Skills Check Off #1

Tactile Discrimination "Fine-Touch"

Inability to correctly identify objects, areas touched, number written in hand, discriminate between 2 points, or identify areas simultaneously touched maybe seen in lesions of the sensory cortex.

Cranial Nerve I

OLFACTORY Smell/ nostril checks: pt closes eyes + one nare+ sniff+ identify odor (coffee, vanilla, perfume). Repeat w/other nare.

Meningeal Irritation "Inflammation"

#1 Kernig's Sign: when you flex the clients leg at both the hip and the knee, then straighten the knee. Pain and increased resistance to extending the knee are a positive Kernig's sign, when bilateral, may suggest meningeal irritation. #2. Burdzinski's Sign: As you flex the neck, watch the hips and knees, in reaction to your maneuver. Flexion of the hips and knee's is a (+) sign and suggests meningeal irritation.

What is the Purpose of a Neurological Assessment?

#1. Key component in care of neurological patient. #2. helps detect the presence of neurological disease or acute trauma/injury and helps monitor the progression. #3. Determines the type of care you will provide and gauges the patient's response to your interventions.

5 parts in the Evaluation of Level of Consciousness (LOC)

1. Full Consciousness.....awake/ responsiveness 2. Lethargy.....drowsy/ sleepy 3. Obtunded.....less than full alertness, mentally dulled by trauma or medical condition. 4. Stupor.....arouses to painful stimuli 5. Coma.....unconscious/ not arousable

Types of Tactile Discrimination OR Fine-Touch

1. Stereogenous: place key in hand. 2. Graphesthesia: draw on hand or back. 3. 2-point discrimination: touch 2 points and then move closer until you are only touching 1 point. Normal Findings include: finger-tips at 2-5mm, forearm at 40mm, dorsal-hands at 20-30mm, back at 40mm and thighs at 70mm apart.

6 Cardinal Fields of Gaze

1.Tell patient to follow your finger/penlight- Pt does NOT move their head. 2. With Pt's head steady have them follow the movement of your pen with eyes only. 3. Hold object 6-12 inches away & move it slowly clockwise in all 6 positions. Note parallel movement & nystagmus (a fine osculating movement best seen around the Iris)

How many pairs of cranial nerves are there?

12

How to grade Eye Opening

4 spontaneous 3 to sound 2 to pain 1 never (closed)

How to grade Verbal Responses

5 oriented 4 confused conversation 3 inappropriate words 2 incomprehensive sounds 1 none

Primative Reflexes

A (+) Babinski sign is a normal finding in pediatric patients less than two years old. Dorsi flexion of great toe and fanning of other toes. In children older than 2 years old, it may be caused by lesions in the upper motor neurons. Unconscious states d/t drug and alcohol intoxication or subsequent to epileptic seizure may also cause it.

Neurological Assessment

A changing of V/S is not a reliable source of deterioration as often this findings result in irreversible brain damage.

Cranial Nerve VI (6)

ABDUCENS Six Cardinal Fields. Done with 3 & 4

Cranial Nerve VIII (8)

ACOUSTIC/ AUDITORY/ VESTIBULOCOCHLEAR Weber: hit on your palm, place vibrating fork on top of skull, & ask if sound heard equally on both sides. Rinne: checks bone conduction vs. air conduction of sound. Hit tuning fork on palm, place base of fork behind ear & have pt tell you when no longer heard. Then hold fork 1/2 inch in front of ear & have pt tell you when no longer heard. Whisper Test: See if pt can hear whispering. Balance Test: have pt stand w/feet together w/eyes open, then close eyes w/arms at sides. Wait about 20secs. if possible & watch for swaying. Romber Test (+): indicates proprioception of vesitibular dysfunction.

Oculovestibular Reflex

AKA "Ice Caloric" an M.D. will instill at least 20 mls of ice water into the patient's eye. *Is not a popular technique. Patient's with an intact brain-stem, the eye's will move laterally toward the affected ear. & Patient's will severe brain-stem injury, the "gaze" will remain at mid-line.

Glasgow Coma Scale (GCS)

Based on 3 pt. responses 1. Eye Opening.....NOT vision (4) 2. Motor Responses (check types of flexion) (6) 3. Verbal Responses (5)

Cranial Nerve VII (7)

FACIAL smile, frown, taste: Have pt smile, show teeth, puff cheeks (apply pressure), frown & raise eyebrows. Look for symmetry. Close eyes....try to open them. Touch applicator to 2/3 of tongue w/ salt, sugar (sweet), or sour (lemon) to check taste. Rinse mouth between substances.

Assessment in the Unconscious patient

First speak, increase volume, then try the following: 1. Apply a noxious stimulus & observe the patient's response. Supraorbital (above the eyes) Trapezius muscle sqeeze......less traumatic Mandibular (jaw) pressure Sternal (breastbone) rub-can cause soft-tissue brusing be cautious. * Do NOT apply longer than 30 secs. *

Cranial Nerve IX (9)

GLOSSOPHARYNGEAL talk, swallow, gag: Open mouth and say "AH" while you look to see if uvula is midline. Test gag reflex w/cotton applicator (warn pt 1st) touching the throat slightly. Have pt swallow small amount of liquid.

How to grade Motor Dysfunction

Grade each extremity using a motor scale EXAMPLE: +4 (normal), 0 (NO movement) 6 obeys commands 5 localizes pain 4 normal flexion (withdrawal) 3 abnormal flexion 2 extension 1 no movement

Cranial Nerve XII (12)

HYPOGLOSSAL Tongue: stick out tongue & retract, move tongue right & left. Look for deviation from midline. Push tongue against the inside of their cheek & test the strength by putting your hand on outer cheek. Do both sides.

Assessing for signs of Motor Dysfunction

Have the Pt. 1. Flex & extend their arm against your hand 2. Squeeze your fingers 3. Lift their leg while you press down on thigh 4. Hold their leg straight& lift it against gravity 5. Flex & extend their foot against your hand 6. Also check arm pronation or drift (arms in front, palms up for *15-30 secs. to see if limbs are weak. *

Position Sensation:

Inability to identify the directions of movements. May be seen in posterior columns disease or peripheral neuropathy. 2 Most Common disease processes seen are: DM II and chronic alcohol abuse.

Deep-Tendon Reflexes

Includes Triceps, biceps, brachloradialls, patellar and achillies. We are assessing superficial relexes.

Crushing's Triad

Late sign of increased Intra-Cranial Pressure (ICP) Examples: DVT,PE,... S/S: Increasing systolic BP, with a widening pulse pressure, bradycardia, decreased respirations.

Decelebrite

Mid-brain and ponds are invloved. The arms are rigid and palms turned away from body.

Cranial Nerve III

OCCULOMOTOR Six Cardinal Fields. Use penlight to check PERRLA (don't move head). Test for accommodation: ask pt to stare straight ahead at distant point, hold penlight in front of them & have them shift gaze from distant point to penlight. Eyes should converge (turn inward) & pupils should constrict as they focus on light.

Cranial Nerve II

OPTIC Snellen chart/ print: near vision by reading paper. Watch head position & observe closeness or distance of page to face. Far distance & color= Snellen Chart. Use opthalmuscope to see optic disk color & shape

PERRLA Assessment

Pupils Equal Round Reactive to Light & Accommodation Cranial Nerves involved: 3,4, & 6 makes my eyes do tricks 1.Size equal: use scale on penlight to measure pupil size in millimeters. 2. Light reflexes: hand on forehead-shine light in from side to look for direct light reflex-consensual light reflex in other eye 3. Swinging light test: shine light in one eye (get normal consensual reflex in other eye). Shine light in other eye- dilates & then constricts. 4. Accommodation: focus & follow light in-pupils should constrict & converge (cross-eyed)

Total Score of GCS

Range from 3-15 Best score is a 15 A score of 8 or lower usually indicates coma

Cranial Nerve XI (11)

SPINAL/ ACCESSORY Shoulder shrug, neck twist: Have pt shrug shoulders, turn head left & right, & put ear to shoulder on both sides.

Cranial Nerve V (5)

TRIGEMINAL aw, bite, cotton test: Pt closes both eyes. Have pt state "now" everytime cotton is felt. Brush cotton from temple to tip of nose, temple to lower lip, and jaw to mandible. Clench teeth and open & close mouth. Feel jaw line for muscle strength while they clench teeth. Look for symmetry.

Cranial Nerve IV (4)

TROCHLEAR Six Cardinal Fields. Done with 3

Cranial Nerve X (10)

VAGUS Gag Reflex: Done with Gag reflex (9). Are they talking or having slurred speech.

Propreoception

position of one's body parts. Example: Instruct the patient to close his or her's eyes and point there index finger in a upward or downward direction.

Aniscoria

pupil equality. pupils unequally found in 20% of clients.

Brain-stem Reflexes

stuporous or comatose patients. check protective reflexes. Example: coughing, gag-reflex, simple swallow test. Oculocephalic (Doll's-eyes):assess by turning the patients head briskly from side to side. The eyes should move to the left while the head is turned to the right. If the reflex is absent, there will be NO eye-movement. If it is normal, eye's move slowly towards the cold side. Tests: Mid-brain deterioration

Weber Test

with conduction hearing loss, client reports lateralization of sound of poor ear. With sensorneural hearing loss, client reports lateralization of sounds to good ear. Normal findings: vibrations is heard equally well in both ears.

Rhinne Test

with conduction loss, bone conduction sounds are heard longer than or equally as long as air conduction sounds. With sensorineural loss, air conduction is longer than bone conduction.