Ch 60 Assessment of Neurologic Function

Sensory Tests: Neuro

- eyes should be closed during testing - pain (sharp vs. dull) - temperature - light touch - vibration - propriocep - Tactile Discrimination: eyes should be closed for both tests; stereognosis; graphesthesia; 2 point discrimination; point localization

Proprioception assessment

-PROM of extremities with eyes closed -verbal description of statically held position -OR- -pt duplicates the joint position on the contralateral side

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Helicopod gait

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed

Clonus Explanation: Clonus occurs when the foot is abruptly dorsiflexed. It continues to "beat" two or three times before it settles into a position of rest. Sustained clonus always indicates the present of central nervous system disease and requires further evaluation. Ataxia is incoordination of voluntary muscle action. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive movement. Flaccid posturing is usually the result of lower brain stem dysfunction; the client has no motor function, is limp, and lacks motor tone.

Assessed by testing gag reflex

Cranial nerve X

Clonus test

Flex the dorsal foot upward. Positive test = 2-3 or more uncontrollable shaking of the dorsal foot

stereognosis test

Place a familiar object in the patient's hand and request identification using only one hand

sensory, motor, or both mnemonic

Some Say Money Matters But My Brother Says Big Brains Matter Most

Weber test

Tells where sound lateralizes to

Graphesthesia test

Tests the patient's ability to recognize a number or letter written on the palm with a dull object.

Rigidity (neuro)

an increase in muscle tone at rest characterized by increased resistance to passive movement

Rhinne test

compares air conduction and bone conduction. place stem of the vibrating tuning fork on the person mastoid process and ask him or her to signal when the sound goes away.

Dystrophic gait (toddler gait)

lordotic, waddling gait

Romberg Heel to shin Finger to nose Stand on one foot Gait/opposite arm swing

motor/coordination tests

Ataxic gait

staggering and unsteady

Flaccid posturing

usually the result of lower brain stem dysfunction; the client has no motor function, is limp, and lacks motor tone.

Steppage gait

A gait pattern in which the feet and toes are lifted through hip and knee flexion to excessive heights; usually secondary to dorsiflexor weakness. The foot will slap at initial contact with the ground secondary to the decreased control. Like walking with drop foot.