Transcript The_Neuro_Examx 560.1 KB

Jackie Zolotsky Bridges, RN, MSN, CRNP, CSN
Parkland School District
Certified School Nurse
Voices of School Health Conference
August 16 & 17, 2016
Describe the purpose of a focused neurological
exam in the school setting
 Decide what components of the student’s history
are necessary in a neurological exam
 How to evaluate the student’s Mental Status
 How to assess the function of the student’s Cranial
Nerves
 How to assess the student’s Motor Function
 How to assess the student’s Sensory Function,
Reflexes, Gait & Coordination
 How to reach a conclusion about the student’s
overall status based on the neurological exam
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“A systematic examination of the
nervous system, including an
assessment of mental status, of the
function of each of the cranial
nerves, of sensory and
neuromuscular function, of the
reflexes, and of proprioception and
other cerebellar functions.” (Mosby)
It surveys the functioning of nerves
delivering sensory information to
the brain and carrying motor
commands (peripheral nervous
system) and impulses back to the
brain for processing and
coordinating (central nervous
system).
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1. MENTAL STATUS: assessing normal
orientation to person, place and time, space,
and speech
2. CRANIAL NERVES (12): Checking the eyes
with an ophthalmoscope and also assessing
facial muscles strength and functioning
3. MOTOR FUNCTION: checking for tone,
drift, and heel and toe walking
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4. SENSORY FUNCTION: cold and vibration
testing
5. DEEP TENDON REFLEXES: using a reflex
hammer (or other instrument) on an area
above a nerve to emit a reflex (usually
movement of muscle groups)
6. COORDINATION AND GAIT: finger to nose
testing and observing the patient walk
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After an injury, particularly a head injury – the
neurological exam can provide clues to possible
neurological dysfunction.
Depending on what part of the neurological exam is
abnormal – it can help the CSN determine whether or
not the injury is life threatening, urgent – or can be
evaluated after school.
The CSN is the first medical professional to evaluate
the injured student. The more information the CSN
can obtain in her evaluation, the better informed
decision she can make as to the type of care the
student requires.
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Good old vital signs are imperative in a
neurological evaluation.
Should be done every 15 minutes for a
conscious student – every 5 minutes for an
unconscious student.
Gives the CSN an initial observation into the
severity of the situation.
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Intracranial pressure (ICP) can result from head trauma.
ICP produces a specific set of changes known as Cushing's
triad. Cushing's triad consists of: increasing systolic blood
pressure with a widening pulse pressure, decreased pulse
and decreased respirations.
Cushing's triad is a late sign of increased ICP. Once this
pattern of vital signs occurs, brain stem herniation is
already in progress and it may be too late to reverse it.
To detect increasing ICP before it reaches this point, the
CSN should look for subtle changes in blood pressure,
respirations, change in level of consciousness or
uneven/unreactive pupils.
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Headache
Nausea
Vomiting
Lethargy
Diplopia
Blurred Vision
Memory Problems
Declining cognitive functioning
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It is important to get as much information from
the student as possible.
They history should be detailed and
chronological . It should contain information
pertaining to events that occurred prior to,
during and after the injury that occurred.
While taking the history – note the behavior of
the student. Are they thinking, acting and
speaking appropriately?. Are they coherent?
Does the information they give make sense? If
the answer is “NO” to any of these questions –
you will need to perform a more detailed mental
status exam.
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The student’s mental status and level of
consciousness provide critical information about
their neurological functioning.
The Mini Mental Status exam is a quick and
reliable screening tool to evaluate the student’s
mental status.
The Glasgow Coma Scale is also used in many
medical settings as part of the routine Neuro
Exam – not truly necessary in the school setting.
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A set of 12 nerves that relay messages
between the brain and the head and neck and
control motor and sensory functions,
including vision, smell, and movement of the
tongue and vocal cords.
An abnormality found during Cranial Nerve
testing can give helpful information in
determining where the dysfunction is in the
brain.
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Cranial Nerve I - Olfactory (sensory)–smell
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Cranial Nerve II - Optic (sensory)–visual acuity,
pupil size and reactivity to light, visual field
◦ TEST: Close eyes and smell (this test is usually omitted )
◦ TEST: Snellen, penlight from side of face to test pupils
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Cranial Nerve III – Oculomotor (motor) – pupil
constriction, raising eyelid and movement of eye
◦ Innervates extra ocular muscles affecting lateral/vertical
movement of eye (inferior oblique, inferior rectus,
superior rector, medial rectus) as well as top of eye
rotating away from nose
◦ TEST: Use of penlight to test EOMI in 6 cardinal
directions
◦ NOTE: A physical anisocoria (difference in pupillary size
by about 20%) may be present – can be normal.
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Cranial Nerve IV – Trochlear (motor) – movement of eye
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Cranial Nerve V – Trigeminal (motor and sensory) –
Sensation of face, chewing, corneal reflex
◦ Innervates Superior Oblique muscle for downward and inward
movement of eye, and top of eye rotating in towards nose
◦ TEST: Use of penlight to test EOMI in 6 cardinal directions
◦ Motor – innervates masseter and temporalis muscles
Have student clench their mouth, move jaw side to side,
palpate TMJ
◦ Sensory - Can student feel touch on cheek & forehead with eyes
closed.
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Cranial Nerve VI – Abducens (motor) – movement of eye
◦ Innervates lateral rectus muscle for lateral movement of eye
(looking side to side)
◦ TEST: Use of penlight to test EOMI in 6 cardinal directions
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Cranial Nerve VII – Facial (motor and sensory) – facial movements
and symmetry
◦ Innervates temporal and masseter muscles
◦ Have student smile, frown, puff cheeks, open/shut eyes, show teeth, raise
eyebrows
◦ Bell’s palsy is peripheral CN7 dysfunction
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Cranial Nerve VIII – Acoustic & Equilibrium (sensory)
◦ Carries sound impulses from cochlea to brain
◦ Whisper test
◦ Tuning fork for Weber Test
 conductive hearing deficit, the Webber will lateralize to the affected ear.
BC>AC
 sensorineural deficit, the Webber will lateralize to the normal ear AC>BC
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Cranial Nerve IX – Glossopharyngeal - (motor and sensory)
◦ Check for gag reflex
◦ Have student say “Ahhh”. Check uvula. Is it midline?
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Cranial Nerve X – Vagus (motor and sensory)
– Swallow, voice, defecation
◦ Have student swallow
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Cranial Nerve XI – Spinal Accessory (motor) -
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Cranial Nerve XII – Hypoglossal (motor)
tongue movement
◦ Have student shrug shoulders
◦ Have student turn cheek into your hand
◦ Have student move their tongue, is it midline?
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Purpose of these tests is to note any abnormality
If a test is abnormal – it denotes a possible
problem with the specific cranial nerve.
Most often, these tests will be completely normal
in the school setting.
Occasionally – you will see an “abnormality” (i.e.
- anisocoria) that is NORMAL for the student.
CN testing still helpful in determining a possible
injury or abnormality. ESPECIALLY pupillary
reaction to light and pupillary size.
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Assess motor strength bilaterally – looking for
variations from L to R– possibly indicating
dysfunction
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Observe: Major muscle groups for symmetry/atrophy
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Tests:
◦ Flex and extend arm against your hand
◦ Squeeze your fingers
◦ Lifting their leg against your hand while you exert
downward pressure on their thigh
◦ Pushing their leg down against your hand while you push
up.
◦ Plantar flexion and dorsiflexion of foot against your hand
Grade strength on the following scale
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+5 - full ROM, full strength
+4 - full ROM, less than normal strength
+3 - can raise extremity but not against resistance
+2 - can move extremity but not lift it
+1 - slight movement
0 - no movement
Other motor functioning test: Pronator Drift
-Have student stand with palms facing ceiling and
eyes closed. If hands/arms turn inward (pronation)
or start to drift down, the limb is weak (possible
nerve damage)
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Evaluates student’s ability to perceive and
identify sensations with their eyes closed.
TEST
◦ Using a variety of sensations (sharp vs. dull/soft
touch) – alternate between right and left sides of
the body – working your way from face to feet.
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Proprioception
◦ Have student close eyes, move the big toe up or down and
have student tell you which direction you are moving it in
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Stereognosis
◦ Have student close eyes and place an object in their hand
(key or money) and have them tell you what the object is
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Vibration sense
◦ Place tuning fork on finger joint or on joint of toe – have
them tell you when vibration stops.
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May also test hot vs. cold sensation
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Not routinely assessed in the school setting.
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Should be assessed if a spinal cord injury is a concern
(however, would be calling 911)
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Achilles (S1, S2)
Patellar (S3, S4)
Biceps (C5, C6)
Triceps (C7, C8)
Babinski reflex (great toe dorsiflexion and other toes
fan out)
Graded on a scale 0-4 (0 being absent, 2+ is normal,
4 hyper reflexive)
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Examining overall balance and coordination
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Testing
◦ Observe normal gait, toe, heel and tandem walking
(tandem walk >5yr)
◦ Finger, nose, finger exam
◦ Rapid alternating movement
◦ Romberg test
 Eyes open, feet together, hands at sides – no swaying
 Eyes closed, feet together, hands at sides
 If there is swaying – positive Romberg test
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Are the vital signs consistent and within normal
limits, or are they beginning to change?
Is the student’s mental status impaired? Has it
changed during the exam?
Based on observations and testing – does there
seem to be any impairment or deficit?
Have you noticed any change at all in the overall
evaluation of your student?
The neurological exam can assist in answering
these questions.
While the CSN cannot diagnose – they can come
up with differential diagnoses and determine the
severity of the situation.
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Haslam, Robert H. A. "The Nervous System." In Nelson Textbook of Pediatrics , 17th ed. Edited
by Richard E. Behrman et al. Philadelphia: Saunders, 2004.
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http://www.healthcommunities.com/brain-nerve-tests/what-is-a-neuro-exam.shtml
zz4Gbw0G7Xs
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http://www.healthofchildren.com/N-O/Neurologic-Exam.html#ix
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http://www.jems.com/articles/2008/10/brain-injury-basics-0.html
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http://www.modernmedicine.com/modern-medicine/content/neurological-assessmentrefresher
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neurologic examination. (n.d.) Mosby's Medical Dictionary, 8th edition. (2009). Retrieved
August 5 2016 from http://medical-dictionary.thefreedictionary.com/neurologic+examination
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http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/The-CompleteNeurological-Examination.aspx
Thank you!