Hello and welcome to topic 6 of NSG 316 Health Assessment. Today we'll be discussing the neurologic system. As always, we will first review our learning objectives, which are to describe techniques used to assess the neurological system, identify appropriate neurological assessment and cranial nerve assessment techniques for clients based on age, development, and other psychosocial or environmental variables.
differentiate between normal and abnormal neurological and cranial nerve assessment findings that require further evaluation and lastly document health history and key components of neurological and cranial nerve assessments in the client record just a reminder that there is an additional set of slides for your review that do not have a voiceover but do cover neurological anatomy and physiology these are to be reviewed independently and will be important foundational content for understanding this section. Something that's important to remember is that as the brain develops and ages, it does undergo a significant amount of changes. But it should be noted that brain atrophy is normal in healthy aging and it should be symmetric and generalized on neurologic imaging.
So, atrophy with a steady loss of neuron structure in the brain and spinal cord is actually expected in the older adult. We'll see loss of weight and volume with thinning of the cerebral cortex, reduced subcordial brain structures, and expansion of the ventricles. The aging adult will experience the velocity of nerve conduction decreasing between 5 and 10%, making their reaction time slower in some older adults. An increased delay at the synapse also occurs, so the impulse takes longer to travel. As a result, touch and pain sensation, taste, and smell may be diminished.
It's important to note that these are expected findings. The motor system may show a general slowing of movement, muscle strength, and agility may decrease. A generalized decrease occurs in muscle bulk, which is most apparent in the dorsal hand muscles. Muscle tremors may occur in the hands, head, and jaw, along with possible repetitive facial disc... facial...
grimacing also called dyskinesias aging is accomplished by a progressive decrease in cerebral blood flow and oxygen consumption in some people this causes dizziness and a loss of balance with position change these people need to be taught to get up slowly so they do not experience balance issues otherwise they have an increased risk for falls resulting in an increased risk for injury in addition older people may forget that they fell which makes it hard to diagnose the cause of the injury. Some of the age-related changes that are expected in the older adult client are actually considered abnormal in the younger adult. So things like a general loss of muscle bulk, muscle tone in the face, neck, and around the spine, and decreased muscle strength are actually expected findings in the aging adult.
but would be considered abnormal in a younger adult client. We also see impaired fine coordination and agility, loss of vibratory sense in the ankle, or decreased or absent Achilles reflexes. Pupillary meiosis may occur, there may be irregularities in pupil shape, and a decreased pupillary reflex.
When it comes to culture and genetics, there are a few things that need to be noted. In particular, that racial and ethnic disparities do exist related to strokes. The age-adjusted risk of ischemic stroke is twice as high in black persons than in whites and about 1.7 times higher in Hispanics or Latinos than in whites. This may be due to both cultural and socioeconomic factors.
When it comes to geographic disparities, it's important to note that Eight states have a high stroke mortality rate and they're concentrated in the U.S. in the southeast region. This is called the stroke belt. Within the stroke belt, even higher stroke mortality occurs in the coastal plain of North Carolina, South Carolina, and Georgia. This is called the stroke buckle. The stroke belt includes more rural residents than other areas do, more black residents, more people with traditional stroke risk factors, higher levels of inflammation and infection and more residents with low socioeconomic status higher levels of inflammation and infection are emerging risk factors for stroke Two sets of mechanisms are important here.
Increased systemic inflammation alone may increase stroke risk and the inflammation then may heighten the effect of traditional stroke risk factors. A strong neurological assessment includes a significant amount of subjective data questions including questions about headache, head injury, dizziness, vertigo, seizures, tremors, weakness, In coordination, numbness, tingling, difficulty swallowing or speaking, any history of medical issues, and any environmental or occupational hazards. So we'll ask the client questions such as any unusual, frequent, or severe headaches. Do you ever feel lightheaded or have a swimming sensation like feeling faint? Have you ever had any convulsions?
Do you experience any shakes or tremors in the hands or face, etc.? When reviewing neurological signs and symptoms, we want to assess history as well as present problems. So we want to know about any current problems with dizziness, for example, but also any previous problems. In addition to this, we'll ask follow-up questions like, does this occur when you sit or stand up?
What provokes the action or the experience for the patient? Is it worse or better after you get up or sit down or after eating? Does it occur with any medications?
Often patients will experience a significant amount of dizziness with certain medications. You'll discuss this more in pharmacology. For men we want to ask, do you ever get up at night and feel faint while standing to urinate?
And then how does dizziness affect your daily activities? Are you able to drive safely and maneuver within your house safely? We also want to ask questions about memory changes and mental function. any tremors that the patient may be experiencing, and we'll discuss the difference between different types of tremors that may occur later on in the presentation. Also want to know about any sudden changes in vision or loss of visualization completely, so a fleeting blindness, and then also correlating this to other signs and symptoms like weakness, and we'll want to know about any experiences they may have had with loss of consciousness.
There are three components or steps for neurological examination. First is the screening for neurologic examination. This is something that we do for all patients. Then if there's a positive for the screening in neurologic examination, we'll conduct a complete neurological examination. So this is for persons with neurologic concerns like headache, weakness, or loss of coordination, or they're demonstrating signs of neurologic dysfunction.
Once we've established that the patient has a problem and they've had a complete neurologic examination, we then may be tasked with doing neurologic recheck examinations. These are for persons with demonstrated neurologic deficits who require periodic assessments. An example of this may be a client who's had a stroke and we need to continually check on any residuals they may have as a result of this stroke. So we're trying to determine are they getting better or worse?
or is their condition unchanged when we look at part of the neurological examination it will include things like mental alertness and mental status checking of the cranial nerves motor function sensation and reflexes neurological examination should be something that's integrated throughout the entire head to toe assessment so as you move from head to toe you're literally going to be assessing neurologic function as you go so you'll for example test cranial nerves while assessing the head and neck and you'll test superficial and abdominal reflexes while assessing the abdomen we're going to record all neurologic data together as one functional unit though and it's important for us to know the specific steps or sequence that will follow for a complete neurological examination this is something that you're going to want to have memorized First, we assess mental status, then cranial nerves, the motor system, the sensory system, and then reflexes. A complete neurological exam includes all five components in that specific order. Equipment for our objective data collection for a neurological assessment may include items such as a pen light, a tongue blade, cotton swab, cotton ball, possibly a tuning fork, and a percussion hammer.
After assessing mental status, we'll move on to the assessment of cranial nerves. You will need to know all 12 cranial nerves, starting with cranial nerve 1, which is the olfactory nerve. Now this is not routinely tested.
Because we're testing sense of smell, we do that in those who report loss of a sense of smell, have had a head trauma, any abnormal mental status, or the presence of intracranial lesion is suspected. With the person's eyes closed, you're going to occlude one nostril and present a familiar aromatic substance. Please make sure that you select something that is pleasant, smelling for the client to review, and that's something that is going to cause disgust or discomfort. So we typically pick substances like coffee, orange, vanilla, soap, or peppermint.
Normally, the person can identify an odor on each side of the nose. Normally, this can be decreased with aging as we've previously discussed. So a diminished sense of smell may be an expected age-related change.
Asymmetry in sense of smell is important to note. Now there may be a number of reasons why a client may have diminished sense of smell, such as occlusion, right? We've all had a stuffed up nose and had difficulty tasting or smelling as a result of that.
COVID-19 presented loss of smell as a potential symptom. So there could be an explanation for why the client has a diminished sense of smell, but it's still important to us for us to note and to recognize the correct terminology for abnormal functioning, which would be anosmia, a loss of sense of smell. Additional testing of cranial nerves includes our ocular motor function.
So with cranial nerve 2, we're assessing the optic nerve. This tests visual acuity and visual fields by confrontation. You'll use an ophthalmoscope to examine the ocular fundus and to determine color, size, and shape of the optic disc. With our additional cranial nerves associated with ocular function, we'll look at the ocular motor, trochlear, and abducens nerves.
Palpebral fissures usually are equal in width. We'll check the pupil size for regularity, equality, direct and consensual light reaction, and accommodation. So you may have read this as perla, which we'll get into when we start discussing assessment of the eyes.
But the pupils should be equal, round, and reactive to light and accommodation we're also assessed for extra ocular movements by cardinal position changes of gaze so this is when you ask the patient to follow your pen light you don't necessarily have the pen light on but you're having them follow an object movement in those cardinal positions of gaze or cardinal points of gaze there are six positions that we Now, we may see some abnormalities as a result of this movement. So we're checking for extraocular movements, and if those occur, that would be considered an abnormality. An example of this is nystagmus, which is the back-and-forth oscillation of the eyes. When assessing for nystagmus, there are a few things that we need to note.
Is the presence of nystagmus in one or both eyes? Is it moving equally from left to right, or is it a jerk? What is the amplitude, the frequency, and the plane of movement? Which direction is the eye oscillating? Cranial nerve 5 is the trigeminal nerve.
This tests motor function, and specifically the muscles of mastication, or the ability to chew or clench. so we have to palpate the temporal and masseter muscles as the person clenches their teeth the muscles should feel equally strong on both sides we should try to separate the jaw by pushing down on the chin and normally you cannot so testing against resistance as far as sensory function is concerned with the person's eyes closed we'll test light touch sensation by touching a cotton wisp to designated areas on the person's face forehead cheeks and chins this tests all three divisions of cranial nerve 5, ophthalmic, maxillary, and mandibular. We will also use the cotton wisp to assess corneal reflex. Now we want to differentiate this from corneal light reflex, which is tested in a different way.
We can omit this test unless the person has abnormal facial sensation or abnormalities of the facial movements. We won't necessarily be testing this routinely. we want the patient to remove their contact lenses and we want to bring the cotton cotton wisp toward the eye from the side so that we can try to minimize defense defensive blinking people can be very sensitive with their eyes and maybe a little bit fearful of being touched on the eye all right we're going to use the cotton wisp to lightly touch the cornea now normally the person will blink bilaterally so the reflex should occur on both sides corneal reflex may be decreased or absent in those who have worn contact lenses because they're actually used to touching the eye all right so they've been desensitized to this um this we can test sensory afferent and cranial nerve 5 and motor afferent and cranial nerve 7. Assessment of the facial nerve can be quickly and routinely tested in your standard head-to-toe.
This looks at mobility and facial symmetry of the face. So this is when you ask the patient to smile, frown, close their eyes tightly against your attempt to open them, lift up the eyebrows, show their teeth, puff out their cheeks. And we want to see that things are occurring equally on both sides, that symmetry is present, and that when they push the air out, that air is escaping equally from both sides.
Now, we test the motor function routinely. We don't necessarily test sensory function routinely. So we'll test sensory function only when you suspect a facial nerve injury in the client. So when indicated, test the sense of taste by applying the cotton applicator covered with a solution of sugar, salt, or lemon juice to the tongue and ask the person to identify taste.
But again, taste is not something that is routinely tested. only if abnormalities are suspected. The acoustic nerve, or the vestibulocochlear nerve, tests hearing acuity, typically by using a whispered voice test.
This is a common, quick, easy test to assess hearing. We'll learn more about the whispered voice test in topic seven. But you can just assess hearing based on conversational experiences with the patient. So are they able to hear and understand as you articulate teaching and words to them?
We will also routinely assess motor function in the glossopharyngeal and vagus nerves. So we'll depress the tongue with a tongue blade and note pharyngeal movement as the person says ah or yawns. We should be able to visualize the uvula and the soft palate should rise in the midline and tonsillar pillars should move medially.
We don't always assess gag reflex in the patient, but we can do this by touching posterior pharyngeal, and that will induce a gag in the patient, and the voice should sound smooth and not strained. Now, sensory function, glossopharyngeal does mediate taste on the posterior third of the tongue, but this is too difficult for us to test. Assessment of the spinal accessory nerve involves an examination of the sternomastoid and trapezius muscles for equal size. We'll also check for equal strength by asking the person to rotate their head against resistance applied on the side of the chin.
So as you can see in the picture, the patient is turning his head against resistance from the nurse. We're going to also ask the patient to shrug shoulders against resistance as well. These movements should feel equally strong on both sides of the body. If they're not equally strong, this can indicate an abnormality.
For the hypoglossal nerve, we'll inspect the tongue. No wasting or tremors should be present. We'll note the forward thrust in the midline as the person protrudes or sticks out their tongue.
We'll ask the person to say phrases like light, tight, and dynamite, and note lingual speech. We should hear the sounds of the letters L, T, D, and N, and that they are clear, distinct please note for all 12 cranial nerves that you will need to know their Roman numeral their cranial nerve name the type of cranial nerve and their function so is for example cranial nerve one is the olfactory nerve this is a sensory nerve and its function is sense of smell right so some of our nerves are sensory some of them are motor specific and some are mixed it will be important for you to know all of them mixed refers to a nerve carrying a combination of motor and sensory or motor and parasympathetic or motor and sensory and parasympathetic functions here's a fun infograph for your review there's also a video that's posted in the discussion that points to how to draw the cranial nerve face so you can work through this step by step. But this helps you to create a visual representation of the location of the cranial nerves and their corresponding number.
Please use this link to review a complete cranial nerve examination. When it comes to health assessment, an assessment of normals and abnormals is essential. So recognizing abnormalities in cranial nerves is important for us to note.
We will need to know what proper functioning looks like and what a potential problem. may indicate a potential problem. So for example, in cranial nerve 1, the olfactory nerve, anosmia would be a decrease or loss of smell bilaterally.
So this may be occurring on both sides. Humanosmia is a visual defect that affects half of the visual field. So this would be an abnormality that's found with cranial nerve 2. It's really important that we know the correct terminology for our normals.
and are abnormal so please review these carefully for each of the cranial nerves abnormalities in cranial nerve 3 for ocular motor function can include things like a dilated pupils ptosis where the eye turns out and slightly down a failure for the eye to move up in or down or an absent light reflex right the when you shine a light into the client's eyes the pupils should constrict right bilaterally For the trochlear nerve, there may be a failure to turn the eye down or out. And with a trigeminal nerve, there may be absent touch and pain or paresthesias, no blinking, or a weakness of the masseter or temporalis muscles. For the abducens, there may be a failure to move laterally.
For the facial nerve, maybe absent or asymmetric facial movement. So the patient may smile and only one side of their face actually moves. or there may be a loss of taste for the acoustic nerve there may be a decrease of loss or hearing or loss of hearing and for glossopharyngeal nerve there may be an absence of gag reflex for the vagus nerve we may see that the uvula deviates to the side gag reflex is not present or the voice quality of the client is hoarse or brassy or has a nasal twang or is husky dysphagia may occur which means that the patient can't swallow appropriately and so they may regurgitate fluids through the nose or aspirate we also may see with the spinal accessory nerve that absent movement of the sternomastoid or trapezius muscles can occur and with a hypoglossal nerve it may maybe the tongue deviates to the side or there's a slowed rate of tongue movement As part of a head to toe assessment, we need to look at the motor system and sensory testing that may occur.
So inspecting and palpating the muscles is something that we'll do consistently throughout our head to toe assessments. Now muscle inspection strength and tone will be discussed further in an upcoming topic in our final unit, but we do want to always compare the right side with the left. Strength and size should be equal or symmetrical or fairly close to it, right? If we see something that's asymmetric, it can indicate an abnormality. So strength should be equal on both sides, size should be equal on both sides.
Now, sometimes it's difficult to assess muscle mass in very obese clients, but we still need to review muscle testing. We'll also look at strength. So we'll test muscle groups for extremities and in the neck and the trunk.
We'll look at tone. and we'll note any involuntary of movements that are occurring when assessing for the intactness of cerebellar function we can conduct a balance test or a romberg test a balance test is probably something that you've done if you've ever had a sports physical or routine physical that really was detailed um but what we're looking at is gait so observing the person walking 10 to 20 feet turning and then returning back to their starting point we should see an opposing arm swing that is coordinated well the patient should be able to walk in a straight line in a heel-to-toe fashion and they should also be able to walk on their toes or heels for a few steps now obviously we won't be able to assess gait in this manner on every single patient right patients may not have the ability to walk or they may have impaired morbidity so with especially with our older adult clients we want to be careful when conducting this assessment and ensuring that we're promoting safe activity independence for our clients so it may not be appropriate for us to ask them to walk heel to toe or on their toes or heels for a few steps because they may have decreased cerebellar function and an increased risk of falls in contrast to the balance test where we have clients walking the wrongberg test is where we have clients standing still we have them stand up with their feet together and their arms at their sides When we get them into a stable position, we want the client to close their eyes and hold the position for 20 seconds. Now, the patient shouldn't sway or move while we're conducting this activity. But we want to, if we suspect that there may be a potential issue or if the patient is a little bit more fragile, we want to make sure that we're ensuring their safety by staying nearby.
Now, we want the client to keep their feet together because separating their feet will give them a wider base and will increase their ability to balance we also may ask the client while we're conducting this test if they can do a shallow knee bend or hop in place on one leg and then the other now some individuals can't hop because of aging or obesity so we want to be careful when we ask for these components of the assessment we also need to look at coordination and skilled movements in particular we'll assess for rapid alternating movement we can use a pat knee test finger to finger test finger to nose or heel to shin test now we will see changes with aging in the speed and coordination associated with these movements but we should be able to see a rhythmic pattern that can increase in speed as the client progresses normal functioning should be smooth and coordinated and we should see accuracy with the finger to nose test or the finger to finger test or heel to shin right We want to make sure that things are moving in the correct direction and that there's not any mishaps or one side isn't moving faster than the other. So once again, we're looking at those side by side comparisons. Now, we may see abnormalities in muscle tone, such as flaccidity, spasticity, rigidity, or a cogwheel rigidity that's common in Parkinson's disease.
So when we see loss of muscle tone and function, This can correlate to nerve function that is abnormal or absent. Abnormalities in muscle movement can occur for a number of reasons. In paralysis, we have a complete loss of muscle movement or motor function in that particular area where the paralysis is occurring. With tics, we have involuntary movements that may increase with stress. With a seizure disorder, we may see uncontrolled muscle movements throughout the entire body that are brought on by disease processes such as epilepsy or an elevated body temperature.
And then we also may see tremors. You'll want to differentiate between a resting tremor and an intention tremor. There are a couple of videos here that you can review, but what you want to take note of is that a resting tremor just like in the name occurs at rest and intention tremors occur with activity so a client may be just sitting and their hand may shake for example they may have a resting tremor resting tremors can occur with things such as substance abuse like alcohol abuse and intention tremors are associated with an activity so you may know somebody who when they go to write their handwriting gets a little bit shaky but otherwise their hand doesn't shake or when they try to brush their teeth or use a fork or feed themselves they may have a little bit of a shake to their hands those are intention tremors make sure you can differentiate between the two and that you also know your terminology so for example chorea is an abnormal involuntary movement disorder and athetosis is a slow involuntary movement of the fingers hands and toes Your book actually has some really great outlines for each of these movements that would be beneficial for you to review. Abnormalities and gaits can really be a hallmark of a neurologic disorder.
So we may be seeing things like Parkinsonian, festinating, which there's a nice video for, scissor walking, steppage or foot drop, waddling, a short leg. Your textbook actually has some excellent images and descriptions for each of these gate abnormalities. So these images and this table actually presented is found directly in your text and really has a good detailed description of the characteristic appearance of each abnormal gate that may occur. so for example with the parkinsonian fascinating there's a video associated with this but we'll see this stooped posturing the trunk is pitched forward the elbows and hips and knees are flexed and the steps are short and they're sort of a shuffling gait for the client there may be hesitation to begin walking and it may be difficult for the client to stop suddenly the person may hold their body rigidly and they walk and turn the body as one fixed unit it makes it difficult to change direction so please make sure that you review each of these gait abnormalities you can also practice walking that way yourself in the privacy of your own home and looking at the different ways that these may present in the client as well as what the potential causes may be you'll also want to familiarize yourself with patterns of motor system dysfunction.
So there are a number of conditions that can cause motor system dysfunction such as parkinsonism, there can be cerebellar dysfunction, paraplegia, multiple sclerosis is common. And so looking at these and reviewing the different types of presentation that may occur as a result of these motor system dysfunctions will be important for you to remember. The textbook also has some excellent pictures for posturing. Abnormal posturing occurs when a patient is unresponsive or has an altered level of consciousness and we'll see various positioning such as decorticate rigidity and decerebrate rigidity. So there may be upper extremities where the flexion of the arms and wrists and fingers are tight up against the body.
or they may be stiff and extended in decerebrate rigidity and pushed away from the body. So decorticate, I kind of think of it as like a protective positioning, and decerebrate is when there's no protection occurring. Now, it is important to remember that these are abnormal postures that should not be occurring in the client and typically occur when the patient has had or experienced trauma or paralysis.
So these can indicate... a deficit in neurologic function. Now, we've discussed the assessment of motor function, but we also need to assess the sensory system. And this identifies various sensory stimuli in order to test intactness of the peripheral nerve fibers, sensory tracts, and higher cortical discrimination.
So we have some routine screening procedures that we'll do on clients. We'll test for superficial pain. light touch and vibration in a few distal locations.
We'll also do complete testing of the sensory system when those neurologic systems or neurologic deficits are noted. We may see areas with localized pain, numbness and tingling, or if you discover any abnormalities, you'll want to do complete testing. When we're doing testing, we're going to compare sensations on symmetric parts of the body.
Once again, we're comparing one side of the body with the other. If we see decreased sensation, we need to map it by systemic testing of that area. So we're actually feeling around the area and creating a border where the decreased sensation is occurring so we can see to what extent it occurs on the body.
We're going to proceed from the point of decreased sensation toward the sensitive area and ask the person to tell where a sensation changes. Then you can map the exact borders of the deficit area and draw the results on a diagram. Now when we conduct these tests, it's important that the person's eyes are closed so they're unaware if they're being touched if the sensation is completely diminished in the area. We also will explain what's happening and exactly how the person should respond.
so when we're touching the area we're explaining to them before we touch them and explaining what response we want to get as we touch them when assessing the spinothalamic tract we may use something like pain like the person's ability to perceive a pin prick temperature we can test temperature sensation only when pain sensation is abnormal so if the client's not feeling pain we need to evaluate whether or not they can assess differentiation in temperature right Also, we'll assess light touch and we'll touch specific areas on the body using a light wisp of cotton. And then we'll continually be comparing the symmetrical points on the body. So if we're feeling the arms, we're assessing both arms at the same time, both legs at the same time, both sides of the chest, both hands, right?
Additionally, when assessing the posterior column tract, we may use vibration to test the patient's ability to feel vibration from a tuning fork. over bony prominences. And again, we'll be comparing both sides.
We also may assess position or kinesthesia, testing the person's ability to perceive passive movements of the extremity. And we'll use tactile discrimination or fine touch tests to determine discrimination or the ability of sensory cortex. So things that we may be looking at are two-point discrimination to test the ability to distinguish between separation of two simultaneous pinpoints on the skin so they can they tell exactly where the sensation is occurring and looking at point location so touching the skin and withdraw the stimulus promptly and then ask the patient to indicate where they were touched now common patterns of abnormality that may occur are things like peripheral neuropathy which can occur with a number of disease processes including diabetes mellitus and this is a loss of sensation that involves all modalities but the loss is most severe distally at the feet and the hands i've actually seen patients have complete loss of sensation to their toes as a result of uncontrolled diabetes so much so that they had injury that did not heal and ended up requiring amputation we also may see that individual nerves or roots may become damaged and cause a loss of sensory modalities so This means that the area that is impacted by the nerve loses sensation. And then we may see spinal cord hemissection, which is a loss of pain, temperature on the contralateral side, or loss of vibration and position discrimination on the ipsilateral side.
Once again, your textbook has a great table for resource and images related to the type of sensory loss. the characteristics and the possible causes so this first one peripheral neuropathy is the loss of all sensation that affects the nerves at the same length but spares the face so it affects the longest nerves first the feet then the fingertips right as sensory testing moves more proximally anesthesia zone at the toes and fingertips merges into hypostasia and then gradually becomes healthy so sensation may increase as we move more proximally toward the patient's core. These can be long-term complications of diabetes as a cause because there's problems with damage to the membrane of the capillaries.
But this can also occur with chemotherapy or chronic alcoholism. Please make sure that you review this table and the abnormalities and sensory loss that are outlined. Additional abnormalities that may be commonly seen are a complete transection of the spinal cord. So we have complete loss of sensory modalities below the level of the lesion. So you may have somebody who becomes paraplegic or quadriplegic depending on the location of the damage to the spinal cord.
thalamus the loss of all sensory modalities on the face arm and leg and the cortex loss of discrimination on the contralateral side and so there may be loss of recognition of shapes and weights and finger finding once again these abnormalities are clearly outlined with visualization and characteristics and causes in the table Assessment of deep tendon reflexes is an important part of a neurological assessment. This measurement of stretch reflexes reveals the intactness of the reflex arc at specific spinal levels and normal override on the reflex of higher cortical levels. So when we're assessing deep tendon reflexes, we're testing the intactness of the spinal column.
So the limbs should be relaxed and the muscles should be partially stretched. We want to stimulate the reflex by directing a short snappy blow of a reflex hammer onto the muscle's insertion tendon. Now the typical tool for this is a reflex hammer, although you can use the blade of the hand and I've even seen the bell of the stethoscope used.
or the diaphragm we can compare the right and the left side responses which should be equal now the reflex reflex response is graded on a four point scale it will be important for you to review the components of this scale noting that four is very brisk and has a hyperactive response with clonus three is brisker than average and may indicate disease but is not always indicative of disease. Two is average or normal, and one is diminished or considered a low normal, particularly for older adult clients. We may see that a one is an expected outcome. Reflexes may be diminished over time with age.
And then zero is, of course, no response. Now, it's important to remember that this is a subjective scale and requires some clinical practice. Even then, the scale is not completely reliable because no standard exists to say how brisk a reflex should be to warrant a grade of 3+.
Also, a wide range of normal exists in reflex responses. Healthy people may have diminished reflexes or they may have brisk ones. Your best plan is to interpret deep tendon reflexes only within the context of the rest of the neurological examination.
So look at your client holistically. Don't just focus on one component of a neurological assessment. When testing reflexes, it's important to know when assessing a deep tendon reflex, what area of the spinal column is actually being assessed. So the bicep reflex tests C5 and C6. Tricep reflex tests C7 and C8.
Make sure you practice appropriate assessment of each of these reflexes. know the locations of how and how to appropriately conduct the assessments. We'll also look at the brachial cordalis reflex, which is C5 to C6, the quadriceps reflex, which is L2 to L4, and the Achilles reflex, which is the L5 to S2.
The quadriceps reflex is probably the one that you've most commonly seen. you will be assessing other reflexes as well. Abnormalities in deep tendon reflexes include clonus, which is a set of rapid rhythmic contractions of the same muscle.
This typically occurs with a 4 plus rating on a deep tendon reflex. And then there's hyperreflexia or hyporeflexia, which also indicates whether the client is high or low on the grading scale superficial and abdominal reflexes are tested when assessing the abdomen of the client so when the client's in a supine position with the knee slightly bent use the handle end of the reflex hammer to stroke the skin we want to move from each corner towards the midline at the upper and lower abdominal levels the normal response ipsilateral contraction of the abdominal muscles with observed deviation of the umbilicus toward the stroke not all reflexes are routinely done but we do need to know how to appropriately do the Christmas cremasteric reflex and the plantar reflex a plantar reflex we position the thigh with a slight external rotation and we use the reflex hammer to draw a light stroke up the lateral and toward and across the ball of the foot like an upside down j the normal response is planter flexion of the toes and inversion and flexion of the forefoot in the aging or older adult client we will still use the same examination as we use on younger adults but we do need to be aware that aging adults may show a slower response to your requests especially those calling for coordination of movements So some of those rapid alternating movement tests may be a little slower or sluggish. We also want to note any decrease in muscle bulk is most apparent in the hands, as seen by the guttering between the metacarpals. So grip strength should still remain relatively good, but we may see a decrease in muscle size.
Essential tremors can occasionally occur, and these are typically benign. but they include things like the intention tremor of the hands so we may see that as the client ages when they move toward an object or try to write or practice that fine motor function with the hand they may have a slight intention tremor additionally the gait may be slower and more deliberate than in a younger person and it may deviate slightly from a midline path As we age, we'll note that deep tendon reflexes are less brisk, so knee jerks may be lost, but that doesn't occur super often, but ankle jerks are very commonly lost in clients. The plantar reflex may also be absent or difficult to interpret.
Well, Klonus typically occurs with our plus four grade deep tendon reflex assessment. So when we test for Klonus, particularly when recesses reflexes are hyperactive, we support the lower leg in one hand and with your other hand you move the foot up and down a few times to relax the muscle. With a normal response you'll feel no further movement, but when clonus is present you'll feel and see rapid rhythmic contractions of the calf muscle and movement of the foot. As previously discussed, there are three different types of assessments for a neurologic assessment, right? So we do a neurologic screening on all patients.
abnormalities are indicated we do a complete neurologic testing right and then we sometimes have neurologic reflex now some are sorry neurologic rechecks some hospitalized persons may have a head trauma or neurologic deficit like a stroke or due to a systemic disease that causes us or requires us to do frequent neurologic rechecks so there could be signs of increasing intracranial pressure that are causing this but we want to use the abbreviation of neurologic examination in the following sequence. So whenever we have a sequence of events or activities, we want to have those memorized. And our sequence of activities for the neurologic recheck is to check level of consciousness, then motor function, then pupillary response, then vital signs.
Level of consciousness includes assessing for orientation or using the Glasgow Coma Scale. We'll also look at the fact that a change in level of consciousness is the single most important factor in this examination. So if we see that a patient has a sudden onset of confusion, that should be a key indication that there is a neurologic issue.
Now, it can be due to other factors, but we want to rule out any neurologic problems. We'll look at motor functions, so we'll check voluntary responses or give simple commands. We'll check pupillary response and we'll note the size and symmetry of both pupils by shining light into the pupils.
We'll check vital signs and monitor them routinely and then we'll use a Glasgow Coma Scale. This is an accurate and reliable tool that allows us to assess neurologic function. now we've already stated that a change in level of consciousness is the single most important factor in the examination it is the earliest and most sensitive index of change in neurologic status but a change in consciousness may be subtle so we need to note any decreasing level of consciousness disorientation memory loss uncooperative behavior or even complacency in a com in a previously combative person right we also need to note the ease of arousal and the state of awareness or orientation in the patient. We have to assess orientation by asking questions about person, place, and time or situation. The Glasgow Coma Scale is divided into three separate areas.
First, we test for eye opening response, motor response, and verbal response. Now, in an alert and oriented person, we should see spontaneous eye opening. they should be able to follow verbal commands for movement and then we should see a verbal response so when we ask questions the client should be able to appropriately answer those questions such as who they are where they are and what's going on now we can assign a number based on their eye opening response motor response and verbal response that gives us a total a normal total for a gcs or glasgow coma scale is 50. But we need to know as well what some of the other numbers may indicate. The scale with its three separate areas is rated separately.
So we'll assess eye opening, motor function, and verbal response individually. Now the three numbers are then added together and the total score reflects the functional level in the brain. Again, a fully alert healthy person has a score of 15. whereas a score of seven or less reflects a coma. Serial assessments can be plotted on a graph to illustrate visually whether the person is stable, improving, or deteriorating.
Now, this is important if we have a patient who has experienced something like, for example, a seizure, right? We may see that they go from a GCS of 15 to a GCS of less than 7, and then they go higher than 7 but may still be confused as they come out of an epileptic state. So that's just one example of changes that we may see within a few hours of a patient.
But anytime we have a significant change in GCS, we want to document it. and it may require emergent follow-up depending on the change. Ideally, we want our clients to improve or to get back to their baseline. But the GCS assesses the functional state of the brain as a whole, not any particular site in the brain. The scale is easy to learn and master and has a good inter-rater reliability.
It's one of the best scales that's out there and is routinely used in acute care settings. And finally, just for a quick review, we want to make sure that we know the complete summary checklist for a neurological examination. We will assess mental status, cranial nerves, motor function, sensory function, and then reflexes.
We follow this trajectory in order. Mental status, cranial nerves, motor function, sensory function, and reflexes. Thank you for participating in the voiceover today. please continue to reach out to your instructor if you have any questions and please make sure that you're reviewing the objectives and reviewing the exam blueprints that are found on the Clon HCP page as a reference and a guide in preparation for your exam.