Assessment Chapter 15 Neurologic System

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Sensory: Smell reception and interpretation
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Olfactory (CNI)
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Sensory: Visual acuity and visual fields
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Optic (CNII)
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Motor: Raise eyelids, most extraocular movements Parasympathetic: Pupillary constriction, change lens shape
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Oculomotor (CNIII)
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Motor: Downward, inward eye movement
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Trochlear (CNIV)
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Motor: Jaw opening and clenching, chewing and mastication Sensory: Sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin
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Trigeminal (CNV)
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Motor: Lateral eye movement
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Abducens (CNVI)
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Motor: Movement of facial expression muscles except jaw, close eyes, labial speech sounds(b,m,w,and rounded vowels) Sensory: Taste-anterior two thirds of tongue, sensation to pharynx Parasympathetic: Secretion of saliva and tears
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Facial (CNVII)
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Sensory: Hearing and equilibrium
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Acoustic or vestibulocochlear (CNVIII)
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Motor: Voluntary muscles for swallowing and phonation Sensory: Sensation of nasopharynx, gag reflex, taste-posterior one third of tongue Parasympathetic: Secretion of salivary glands, carotid reflex
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Glossopharyngeal (CNIX)
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Motor: Voluntary muscles of phonation(guttural speech sounds) and swallowing Sensory: Sensation behind ear and part of external ear canal Parasympathetic: Secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract
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Vagus (CNX)
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Motor: Turn head, shrug shoulders, some action for phonation
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Spinal accessory (CNXI)
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Motor: Tongue movement for speech sound articulation(l,t,n) and swallowing
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Hypoglossal (CNXII)
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Cranial Nerves In Order:
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Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Accoustic/Vestibulocochlear, Glossopharyngeal, Vagus, Spinal Accessory, Hypoglossal ( On Old Olympus Towering Top A Fin And German Viewed Some Hops)
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Cranial Nerve Types:
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Sensory – Olfactory, Optic, Acoustic/Vestibulocochlear Motor – Oculomotor, Trochlear, Abducens, Spinal Accessory, Hypoglossal Both – Trigeminal, Facial, Glossopharyngeal, Vagus (Some Say Marry Money But My Brother Says Bad Businessto Marry Money)
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The nurse gives a key to a patient with a tumor in the cerebrum and asks the patient to close her eyes and identify the object. The patient manipulates the key but she cannot identify what it is. From this finding the nurse suspects that the patient’s tumor is located in which lobe of the cerebrum? 1 Frontal lobe 2 Parietal lobe 3 Temporal lobe 4 Occipital lobe
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2 Parietal lobe
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During a symptom analysis the patient reports a pain that radiates from the right lateral thigh, over the knee, and around to the right medial ankle. The nurse refers to the dermotome map to determine that the patient’s description of pain is consistent with dysfunction of which spinal nerve? 1 Second lumbar (L2) 2 Third lumbar(L3) 3 Fourth lumbar(L4) 4 Fifth lumbar(L5)
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3 Fourth lumbar(L4)
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The nurse is checking the deep tendon reflexes of a patient who has compression of the fifth and sixth cervical nerves on the right. Which deep tendon reflex is diminished? 1 Right bicep reflex 2 Left brachioradialis reflex 3 Right triceps reflex 4 Left patellar reflex
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1 Right bicep reflex
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When assessing a patient with a tumor within the medulla oblongata, the nurse notes which abnormal finding: 1 Absent gag reflex 2 Inability to smile and raise eyebrows 3 Loss of sensation to the face 4 Hearing deficit with unsteady gait
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1 Absent gag reflex
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Which techniques does the nurse use to test the triceps reflex: 1 Holds the knee in a slightly flexed position while stroking the end of the foot with a dull object 2 Holds the patient’s relaxed forearm with the hand slightly pronated while striking the appropriate tendon with a reflex hammer 3 Hold the patient’s relaxed arm with elbow flexed at a 90 degree angle, places a thumb over the appropriate tendon, and strikes the thumb with the pointed end of the reflex hammer 4 Holds the patient’s relaxed arm with elbow flexed at a 90 degree angle in one hand and strikes the appropriate tendon just above the elbow with either end of the reflex hammer
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4 Holds the patient’s relaxed arm with elbow flexed at a 90 degree angle in one hand and strikes the appropriate tendon just above the elbow with either end of the reflex hammer
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Which technique is used to assess the cerebellum: 1 Application of a pointed tip of a paper clip to lightly prick various areas of the upper and lower extremities to test for sensation 2 Having the patient walk on the heels and then on the toes to test for balance 3 With the patient’s eyes closed, grasping the their finger or toe and moving its position 1cm up or down to determine if the patient perceives that the digit has moved 4 Having the patient lie supine and flex the hips and knees to test for mobility and ROM
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2 Having the patient walk on the heels and then on the toes to test for balance
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The nurse is preparing to assess a patient’s peripheral nervous sensory function. Which assessment test would the nurse use? 1 Light touch sensation 2 Two-point discrimination 3 Romberg 4 Rinne’s
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1 Light touch sensation
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Sensory neurologic testing cannot realistically be performed with children until they are: 1 At least 6 months old 2 Toddlers 3 Kindergarten age 4 Middle school age
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3 Kindergarten age
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Which statement regarding variations in neurologic functioning is true? 1 African-American adults have an enhanced reflex response. 2 American Indian children tend to develop early motor skills more rapidly than other children. 3 Asians have a greater sensation than do whites. 4 The function of the neurologic system is consistent across racial lines.
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4 The function of the neurologic system is consistent across racial lines.
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The nurse assesses an active reflex response. Which score should be documented? 1 1+ 2 2+ 3 3+ 4 4+
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2 2+
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The nurse is assessing an older adult’s neurologic status. The nurse should be aware that the neurologic responses of older adults: 1 Should be the same as those of younger adults 2 May be slower than those of younger adults 3 Are present but difficult to evaluate 4 Are enhanced as a result of irritability
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2 May be slower than those of younger adults
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The nurse is assessing the olfactory nerve. Which instructions should the nurse give to the patient before assessment? 1 \”Lie down on your back.\” 2 \”Close your eyes.\” 3 \”Close both of your nostrils.\” 4 \”Breathe through your mouth.\”
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2 \”Close your eyes.\”
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The nurse notices that a patient is able to understand what is said but has trouble formulating a response. The nurse suspects: 1 Parkinson’s disease 2 Guillain-BarrĂ© syndrome 3 Receptive aphasia 4 Expressive aphasia
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4 Expressive aphasia
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The nurse notes that the patient is able to touch each finger to his thumb in rapid sequence. This finding indicates that the patient: 1 Has intact trochlear and abducens cranial nerves 2 Has appropriate cerebellar function 3 Has an intact spinal accessory nerve 4 Has appropriate kinesthetic sensation
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2 Has appropriate cerebellar function
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A 52-year-old obese male who smokes and has diabetes has risk factors for: 1 Seizures 2 Guillain-Barré syndrome 3 Multiple sclerosis 4 Cerebrovascular accident
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4 Cerebrovascular accident
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The nurse is assessing a patient’s neurologic status. What assessment should the nurse perform? Select all that apply. 1 Romberg test 2 Glasgow Coma Scale 3 Tonic neck 4 Corneal reflex 5 Mini-Mental State Exam 6 Recall test
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4 Corneal reflex 5 Mini-Mental State Exam 6 Recall test
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The nurse is preparing to assess a patient’s cortical sensory function. Which assessment test would the nurse use? 1 Light touch sensation 2 Two-point discrimination 3 Romberg 4 Rinne’s
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2 Two-point discrimination
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The nurse is preparing to assess a patient’s balance. Which assessment test would the nurse use? 1 Light touch sensation 2 Two-point discrimination 3 Romberg 4 Rinne’s
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3 Romberg
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The nurse is preparing to do a screening test for hearing on a patient. Which assessment test would the nurse use? 1 Light touch sensation 2 Two-point discrimination 3 Romberg 4 Rinne’s
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4 Rinne’s
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The nurse assesses a slightly hyperactive reflex response. Which score should be documented? 1 1+ 2 2+ 3 3+ 4 4+
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3 3+
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The nurse assesses a brisk, hyperactive reflex response with intermittent clonus. This is usually indicative of a disease process. Which score should be documented? 1 1+ 2 2+ 3 3+ 4 4+
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4 4+
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The nurse assesses a sluggish or diminished reflex response. Which score should be documented? 1 1+ 2 2+ 3 3+ 4 4+
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1 1+
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The nurse notices that a patient is able to speak but has trouble understanding what is said. The nurse suspects: 1 Parkinson’s disease 2 Guillain-BarrĂ© syndrome 3 Receptive aphasia 4 Expressive aphasia
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3 Receptive aphasia
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ASSESS mental status and level of consciousness. Say patient’s name and note the response. The patient is expected to turn toward you and respond appropriately. NORMAL finding: The patient should be oriented to time, place and person.
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ABNORMAL finding: Patients who do not know their name or location are disoriented. Those who require excessive stimulation or even painful stimulation to respond have a decrease in level of consciousness. A change in level of consciousness is the first sign of impaired cerebral function.
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EVALUATE speech for articulation and voice quality and conversation for comprehension of verbal communication. NORMAL finding: Patient voice should have inflection and sufficient volume with clear speech. Responses indicate an understanding of what was said.
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ABNORMAL finding: Errors in choice of words or syllables; difficulty in articulation which could involve impaired thought process or dysfunction of the tongue or lips; slurred speech/tone; poorly coordinated or irregular speech; monotone or weak voice; nasal tone, rasping, or hoarseness; whispering voice; stuttering.
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OBSERVE gait for balance and symmetry. NORMAL finding: Should be able to maintain upright posture, walk unaided, maintain balance, use opposing arm swing (observing equilibrium is a test of CNVIII)
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ABNORMAL finding: Poor posture, ataxia, unsteady gait, rigid or absent arm movements, wide-based gait, trunk or head held tight, lurching or reeling, scissors gait, or parkinsonian gain(stooped posture, flexion at hips, elbows, and knees)
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NOTICE the cranial nerve function The olfactory nerve(CNI) is frequently not tested, if patient mentions altered taste this may indicate a need to test for smell.
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ABNORMAL finding: Absence of smell or lack of taste of food and drink
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NOTICE the cranial nerve function When the patient walks around in the room and sees the chair to sit down, the optic nerve(CNII) is intact
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ABNORMAL finding: Bumps into furniture, squints, or needs assistance to locate a chain, it may be an indication of a vision problem
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NOTICE the cranial nerve function Observe a patient’s eye movements during the interview. When the eyes move equally from side to side, up and down, and obliquely, the oculomotor nerve(CNIII), trochlear nerve(CNIV), and abducens nerve(CNVI) are intact
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ABNORMAL finding: Eyes do not move or move in opposite directions
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NOTICE the cranial nerve function When the patient’s eyes blink, the ophthalmic branch of the trigeminal nerve(CNV) is intact
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ABNORMAL finding: Lack of blinking
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NOTICE the cranial nerve function Patient’s face is symmetric when talking, the facial nerve(CNVII) is intact
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ABNORMAL finding: Face appears asymmetric
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NOTICE the cranial nerve function When the patient hears you, the acoustic or vestibulocochlear nerve(CNVIII) is intact
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ABNORMAL finding: Indications of hearing loss include the patient asking to repeat yourself; repeatedly misunderstanding questions asked; leaning forward or placing the hands behind the ears to screen out environmental noises
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NOTICE the cranial nerve function Observe the patient swallowing, the glossopharyngeal nerve(CNIX) and vagus nerve(CNX) are intact
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ABNORMAL finding: Inability to swallow saliva
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NOTICE the cranial nerve function Hearing the patient’s guttural speech sounds, such as k or g, indicates another function of the vagus nerve(CNX) is intact
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ABNORMAL finding: Absence of guttural sounds or nasal speech may indicate vagus nerve abnormality
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NOTICE the cranial nerve function When patient shrugs shoulders or turns the head during an interview, the spinal accessory nerve(CNXI) is intact
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ABNORMAL finding: Absence or difficulty in turning head or shrugging
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NOTICE the cranial nerve function When the patient enunciates words, the tongue and hypoglossal nerve(CNXII) is intact
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ABNORMAL finding: Speech that is not clearly articulated may indicate an abnormality with the tongue
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EVALUATE extremities for muscle strength Ask patient to flex the muscles being evaluated and then resist when you apply opposing force against the muscle. NORMAL finding: Expect muscle strength to be 5/5, bilaterally symmetric, with full resistance to opposition.
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ABNORMAL finding: A fasciculation observed or palpated; Paralysis
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TEST extremities for deep tendon reflexes Hold the reflex hammer between your thumb and index finger and briskly tap the tendon with a flick of the wrist. The patient must be relaxed and sitting or lying down. To elicit the triceps reflex, ask the patient to let their relaxed arm fall onto your arm. Hold the arm with the elbow flexed at a 90 degree angle in one hand. Palpate and then strike the triceps tendon just above the elbow with either end of the reflex hammer. An alternative arm position is to grasp the upper arm and allow the lower arm to bend at the elbow and hang freely, then strike the triceps tendon.
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NORMAL finding: Expected response is the contraction of the triceps muscle that causes visible or palpable extension of the elbow. ABNORMAL finding: May range from a hyperactive to a diminished response. Observe whether abnormal reflex response is unilateral or bilateral. Hyperactive reflexes are found in spinal cord injuries, calcium and magnesium deficits, and hyperthyroidism. Diminished reflexes are found in calcium or magnesium excesses, hypothyroidism, spina bifida, or Guillain-Barre syndrome.
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TEST extremities for deep tendon reflexes Hold the reflex hammer between your thumb and index finger and briskly tap the tendon with a flick of the wrist. The patient must be relaxed and sitting or lying down. The biceps reflex is elicited by asking the patient to let his or her relaxed arm fall onto your arm. Hold the arm with elbow flexed at a 90 degree angle and place a thumb over the biceps tendon in the antecubital fossa and your fingers over the biceps muscle. Using the pointed end of the reflex hammer, strike your thumb instead of striking the tendon directly.
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NORMAL finding: Expected response is the contraction of the biceps muscle that causes a visible or palpable flexion of the elbow. ABNORMAL finding: May range from a hyperactive to a diminished response. Observe whether abnormal reflex response is unilateral or bilateral. Hyperactive reflexes are found in spinal cord injuries, calcium and magnesium deficits, and hyperthyroidism. Diminished reflexes are found in calcium or magnesium excesses, hypothyroidism, spina bifida, or Guillain-Barre syndrome.
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TEST extremities for deep tendon reflexes Hold the reflex hammer between your thumb and index finger and briskly tap the tendon with a flick of the wrist. The patient must be relaxed and sitting or lying down. The brachioradialis reflex is elicited by asking patient to let his or her relaxed arm fall in your hand. Hold the arm with the hand slightly pronated. Using either endo of the relex hammer, strike the brachioradialis tendon directly about 1 to 2 inches above the wrist.
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NORMAL finding: Expected response is pronation of the forearm and flexion of the elbow ABNORMAL finding: May range from a hyperactive to a diminished response. Observe whether abnormal reflex response is unilateral or bilateral. Hyperactive reflexes are found in spinal cord injuries, calcium and magnesium deficits, and hyperthyroidism. Diminished reflexes are found in calcium or magnesium excesses, hypothyroidism, spina bifida, or Guillain-Barre syndrome.
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TEST extremities for deep tendon reflexes Hold the reflex hammer between your thumb and index finger and briskly tap the tendon with a flick of the wrist. The patient must be relaxed and sitting or lying down. The patellar reflex is tested with the patient sitting with legs hanging free. Flex the knee at a 90 degree angle and strike the patellar tendon just below the patella. When no response is found, divert the patient’s attention to another muscle activity such as pulling the fingers of each hand against each other, while the patient is pulling, strike the patellar tendon.
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NORMAL finding: Expected response is the contraction of the quadriceps muscle, causing extension of the lower leg. ABNORMAL finding: May range from a hyperactive to a diminished response. Observe whether abnormal reflex response is unilateral or bilateral. Hyperactive reflexes are found in spinal cord injuries, calcium and magnesium deficits, and hyperthyroidism. Diminished reflexes are found in calcium or magnesium excesses, hypothyroidism, spina bifida, or Guillain-Barre syndrome.
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TEST extremities for deep tendon reflexes Hold the reflex hammer between your thumb and index finger and briskly tap the tendon with a flick of the wrist. The patient must be relaxed and sitting or lying down. The Achilles tendon is tested by flexing the patient’s knee and dorsiflexing the ankle 90 degrees. Hold the bottom of the patient’s foot in one hand while you use the flat end of the relex hammer to strike the Achilles tendon at the level of the ankle malleolus.
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NORMAL finding: Expected response is the contraction of the gastrocnemius muscle, causing plantar flexion of the foot. ABNORMAL finding: Test for ankle clonus if reflexes are hyperactive. Support the patient’s knee in a partly flexed position. With the other hand sharply dorisflex the foot and maintain it in flexion. There should be no movement of the foot. Rhythmic oscillations between dorsiflexion and plantar flexion are abnormal responses,
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A localized uncontrollable twitching of a single muscle group inverted by a single motor nerve fiber that may be observed or palpated. Causes include adverse effects of medications, cerebral palsy, neuralgia, and poliomyelitis.
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Fasciculation
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Lack of voluntary movement that is spastic or flaccid.
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Paralysis
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The involuntary contraction of muscles and occurs with pyramidal tract injury that occurs after a spinal cord injury or cerebrovascular accident(CVA)
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Spastic paralysis
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The lack of muscle tone and deep tendon reflexes that occurs after lower motor neuron damage such as injury t the cauda equine from spina bifida
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Flaccid paralysis
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TEST extremities for deep tendon reflexes Test the five deep tendon reflexes(triceps, biceps, brachioradial, patellar, and Achilles) using a reflex hammer. Compare the reflexes bilaterally. Reflexes are graded on a scale of 0 to 4, with 2 being the expected finding.
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0 : No response 1+ : Sluggish or diminished 2+ : Active or expected response 3+ : Slightly hyperactive, more brisk than normal; not necessarily pathologic 4+ : Brisk, hyperactive with intermittent clonus associated with disease
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ASSESS cranial nerves. Test these nerves when you suspect an abnormality: TEST nose for smell Evaluate the olfactory cranial nerve(CNI). Have patient close eyes and mouth. Occlude one nostril while testing the other. Ask patient to identify common aromatic substances held under the nose, such as coffee, toothpaste, orange, the patient should be able to identify the aromas
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ABNORMAL finding: An inability to smell anything or incorrect identification of odors is abnormal. Nasal allergies can impair ability to smell. Loss of smell may be caused by an olfactory tract lesion. Anosmia is the term used for loss of or impaired sense of smell
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Term used for loss of or impaired sense of smell:
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Anosmia
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ASSESS cranial nerves. Test these nerves when you suspect an abnormality: TEST eyes for visual acuity. Test the optic nerve (CNII) for visual acuity using Snellen’s chart and an opthalmoscopic examination of the eye.
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ABNORMAL finding: Refer the patient to an ophthalmologist for further evaluation of vision and eye function when abnormalities are suspected.
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TEST eyes for visual acuity. Snellen’s chart to test optic nerve (CNII). Patient can sit or stand 20ft from the chart. If patient has glasses or contacts, leave in place. Cover one eye and read the line of smallest letters that is possible to read. Test the other eye and then test both eyes using the same procedures. Document the line read completely, using the fraction printed at the end of the line, indicate if patient was wearing glasses or contacts. Next to assess perception ask the patient to use both eyes to distinguish which of the two horizontal lines is longer. Finally ask the patient to name the colors of the two horizontal lines to document red and green color perceptions. Use the E Chart for patients who cannot read.
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NORMAL finding: The reading pattern should be smooth. The expected finding is 20/20. A finding of 20/30 means that the patient can read at 20 feet what a person with normal vision can read at 30 feet. If the patient can read all the letters in the 20/30 line and two letters in the 20/20 line, document the finding as 20/30 +2 . ABNORMAL finding: Note any hesitancy, squinting, leaning forward, blinking, or facial expressions indicating that the patient is struggling to see. The larger the denominator, the poorer the vision. If vision is poorer than 20/30 or unable to distinguish colors or line length, refer to ophthalmologist or optometrist. Person is considered legally blind when the best corrected visual acuity is 20/200.
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ASSESS cranial nerves. Test these nerves when you suspect an abnormality: TEST eyes for peripheral vision. The presence of peripheral vision indicates function of optic nerve(CNII). Called the confrontation test. Face the patient, standing or siting at a distance of 2 to 3 feet. Ask patient to cover one eye and look directly at you as you cover your own eye directly opposite the patient’s covered eye. Extend finger to the farthest peripheral and gradually bring the object close to the midline. Ask patient to report when they first sees the object, you should see the object at the same time. Slowly move the object inward from the periphery in four directions. Move fingers anteriorly, inferiorly, temporally, and nasally. Estimate the angle between the anteroposterior axis of the ey and the peripheral axis when the finger or object is first seen.
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NORMAL finding: Normal values are 50 degrees anteriorly, 70 degrees inferiorly, 90 degrees temporally, and 60 degrees nasally. The temporal value is greater than the nasal value because of the position of the opaque card covering one eye. ABNORMAL finding: If the patient cannot see the object at the same time that you see it, peripheral field loss is suspected. Refer patient to an eye care specialist for more precise testing.
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OBSERVE eyes for extraocular muscle movement the oculomotor(CNIII), trochlear(CNIV), and abducens(CNVI) nerves are tested together because they control muscles that provide eye movement. ASSESS eye movement for the six cardinal fields of gaze. While patient is looking at you, position your finger 10 to 12 inches from the patient’s nose. Ask patient to keep head still and use the eyes only to follow your finger or an object in your hand. Move the object from its center position to upper outer extreme, hold there, move back to center, to lower inner extreme, and hold there. Move the object to temporal nasal extremes holding there momentarily. Move the object to opposite upper outer extreme and back to opposite lower inner extreme. An alternative method is to move your finger slowly in a circle to each of the six directions. Stop in each position so the patient can hold the gaze briefly before moving to the next position
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NORMAL finding: Normally there will be parallel tracking of the object with both eyes. Mild nystagmus at extreme lateral gaze is also normal. ABNORMAL finding: Nystagmus is involuntary movement of the eyeball in a horizontal, vertical, rotary, or mixed direction. It may be congenital or acquired from multiple causes. Eye movements that are not parallel indicate extraocular muscle weakness or dysfunction of CNIII, CNIV, or CNVI. Report ptosis, eyelid droop, that may occur with ocular myasthenia gravis
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OBSERVE eyes for pupillary size, shape, equality, constriction, and accommodation NORMAL finding: Pupils should appear equal, round, and reactive to light and accommodation.
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ABNORMAL finding: Increased intracranial pressure or trauma to the midbrain may exert pressure on CNIII, resulting in diminished to absent pupillary constriction. Pupil size can be changed by drug effects such as constricted by heroin or morphine and dilated by cocaine.
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EVALUATE face for movement and sensation Evaluate the trigeminal nerve(CNV) for facial movement and sensation. Test motor function by having the patient clench their teeth then palpate the temporal and masseter muscles for muscle mass and strength. There should be bilaterally strong contractions.
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ABNORMAL finding: Inequality in muscle contractions, pain, twitching, or asymmetry is abnormal. Disorders of the pons may cause altered function of CNV, or CNVII. A tic or mimic spasm is an involuntary movement of small muscles, usually of the face. Occasional tics may have psychogenic causes aggravated by anxiety or stress.
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EVALUATE face for movement and sensation To test sensation of light touch, have the patient close their eyes while you wipe cotton lightly over the anterior scalp(ophthalmic branch), paranasal sinuses(maxillary branch), and jaw(mandibular branch). A tickle sensation should be reported equally over the three areas touched. Repeat the procedure on the other side of the face.
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ABNORMAL finding: Decreased or unequal sensation is abnormal. Record the extent of the involved areas of the face.
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EVALUATE face for movement and sensation To test deep sensation, use alternating blunt and sharp ends of a paper clip over patient’s forehead, paranasal sinuses, and jaw. The patient should be able to feel pressure and pain equally throughout these areas and differentiate between sharp and dull. Repeat the procedure on the other side of the face.
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ABNORMAL finding: Decreased or unequal sensation is abnormal. Trigeminal neuralgia is characterized by stablike pain radiating along the trigeminal nerve, caused by degeneration of or pressure on the nerve.
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EVALUATE face for movement and sensation Test the ophthalmic branch(sensory) of CNV and motor function of CNVII by testing for the corneal reflex. This test may be omitted when the patient is alert and blinking naturally. Ask the patient to remove contact lenses if applicable and to look up and away from you. Approach from the side and lightly touch the cornea with a wisp of cotton.
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NORMAL finding: There should be a bilateral blink to corneal touch. Patients who wear contact lenses regularly may have diminished or absent reflex. ABNORMAL finding: Absence of a blink is abnormal. Be sure to check that this abnormal response is not caused by the presence of contact lenses.
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EVALUATE face for movement and sensation Evaluate the facial cranial nerve(CNVII) for movement. Inspect the face at rest and during conversation. Have the patient raise the eyebrows, purse the lips, close eyes tightly, show the teeth, smile, and puff out the cheeks. Patient should be able to correctly perform each request, and the movements should be smooth and symmetric.
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ABNORMAL finding: Asymmetry, facial weakness, drooping of one side of the face or mouth or inability to maintain position until instructed to relax is abnormal. Unilateral paralysis of the facial nerve occurs in Bell’s palsy.
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TEST ears for hearing Evaluate the acoustic or vestibulocochlear nerve(CNVIII) for hearing. Assessment of sensorineural hearing loss using the Rinne and Weber’s test . Tests for the vestibular function of CNVIII usually are not performed.
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ABNORMAL finding: Sensorineural hearing loss may be indicated using Weber’s test by lateralization of sound to the unaffected ear or the Rinne test when air conduction is longer than bone conduction in the affected ear but by a less than 2:1 ratio.
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Weber’s Test Procedure: This test uses a tuning fork to assess hearing. Activate the tuning fork by holding it by the base stem and striking the forked section against the base of the palm. Immediately place the base of the fork on the midline of the patient’s skull. Ask the patient to indicate in which ear the sound is heard louder.
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FINDING: Because sound is transmitted along the skull to the inner ear, the patient should hear the tone equally in both ears. ABNORMAL finding: Sensorineural hearing loss may be indicated using Weber’s test by leteralization of sound to the unaffected ear or the Rinne test when air conduction is longer than bone conduction in the affected ear but by a less than 2:1 ration
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Rinne Test The Rinne test uses a tuning fork to assess hearing by comparing air conduction of sound to bone conduction of sound. The AC route through the ear canal is a more sensitive route. Procedure: Ask patient to indicate when the sound is no longer heard when the tuning fork is placed on the bone and when it is placed in front of the ear. After striking the fork, immediately place the base of the tuning fork directly on the patient’s mastoid process. The patient should be able to hear the tone. Instruct the patient to tell you when the tone can no longer be heard. When the patient indicates the tone can no longer be heard, not the number of seconds counted. Quickly remove the fork from the mastoid process, invert the fork, and hold the vibrating section of the tuning fork in front of the patient’ ear. Begin timing again. The patient should be able to hear the tone again. Instruct patient to tell you when the vibration is no longer heard. When patient no longer hears the tone note the time.
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FINDING: Tone should be heard in front of the ear twice as long as the tone heard when the fork was on the mastoid process. (AC>BC by 2:1) ABNORMAL finding: Sensorineural hearing loss may be indicated using Weber’s test by leteralization of sound to the unaffected ear or the Rinne test when air conduction is longer than bone conduction in the affected ear but by a less than 2:1 ration
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TEST tongue for taste Evaluate taste over the anterior and posterior tongue. For the anterior two thirds of the tongue(CNVII), instruct the patient to stick out the tongue and leave it out during the testing process. Use a cotton applicator to place on the patient’s anterior tongue small quantities of salt, sugar, and lemon one at a time. Test the glossopharyngeal nerve for taste of the posterior one third of the tongue or pharynx(CNIX).
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NORMAL finding: The patient should be able to taste bitter and sour taste. Taste, the sensory component of CNVII and CNIX, usually is not tested unless the patient reports a problem. ABNORMAL finding: Inability to identify tastes or consistently identifying a substance incorrectly is abnormal. Loss of smell and taste may occur together. Patients who are chronic smokers may have decreased taste.
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INSPECT oropharynx for gag reflex and movement of soft palate Evalutate the glossopharyngeal nerve(CNIX) and the vagus nerve(CNX) together for movement of the soft palate and gag reflex. Instruct the patient to say \”ah\” to test CNX. There should be equal upward movement of the soft palate and uvula bilaterally. To test the gag reflex, touch the posterior pharynx with the end of a tongue blade; the patient should gag momentarily. Movement of the posterior pharynx and gag reflex test CNIX.
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ABNORMAL finding: Asymmetry of the soft palate or tonsillar pillar movement, any lateral deviation of the uvula, or absence of the gag reflex may indicate disorders of the medulla oblongata. For example, tumors in the medulla oblongata may cause pressure on CNIX or CNX.
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TEST tongue for movement, symmetry, strength, and absence of lesions Evaluate the hypoglossal nerve(CNXII) for movement and symmetry. Ask patient to protrude his or her tongue. Note symmetry. Then ask patient to move tongue toward the nose, the chin, and side to side. Wearing gloves, grasp tong and palpate all sides. Test the muscle strength of the tongue by asking patient to press the tip of tongue inside the cheek while you resist the pressure from outside the patient’s cheek with your fingers.
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NORMAL finding: Tongue should be moist, pink, and symmetric without lumps, nodules, or ulcers. Tongue strength should be evident by resistance to outside pressure ABNORMAL finding: Asymmetric movement or weakness of the tongue may indicate impairment of the hypoglossal cranial nerve(CNXII). The tongue deviates toward the impaired side. Tumors of the tongue may develop from alcohol, tobacco, or chronic irritation
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TEST shoulders and neck muscles for strength and movement Have patient turn his or her head to the side against your hand; repeat with other side. Observe the contraction of the opposite sternocleidomastoid muscle and note the force of movement against your hand. Movement should be smooth, and muscle strength should be strong and symmetric. Evaluate the spinal accessory nerve(CNXI) for movement. Ask patient to shrug shoulders upward against your hand.
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NORMAL finding: Contraction of the trapezius muscles should be strong and symmetric. ABNORMAL finding: Weakness or pain when pushing against your hand or asymmetry is abnormal ABNORMAL finding: Unilateral or bilateral muscle weakness or any pain or discomfort is abnormal
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. TEST for balance. Perform Romberg test. Have patient stand with feet together, arms resting at sides, eyes open, and then eyes closed. Stand close to patient with arms ready to catch them if they begin to fall off balance.
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NORMAL finding: There will be slight swaying but the upright posture and foot position should be maintained ABNORMAL finding: If the patient sways with eyes closed but not open, the problem is probably proprioceptive. If patient sways with eyes open and closed the problem is probably a cerebellar or vesticular disorder and is documented as a positive Romberg sign.
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test for balance. Have patient close their eyes and stand on one foot and then the other.
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NORMAL finding: Patient should be able to maintain position for at least 5 seconds ABNORMAL finding: Inability to maintain single foot balance for 5 seconds is abnormal.
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test for balance. Have patient walk in tandem, placing the heel of one foot directly against toes of the other foot.
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NORMAL finding: Patient should be able to maintain this heal to walking patter along a straight line ABNORMAL finding: Inability to walk heal to toe or using a wide based gait to maintain the upright posture is abnormal.
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test for balance. Have patient hop on one foot and then on the other.
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NORMAL finding: Patient should be able to follow directions successfully and have enough muscle strength to accomplish task ABNORMAL finding: Inability to hop or maintain single leg balance is abnormal.
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test for balance. Have patient hold one hand outward and perform several shallow or deep knee bends.
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NORMAL finding: Patient should be able to follow directions successfully with muscle strength to accomplish the task ABNORMAL finding: Inability to perform activity because of difficulty with balance or lack of muscle strength is abnormal
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test for balance. Have the patient walk on toes, then heels. Patient should be able to follow directions, walking several steps on the toes and then on the heels.
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NORMAL finding: The patient may need to use hands to maintain balance, but should be able to walk several steps ABNORMAL finding: Inability to retain balance, poor muscle strength, or inability to complete the activity is abnormal
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test upper extremity coordination. Have patient alternately tap thighs with hands using rapid pronation and supination movements. Timing should be equal bilaterally, and movement purposeful;
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NORMAL finding: The patient should be able to maintain a rapid pace ABNORMAL finding: Inability to maintain rapid pace is abnormal. An intention tremor, such as an involuntary muscle contraction during a purposeful movement of an extremity that disappears when the extremity is not moving, may indicate cerebellar dysfunction
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test upper extremity coordination. Have the patient close eyes and stretch arms outward. Use index fingers to alternately touch the nose rapidly.
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NORMAL finding: The patient should be able to touch the nose repeatedly in rhythmic pattern ABNORMAL finding: Cerebellar dysfunction may cause the patient to miss touching their nose several times or cause the arms to drift downward
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test upper extremity coordination. Evaluate the patient’s ability to perform rapid, rhythmic, alternating movement of fingers by having him or her touch each finger to the thumb in rapid sequence. Test each hand separately.
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NORMAL finding: The patient should be able to perform movement rapidly and purposefully, touching each finger to thumb ABNORMAL finding: Inability to coordinate fine, discrete, rapid movement is abnormal. An intention tremor may be observed during the movement, indicating a cerebellar dysfunction
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test upper extremity coordination. Have patient rapidly move index finger back and forth between their nose and your finger 18in apart. Test one hand at a time.
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NORMAL finding: The patient should be able to maintain activity with a conscious, coordinated effort. ABNORMAL finding: Inability to maintain continuous touch both with the patient’s own nose and your finger, inability to maintain the rapid movement, or obvious difficulty coordinating is abnormal.
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TEST cerebellar function for balance and coordination: When patient reports or you observe impaired balance, test cerebellar function. Use at least two techniques for each area assessed. Choose these techniques based on the patient’s age and overall physical ability. For example, not every patient should have to perform deep knee bends. Test lower extremity coordination. With patient laying supine, ask patient to place the heel of one foot to the knee of the other let, sliding it all the way down the shin. Repeat on other leg.
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NORMAL finding: Patient should be able to run the heel down the opposite shin purposefully, with equal coordination. ABNORMAL finding: Patients with cerebellar disease may overshoot the knee and oscillate back and forth. With loss of position sense, the patient may lift the heel too high and have to look to ensure that it is moving down the shin.
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ASSESS peripheral nerves. ASSESS for sensation. Ask patient to close their eyes during the test of sensory function. Areas routinely assessed are the hands, lower arms, abdomen, lower legs, and feet. If sensation is intact, no further evaluation is needed; if impaired, assess sensation systemically from digit up or from shoulder or hip down to identify the area that is without sensation. Compare bilateral responses in each sensory testing area. Try to map out the area involved using the dermatome map to identify the spinal nerve providing sensations to that area of the body.
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ABNORMAL finding: Impaired or absent sensation is abnormal. Absence of sensation may be caused by compression of the nerve, whereas inflammation of the nerve may cause abnormal sensation. Diabetes mellitus may cause absent or abnormal sensation.
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ASSESS peripheral nerves. ASSESS for sensation. To test sensation to light touch(superficial touch), use a cotton wisp and the lightest touch possible to test each designated area(patient’s eyes are closed).
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NORMAL finding: The patient should perceive light sensation and be able to correctly point to or name the spot touch. ABNORMAL finding: Include the patient reporting that they do no feel the light touch, incorrectly identifying the area touched, not feeling the vibration, or reporting an asymmetric response.
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ASSESS peripheral nerves. ASSESS for sensation. Test sharp dull sensation by using the pointed tip of a paper clip, or sharp edge, to lightly prick each designated area(patient’s eyes are closed). Alternate sharp and dull sensations to more accurately evaluate the patient’s response.
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NORMAL finding: The patient should be able to distinguish sharp from dull and identify the area touched. ABNORMAL finding: Patient reporting that they do not feel the sharp or dull touch, being unable to distinguish between sharp and dull, or reporting an asymmetric response.
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ASSESS peripheral nerves. ASSESS for sensation. Ask patient to close eyes for the test of vibratory sense. Place a vibrating tuning fork on a bony area such as the styloid process of the radius(wrist), medial or lateral malleolus(ankle), and sternum(chest) and ask patient to describe the sensation. Patient should feel a sense of vibration, and when vibration is not present; stop vibration of the tuning fork by touching it with your fingers without moving it from its location on the bony prominence.
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ABNORMAL finding: Unequal or decreased vibratory sensation is abnormal. The patient may not be able to distinguish the change in sensation from vibration to nonvibration or may not feel the vibration is one or more locations. Referring to the dermatome drawing helps to identify the spinal nerve supplying this area. This may be found in patients with diabetes mellitus and those who have had a CVA or spinal cord injury.
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ASSESS peripheral nerves. ASSESS for sensation. Test kinesthetic sensation by grasping the patient’s finger or toe and moving its position 1cm up or down, patient’s eyes are closed.
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NORMAL finding: Patient should be able to describe how the position has changed. ABNORMAL finding: Inability to distinguish the change in position may indicate impairment of sensory(afferent nerves) or parietal lobe.
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ASSESS peripheral nerves. ASSESS for sensation. Test stereognosis by asking patient to close eyes. Place a small, familiar object in the patient’s hand and ask them to identify it.
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NORMAL finding: Patient should properly identify object ABNORMAL finding: Altered stereognosis may indicate a parietal lobe or sensory nerve tract dysfunction and is documented as tactile agnosia.
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ASSESS peripheral nerves. ASSESS for sensation. Test two point discrimination by touching selected parts of the body simultaneously while the patient’s eyes are closed. Use the points of two applicators or reshape a paper clip so two prongs can be pressed lightly against the patient’s skin simultaneously. Ask patient how many points they detect.
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ABNORMAL finding: Inability to distinguish two point discrimination is abnormal. Report the anatomic location of the sensory alteration.
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ASSESS peripheral nerves. ASSESS for sensation. Evaluate graphesthesia using a blunt instrument to draw a number or letter on the patient’s hand, back, or other area, with patient’s eyes closed.
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NORMAL finding: Patient should be able to recognize the number or letter drawn ABNORMAL finding: If the patient cannot distinguish the number or letter, they may have a parietal lobe lesion.
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ASSESS peripheral nerves. ASSESS for sensation. Check for plantar reflex(Babinski reflex). Using the end of the handle on the reflex hammer, stroke the lateral aspect of the sole of the foot from heel to ball, curing medially across the ball of the foot.
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NORMAL finding: Expected finding should be plantar flexion of all toes. ABNORMAL finding: Dorsiflexion of the great toe with fanning of the other toes is an abnormal response termed a positive Babinski’s sign and may indicate pyramidal(motor) tract disease
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EVALUATE for superficial reflexes Testing abdominal reflexes. In assessing the neurologic system, you correlated the expected response wit the spinal level involved.The testing of superficial reflexes however there is little significance to their presence or absence. FOR MALE PATIENTS: Check the cremasteric reflex. Lightly stroke the upper, inner aspect of the thigh with the reflex hammer or tongue blade. The ipsilateral testicle should rise slightly.
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ABNORMAL finding: Absence of the cremasteric reflex is seen in disorders of the pyramidal(motor) tract above the level of the first lumbar.

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