Sherpath- Findings for the Neurologic System

Normal Assessment Findings: Moro Reflex...

Symmetric abduction and extension of arms; fingers fan out, thumb and index finger form a C; arms then adduct in embracing motion followed by relaxed flexion; legs follow similar pattern of response (present at birth; diminishes by 3-4 months; disappears by 6 months)

Abnormal Neurologic Examination Findings: Cranial Nerves...CN I:

Inability to discriminate odor

Normal Findings-Neurologic Variations in Infants: Indirect Cranial Nerve Evaluation...CN VII:

-Ability to wrinkle the forehead -Symmetric smile

Normal Findings-Neurologic Variations in Infants: Indirect Cranial Nerve Evaluation...CN VIII:

-Acoustic blink reflex: blinks in response to loud sound; infant may habituate to repeated testing; moves eyes in direction of sound; freezes position with high-pitched sound -Doll's eye maneuver: Infant's eyes should turn in the direction of rotation and in the opposite direction when rotation stops

Specific muscle movements are paired with the deep tendon reflexes that elicit them in the list.

-Biceps reflex: contraction of biceps muscle -> flexion of elbow -Triceps reflex: contraction of triceps muscle -> extension of elbow -Brachioradial reflex: pronation of forearm and flexion of elbow -Patellar reflex: contraction of quadriceps muscle -> extension of lower leg -Achilles reflex: contraction of gastrocnemius muscle -> plantar flexion of foot

Normal Findings-Neurologic Variations in Infants: Indirect Cranial Nerve Evaluation...CN XII:

-Coordinated sucking and swallowing ability -Mouth will open and tip of tongue should rise in a midline position when nose is pinched

Neurologic Variations in Infants: Indirect Cranial Nerve Evaluation...

-Cranial nerves are not directly assessed in infants as they are in adults. -Instead, they can be indirectly assessed through careful observation.

Normal Neurologic Examination Findings: Adult Deep Tendon Reflexes...

-Deep tendon reflexes are used to evaluate the function of specific spine segmental levels. -The nurse should assess for a specific muscle movement when a particular tendon is struck with the reflex hammer. -Deep tendon reflexes are evaluated on a scale of 0 to 4+ based on the identified level of force of the muscle movement.

Abnormal Neurologic Examination Findings: Cranial Nerves...CN IX and X:

-Deviation of uvula to side -Drooping -Hoarseness -Difficulty with guttural sounds

Abnormal Neurologic Examination Findings: Cranial Nerves...CN VII:

-Difficulty enunciating -Unusual facial movements, tics -Inability to close eyes -Eyelid sagging -Disappearance of skin creases -Asymmetry of features or expression

Abnormal Neurologic Examination Findings: Cranial Nerves...CN VIII:

-Difficulty hearing or asymmetry in hearing -Absence of an eye blink

Abnormal Findings in Adult Central Nervous System...

-Diseases of the central nervous system alter neurologic functions in disease-specific ways. -The nurse should assess the patient for certain abnormal findings when collecting the subjective data and objective data during the neurologic assessment.

Normal Assessments: How to test the Cranial Nerve III (Oculomotor), Cranial Nerve IV (Trochlear), and Cranial Nerve VI (Abducens)?

-Eyelids—palpebral fissures symmetric; no ptosis, no entropion, no ectropion -Pupillary Light Reflex—bilateral pupils equal, round, and reactive to light directly and consensually -Accommodation—bilateral pupils converge and constrict with accommodation -Extraocular Eye Movements—bilateral eyes move symmetrically along same plane with movement throughout the six cardinal fields of gaze; no nystagmus (tremor) noted during movements

Normal Assessments: How to test the Cranial Nerve VII (Facial Nerve)?

-Face symmetric -Patient able to discriminate between salt and sweet substances placed on sensitive tongue areas -Patient able to move face symmetrically through various facial expressions without tics or tremors (raise eyebrows, squeeze eyes shut, wrinkle forehead, frown, smile, show teeth, purse lips, puff out cheeks)

Abnormal Neurologic Examination Findings: Cranial Nerves...CN XII:

-Fasciculations -Asymmetry -Atrophy -Weak tongue thrust

Abnormal Findings in Nervous System of a Pregnant Woman...

-Intrapartum maternal lumbosacral plexopathy is a neurologic condition that can occur in late pregnancy or during delivery. -Neuropathy is caused by nerve compression between the maternal pelvic rim and the fetal head. -Below are the subjective and objective neurologic findings in a pregnant woman with intrapartum maternal lumbosacral plexopathy.

With each type of sensory stimulus, expected findings include:

-Minimal differences from side to side -Correct description of sensation -Recognition of side of body tested -Location of sensation/movement and whether proximal or distal to previous stimulus

Normal Assessments: How to test the Cranial Nerve V (Trigeminal Nerve)?

-Motor—no tremors or twitches noted in face; symmetric muscle tone palpated over bilateral jaw muscles with clenched teeth/no fasciculations noted -Sensory—patient able to discriminate between sharp, dull, and light touch sensation over face with eyes closed; corneal reflex intact when symmetric blink reflex is present in response to bilateral corneal stimulation

Abnormal Neurologic Examination Findings: Cranial Nerves...CN V:

-Muscle atrophy -Deviation of jaw -Impaired sensation

Abnormal Findings for the Infant Neurologic System: Cerebral Palsy?

-Neurologic Condition ---Cerebral Palsy: permanent disorders of movement and posture development secondary to disturbances during fetal or infant brain development -Abnormal Findings: Subjective Data ---Delays in gross motor development ---Limitation in activity ---Hearing, speech, and language disorders ---Seizures ---Poor sucking and/or swallowing difficulties -Abnormal Findings: Objective Data ---Cognitive impairment/learning disabilities ---Spastic muscles ---Persistent primitive reflexes ---Increased deep tendon reflexes ---Changes in muscle tone

Abnormal Findings for the Infant Neurologic System: Myelomeningocele (Spina Bifida)?

-Neurologic Condition ---Myelomeningocele (spina bifida): congenital vertebral defect in which spinal cord contents protrude -Abnormal Findings: Subjective Data ---Loss of bowel or bladder control ---Mobility problems -Abnormal Findings: Objective Data ---Exposed meningeal sac ---Paralysis or weakness ---Hydrocephalus ---Learning disabilities

Abnormal Findings for the Infant Neurologic System: Shaken Baby Syndrome?

-Neurologic Condition ---Shaken baby syndrome: severe form of child abuse: violent shaking of infants younger than 1 year -Abnormal Findings: Subjective Data ---Irritability ---Lethargy ---Seizure with or without loss of consciousness ---Decreased eating/nursing -Abnormal Findings: Objective Data ---Retinal hemorrhages ---Fingerprint bruises

Abnormal Findings for the Infant Neurologic System...

-Neurologic conditions that may affect infants and children include cerebral palsy, spina bifida, and shaken baby syndrome. -The nurse should know what to expect to find in these conditions when collecting subjective data from the parents and while performing the objective neurologic assessment.

Normal Findings-Neurologic Variations in Infants: Indirect Cranial Nerve Evaluation...CNs II, III, IV, and VI:

-Optical blink reflex: quick closure of the eyes and dorsal flexion of the infant's head -Intense gaze at close object or face -Focus with both eyes -Doll's eye maneuver: Infant's eyes should turn in the direction of rotation and in the opposite direction when rotation stops

Normal Assessments: How to test the Cranial Nerve XI (Spinal Accessory Nerve)?

-Positive range of motion of sternocleidomastoid and trapezius muscles bilaterally -Equal strength of sternocleidomastoid and trapezius muscles against resistance bilaterally

Neurologic Variations in Infants: Primitive Reflexes...

-Posture and movement of the developing infant are evaluated by the primitive reflexes. -Primitive reflexes are normal infant variations. -They appear and disappear during the development of the central nervous system. -The nurse evaluates these movements for symmetry and smoothness.

Assessing Gait...

-Regular walking: expect continuous sequencing of stance and swing, step after step; gait should have smooth, regular rhythm and symmetric stride length; trunk posture should sway with gait phase, and arm swing should be smooth and symmetric. -Heel-to-toe walking (tandem gait): expect consistent contact between heel and toe with the possibility of slight swaying.

Normal Findings-Neurologic Variations in Infants: Indirect Cranial Nerve Evaluation...CN V:

-Rooting reflex: infant should open the mouth and turn the head in the direction of stimulation; if the infant has been fed recently, minimal or no response is expected -Sucking reflex: tongue should push up against finger with good strength

Neurologic Variations in Older Adults...The neurologic examination of an older adult is identical to an adult examination. However, some neurologic variations are expected:

-Slowed reaction time, tremors, and anxiety may result from certain medications -Diminished sense of smell, taste, and hearing (mid- to high-frequency) -Diminished sense of sight (decrease in color discrimination, reduced upward gaze, delayed adjustment to changes in lighting) -Decreased corneal reflex -Reduced gag reflex -Gait becomes shorter (shorter steps and less lifting of feet) -> shuffling; arms more flexed, legs flexed at hips and knees -Decreased tactile and vibratory sensations -Deep tendon reflexes are less brisk to absent (first lower extremities, then upper) -Superficial reflexes may disappear

Abnormal Findings in Nervous System of a Pregnant Woman: Subjective & Objective Data?

-Subjective neurologic data: intermittent, radiating pain from buttock into leg -Objective neurologic findings: unilateral foot drop

Normal Neurologic Examination Findings: Adult Superficial Reflexes...

-Superficial reflexes are used to evaluate the function of specific segmental levels. -Plantar Reflex: When the plantar reflex is elicited, the nurse should expect plantar flexion of the toes. -Abdominal Reflex (upper abdominal and lower abdominal): When the abdominal reflex is elicited, the nurse should expect slight movement of umbilicus toward each area of stimulation to be bilaterally equal. -Cremasteric Reflex (male only): When the cremasteric reflex is elicited, the nurse should expect the testicle and scrotum to rise on the side of the thigh being stroked.

These expected neurologic findings include:

-Symmetric and smooth movements with spontaneous activities -Purposeful reaching and grasping for objects without tremors or overshooting (begins at 2 months and progresses) -Patellar tendon reflex present at birth; Achilles and brachioradial tendon reflexes appear at 6 months -Coordinated sucking and swallowing -Plantar reflex: Positive Babinski reflex expected until age 16 to 24 months (fanning of toes and dorsiflexion of big toe) -Hands held in fists for first 3 months (then begin to open for longer periods) -Withdrawal of all limbs from painful stimulus

Normal Neurologic Examination Findings: Cerebellar Function...

-The cerebellum is responsible for equilibrium and gait. -Equilibrium is evaluated with the Romberg test, and gait is evaluated by observation of the patient walking.

Neurologic Variations in Infants...

-The nervous system of an infant is immature at the time of birth and further develops during the first year of life. -Neurologic variations are expected, but certain findings should be observed in a healthy infant's nervous system.

What does proprioception test do?

-They evaluate the unconscious perception of movement and spatial orientation arising from stimuli within the body itself. -These stimuli are detected by nerves within the body.

Normal Assessments: How to test the Cranial Nerve XII (Hypoglossal Nerve)?

-Tongue thrust is midline, symmetric, and forceful without fasciculations -Tongue strong against resistance bilaterally -Tongue moves side to side without difficulty or tremors

Normal Assessments: How to test the Cranial Nerve IX (Glossopharyngeal Nerve)? Cranial Nerve X (Vagus Nerve)?

-Uvula and soft palate move midline and symmetrically with phonation -Positive (+) gag reflex

Normal Assessments: How to test the Cranial Nerve II (Optic Nerve)?

-Visual acuity test—patient able to read letters at 20 feet away from Snellen chart -Confrontation test—patient's peripheral vision corresponds to examiner's peripheral vision -Ophthalmologic examination— ---Positive (+) red reflex (white light from scope bounces off retina with red color) ---Retinal arteries and veins present ---Optic disc—margins well defined; color yellow to creamy pink; 1.5 mm diameter ---Macula—fovea centralis located 2 disc diameters temporal to optic disc; no blood vessels enter fovea; appears as lighter dot surrounded by avascular area

Normal Assessments: How to test the Cranial Nerve VIII (Acoustic Nerve)?

-Whisper test—patient able to correctly repeat at least 50% of words whispered in each ear -Weber test—sound from tuning fork heard equally in both ears -Rinne test—air conduction of sound > bone conduction of sound bilaterally

Normal expectations of children's neurologic examinations include:

-Wide-based gait of beginner walker with some wobbling -In older children, walking with feet closer together and better balance -No tremors, no overshooting with reaching, grasping, or releasing toys -Increasing ability to walk heel-to-toe, hop, and jump in childhood ---All neurologic examinations performed on adults can be performed on children, with similar findings expected.

Normal Findings of Cerebellar Function: Romberg Test Assessing Equilibrium...

-With arms straight at sides of body: expect balance to be maintained with the possibility of slight swaying. -With feet slightly apart and examiner pushing on shoulders: expect recovery of balance quickly. -With arms straight at sides of body and standing on one foot: expect slight swaying along with ability to maintain balance for 5 seconds on each foot. -With eyes open and hopping on one foot: expect ability to hop on each foot for 5 seconds without loss of balance.

Deep tendon reflex responses are scored as shown in the table.

0 No response 1+ Sluggish or diminished 2+ Active or expected response 3+ More brisk than expected, slightly hyperactive 4+ Brisk, hyperactive, with intermittent or transient clonus

Normal Findings-Neurologic Variations in Infants: Indirect Cranial Nerve Evaluation...CN IX and X:

Ability to swallow; active gag reflex

Abnormal Neurologic Examination Findings: Cranial Nerves...CNs II, III, IV, and VI:

Absence of lateral gaze

Proprioception Test: Rapid Alternating Movement Tests...

Accuracy of movements with finger-to-nose test (eyes open and eyes closed): expect movements to be rapid, smooth, and accurate; no tremors, tics, or fasciculations.

Proprioception Test: Rapid Alternating Movement Tests...

Accuracy of movements with heel-to-shin test: expect movement of heel along shin maintaining contact in straight line without deviations; no tremors, tics, or fasciculations.

Normal Assessment Findings: Stepping...

Alternate flexion and extension of legs, simulating walking (present from birth to 8 weeks; disappears before voluntary walking)

Normal Neurologic Examination Findings: Primary Sensory Functions...

Assessment of primary sensory functions includes examination of superficial touch, superficial pain, temperature, deep pressure, vibration, and position of joints.

Normal Neurologic Examination Findings: Cortical Sensory Functions...

Cortical sensory functions evaluate stereognosis, two-point discrimination, extinction phenomenon, graphesthesia, and point location.

What does the neurologic assessment entail?

It encompasses many specific procedures aimed at collecting data on the health status of the patient's CNS, PNS, and cranial nerves and reflexes.

What is Extinction Phenomenon?

Expect ability to state number of stimuli and where felt; expect similar sensations to be felt bilaterally.

What is Stereognosis?

Expect identification of object by touch and manipulation.

What is Two-Point Discrimination?

Expect identification of one point or two points touching skin.

What is Point Location?

Expect localization of stimulus.

What is Graphesthesia?

Expect recognition of figure drawn on palm.

Normal Assessment Findings: "Fencing" (asymmetric tonic neck)...

Extension of arm and leg on side to which head is turned; flexion of opposite arm and leg (appears at the age of 2-3 months; disappears at 6 months)

Normal Assessment Findings: Placing...

Flexion of the hips and knees and lifting of foot as if stepping up onto surface (appears at 4 days of age; disappearance varies)

Normal Assessment Findings: Rooting Reflex...

Moves head and opens mouth to external mouth stimulation when hungry (birth to 3-4 months)

Proprioception Test: Rapid Alternating Movement Tests...

Rapid rhythmic alternating movements with hand-patting maneuver/palm up then palm down: expect smooth movements with maintenance of rhythm and increasing speed; no tremors, tics, or fasciculations.

How to test the Cranial Nerve I (Olfactory Nerve)?

Sniff test—patient able to perceive odor in each nostril equally and identify it

Normal Assessment Findings: Palmar Grasp...

Strong grasp of finger (birth to 2 months; disappears at 3 months)

CNS-Abnormal Findings of Meningitis: Subjective & Objective Data?

Subjective: -Headache or stiff neck -Lethargy and/or malaise -Irritability Objective: -Altered mental status, confusion -Nuchal rigidity -Altered level of consciousness

PNS-Abnormal Findings of Guillain-Barre Syndrome: Subjective & Objective Data?

Subjective: -Progressive weakness -Difficulty walking -Paresthesia -Muscle pain -Drooling Objective: -Hypoactive deep tendon reflexes -Ataxia -Diplopia -Dysphagia -Respiratory distress

PNS-Abnormal Findings of Bell Palsy: Subjective & Objective Data?

Subjective: -Rapidly progressive muscle weakness (unilateral) -Facial numbness Objective: -Eyelid unable to close -Sagging of lower eyelid -Disappearance of facial creases and nasolabial fold -Ptosis

CNS-Abnormal Findings of Stroke: Subjective & Objective Data?

Subjective: -Sudden numbness or weakness -Sudden confusion or trouble with speech -Ataxia -Intense headache Objective: -Altered level of consciousness -Weakness -Paralysis of face/extremities -Drooling -Aphasia

PNS-Abnormal Findings of Parkinson Disease: Subjective & Objective Data?

Subjective: -Tremors -Slowing of voluntary movements -Numbness, tingling, or soreness Objective: -Ataxia -Shuffling gait -Dysphagia -Slurred speech -Impaired cognition

CNS-Abnormal Findings of Multiple Sclerosis: Subjective & Objective Data?

Subjective: -Urinary problems (frequency, hesitancy, urgency) -Sexual dysfunction -Blurry, double, or loss of vision Objective: -Muscle weakness -Ataxia -Hyperactive deep tendon reflexes -Paresthesia -Cognitive changes

Normal Neurologic Examination Findings: Cranial Nerves I, II, III, IV, and VI

The 12 cranial nerves are assessed to evaluate the sensory and motor function of the head, face, and neck.

Neurologic Variations in Children...

The neurologic examination of young children is conducted through an observation of neuromuscular developmental progress and skills, often through play.