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Physical & neurological examination

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complete physical & neurological examination , helpful for students

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Physical & neurological examination

  1. 1. PHYSICAL & NEUROLOGICAL EXAMINATION Presentation BY Ms Neha Bhatt
  2. 2. Introduction Assessment is an important component of nursing process. A complete nursing assessment includes both the collection of subjective data and objective data. The complete health history is performed to collect as much subjective data about a client as possible. Objective data include information about the client that the nurse directly observes during interaction with him and information elicited through physical assessment techniques.
  3. 3. 1. Physical Examination: Four basic techniques must be mastered before professional can perform a thorough and complete assessment of the client. By using a systematic approach, examiner will less likely to forget an area. Four techniques used are: • Inspection. • Palpation. • Percussion. • Auscultation.
  4. 4. • These techniques need to be organized in sequence except while performing abdominal assessment, as palpation and percussion can alter bowel sounds. The sequence for assessing the abdomen is inspection, auscultation, percussion and palpation.
  5. 5. i) Inspection: • Inspection involves vision, smell and hearing to observe normal conditions and deviations. Performed correctly, inspection can reveal more than other techniques. • Inspection begins from first meeting with the patient and continues throughout the health history and physical examination. As the examiner assess each body system, observe for color, size, location movement, texture, symmetry, odor, and sounds.
  6. 6. ii)Palpation Palpation required examiner to touch the patient with different parts, using varying degrees of pressure. To do this, examiner need short fingernails and warm hands. Always palpate tender areas last. Information about the purpose of touch to different parts is essential.
  7. 7. Palpate to evaluate: • Evaluation of the following features are required: • Texture-rough or smooth? • Temperature-warm, hot or cold? • Moisture-dry, wet or moist? • Motion-still or vibrating? • Consistency of structures-solid or fluid filled?
  8. 8. iii)Percussion:  Percussion involves tapping fingers or hands quickly and sharply against parts of the patient’s body, usually the chest or abdomen. The technique helps to locate organ borders, identify organ shape and position and determine if an organ is solid or filled with fluid or gas.  Percussion requires a skilled touch and trained ear to detect slight variations in sound. Organs and tissues, depending on their density, produce sounds of varying loudness, pitch and duration. For instance, air-filled cavities, such as the lungs, produce markedly different sounds than do the liver and other dense tissues.  The examiner has to move gradually from areas of resonance to those of dullness and them compare sounds. Also, compare sounds on one side of the body with those on the other side.
  9. 9. iv)Auscultation: • Auscultation, usually the last assessment step, involves listening for various breath, heart and bowel sound with a stethoscope. To prevent the spread of infection among patients, clean the hearts and end pieces of the stethoscope with alcohol or a disinfectant after every use.
  10. 10. 2. History collection among neurological patients • A thorough and accurate history of a neuro patient is often very helpful in assessing their condition. The character of symptoms, distribution, temporal profile of symptoms, epidemiological associations are often needed in detail in neurological patients in comparison to other general diseases. The fact that in neurological patients their cerebral dysfunction may limit or distort the account of history third party sources of information are most often needed.
  11. 11. 3. Neurologic Examination • Neurological examination is one of the key components of nursing practice. It plays a pivotal role in localization of the problem. It encompasses history collection, and the physical examination. Observation is the most important key for neurological examination. The exam requires skill and patience, from the examiner.
  12. 12. a) A thorough neurologic examination may take 1 to 3 hours; however, routine screening tests are usually done first. If the results of these tests raise questions, more extensive evaluations are made. Three major considerations determine the extent of a neurologic exam: b) The client’s chief complaints c) The client’s physical condition (i.e., level of consciousness and ability to ambulate), as many parts of the examination require movement and coordination of the extremities d) The client’s willingness to participate and cooperate.
  13. 13. 3.1 Equipments Needed • Reflex Hammer • 128 and 512 (or 1024) Hz Tuning Forks • A Snellen Eye Chart or Pocket Vision Card • Pen Light • Ophtalmoscope • Sugar/salt
  14. 14. • Coffee powder/any scented material • Disposable safety pin • Tongue depressors • Wisps of cotton to assess light- touch sensation • Test tubes of hot and cold water for skin temperature assessment
  15. 15. 3.2 The components of neurological examination includes Assessment of: • Level of consciousness • Mini Mental Status Exam. • Cranial nerves • Motor System. • Sensory System. • Deep tendon reflexes • Coordination and balance • Brain stem reflexes
  16. 16. 3.3 Assessment of Level of consciousness General appearance: • Note the patient’s personal hygiene and dress. Is it appropriate for the environment. • Make a note of the age, height, build and weight. Is the patient obese or cachectic? • Check the vital signs including temperature, pulse, respiratory rate and blood pressure.
  17. 17. Level of consciousness • Glasgow coma scale is an objective method to assess the level of consciousness in the patients with neurological disorders. This scale describes conscious level in terms of eye opening, verbal response and motor response. These are having 4, 5, 6 categories each respectively. On examination, observer has to assign one score to the observed category to each parameter. The minimum score is 3 and maximum is 15.
  18. 18. Eye Opening (E) Verbal Response (V) Motor Response (M) 4=Spontaneous 3=To voice 2=To pain 1=No response 5=oriented 4=Disoriented conversation 3=Non comprehensible words, 2=Incoherent sounds 1=No response 6=obeys commands 5=Localizes pain 4=Withdrawl flexion 3=abnormal flexion Decorticate posture 2=abnormal extension Decerebrate posture 1=No response
  19. 19. For children under 5, the verbal response criteria are adjusted as follow SCORE 2 to 5 yrs 0 to 23 months 5 Appropriate words or phrases Smiles or coos appropriately 4 Inappropriate words Cries and consolable 3 Persistent cries and/or screams Persistent inappropriate crying &/or screaming 2 Grunts Grunts or is agitated or restless 1 No response No response Children with a Glasgow Coma Scale of 3-8 are considered comatose
  20. 20. 3.4 Mental Status Examination • Evaluation of mental status is a part of the neurological examination. The appearance, behaviour, level of consciousness, attention, concentration, memory, orientation, abstraction, judgment, language and speech are assessed in this.
  21. 21. 4. Examination of the Cranial Nerves The following is a summary of the cranial nerves and their respective functioning. • I Olfactory- Smell • II .optic-Visual acuity, visual fields and ocular fundi • II,III . Occulo motor- Pupillary reactions • III,IV,VI . Trochlear, Abducens- Extra-ocular movements, including opening of the eyes • V. Trigeminal- Facial sensation, movements of the jaw, and corneal reflexes
  22. 22. • VII. Facial-Facial movements and gustation • VIII. Vestibulo cohlear -Hearing and balance • IX,X. Glassopharngeal,Vagus-Swallowing, elevation of the palate, gag reflex and gustation • V,VII,X,XII. Hypoglossal-Voice and speech • XI. Spinal accessory, shrugging the shoulders and turning the head • XII. Hypoglossal-Movement and protrusion of tongue
  23. 23. 4.1 Cranial Nerve I (olfactory) • Evaluate the patency of the nasal passages bilaterally. Ask the patient to close their eyes, occlude one nostril, and place any familiar scented substance near the patent nostril and ask the patient to report what it is. Switch nostrils and repeat. • .
  24. 24. 4.2 Cranial Nerve II (optic) • The components of testing include visual acuity, visual field, optic fundus and pupillary reaction Visual acuity: • Severe deficit can be assessed testing whether patient can see light or movements, or can the patient count fingers. Patient may also be assessed to read newspaper or book having bigger letter size. To examine mild deficit, examiner record reading activity with Snellen’s chart or hand chart.
  25. 25. • Perform this part of the examination in a well-lit room and make certain that if the patient wears glasses, during the exam. Hold the chart 14 inches from the patient's face, and ask the patient to cover one of their eyes completely with their hand and read the lowest line on the chart possible. Have them repeat the test covering the opposite eye. For Snellen’s chart, 6 meters distance is expected to read letters. Test each eye separately.
  26. 26. Assessing Visual Fields by Confrontation test • Stand two feet in front of the patient and have them look into your eyes. • Hold your hands about one foot away from the patient's ears, and wiggle a finger on one hand. • Ask the patient to indicate which side they see the finger move. • Repeat two or three times to test both temporal fields. • If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card
  27. 27. • Using an ophthalmoscope, observe the optic disc, physiological cup, retinal vessels. Note the pulsations of the optic vessels, check for a blurring of the optic disc margin and a change in the optic disc's color form its normal yellowish orange. The initial change in the ophthalmoscopic examination in a patient with increased intracranial pressure is the loss of pulsations of the retinal vessels.
  28. 28. In the assessment of pupils note: • Size (small- miosis/ large-mydriasis) • Shape • Equality • Reaction to light: Both pupil constrict when light is shown in either eye. • Reaction to accommodation and convergence.
  29. 29. 4.3 Cranial Nerves III, IV and VI (Oculomotor, trochlear, abducens) • Observe for Ptosis • Test Extra ocular Movements • Stand or sit 3 to 6 feet in front of the patient. • Steady the patients head and ask him to follow your finger with their eyes without moving their head. • Check gaze in the six cardinal directions • Check for nystagmus. • Questions the patient about diplopia.
  30. 30. 4.4 Cranial Nerve V ( Trigeminal ) • Assess for pain, temperature and touch. Palpate the masseter muscles while you instruct the patient to bite down hard. Also note masseter wasting on observation. Next, ask the patient to open their mouth against resistance applied by the instructor at the base of the patient's chin
  31. 31. • Test the Three Divisions for Pain Sensation • Explain what you intend to do. • Use pin prick to test the sensation of the forehead, cheeks, and jaw on both sides. • Test the three divisions (maxillary, mandibular &ophthalmic) for temperature sensation with a tuning fork heated or cooled by water. • Test the three divisions for sensation to light touch using a wisp of cotton
  32. 32. • Test the Corneal Reflex • Ask the patient to look up and away. • From the other side, touch the cornea lightly with a fine wisp of wet cottonwool. • Look for the normal blink reaction of both eyes. • Repeat on the other side
  33. 33. 4.5 Cranial Nerve VII (Facial) • Observe for any facial droop or asymmetry or eyeclosure. • Ask Patient to do the following, note any lag, weakness, or asymmetry • Raise eyebrows(to wrinkle forehead) • Close both eyes to resistance • Smile • Frown • Show teeth • Puff out cheeks
  34. 34. 4.6 Cranial Nerve VIII (Vestibulocochlear) • Assess hearing by instructing the patient to close their eyes and to say "left" or "right" when a sound is heard in the respective ear. Vigorously rub your fingers together very near to, yet not touching, each ear and wait for the patient to respond. After this test, ask the patient if the sound was the same in both ears, or louder in a specific ear
  35. 35. Test for lateralization (Weber): • Use a 512 Hz or 1024 Hz tuning fork. • Start the fork vibrating by tapping it on your opposite hand. • Place the base of the tuning fork firmly on top of the patient's head. • Ask the patient where the sound appears to be coming from (normally in the midline).
  36. 36. Compare air and bone Conduction (Rinne) • Use a 512 Hz or 1024 Hz tuning fork. • Start vibrating the tuning fork by tapping it on your opposite hand. • Place the base of the tuning fork against the mastoid bone behind the ear. • When the patient no longer hears the sound, hold the end of the fork near the patient's ear (air conduction is normally greater than bone conduction).
  37. 37. 4.7 Cranial Nerves IX and X (glossopharyngeal and vagus) • Listen to the patient's voice. If there is vocal cord paresis(X nerve palsy)voice may be high pitched. • Ask Patient to Swallow to note swallowing difficulty. • Watch the movements of the soft palate and the pharynx by asking the patient to Say "Ah“ • Test Gag Reflex (Unconscious/Uncooperative Patient) • Stimulate the back of the throat on each side.It is normal to gag after each stimulus •
  38. 38. 4.8 Cranial Nerve XI (spinal accessory) • Look for atrophy or asymmetry of the trapezius muscles. • Ask patient to shrug shoulders against resistance. • Ask patient to turn their head against resistance. Watch and palpate the sternocleidomastoid muscle on the opposite side. • Repeat this manoeuvre on the opposite side. The patient should normally overcome the resistance applied by the examiner. Note any asymmetry.
  39. 39. 4.9 Cranial Nerve XII (hypoglossal) • The hypoglossal nerve controls the intrinsic musculature of the tongue and is evaluated by having the patient stick out their tongue and move it side to side. Normally, the tongue will be protruded from the mouth and remain midline. Note deviations of the tongue from midline, a complete lack of ability to protrude the tongue, tongue atrophy and fasciculations on the tongue.
  40. 40. 4.10 Sensory Examination The sensory modalities tested include pain, temperature, vibration, joint position and touch. Pain: Break off the wooden part of a cotton swab to make a sharp object or use a disposable, sterilized safety pin. Ask the patient with eyes closed to distinguish sharp end of the pin from dull.
  41. 41. Temperature: Test coldness with metal tuning fork. The patient should be able to identify cool vs. warmer objects or take two test tubes filled with hot water and cold water separately. Surface on the body at different times and observe reaction. Vibration: Test with low-frequency (128) tuning fork. The patient should be able to sense the vibration of the tuning fork Joint position or Proprioception: With eyes closed, patient distinguishes whether finger and toe are moved up or down.
  42. 42. Touch: Test light touch with a cotton swab. The patient distinguishes touch vs. no touch. Special tests of sensory function Stereognosis: With eyes closed, patient identifies pen, paper clip or coin placed in hand. This tests the parietal sensory cortex and posterior columns Graphesthesia: With eyes closed, patient identifies numbers or figures or shapes written on palm. This tests the sensory cortex and integration. Two-point discrimination: Patients should be able to distinguish two simultaneous points of different intensity 2 to 10 mm apart on fingers and hands. Compare patient's two sides
  43. 43. 4.11 Motor System Examination • The motor system evaluation is divided into the following: Muscle bulk, muscle tone, involuntary movements and muscle strength. • Systematically examine all of the major muscle groups of the body. • Note the muscle bulk (atrophy, hypertrophy, normal). • Feel the tone of the muscle (flaccid, clonic, normal). • Presence of any abnormal movements like tremor, fasciculation’s, tics. • Test the strength of the muscle group.
  44. 44. Muscle strength grading: If pyramidal weakness is suspect test the power of muscle with reference to pressure and gravitation. Assign scores as follows: • 0-No muscle contraction is detected • 1-A flicker or trace contraction is noted in the muscle while the patient attempts to contract it. • 2-The patient is able to actively move the muscle with gravity eliminated.
  45. 45. • 3-The patient may move the muscle against gravity but not against resistance from the examiner. • 4-The patient may move the muscle group against some resistance from the examiner. • 5-The patient moves the muscle group and overcomes the resistance of the examiner. This is normal muscle strength
  46. 46. 4.12 Deep Tendon Reflexes Observing reflexes is the most objective part of the neurological exam, since the reflexes are not under voluntary control and testing does not depend on the patient's cooperation, attitude, or awareness. • Biceps reflex tests C5-6: The biceps reflex is elicited by placing your thumb on the biceps tendon and striking your thumb with the reflex hammer and observing the arm movement. • Brachioradialis reflex also tests C5-6. The brachioradialis reflex is observed by striking the brachioradialis tendon directly with the hammer when the patient's arm is resting. Strike the tendon roughly 3 inches above the wrist. Note the reflex supination.
  47. 47. • Triceps: tests C7-8. The triceps reflex is measured by striking the triceps tendon directly with the hammer while holding the patient's arm with your other hand • Quadriceps (knee jerk): tests L2-L4 With the lower leg hanging freely off the edge of the bench, the knee jerk is tested by striking the quadriceps tendon directly with the reflex hammer. • Achilles (ankle jerk): tests L5-S2 The ankle reflex is elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion.
  48. 48. Deep tendon reflex grading • 4+ very brisk, hyperreflexive, with clonus • 3+brisker or more reflexive than normally • 2+normal • 1+ normal, diminished • 0 no response
  49. 49. 4.12 Co-ordination and Balance • The stance (attitude of standing) and the gait of the patient have to be observed for irregularities. The tests of co-ordination include Finger –nose test, heel –shin test, rapid alternating movements. Balance is tested using the Romberg's sign test. • Finger -nose test: Ask the patient to extend their index finger and touch their nose, and then touch the examiner's outstretched finger with the same finger. Ask the patient to go back and forth between touching their nose and examiner's finger. This tests the upper extremity co-ordination.
  50. 50. Heel- shin test: ask the patient to place the heel on the opposite shin and run up to the knee and back to ankle. The patient should be able to perform it quickly and without side-to-side wavering. Rapid Alternating Movement Ask the patient to place their hands on their thighs and then rapidly turn their hands over and lift them off their thighs. Ask the patient to repeat it rapidly for 10 seconds. Normally this is possible without difficulty. Dysdiadochokinesis is the clinical term for an inability to perform rapidly alternating movements
  51. 51. Romberg’s test • Ask the patient to stand still with their heels together, arms on the side and close their eyes. If the patient loses their balance, the test is positive.
  52. 52. 4.13 Assessment of brain stem reflexes Pupillary response to light: The response to bright light should be absent in both eyes. The pupil should be observed closely for one minute to allow time for a slow response to become evident. Widely dilated pupils are not a necessary criterion for brain death but fixed pupils with no response to light are mandatory. Corneal reflex: This should be absent.
  53. 53. Oculo cephalic reflex (Doll’s eye phenomenon): This test must not be performed in patients with an unstable cervical spine. The head is turned from starting position to a new steady position and briskly to the opposite side. The eyes move denoting the integrity of the medial longitudinal fasciculus in the brain stem. Gag reflexes: This should be absent. A tongue depressor is used to stimulate each side of the oropharynx and the patient observed for any pharyngeal or palatal movement.
  54. 54. Cough reflex: A suction catheter is introduced into the endotracheal or tracheostomy tube to deliberately stimulate the carina. The patient is closely observed for any cough response or movement of the chest or diaphragm. Oculovestibular reflex: Slow irrigation with at least 5-ml of ice-cold water is performed into the external auditory canal while, the eyes are held open by an assistant. The eyes should be observed for one minute after irrigation is completed before repeating the test on the other side. An intact oculovestibular reflex causes tonic deviation of the eyes towards the irrigated ear. Any movement of one or both eyes, whether conjugate or not, excludes the diagnosis of brain death. In a brain dead patient the eyes remain fixed. Combined ice-cold water caloric stimulation and head rotation has been suggested as the most pro-found stimulation for deeply unconscious patients.
  55. 55. conclusion A thorough physical examination including history with focus on neurological examination helps the nurse in nursing assessment and formulation of diagnosis. An accurate and timely neurological examination performed by a nurse can pick up the subtle changes in patients, which often prove crucial in areas like emergency department and critical care units. Practicing the examination and examining the practice makes one confident and skilled in the neurological examination.

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