe of the cerebral cortex . 8.Reflex Activity ABNORMAL REFLEX

77. Grasp reflex It is an involuntary flexion-adduction movement involving the hands and digits.As the name implies, the action resembles a grasping motion of the hand. The reflex can be elicited by moving an object distally along the palm.The movement breaks down into two phases – a catching phase and a holding phase.The catching phase features the initial brief muscular contraction following stimulation of the palm, whereas the holding phase features traction of the tendons associated with the contracting muscles. 8.Reflex Activity ABNORMAL REFLEX

78. Provide a clam, suitable environment Collect the personal data with patient &family members Set the equipment needed for neurological examination Assess the current level of consciousness, monitor vital parameters – temperature, pulse, respiration, blood pressure, pupillary reaction, whether decerebrating or decorticating. Thorough mental status examinations should be done & recorded accurately . NURSES ROLE IN NEUROLOGICAL EXAMINATION

79. Assessment of cranial nerves should be done correctly & recorded. Assessment of motor, sensory & cerebellar functions should be done & be recorded accurately. During the examination, she should maintain a good support with patient &family members She should instruct the procedure correctly& then they should be asked to do it. Should be informed to the concerned unit doctors if there is any change. NURSES ROLE IN NEUROLOGICAL EXAMINATION