Unit-02 NERVOUS SYSTEM ASSESSMENT Provided By Immam Ud Din.pptx

Nervous System

1. UNIT-II : ASSESSMENT OF THE MENTAL STATUS AND SENSORY NEURO SYSTEM By: Farzana Kausar Khattak Lecturer KMU-INS

2. OBJECTIVES By the end of the unit, learners will be able to: Perform mental status examination of a client. Assess cranial nerve, sensory, sense of proprioception and cerebellar functions and deep tendon reflexes. Document findings. List the changes in the nervous system that are characteristics of the aging process. 2 11/22/2023 Farzana Khattak

3. ASSESSMENT OF THE NEUROLOGICAL SYSTEM A complete neurological assessment consists of five steps: Mental Status Exam Cranial Nerve Assessment Reflex Testing Motor System Assessment Sensory System Assessment A simple means of gathering a great deal of information about the patient's neurological system is to observe the patient walking, talking, seeing, and hearing. Watching the patient entering the room is also important in giving the examiner information. 3 11/22/2023 Farzana Khattak

4. As the patient enters the room, check the following : Posture and motor behavior Dress, grooming, and personal hygiene Facial expression Speech manner, mood, and relation to persons and things around him 4 11/22/2023 Farzana Khattak

5. HEALTH HISTORY COMMON CHIEF COMPLAINTS Headache Seizure Syncope Pain Disturbances in gait Visual changes Vertigo Memory disorders Difficulty with swallowing or speech 5 11/22/2023 Farzana Khattak

6. PAST HEALTH HISTORY Medical Neurologic specific Non-neurologic s pecific Surgical Medications Antidepressants, narcotics , anti anxiety and anti seizure medications Injuries and accidents 6 11/22/2023 Farzana Khattak

7. FAMILY HEALTH HISTORY Congenital defects Headaches Alzheimer’s disease (senile dementia) SOCIAL HISTORY Alcohol, drug, tobacco use Sexual practices Travel history Work and home environment Hobbies and leisure activities Stress 7 11/22/2023 Farzana Khattak

8. HEALTH MAINTENANCE ACTIVITIES Sleep Diet Exercise Use of safety devices Health check-ups 8 11/22/2023 Farzana Khattak

9. OBJECTIVE DATA -THE PHYSICAL EXAM EQUIPMENT NEEDED Penlight Tongue blade Cotton swab Cotton ball Tuning fork Percussion hammer 9 11/22/2023 Farzana Khattak

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11. ASSESSMENT OF MENTAL STATUS ASSESS PHYSICAL APPEARANCE AND BEHAVIOR Posture & movement Ability to wait patiently Posture is slumped, relaxed or stiff Patient movement Patient’s gait 11 11/22/2023 Farzana Khattak

12. DRESS, GROOMING, PERSONAL HYGIENE Cleanliness Condition Age appropriateness Weather appropriateness IN PERSONAL GROOMING YOU WILL WATCH FOR: Adequacy O dor 12 11/22/2023 Farzana Khattak

13. FACIAL EXPRESSION Appropriateness Variations Symmetry 13 11/22/2023 Farzana Khattak

14. NORMAL FINDINGS Posture erect, gait smooth, body movements symmetrical. Clean, well-groomed, clothing appropriate for age and weather. Facial expressions appropriate to conversation content, symmetrical. Affect appropriate to situation and cultural norms. 14 11/22/2023 Farzana Khattak

15. COMMUNICATION NORMAL FINDINGS Able to produce spontaneous, coherent (logical) speech. ABNORMAL FINDINGS Expressive Aphasia ( Broca's A phasia): P atient know what he/she wants to say, but have trouble saying or writing his/her thoughts. Receptive A phasia ( Wernicke's A phasia): Affects ability to read and understand speech. Patient can hear what people say or see words on a page, but have trouble making sense of what they mean . Global A phasia: T he loss of almost all language ability . Patient can't speak, understand speech, read, or write . 15 11/22/2023 Farzana Khattak

16. LEVEL OF CONSCIOUSNESS The single most valuable indicator of neurological function is the individual's level of consciousness . You can legally describe the patient's condition in the nursing notes by saying, "appears to be" alert or lethargic or so forth . Alert : The patient is awake, verbal and motor responsive . Lethargic : The patient is sleepy or drowsy but awake and respond appropriately to command . Stupor: S tate of reduced consciousness with limited responsiveness. Semi coma: D eeper state of unconsciousness with minimal to no responsiveness . Coma: The patient is completely unresponsive . 16 11/22/2023 Farzana Khattak

17. GLASGOW COMA SCALE Mild: 13-15 Moderate: 9-12 Severe: 3-8 17 Eye Opening Spontaneous                        4 To Voice                        3 To Pain                         2 None                              1 Verbal Oriented                              5 Confused                             4 Inappropriate Words             3 Incomprehensible Sounds      2 None                                    1 Motor Obeys Commands               6 Localizes Pain                       5 Withdraws to Pain               4 Flexion to Pain  (Decorticate) 3 Extension to Pain ( D ecerebrate ) 2 None                                    1 11/22/2023 Farzana Khattak

18. COGNITIVE ABILITIES AND MENTATION ATTENTION TESTS Series of numbers, serial 3’s or 7’s. Ask the patient to repeat the series or counting backward from 100 by threes. NORMAL FINDINGS Pt able to correctly repeat series. 18 11/22/2023 Farzana Khattak

19. MEMORY TESTS For short term memory give a list of 3 items that a patient is to remember and repeat in 5 mins. During the 5 mins carry on the conversation. Long term memory is the memory that is retained for at least 24 hours. Ask for the name of spouse, birthday of spouse, name of the president. NORMAL FINDINGS The patient should be able to correctly respond to questions and to identify all the objects. 19 11/22/2023 Farzana Khattak

20. CALCULATION TESTS Count up in 3’s starting at 100 to 150. NORMAL FINDINGS Patient able to calculate the correct numbers. ABNORMAL FINDINGS: Dyscalculia: Inability to perform calculations. 20 11/22/2023 Farzana Khattak

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22. SENSORY ASSESSMENT Divides into 3 sections : Exteroceptive Sensation (Superficial) Light Touch Superficial Pain Temperature Proprioceptive Sensation (Deep, Position sense) Motion Position Vibration Cortical Sensation (Localization) Stereognosis Graphesthesia Discrimination 22 11/22/2023 Farzana Khattak

23. EXTEROCEPTIVE SENSATION Assess the patients ability to detect on their legs, arms, abdomen. Light Touch (cotton wisp) Superficial P ain (sharp/dull) Temperature (hot/cold) 23 11/22/2023 Farzana Khattak

24. ABNORMAL FINDINGS Anesthesia: Absence of touch sensation Hypoesthesia: Diminished sense of touch Hyperesthesia : Increased sense of touch Paresthesia: T ingling , burning, or pricking sensation Dysesthesia: A bnormal interpretation of stimulus i.e. burning or tingling Analgesia: Insensitivity to pain Hypoalgesia : Diminished sensitivity to pain Hyperalgesia: I ncreased sensitivity to pain 24 11/22/2023 Farzana Khattak

25. PROPRIOCEPTIVE SENSATION MOTION & POSITION Move patient’s fingers/toes up & down Normal Findings: Pt should be able to correctly identify the changes in position of body. VIBRATION Use tuning fork on bony prominences Patient will report buzzing feeling at onset & end 25 11/22/2023 Farzana Khattak

26. CORTICAL SENSATION . STEREOGNOSIS GRAPHESTHESIA TWO POINT DISCRIMINATION 26 11/22/2023 Farzana Khattak

27. CRANIAL NERVES “ O hh O hh O hh ’ T o T ake A F amily V acation A nd G o V agus A fter H our” OR “ O n O ld O lympus’ T owering T op, A F in V an G erman V iewed A H op” AND “ S ome S ay M arry M oney, B ut M y B rother S ays B ig B rains M atter M ore” I – Olfactory (S) VII – Facial (B) II – Optic (S) VIII - Auditory (V-C ) (S) III – Occulomotor (M) IX – Glossopharyngeal (B) IV – Trochlear ( M) X – Vagus (B) V – Trigeminal (B) XI - Spinal/Accessory (M) VI – Abducent (M) XII – Hypoglossal (M) 27 11/22/2023 Farzana Khattak

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29. OLFACTORY (I) Ask the patient to close the eyes. Test each side by asking the patient to occlude each side. Ask the patient to inhale deeply. Present one odor at a time. ABNORMAL FINDING Anosmia (loss of sense of smell ) OPTIC (II) Visual acuity Visual fields Funduscopic 29 11/22/2023 Farzana Khattak

30. OCULOMOTOR (III) Cardinal Fields of Gaze Pupil reactions ( direct, consensual, accommodation) TROCHLEAR (IV) Cardinal Field of Gaze 30 11/22/2023 Farzana Khattak

31. TRIGEMINAL (V) Motor Palpate temporalis muscle Palpate masseter muscle Bite down on tongue blade Sensory Close eyes Touch 3 sensory areas of trigeminal nerve with cotton, sharp, dull, temperature hot/cold. 31 11/22/2023 Farzana Khattak

32. ABDUCENS (VI) Cardinal Field of Gaze FACIAL (VII) Motor Note symmetry Note muscle contractions Frown Raise eyebrows Wrinkle forehead Close eyes against resistance Smile Show teeth Whistle Puff cheeks against resistance 32 11/22/2023 Farzana Khattak

33. ABNORMAL FINDINGS Bells Palsy Sensory Test taste with eyes closed Sweet, sour, bitter, salty ABNORMAL FINDINGS Ageusia (loss of taste) Hypogeusia (diminution of taste) 33 11/22/2023 Farzana Khattak

34. ACOUSTIC (VIII) Cochlear division Weber Test RinneTest Vestibular division Assess for vertigo 34 11/22/2023 Farzana Khattak

35. GLOSSOPHARYNGEAL (IX) VAGUS (X) Examine soft palate Uvula movement Gag reflex Assess quality of speech Ability to swallow H2O Taste on posterior 1/3 of tongue 35 11/22/2023 Farzana Khattak

36. SPINAL ACCESSORY (XI) Inspect muscles of neck Assess strength of muscles against resistance for neck Assess strength of muscles against resistance for shoulders 36 11/22/2023 Farzana Khattak

37. HYPOGLOSSAL (XII) Assess movement of tongue using tongue depressor Assess ability to say “la , la, la” 37 11/22/2023 Farzana Khattak

38. ASSESSMENT OF MOTOR SYSTEM Observe gait and posture. Balance Walk heel to toe. Walk on toes, walk on heels Stand on one foot, hopping Deep knee bend Muscle tone, mass, involuntary movements and muscle strength on 0-5 scale 11/22/2023 Farzana Khattak

39. INVOLUNTARY MOVEMENTS Tremors Tics Spasms Myoclonus Note the involuntary movement in relation to : Posture Activity Fatigue Emotion Other factors 11/22/2023 Farzana Khattak 39

40. TERMS TO DESCRIBE MOVEMENT Flexion Extension Abduction Adduction Pronation Supination 11/22/2023 Farzana Khattak 40

41. MORE TERMS FOR MOVEMENT Circumduction Inversion Eversion Rotation Protraction Retraction Elevation Depression 11/22/2023 Farzana Khattak 41

42. CEREBELLAR FUNCTIONS (COORDINATION, STATION, GAIT) PRONATOR DRIFT Have the patient extend the arms out in front with palms up for 20 seconds. Observe for downward drifting of an arm. There should be no downward drifting of an arm. 11/22/2023 Farzana Khattak 42

43. CEREBELLAR FUNCTIONS (COORDINATION, STATION, GAIT) COORDINATION Instruct the patient to sit facing you, with eyes open and arms outstretched. Ask the patient to first touch the index finger to the nose, then to alternate rapidly with the index finger of the opposite hand. With the patient’s eye closed, have the patient continue to rapidly touch the nose with alternate index fingers. Finger to Nose Test 11/22/2023 Farzana Khattak 43

44. COORDINATION AND FINE MOTOR SKILLS RAPID RHYTHMIC ALTERNATING MOVEMENTS Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed. P erson should be able to do these movements smoothly, maintaining rhythm, with increasing speed. Observe for slow, stiff, non-rhythmic, or jerky movements. 44 11/22/2023 Farzana Khattak

45. COORDINATION AND FINE MOTOR SKILLS ACCURACY OF MOVEMENT Finger-to-finger test with person’s eyes open Movements should be rapid, smooth, and accurate Finger to nose test with person’s eyes closed Movement should be smooth, accurate, and rapid Heel-to-shin with person supine, sitting, or standing Should move heel from knee up and down the shin in a straight line, without irregular deviations to the side 11/22/2023 Farzana Khattak 45

46. COORDINATION AND FINE MOTOR SKILLS BALANCE: EQUILIBRIUM Romberg test Have person stand with arms at side and feet together Have person perform initially with eyes open and then with eyes closed Stand close to prevent falls person should maintain position with eyes open or closed for 20 seconds with only minimal swaying If the Romberg is positive (i.e. there is significant swaying or the person has to take a step to maintain/regain balance) DO NOT DO OTHER TESTS OF BALANCE 46 11/22/2023 Farzana Khattak

47. COORDINATION AND FINE MOTOR SKILLS BALANCE: EQUILIBRIUM Have person stand with feet slightly apart Examiner pushes shoulders with enough effort to throw person off balance Recovery should be quick Ability to balance on one foot with eyes closed for at least 5 seconds Ability to hop in place on one foot for at least 5 seconds 47 11/22/2023 Farzana Khattak

48. REFLEXES A reflex is defined as an immediate and involuntary response to a stimulus . DEEP TENDON Grading scale 0–4 Compare right to left Brachioradialis Biceps Triceps Patellar Achilles SUPERFICIAL Abdominal Plantar C remasteric 48 11/22/2023 Farzana Khattak

49. BICEPS Have the patient's elbow at about a 90° angle of flexion with the arm slightly bent down. Grasp the elbow with your left hand so the fingers are behind the elbow and your abductee thumb presses the biceps brachial tendon . Strike your thumb a series of blows with the rubber hammer, varying your thumb pressure with each blow until the most satisfactory response is obtained . Normal reflex is elbow flexion (bending ( 49 11/22/2023 Farzana Khattak

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51. BRACHIORADIALIS 1-2 inches above the wrist Support the relaxed arm either on the lap or semi pronated on your forearm Strike above the styloid process a few centimeters above the wrist on the thumb side Response – flexion and supination of the forearm 51 11/22/2023 Farzana Khattak

52. TRICEPS Grasp the patient's wrist with your left hand and pull his arm across his chest so the elbow is flexed about 90° and the forearm is partially bent down . Tap the triceps brachial tendon directly above the olecranon process. The normal response is elbow extension . 52 11/22/2023 Farzana Khattak

53. PATELLAR REFLEX (KNEE JERK) Have the patient sit on a table or high bed to allow his legs to swing freely . Tap the patellar tendon directly with a rubber hammer . Normally, the knee extends . Conduct the reflex check as shown in this figure if the patient must be lying down. Put your hand under the popliteal fossa and lift the patient's knee from the table or bed. Tap the patellar tendon directly . 53 11/22/2023 Farzana Khattak

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55. ACHILLES REFLEX The Achilles reflex is a monosynaptic stretch reflex similar to the patellar reflex. In the Achilles reflex, the hammer taps the Achilles tendon while the foot is dorsiflexed, and the foot, in response, should jerk toward the plantar surface. 11/22/2023 Farzana Khattak 55

56. PLANTAR (BABINSKI) Grasp the ankle with your left hand . Use a blunt point and moderate pressure and stroke the sole of the foot near its lateral border. Stroke from the heel toward the ball of the foot where the course should curve across the ball of the foot to the medial side, following the bases of the toes . A normal reflex is for the patient to have plantar flexion of all his toes . 56 11/22/2023 Farzana Khattak

57. DEEP TENDON REFLEXES SHOULD BE GRADED ON A SCALE OF 0-4 - Absent (A): The reflex is completely absent, and there is no response to the stimulus. 1 - Diminished (D): The reflex is present but weaker than normal. 2 - Normal (N): The reflex is within the normal range and has a typical response. This is the expected response for a healthy individual. 3 - Increased (I): The reflex is more pronounced or hyperactive compared to the normal response. There may be a repeat or sustained response. 4 - Clonus (C): In some cases, particularly for certain deep tendon reflexes like the ankle reflex, a sustained rhythmic oscillation of the muscle can be observed, referred to as "clonus." 57 11/22/2023 Farzana Khattak

58. DOCUMENTATION The patient is alert and oriented to person, place, and time or by the shortened phrase, “Alert and oriented x 3 .” with normal speech.  No motor deficits are noted, with muscle strength 5/5 bilaterally.  Sensation is intact bilaterally . Reflexes are 2+ bilaterally. Cranial nerves are intact. Cerebellar function is intact. Memory is normal and thought process is intact. No gait abnormalities are appreciated.  11/22/2023 Farzana Khattak 58

59. VIDEO LINK https:// www.youtube.com/watch?v=Sqb8icF6QhE https:// www.youtube.com/watch?v=dPXsgXwNhDE https:// www.youtube.com/watch?v=HATxsrAvqsc 11/22/2023 Farzana Khattak 59

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