NURS 6512 Assignment Neurological Examination
NURS 6512 Assignment Neurological Examination
Short of opening a patient's cranium or requesting a brain scan, what can an advanced
practice nurse do to determine the cause of neurological symptoms? A multitude of
techniques can be used to generate a neurological diagnosis.
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due this
week, it is recommended that you practice performing a neurological examination.
Note: This is an optional practice physical assessment.
Arrange an appropriate time and setting with a volunteer "patient" to perform a
Download and review the Neurological Checklist provided in this week's Learning
Resources as well as review Seidel's Guide to Physical Examination online media.
The Lab Assignment
Perform the neurological examination. Be sure to cover all of the areas listed in the
checklist and to use the plexor appropriately.
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient’s medical history, but not deeper investigation such as neuroimaging. It can be used both as a screening tool and as an investigative tool, the former of which when examining the patient when there is no expected neurological deficit and the latter of which when examining a patient where you do expect to find abnormalities. If a problem is found either in an investigative or screening process, then further tests can be carried out to focus on a particular aspect of the nervous system (such as lumbar punctures and blood tests).
In general, a neurological examination is focused on finding out whether there are lesions in the central and peripheral nervous systems or there is another diffuse process that is troubling the patient. Once the patient has been thoroughly tested, it is then the role of the physician to determine whether these findings combine to form a recognizable medical syndrome or neurological disorder such as Parkinson’s disease or motor neurone disease. Finally, it is the role of the physician to find the cause for why such a problem has occurred, for example finding whether the problem is due to inflammation or is congenital.
A neurological examination is indicated whenever a physician suspects that a patient may have a neurological disorder. Any new symptom of any neurological order may be an indication for performing a neurological examination.
A patient’s history is the most important part of a neurological examination and must be performed before any other procedures unless impossible (i.e., if the patient is unconscious certain aspects of a patient’s history will become more important depending upon the complaint issued). Important factors to be taken in the medical history include:
- Time of onset, duration and associated symptoms (e.g., is the complaint chronic or acute)
- Age, gender, and occupation of the patient
- Handedness (right- or left-handed)
- Past medical history
- Drug history
- Family and social history
Handedness is important in establishing the area of the brain important for language (as almost all right-handed people have a left hemisphere, which is responsible for language). As patients answer questions, it is important to gain an idea of the complaint thoroughly and understand its time course. Understanding the patient’s neurological state at the time of questioning is important, and an idea of how competent the patient is with various tasks and his/her level of impairment in carrying out these tasks should be obtained. The interval of a complaint is important as it can help aid the
Carrying out a ‘general’ examination is just as important as the neurological exam, as it may lead to clues to the cause of the complaint. This is shown by cases of cerebral metastases where the initial complaint was of a mass in the breast.
List of tests
Specific tests in a neurological examination include the following:
|Mental status examination||
||“A&O x 3, short and long-term memory intact”|
|Cranial nerve examination||Cranial nerves (I-XII): sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX, X), tongue movements (XII). These are tested by their individual purposes (e.g. the visual acuity can be tested by a Snellen chart).||“CNII-XII grossly intact”|
||“strength 5/5 throughout, tone WNL”|
|Deep tendon reflexes||Reflexes: masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar (i.e., Babinski sign). Globally, brisk reflexes suggest an abnormality of the UMN or pyramidal tract, while decreased reflexes suggest abnormality in the anterior horn, LMN, nerve or motor end plate. A reflex hammer is used for this testing.||“2+ symmetric, downgoing plantar reflex“|
|Sensation||Sensory system testing involves provoking sensations of fine touch, pain and temperature. Fine touch can be evaluated with a monofilament test, touching various dermatomes with a nylon monofilament to detect any subjective absence of touch perception.||“intact to sharp and dull throughout”|