NEUROLOGIC

EXAMINATION
Presented by:
Reyna Paredes

HEALTH HISTORY
History of Present Illness
Important aspect of neurologic
assessment
Initial Interview
Provides an excellent opportunity to
systematically explore the patients current
condition and related events
while observing the:

Overall appearance
Mental status
Posture
Movement
Affect

HEALTH HISTORY
Depending on the patients condition, the
nurse may rely on:
YES or NO answer
Review of Medical Records
Input from Family

HEALTH HISTORY INCLUDES:

Onset, character, severity, location duration

and frequency of signs and symptoms.
Complaints
Precipitating, aggravating and relieving
factors
Progression, remission and exacerbation
Presence or absence of similar signs and
symptoms among family members
History of genetic disease

HEALTH HISTORY

Review of medical history including

the system-by-system evaluation is
part of the nursing history.
The nurse should be aware of history
of trauma or falls that may have
involved the head or spinal injury.
Questions about the use of alcohol,
medications and illicit drugs are also
relevant.

PHYSICAL ASSESSMENT

General Observation of the client:

a. Posture, gait, coordination: perform

Romberg test
b. Personal hygiene and grooming
c. Evaluate speech and ability to
communicate
a.
b.
c.
d.

Place of speech: rapid, slow, halting

Clarity: slurred or distinct
Tone: high-pitched, rough
Vocabulary: appropriate choice of words

*** Facial features may suggest specific

syndromes in children

PHYSICAL ASSESSMENT

Mental Status
a. General appearance and behavior
b. Level of consciousness
1. Oriented to person, place and time
2. Appropriate response to verbal and tactile
stimuli
3. Memory, problem solving abilities.

c. Mood
d. Thought content & intellectual
capacity

PHYSICAL ASSESSMENT

Assess Pupillary Status and Eye movement

a. Size of pupils should be equal
b. Reaction of pupils

a. Accommodation: pupillary constriction to

accommodate near vision
b. Direct light reflex: constriction of pupil when light
is shone directly into the eye
c. Consensual reflex: constriction of the pupil in the
opposite eye when the direct light reflex is
tested.

c. Evaluate ability to move eye

a. Note nystagmus
b. Ability of eyes to move together
c. Resting position of iris should be at mid-position
of the eye socket

d. PERRLA

Clinical Manifestation
The clinical manifestation of neurologic disease are as
varied as the disease processes themselves.
Symptoms may be:
Varied or intense
Fluctuating or permanent
Inconvenient or devastating

PAIN
SEIZURES
DIZZINESS a nd VERTIGO
VISUAL DISTURBANCES
WEAKNESS
ABNORMALSENSATION

Clinical Manifestations
PAIN

unpleasant sensory perception & emotional

experience associated with actual or
potential tissue damage
- Subjective
- Acute
> lasts shorter & remits as pathology
resolves
> trigeminal neuralgia, spinal disk disease
- Chronic or persistent
> Lasts longer than 6 months
> degenerative and chronic neurologic cond.

Clinical Manifestations
SEIZURES
- Are the result of abnormal paroxysmal
discharges in the cerebral cortex,
which manifests as alteration in
sensation, perception, movement or
consciousness
- May be long or short
- The type of seizure activity is a direct
result of the brain affected.
- May be a first obvious sign of brain
lesion

Clinical Manifestations
DIZZINESS AND VERTIGO
- Dizziness is an abnormal sensation of
imbalance or movement.
- Variety of causes: viral syndrome, hot
weather, roller coaster rides, middle ear
infections
- About 50% of patients with dizziness
have vertigo (illusion of movement usually
rotation).
- Vertigo is a manifestation of vestibular
dysfunction

Clinical Manifestations
VISUAL DISTURBANCES
Visual defects that cause people to seek
health care can range from decreased
visual acuity associated with aging to
sudden blindness caused by glaucoma
Normal vision depends on :
- functioning visual pathways thought the
retina and optic chiasm
- radiations into the visual cortex in the
occipital lobes

Clinical Manifestations
WEAKNESS
- common manifestation of neurologic
disease (muscle weakness)
- Coexists with other symptoms and can
affect variety of muscles causing
disability
- Can be sudden or permanent or
progressive

Clinical Manifestations
ABNORMAL SENSATION
- Numbness, loss of sensation or
abnormal sensation is a neurologic
manifestation of both cerebral and
peripheral nervous system disease
h
- Usually associated with pain or
weakness and is potentially disabling
- Both numbness and weakness can
significantly affect balance and
coordination
g

PHYSICAL EXAMINATION
The brain and the spinal cord cannot be
examined directly as other body systems
Neurologic examination is an indirect
evaluation that assesses the function of
specific body part controlled
f

5 COMPONTENTS OF
NEURO ASSESSMENT
(1) Cerebral function
(2) Cranial Nerves
(3) Motor system
(4) Sensory System
(5) Reflexes

Assessing Cerebral Function

Cerebral abnormalities may cause:

- disturbance in mental status

- Intellectual function
- Thought content
- Pattern of emotional behavior
- Alteration in perception, motor and
language ability
- Lifestyle change/s

Assessing Cerebral Function

Should be specific and non-judgemental
Avoid using the terms
inappropriate or demented
Specific records on observations
regarding orientation, level of
consciouness, emotional state or thought
content

Assessing the Mental Status

Observe patients appearance & behavior
Note dress, grooming & personal hygiene
Posture, gesture, movements, facial
expression & motor activity
Assess manner of speech & level of
consciousness
Assess orientation to time, place & person

Intellectual Function
A person with an average IQ can:
a. Recite 5 digits backwards
b. Serial 7s (Subtract 7 from 100,
then 7 from that, and so forth)
Interpret proverbs
Ability to recognize similarities
Situational analysis

Thought Content
During the interview, it is important to
assess the patients thought content.
Are the patients thought

Spontaneous
Natural
Clear
Relevant
Coherent

Unusual thoughts like hallucinations,

preoccupation with death and morbid events,
paranoid ideation requires further evaluation

Emotional Status
Is the patients affect natural or even?
Does his or her mood fluctuate
normally?
Are verbal communications consistent
with nonverbal cues?

Perception
The examiner may consider more
specific areas of higher cortical function
Agnosia - inability to recognize objects
seen through the special senses
a patient may see a pencil but knows not what to do with
it or what its called

Screening for visual and tactile agnosia

provides insight into the patients
cortical interpretation ability
Placing a familiar object (key) in the patients hand, have him
identify it with eyes closed

Language Ability
A person with normal neurologic function
can understand and communicate in
spoken and written language.
Aphasia is a deficiency in language
function
Type of Aphasia

Brain area involved

Auditory-receptive
Temporal Lobe
Visual-receptive
Parietal-occipital lobe
Expressive speaking Inferior posterior frontal areas
Expressive writing

Posterior frontal area

Motor Ability
Ask the patient to perform a skilled act
(throw a ball, move a chair)

Performance requires
=> the ability to understand the activity
desired and normal motor strength
Failure signals cerebral dysfunction

ASSESSING THE
CRANIAL NERVES

CARNIAL NERVES
On
Old
Olympus
Towering
Tops
A
Finn
And
German
Viewed
Some
Hops

Olfactory (I)
Optic (II)
Occulamotor (III)
Trochlear (IV)
Trigemenal (V)
Abducens (VI)
Facial (VII)
Acoustic (VIII)
Glossopharyngeal (IX)
Vagus (X)
Spinal Accessory (XI)
Hypoglossal (XII)

M
S
M
M
M/S
M
M/S
S
M/S
M/S
M
M

Cranial Nerve I - Olfactory Nerve

Before testing nerve function, ensure
patency of each nostril by occluding in
turn and asking patient to sniff
Once patency is established, ask patient
to close eyes
Occlude one nostril and hold aromatic
substance (coffee) beneath nose
Ask patient to identify substance
Repeat with other nostril

Cranial Nerve I - Olfactory

Normal:
Patient is able to
identify substance.
(Bear in mind that
some substances may
be unfamiliar,
especially to children)

Abnormal:
Anosmia - loss of sense
of smell.

May be inherited and nonpathological: chronic rhinitis,

sinusitis, heavy smoking,
zinc deficiency, or cocaine
use.
It may also indicate cranial
nerve damage from facial
fractures or head injuries,
disorders of base of frontal
lobe such as a tumor, or
artherosclerotic changes.

Cranial Nerve II - Optic Nerve

Use the snellen chart to check/test:
- distant vision
- color
Client should be 20 feet distant from the chart
Use an object to occlude one eye
Evaluate the vision one eye at a time

Cranial Nerves III, IV and VI

=> Test for ocular rotations,
conjugate movements, nystagmus
** Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis
- using direct & consensual pupillary reaction to light

Testing eye
movements

Testing pupil
accommodation

Abnormal:
Normal:
Able to read without CN II deficits
difficulty
Visual acuity intact
20/20, both eyes
Hippus phenomenon:
Brisk constriction of
pupils in reaction to
light, followed by
dilation and
constriction
- may be normal or
sign of early CN III
compression.

- can occur with stroke or

brain tumor.

Changes in pupillary
reactions
- can signal CN III deficits.

Increased ICP causes

changes in pupillary
reaction
As pressure increases,
response becomes more
sluggish until pupils finally
become fixed and dilated.

CN V - Trigeminal Nerve
a. Testing motor function:

- Ask patient to move jaw from side to

side against resistance and then clench
jaw as you palpate contraction of
temporal and masseter muscles, or to
bite down on a tongue blade.

CN V - Trigeminal Nerve
b. Testing sensory function:
- Ask patient to close eyes
- Touch the face with the wisp of cotton
- Instruct to tell you when he or she feels
sensation on the face.
- Repeat the test using sharp and dull
stimuli (toothpick or tongue blade)
- Instruct to say Sharp or Dull
(Be random, dont establish a pattern)

Testing CN V
sensory function

Cranial Nerve V - Trigeminal Nerve

c. Testing corneal reflex:
- Gently touch cornea with cotton wisp.
o Touching cornea can cause abrasions.
o Alternative approach is to:
> puff air across cornea with a needless
syringe, or
> gently touch eyelash
and look for blink reflex
Testing corneal reflex

Cont. CN V

Normal:
Full range of motion
(ROM) in jaw and
15 strength.
Patient perceives
light touch and
superficial pain
bilaterally

Abnormal:

Weak or absent contraction

unilaterally:

- Lesion of nerve, cervical spine,

or brainstem

Inability to perceive light touch

and superficial pain
- may indicate peripheral nerve
damage.

Trigeminal Neuralgia:

- Neuralgic pain of CN V caused

by the pressure of degeneration
of a nerve

Corneal reflex test used in

patients with decreased LOC

- to evaluate integrity of brainstem.

Cranial Nerve VII - Facial Nerve

a. Testing motor function:
- Ask patient to perform these movements:
smile, frown, raise eyebrows, show upper
teeth, show lower teeth, puff out cheeks,
purse lips, close eyes tightly while nurse
tries to open them.
- Observe face for
flaccid paralysis

Testing CN VII motor function

Cranial Nerve VII - Facial Nerve

b. Testing sensory function:
- Test taste on anterior two-thirds of
tongue for sweet, sour, salty.
F

Sweet: Tip of the tongue

Sour: Sides of back half of tongue
Salty: Anterior sides and tip of tongue
Bitter: Back of tongue
Testing taste sensation

CN VII - Facial Nerve

Normal:
Facial nerve intact
Able to make faces.
Taste sensation on
anterior tongue intact.
(Taste decreased in
older adults.)

Abnormal:
Asymmetrical or impaired
movement:
- Nerve damage, such as
that caused by Bells
palsy or stroke.
Impaired taste/loss of
taste:
- Damage to facial nerve,
chemotherapy or
radiation therapy to head
and neck.

Cranial Nerve VIII - Acoustic Nerve

a. Perform Weber and Rinne tests for hearing
b. Perform watch-tick test by holding watch close
to patients ear.
Watch tick test

c. Perform Romberg test for balance

- Nurse at the back or side of the pt.
- Instruct client to stand straight, feet together,
hands at the side and eyes closed.
(Evaluates the balancing function of the CN VIII)

Cranial Nerve VIII - Acoustic Nerve

Normal:
Hearing intact.
Negative
Romberg test.

Abnormal:
Hearing loss,
nystagmus, balance
disturbance,
dizziness/vertigo:
- Acoustic nerve
damage.
Nystagmus:
- CN VIII, brainstem, or
cerebellum problem or
phenytoin (Dilantin)
toxicity.

Cranial Nerves IX and X

Glossopharyngeal & Vagus Nerves
a. Observe ability to cough, swallow, and
talk.
b. Test motor function:
- Ask patient to open mouth and say ah
while you depress the tongue with a
tongue blade.
- Observe soft palate and uvula.
- Soft palate and uvula should rise medially.
Testing CN IX and
X motor function

CN IX and X
c. Test sensory function of CN IX and motor
function of CN X by stimulating gag reflex.
Tell patient that you are going to touch interior
throat
Then lightly touch tip of tongue blade to posterior
pharyngeal wall.
Observe the pharyngeal movement.
Ask the client to drink a small amount of water
*Note the ease & difficulty of swallowing
*Note quality of the voice or hoarseness
when speaking

CN IX and X
Normal:

Abnormal:
Unilateral movement:
Contralateral nerve damage.
- Damage to CNs IX and X also
impairs swallowing.

Speech clear.

Changes in voice quality (e.g.,

hoarseness): CN X damage.

Swallow and cough

reflex intact.

Elevation and
Diminished/absent gag reflex:
constriction of
Nerve damage
pharyngeal
- Risk for aspiration
musculature and
tongue retraction
indicate positive gag Impaired taste on posterior
portion of tongue:
reflex
Problem with CN IX

CN XI - Spinal Accessory Nerve

a. Test motor function of shoulder and
neck muscles:
=> Ask patient to shrug shoulders upward
against your resistance. (Trapieze muscle)
=> Then ask her or him to turn head from
side to side against your resistance.
(Strenoclaidomastoid muscle)
**Observe for symmetry of contraction and
muscle strength.

Cranial Nerve XI
Normal:
Movement
symmetrical, with
patient moving
against resistance
without pain.
Full ROM of neck
with +5/5 strength.

Abnormal:
Asymmetrical
Diminished
Absent movement
Pain
unilateral or bilateral
weakness:
Peripheral nerve CN
XI damage.

CN XII - Hypoglossal Nerve

a. Have patient say d, l, n, t or a phrase
containing these letters.
- The ability to say these letters requires
use of the tongue.
b. Ask the patient to protrude the tongue.
Observe any deviation from midline, tumors,
lesions, or atrophy.
c. Now ask the patient to move the
tongue from side to side.
Testing CN XII
motor function

Normal:
Abnormal:
Asymmetrical/diminished/
Can protrude
tongue medially. absent movement/deviation
from midline/protruded
No atrophy,
tongue:
Peripheral
nerve
tumors, or
CN
XII
damage.
lesions.
Tongue paralysis results in
dysarthria.

Examining the Motor System

Assessing the patients ability to flex or
extend the extremities against resistance
tests muscle strength.
g

The evaluation of muscle strength

compares the sides of the body with each
other
This way, subtle differences in muscle strength
can easily be detected and described.
f

MUSCLE STRENGTH
Muscle tone (tension present in a
muscle at rest) is evaluated by palpation
Abnormalities in tone include:
Spasticity (increased muscle tone)
Rigidity (resistance to passive strength)
Flaccidity

British Medical Council

Method of Scoring

Balance and Coordination

Cerebellar influence on the motor system is
reflected in balance and coordination.
Coordination of the hands and extremities is
tested by:
Rapid, alternating movements
POINT TO POINT TESTING

Balance and Coordiantion

a. Rapid Alternating Movements (RAM)
Ask the person to pat the knees with both hands, lift
up, turn hands over, and pat the knees with the backs
of the hands.
Then ask to do this faster.
Normal:
done with equal turning
and quick rhythmic
pace

Abnormal:
Lack of coordination
Dysdiadochokinesia
- Slow, clumsy, and sloppy response
- occurs with cerebellar disease

The patient is asked

to pronate and
supinate the hands as
rapid as possible

b. Finger-to-Finger test
With the persons eyes open, ask that he or she use index
finger to touch your finger, then his or her own nose.
After a few times move your finger to a different spot.

Normal:
Movement is smooth
and accurate

Abnormal:
Dysmetria
- clumsy movement with
overshooting the mark
- occurs with cerebellar
disorder
Past-pointing
- constant deviation to one
side

Balance and Coordination

Coordination in the lower extremities is
tested by having the patient run heel down
the anterior surface of the tibia of the other
leg. Each leg is tested
Ataxia is incoordination of voluntary
muscle groups in action
Tremors are rhythmic, involuntary
movements
=>The presence of these movements suggests
cerebellar disease

When abnormality is observed, a thorough

examination is indicated

Balance and Coordination

The cerebellum is responsible for
balance and coordination.
Rombergs Test
- screening test for balance
- the pt stands with feet together
and arms at the side, first with
eyes open and eyes closed for 20
to 30 secs
- slight sway is normal but loss of
balance is abnormal and considered
(+) Romberg rest

Normal:

Abnormal:

Negative Romberg Sways, falls, widens base of

feet to avoid falling
test
Positive Romberg sign
-Loss of balance that occurs
when closing the eyes.
-Occurs with cerebellar
ataxia (multiple sclerosis,
alcohol intoxication)
-Loss of proprioception, and
loss of vestibular function

Perform Tandem Walking

- ask the person to walk a straight line in a heel-to-toe fashion.
- This decreases the base of support and will accentuate any
problem with coordination.
Normal:
Person can walk straight
& stay balanced
Abnormal:
Crooked line walk
Widens base to maintain balance
Staggering, reeling, loss of balance
An ataxia that did not appear now.
Inability to tandem walk is sensitive for
an upper motor neuron lesion, such as
multiple sclerosis.

Hopping in place, alternating knee bends

(some individuals cannot hop owing to aging or obesity)

Examining the Reflexes

Motor reflex are involuntary contraction of
muscles or muscle groups in response to
abrupt stretching near the site of muscle
insertion
Technique: A reflex hammer is used to
elicit a deep tendon reflex.
The tendon is struck briskly, and the
response is compared with the opposite
side of the body (right and left)
The response should be equal

Examining the Reflexes

GRADING the REFLEXES
The absence of reflex is significant,
although ankle jerks (achilles reflex) may
be absent on older people.
Some uses the terms:
PRESENT
ABSENT
DIMINISHED

REFLEXES
Documenting Reflex Findings
Use these grading scales to rate the strength of
each reflex in a deep tendon and superficial reflex
assessment.
Deep tendon reflex grades
0 absent
+ present but diminished
+ + normal
+ + + increased but not necessarily pathologic
+ + + + hyperactive or clonic (involuntary contraction
and relaxation of skeletal muscle)
Superficial reflex grades
0 absent
+ present

 Documentation of reflex finding

ASSESSING REFLEXES
Biceps Reflex
- is elicited by striking the biceps tendon of
the flexed elbow.
- the examiner supports the forearm with
one arm while placing the thumb against
the tendon and striking the thumb with the
reflex hammer.
Normal:
Flexion at the elbow and
contraction of the biceps

ASSESSING REFLEXES
b. Triceps Reflex
- flex pts arm to 90 angle and
positioned in front of the chest
Abduct patients arm and flex it at the elbow.
Support the arm with your non-dominant hand.
Identify triceps tendon by
palpating 2.5 to 5cm
(1-2 in) above the elbow
Normal:
Contraction of triceps with
extension at elbow

ASSESSING REFLEXES
c. Patellar Reflex

Have patient sit with legs dangling.

Strike tendon directly below patella.
Normal:

Contraction of
quadriceps with
extension of knee.

ASSESSING REFLEXES
d. Ankle Reflex
- Achilles reflex
- foot is dorsiflexed at the ankle and
the hammer strikes the stretched
Achilles tendon
Normal:
Plantar flexion of foot.

ASSESSING REFLEXES
e. Test for Clonus
When reflexes are very hyperactive, a
phenomenon called clonus may be elicited
If a foot is abruptly dorsiflexed, it may
continue to beat two to three times before
it settles into a position of rest
The presence of clonus always indicates the
presence of CNS disease and requires
further evaluation
Normal:
No contraction

F. Superficial Reflexes
Abdominal Reflex
Stroke patients abdomen diagonally from
upper and lower quadrants toward umbilicus.
Contraction of rectus abdominis. Umbilicus
moves toward stimulus.

Perianal Reflex
Gently stroke skin around anus with gloved finger.
Normal:
Anus puckers.
Cremasteric Reflex
Gently stroke inner aspect of a males thigh.
Normal:
Testes rise.
Bulbocavernosus Reflex
Gently apply pressure over bulbocavernous
muscle on dorsal side of penis.
Normal:
Bulbocavernosus muscle contracts.

ASSESSING REFLEXES
BABINSKI REFLEX

Stroke sole of patients foot in an arc

from lateral heel to medial ball.
Fanning of toes when stroked laterally
Normal in newborn (found until 16 24 mos)
Indicates CNS disease of motor system

Normal:
Flexion of all toes.

SENSORY EXAMINATION
Highly subjective & requires cooperation of the pt
The examiner should be familiar with dermatomes
Most sensory deficits results from peripheral
neuropathy and follow anatomic dermatomes

Assessment involves:
Tactile sensation
Superficial pain
Vibration
Position sense
** during assessment, pt eyes are kept closed

SENSORY EXAMINATION
Tactile Sensation or Light Touch
- Brush a light stimulus such as a cotton wisp
over patients skin in several locations, including
torso and extremities.
Normal:
Identifies areas
stimulated by light
touch.

Abnormal:
Hypesthesia: diminished capacity for
physical sensation (esp. skin)
Hyperesthesia: Increased sensitivity
Paresthesia: Numbness & tingling
Anesthesia: Loss of sensation.

PAIN and TEMPERATURE

- Stimulate skin lightly with sharp and dull ends of
toothpick/ paper clip
- Apply stimuli randomly and ask patient to identify
whether sensation is sharp or dull.

- Touch patients skin with test tubes filled with hot or

cold water.
- Apply stimuli randomly, and ask patient to identify
whether sensation is hot or cold.

Sensory Examination
VIBRATION and PROPRIOCEPTION
- Place a vibrating tuning fork over a finger
joint, and then over a toe joint.
- Ask patient to tell you when vibration is felt
and when it stops.
- If patient is unable to detect vibration, test
proximal areas as well.

Sensory Examination
Normal:
Vibratory
sensation intact
bilaterally in upper
and lower
extremities.

Abnormal:
Diminished/absent
vibration sense:
- Peripheral nerve
damage caused by
alcoholism, diabetes,
or damage to
posterior column of
spinal cord.

Stereognosis
With patients eyes closed, place a familiar
object, such as a coin or a button, in patients
hand, and ask patient to identify it.
Test both hands using different objects.

Normal:

Abnormal:

Abnormal findings suggest a

Stereognosis
intact bilaterally. lesion or other disorder
involving sensory cortex or a
disorder affecting posterior
column.

Sensory Extinction
Simultaneously touch both sides of patients
body at same point.
Ask patient to point to where she or he was
touched.
Normal:
Abnormal:
Extinction intact. Identification of stimulus on
only one side suggests lesion
or other disorder involving
sensory cortical region in
opposite hemisphere.

Assessing
Level of Consciousness

Level of Consciousness (LOC)

arousal; awareness of self or environment
d

Alert fully awake; appropriate responses to external and

internal stimuli; oriented to person, place and time

s

Lethargic somnolent, drowsy, listless, indifferent to

surroundings, very sleepy, can be aroused from sleep but

when stimulation ceases, falls back to sleep; may be
oriented or confused
d

Stuporous unconscious most of the time but makes

spontaneous movements and response is evoked only by a

strong, continuous, noxious stimuli; loud noises or sounds,
bright light, pressure to sternum, response is usually a
purposeful attempt to remove the stimulus
f

Comatose absence of voluntary response to stimuli

including painful stimuli; no response, no eye opening

score of 7 or less on GCS

Glasgow Coma Scale

- A standardized objective assessment that
defines the LOC by giving it a numeric value.
- Most often after brain surgery
- Document as E_V_M_; for example, E4V5M6.
The three numbers are added; the total score reflects the
brain
functional level.
A fully awake person = 15
Coma = 7 or less
The GCS assesses the functional state of the brain as a
whole, not of any particular site in the brain. (Juarez and Lyon,1995)

Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)

ASSESSING LEVEL OF
CONSCIOUSNESS
a. Test orientation to time, place, and person
Normal:
Awake, alert, and
oriented to time,
place, and person
(AAO x 3)
Responds to
external stimuli

Abnormal:
Disorientation may be
physical in origin
Disorientation can also
be psychiatric in origin
(schizophrenia)
Lathargic or somnolent
Obtunded
Stupor
Coma

Abnormal Findings
Abnormalities in Muscle Movement
Paralysis
Loss or impairment of the ability to move a body part,
usually as a result of damage to its nerve supply.
Loss of sensation over a region of the body.
Hemiplegia
paralysis of one side of the body
Paraplegia
paralysis of both lower limbs due to
spinal disease or injury
Quadriplegia
paralysis of all four limbs or of the entire
body below the neck
Paresis
partial motor paralysis

Abnormal Findings
Abnormalities in Muscle Movement
Fasciculations
Rapid, continuous twitching of resting
muscle

Abnormal Findings
Abnormalities in Muscle Movement
Tic
Repetitive twitching of a muscle group

Abnormal Findings
Abnormalities in Muscle Movement

Myoclonus
Rapid, sudden jerk at a fairly regular
intervals

Abnormal Findings
Abnormalities in Muscle Movement
Tremor
Involuntary contraction of opposing muscle
groups
Rest tremor
Intention tremor

Abnormal Findings
Abnormalities in Muscle Movement

Chorea
Sudden, rapid, jerky,
purposeless
movement involving
limbs, trunk, or face

Abnormal Findings
Abnormalities in Muscle Movement

Athetosis
Slow, twisting,
writhing,
continuous
movement,
resembling a
snake or worm

Neurologic Exam: Meningeal signs

Brudzinskis sign
- neck stiffness
- involuntary flexion of hips and knees
when flexing neck is positive sign for
meningeal irritation

Neurologic Exam: Meningeal signs

Positive Kernigs sign
-excessive pain in the lower back
when examiner attempts to straighten
knees with client supine and knees
and hips flexed

Neurologic Exam: Meningeal

Decorticate posturing (up)

Decorticate posturing (down)

DIAGNOSTIC
EVALUATION

Computed Tomography Scan

Makes use of narrow x-ray beam to scan body part
in successive layers
Images provide cross-sectional views of the brain
displayed on an oscilloscope or TV monitor and is
photographed and stored digitally
Non-invasive and painless and has high degree in
detecting brain lesions
Nursing Intervention:
Teach patient about the need to lie quietly
throughout the entire procedure
Assess for iodine/shellfish allergy
Monitor for side effect of IV or inhalation contrast
agents: flushing, nausea, vomiting

CT SCAN

Positron Emission Tomography (PET)

- Computer based nuclear imaging that produces
images of actual organ functioning.
- Radioactive gas or substance is inhaled or
injected that emits positively charged particles.
- It permits measurement of blood flow, tissue
composition, brain metabolism thus evaluates
brain function.
- Useful in showing metabolic changes in the
brain (Alzheimers disease), locating lesions
(tumor, epiliptogenic lesions), identifying
blood flow and oxygen metabolism in stroke pt
and new therapies for brain tumor.

Positron Emission Tomography (PET)

Key nursing interventions include patient
preparation, which involves explaining the test and
teaching the patient about inhalation techniques and
the sensations (dizziness, light-headedness,
headache) may occur.
IV injection of radioactive substance produces
similar side effects.
Relaxation exercises may reduce anxiety during the
test.

PET Scan

Single Photon Emission Computed

Tomography (SPECT)
3D imaging technique that uses radionuclides
and instruments to detect single photons.
Perfusion study that captures cerebral blood
flow at time of injection of radionuclide.
SPECT is useful in detecting extent & location
of perfused areas of the brain, allowing
detection, localization and sizing of stroke,
detecting tumor progression and evaluation of
perfusion before and after neurosurgical
procedures.

Single Photon Emission Computed

Tomography (SPECT)
Nursing Intervention
Preparation and monitoring
Observe for allegeric reaction.
Pregnancy and breastfeeding are
contraindications.

Magnetic Resonance Imaging

(MRI)
Uses a powerful magnetic
field to obtain images of
different areas of the body
Can identify cerebral
abnormality earlier and
more clearly than any
other diagnostic tests
Useful in monitoring
tumors response to
treatment, Dx of MS

Nursing Intervention: MRI

Relaxation techniques
Advise pt that she can speak with the staff by
means of a microphone inside the scanner
ALL metal objects and magnetic cards are
removed (aneurysm clips, ortho-hardware,
pacemakers, artificial heart valves, IUD)
Medication patches removed (cause burns)
Sedation for claustrophobic pt
Scanning process is painless, but the patient
hears loud thumping of magnetic coils as
magnetic field is being pulsed.

Myelography
Myelogram is an Xray of spinal subarachnoid space
taken with contrast agent (through Lumbar Tap)
Shows distortion of spinal cord or spinal dural sac
caused by tumors, cysts, herniated vertebral disks
Nursing Intervention
Meal before procedure is omited
After myelography, patient to lie in bed with head
elevated up to 45 and remain in bed for 3hrs
Encourage increased fluid intake
Monitor VS

Myelography

CEREBRAL ANGIOGRAPHY
X-ray study of the cerebral circulation with
contrast agent injected to selected artery.
Performed by threading a catheter through the
femoral artery in the groin and up to the desired
vessel.
Uses: Vascular disease, aneurysms, AVM
Digital Subtraction Angiography
- X-ray images of areas in question are taken before and
after injection of contrast agent (peripheral vein) and then
compared

CEREBRAL ANGIOGRAM

Nursing Intervention: CEREBRAL ANGIOGRAPHY

NURSING CARE PRE-TEST
1.) Check allergy to iodine
2.) Keep NPO after midnight or offer clear liquid breakfast only
3.) Explain that the client may have warm, flushed feeling and salty taste in
mouth during procedure
4.) Take baseline vital signs and neuro check
5.) Administer sedation if ordered
NURSING CARE POST-TEST
1.) Maintain pressure dressing over site if femoral or brachial artery used;
apply ice as ordered
2.) Maintain bed rest until next morning as ordered
3.) Monitor vital signs, neuro checks frequently; report any changes
immediately
4.) Check site frequently for bleeding or hematoma; if carotid artery used;
assess for swelling of neck, difficulty swallowing or breathing
5.) Check pulse, color, and temperature of extremity distal to site used.
6.) Keep extremity extended and avoid flexion

Non-invasive Carotid Flow Studies

Uses ultrasound and doppler measurements of
arterial blood flow to evaluate carotid and deep
orbital circulation.
The graph produced indicates blood velocity.
( velocity = stenosis or partial obstruction)

Carotid doppler
Carotid ultrasonography
Oculoplethysmography
Opthalmodensinometry

permits evaluation of
arterial blood flow and
detection of atrial
stenosis, occlusion and
plaques

Transcranial Doppler
Uses the same noninvasive techniques as
Carotid flow studies except it records blood
flow velocities of intracranial vessels
Flow velocity is measured through thin area
of temporal and occipital bones of the skull.
A hand-held doppler probe emits a pulsed
beam; the signal is reflected by a moving
RBC within the blood vessel
Helpful in assessing vasospasm, altered cerebral
blood flow in occlusive vascular dse or stroke

Electroencephalography (EEG)
Represents a record of electrical
activity generated by the brain
through electrodes applied on the
scalp
Used to diagnose seizure
disorders, coma
Tumors, brain abscess, blood
clots may cause abnormal
patterns in electrical activity
Used in making a determination
of BRAIN DEATH

Electroencephalography (EEG)
Nursing Intervention
Withhold medications that may interfere with the resultsanticonvulsants, sedatives and stimulants
Wash hair thoroughly before procedure
Instruct adult client to sleep no more than 5 hrs the night
before.
Coffee, tea, chocolate and cola drinks are omitted
Meal itself is not omitted because an altered glucose level
alters brain wave patterns
It takes 45min-1hour; 12 hours for sleep EEG
Standard EEG - water-soluble lubricant
Sleep EEG - collodion glue for electrode contact (acetone
for removal)

Diagnostic Evaluation
Electromyography (EMG)
- obtained by inserting needle electrode into the skeletal
muscle to measure changes in the electrical potential of the
muscles and the nerves leading to them.
Determine presence of neuromuscular disorders & myopathies.

Nerve Conduction Studies

-A peripheral nerve is stimulated at several points
along its course and recording the muscle action
potential or sensory action potential.
Useful in studying peripheral neuropathies.

Lumbar Puncture and CSF examination

Spinal tap - a needle is inserted into the subarachnoid

space through the 3rd and 4th or 4th and 5th lumbar
interface to withdraw spinal fluid
PURPOSES
1. Measures CSF pressure
h

(normal opening pressure 60-150mmH2O)

2. Obtain specimens for lab analysis, cytology, C&S

(protein - normally not present, sugar - normally present)

3. Check color of CSF (normally clear) and check for

blood
4. Inject air, dye, or drugs into the spinal canal
-

CSF pressure in lateral recumbent position is

70-200mm H20

Lumbar Puncture and CSF examination

CONTRAINDICATION
INCREASED ICP
COAGULOPATHY & DECREASED PLATELETS
SPINAL DEFORMITIES ( SCOLIOSIS, KYPHOSIS)

Lumbar Puncture Guidelines

NURSING CARE PRE-TEST
1.) Have client empty bladder
2.) Position client in a lateral recumbent position with head
and neck flexed onto the chest and knees pulled up.
3.) Explain the need to remain still during the procedure
NURSING CARE POST-TEST
1.) Ensure labeling of CSF specimens in proper sequence
2.) Keep client flat for 12-24 hours as ordered
3.) Force fluids
4.) Check puncture site for bleeding, leakage of CSF
5.) Assess sensation and movement in lower extremities
6.) Monitor vital signs
7.) Administer analgesics for headache as ordered

Queckenstendts Test
lumbar manometric test
performed by compressing jugular veins during Spinal
tap
in pressure caused by compression is noted; then
released and read every 10secs interval.
a slow rise and fall in pressure indicated a partial block
due to lesion compressing the spinal subarachnoid path.
no pressure change => complete block is indicated.
Contraindicated : if intracranial lesion is suspected.

CSF Analysis
CSF should be clear and colorless
Pink, blood-tinged, or glossy bloody CSF
indicates cerebral contusion, laceration or
subarachnoid hemorrhage
Specimens are obtained for: cell count,
culture and glucose and protein testing

Post Lumbar Headache

Mild to severe, may occur few hours to several
days after the procedure.
It is throbbing bifrontal or occipital headache,
dull or deep in character
Cause: leak at puncture site, fluid continues to
escape into the tissues by way of the needle
track from the spinal canal
May be avoided if small-gauged needle is used
and if pt remains prone
after the procedure.

sources
Dillon, Patricia. Nursing Health Assessment. 2nd
Ed. F.A. Davis. 2007
Jarvis, Carolyn. Physical Examination and Health
Assessment. 3rd ed. New York: W.B. Saunder
Company.2000
Bickley. Lyn and Hoekenan, Robert. Bates Guide
to Physical Examination and History Taking. 7th
ed. New York: Lippincott Williams and Wilkins.
1999
Estes, Mary Ellen Zator. Health Assessment &
Physical Examination. 3rd ed. Delmar Learning.
2006

THANK YOU!!!