Neurological Assessment Techniques for Older Adults, Exams of Nursing

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Cranial Nerve I: Olfactory Test - correct answer test sense of smell with familiar odor Cranial Nerve II: Optic Test - correct answer test visual acuity and visual field with confrontation Confrontation Test - correct answer gross measure of peripheral vision

• stand 2 fett from person
• have patient cover one eye, then cover your own eye opposite to the persons covered one
• hold finger as target midline between you and patient, slowly advance to periphery
• as person to say "now" as target is first seen Confrontation Test: normal - correct answer 50 degrees upward 90 degrees temporal 70 degrees down 60 degrees nasal Cranial Nerve III, IV, VI: Oculomotor, Trochlear, Abducens Test - correct answer PERRLA 6 cardinal positions of gaze PERRLA - correct answer pupils equal, round, reactive to light (direct and consensual) and accommodation 6 cardinal positions of gaze - correct answer right & up right right & down left & up left left & down nystagmus - correct answer back-and-forth oscillation of the eyes nystagmus: amplitude - correct answer fine, medium or coarse movement nystagmus: frequency - correct answer constant or fades after few beats nystagmus: plane of movement - correct answer horizontal, vertical, rotary or combo

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Cranial Nerve V: Trigeminal Test - correct answer Motor: asking the client to clench her teeth while you palpate the masseter (muscle of mastication) Sensory- test light touch by having a client closer their eyes while you toucher her face gently with a wisp of cotton, patient identifies location What does the corneal reflex test? - correct answer CN V sensory, CN VII motor Corneal reflex test - correct answer - remove contacts, bring cotton wisp from side, lightly touch cornea NORMALLY: patient blinks bilaterally Cranial Nerve VII: Facial Test - correct answer Motor: have client smile, frown, puff out her cheeks, raise her eyebrows, close her eyes tightly Sensory: anterior 2/3 taste (sugar, salt, lemon juice) Cranial Nerve VIII: Vestibulocochlear Test - correct answer Whispered voice test Cranial Nerve IX & X: Glossopharyngeal and Vagus Test - correct answer Motor: open mouth say "ahh" & gag reflex NORMALLY: uvula and soft palate rise in midline Sensory: CN IX does posterior 1/3 taste Cranial Nerve XI: Accessory Test - correct answer shrug shoulders Cranial Nerve XII: Hypoglossal Test - correct answer say "light, tight, dynamite" screening neuro exam - correct answer perform on well persons who have no significant subjective findings complete neuro exam - correct answer perform on person with neuro concerns neuro recheck exam - correct answer perform on person with demonstrated neuro defect, who requires period ic assessment ansomia - correct answer Decrease or loss of smell occurs bilaterally hemianopsia; hemianopia - correct answer Defective vision or blindness in one half of the visual field ptosis - correct answer drooping eyelid paresthesias - correct answer tingling, prickling, "pins & needles" (sensory loss)

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diplopia - correct answer double vision dysphagia - correct answer difficulty swallowing What are the test to evaluate cerebellar function? - correct answer Balance Test (Gait) Romberg Test Rapid Alternating Movements (RAM) Balance Test (Gait) - correct answer - observe as the person walks 10 to 20 feet, turns and returns to the starting point NORMALLY: gait is smooth, rhythmic and effortless opposing arm swing is coordinating Romberg test - correct answer - ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed for ~20 seconds NORMALLY: patient can maintain posture and balance Rapid Alternating Movements (RAM) - correct answer pat the knees with both hands, turn hands over, then faster NORMALLY: done with equal turning and quick rhythmic pace flaccidity - correct answer decreased muscle tone (hypotonia), muscle feels limp, soft, flabby spasticity - correct answer increased muscle tone (hypertonia) rigidity - correct answer constant state of resistance; resists passive movement in any direction (dystonia) cogwheel rigidity - correct answer Increased tone is released by degrees during passive range of motion so it feels like small, regular jerks. paralysis - correct answer decreased or loss of motor power hemiplegia - correct answer Spastic or flaccid paralysis of one side of the body paraplegia - correct answer symmetric paralysis of both lower extremities quadriplegia - correct answer paralysis of all four extremities paresis - correct answer weakness of muscles rather than paralysis tic - correct answer involuntary, compulsive, repetitive twitching of a muscle group myoclonus - correct answer Rapid, sudden jerk or a short series of jerks at fairly regular intervals. (ex: hiccup)

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fasciculation - correct answer rapid continuous twitching of resting muscle without movement of limb chorea - correct answer sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face irregular intervals, not rhythmic or repetitive athetosis - correct answer slow, writhing involuntary movements tremor - correct answer involuntary contraction of opposing muscle groups resulting in rhythmic movement of one or more joints rest tremor - correct answer occurs when muscles are quiet and supported against gravity (hand in lap), coarse and slow, partly or completely disappears with voluntary movement intention tremor - correct answer worse with voluntary movement (like reaching to a target) spastic hemiparesis - correct answer Arm is immobile against the body, with flexion of the shoulder, elbow, wrist, and fingers and adduction of shoulder; does not swing freely. Leg is stiff and extended and circumducts with each step (drags toe in a semicircle). cerebellar ataxia - correct answer staggering, wide-based gait; difficulty with turns; uncoordinated movement with positive Romberg sign parkinsonian (festinating) - correct answer Posture is stooped; trunk is pitched forward; elbows, hips, and knees are flexed. Shuffling gait. Difficulty with any change in direction. scissors - correct answer knees cross or are in contact, like holding an orange between the thighs. steppage or foot drop - correct answer slapping quality, looks like walking up stairs with no stairs there waddling - correct answer weak hip muscles- when the person takes a step, the opposite hip drops, which allows compensatory lateral movement of pelvis short leg - correct answer Leg length discrepancy >2.5 cm (1 inch). cerebral palsy - correct answer damage to cerebral cortex from a developmental defect (infancy and childhood), intrauterine meningitis or encephalitis, birth trauma, anoxia muscular dystrophy - correct answer a chronic, progressive wasting of skeletal musculature producing weakness contracture and respiratory dysfunction or death

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Parkinsonism - correct answer loss of dopamine-producing neurons causing motor tract disorder symptoms: resting tremor, bradykinesia, cogwheel rigidity cerebellar - correct answer A lesion in one hemisphere produces motor abnormalities on the ipsilateral side. Multiple Sclerosis (MS) - correct answer chronic, progressive, immune mediated disease which axons experience inflammation, demyelination, degeneration and finally sclerosis decorticate rigidity - correct answer upper: flexion of arm, wrist fingers, adduction of arms lower: extension, internal rotation, plantar flexion decerebrate rigidity - correct answer Upper: stiffly extended, adducted, internal rotation, palms pronated. Lower extremities: stiffly extended, plantar flexion; teeth clenched; hyperextended back flaccid quadriplegia - correct answer complete loss of muscle tone and paralysis of all four extremities (completely nonfunctional brainstem) Opisthotonos - correct answer prolonged arching of back, with head and heels bent backward (meningeal irritation) stereognosis - correct answer Test the persons ability to recognize objects by feeling their forms, sizes and weights position (kinesthesia) - correct answer test person's ability to perceive passive movements of extremities Tactile discrimination (fine touch) - correct answer measure the discrimination ability of the sensory cortex Graphesthesia - correct answer ability to "read" a number by having it traced on the skin two point discrimination - correct answer test ability to distinguish separation of two simultaneous pin points on skin extinction - correct answer simultaneously touch both sides of body at the same time, both sensations should be felt point location - correct answer touch skin and withdraw stimulus promptly; ask person to put finger where you touched

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peripheral neuropathy - correct answer Loss of sensation involves all modalities; loss most severe distally at feet and hands individual nerves or roots - correct answer Decrease or loss of all sensory modalities; corresponds to distribution of involved nerve Spinal Cord Hemisection (Brown-Sequard Syndrome) - correct answer injury to one-half of the cord, causing contralateral loss of pain and temp the ipsilateral side side of the lesion has paralysis and loss of vibration and touch sensation Complete transection of spinal cord - correct answer Complete loss of all sensory modalities below level of lesion; associated with motor paralysis and loss of sphincter control thalamus - correct answer loss of all sensory modality son the face, arm and leg on the side contrateral to lesion cortex lesion - correct answer loss of discrimination on contralateral side; loss of graphesthesia, stereognosis, recognition of shapes and weights, finger findings deep tendon reflexes (DTR) - correct answer measurement of stretch reflex reveals intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levels DTR scale - correct answer 0 - no response 1+ - diminished low normal or occurs w reinforcement 2+ - normal 3+ - brisker than average may indicate disease 4+ - hyperactive w/ clonus, very brisk, indicative of disease Clonus - correct answer test when reflex are hyperactive how do you test clonus? - correct answer support lower leg in one hand and with other hand move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing fort, hold stretch what do you normally and abnormally see in a clonus test? - correct answer NORMALLY: you feel no further movement ABNORMALLY: note rapid rhythmic contractions of calf and foot Tempomandibular Joint (TMJ) assessment - correct answer note smooth movement without limitations or tenderness, clicking or popping when jaw opens and closes

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how do you assess the thyroid gland? - correct answer ask client to take a sip of water, hold in mouth, the swallow while palpating thyroid gland

• one hand palpates and the other displaces what is abnormal in palpating the thyroid gland? - correct answer an enlarged thyroid What does the nurse do next if the thyroid gland is enlarged? - correct answer LISTEN FOR BRUIT (turbulent blood flow) check the area they drain from for source of the problem how do you examine lymph nodes? - correct answer gentle circular motion of finger, palpate lymph nodes visual acuity test: snellen chart - correct answer person 20 feet from chart, ask to read smallest line possible what does 10/20 vision mean - correct answer patient reads 10 feet way what a normal person reads 20 feet away visual acuity: jaeger card - correct answer normal: 14/14 without hesitancy or moving card Corneal Light Reflex (Hirschberg Test) - correct answer Assess the parallel alignment of the eye axes by shining a light toward the person's eyes. what is normal for the corneal light reflex test? - correct answer light reflection on cornea should be in same spot on each eye pupillary light reflex - correct answer normal constriction of pupils when bright light shines on retina direct light reflex - correct answer constriction of the same-sided pupil consensual light reflex - correct answer simultaneous constriction of the other pupil red reflex - correct answer red glow that appears to fill the person's pupil caused by reflection of light of inner retina what is a normal finding for the whispered voice test - correct answer person can repeat back a the combo of letters and numbers tuning fork test - correct answer Measure bone and air conduction of sound what is vestibular apparatus and what test is used? - correct answer a sensory organ for detecting sensations of equilibrium.

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• romberg test palpation of the sinus area - correct answer Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over maxillary sinuses below cheekbones tonsil scale - correct answer 1+ visible 2+ halfway between tonsillar pillars and uvula 3+ touching uvula 4+ touching each other NORMAL IS 1- 2 presbyopia - correct answer lens loses elasticity, becoming hard and glasslike. decrease ability to change shape and accommodate near vision cataracts - correct answer transparent fibers of lens begin to thicken and yellow, resulting from a clumping of protein in lens glaucoma - correct answer increased intraocular pressure macular degeneration - correct answer breakdown of cells in macula of the retina
• loss of mental vision is the most common cause of blindness (person may be unable to read fine print, sew, etc) pingueculae - correct answer common non-cancerous growth that forms on conjunctiva otosclerosis - correct answer gradual hardening that causes foot plate of stapes to become fixed in oval window, impeding of sound transmission causing progressive deafness impacted cerumen - correct answer common but reversible cause of hearing loss in older people presbycusis - correct answer type of hearing loss occurring w aging gradual sensorineural loss - correct answer caused by nerve degeneration in inner ear to auditory nerve what tone loss is noticed first in older adults - correct answer high-frequency senile tremors - correct answer benign and include head nodding (as if saying yes or no) and tongue protrusion (older adult) kyphosis - correct answer humpback

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when performing ROM on older adult... - correct answer PERFORM ROM SLOWLY to prevent lightheaded/diziness tension headache - correct answer occurs on both sides across frontal, temporal and occipital region, BAND LIKE TIGHTNESS, non throbbing, non pulsatile migraine headache - correct answer commonly one sided but can occur on both sides, pain behind eyes, temples and forehead, throbbing, pulsating cluster headache - correct answer rare HA, intermittent, excruciating , unilateral, always one sided, often behind or around eye, temple, forehead, cheek, continuous, burning or piercing Parkinsons syndrome facial appearances - correct answer immobility of features produces face that is flat, expressionless, "MASK LIKE" with elevated eyebrows, staring gaze, oily skin, drooling Cushing syndrome facial appearances - correct answer rounded "MOONLIKE" face, prominent jewels, red cheeks and chin, acneiform rash on chest Graves disease facial appearance - correct answer (hyperthyroidism) goiter, eyelid retraction and exophthalmos (bulging eyeballs) Hypothyroidism (myxedema) - correct answer puffy, edematous face, periorbital edema, puffy hands feet, coarse face feature, cool dry skin, coarse hair and eyebrow bells palsy facial appearance - correct answer complete paralysis of one side of face, person cannot wrinkle forehead, raise eyebrows, close eyelids, whistle or show teeth on left side. usually presents w smooth forehead, wide palepral fissure stroke (brain attack/cerebrovasular accident) facial appearance - correct answer note paralysis of lower facial muscle but also note the upper half of the face is NOT affected, person is able to wrinkle forehead and close eyes cachet appearance - correct answer sunken eyes, hollow cheeks and exhausted defeated expression scleroderma - correct answer "hard skin". a chronic connective tissue disorder associated with decreased mobility strabismus - correct answer crossed eyes diplopia - correct answer double vision what do normal conjunctiva look like - correct answer clear and show normal color, pink lower ids and white sclera

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normal eye appearance in African Americans - correct answer have gray/blue or darker color to sclera, normally my see small brown macule (like freckles) on sclera

• may have yellowish fatty deposits beneath lids away from cornea esotropia - correct answer inward turning of the eye exotropia - correct answer outward turning of the eye periorbital edema - correct answer edema around the eyes exophthalmos - correct answer protruding eyeballs Enophthalmos - correct answer sunken eyes ptosis - correct answer drooping upper lid upward palpebral slant - correct answer seen in Asians, also it indicates Down syndrome. ectropion - correct answer the rolling out (eversion) of the edge of an eyelid entropion - correct answer inward turning of the rim of the eyelid blepharitis - correct answer inflammation of the eyelid chalazion - correct answer beady nodule protruding on the lid (an obstruction and inflammation of meibomian gland) hordeolum - correct answer stye, acute localized staph infection of hair follicles at lid margin, painful red swollen dacryocystitis - correct answer inflammation of the lacrimal (tear) sac basal cell carcinoma - correct answer small painless nodule with central ulceration and sharp, rolled out pearly edges, removal, usually cures it anisocoria - correct answer unequal pupil size monocular blindness - correct answer When light is directed into blind eye, no response in either eye. When it is directed to normal eye, both pupils constrict. miosis - correct answer constricted & fixed pupils mydriasis - correct answer dilation & fixed pupil Argyll Robertson pupil - correct answer Constricts w/ accomodation but is not reactive to light. Tonic (Adie's) Pupil - correct answer reaction to light and accommodation is sluggish

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CN III damage - correct answer Unilateral dilated pupil has no reaction to light or accommodation. Ptosis with eye deviating down and laterally may be present. Horner's syndrome - correct answer Unilateral, small, regular pupil does react to light and accommodation. also note Ptosis and absence of sweat (anhidrosis) on same side. Conductive hearing loss causes - correct answer partial loss caused by impacted cerumen, pus, perforated TM, decrease mobility of ossicles sensorinerual hearing loss - correct answer path of inner ear and CN VIII or auditory area of cerebral cortex mixed hearing loss - correct answer combination of sensorineural and conductive hearing loss dry cerumen - correct answer gray, flaky, and frequently forms thin mass in ear canal wet cerumen - correct answer honey brown to dark brown and moist otitis externa - correct answer swimmers ear sebaceous cyst - correct answer a nodule with central black punctum indicates blocked sebaceous glands tophi - correct answer Small, whitish yellow, hard, nontender nodules in or near helix or antihelix; contain greasy, chalky material of uric acid crystals and are a sign of gout. Chondrodermatitis Nodularis Helicus - correct answer Painful nodules develop on the rim of the helix as a result of repetitive mechanical pressure or environmental trauma keloid - correct answer overgrowth of scar tissue bifid uvula - correct answer uvula split completely or partially cleft lip and palate - correct answer congenital split of the lip and roof of the mouth torus palatinus - correct answer bony ridge running in middle of hard palate leukoedema - correct answer a benign lesion occurring on buccal mucosa, is seen more often in African Americans epistaxis - correct answer nosebleed xerostomia - correct answer dry mouth what is a normal appearance in mouth of African Americans - correct answer bluish lips and dark line on gingival margin Edentulous - correct answer lacking teeth

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furuncle - correct answer A small boil located in the skin or mucous membrane; appears red and swollen and is quite painful. foreign body - correct answer putting an object up the nose perforated septum - correct answer hole in septum acute rhinitis - correct answer (nonallergic) first sign is watery discharge which can become purulent with sneezing rhinorrhea - correct answer discharge from the nose allergic rhinitis - correct answer abnormal immune response, rhinorrhea , itching of nose eyes, lacrimation, congestion sneezing Sinusitus - correct answer acute inflames sinus area may have mucopurulent drainage with face pain/pressure nasal polyps - correct answer smooth, pale gray nodules (overgrowth of mucosa) from chronic allergic rhinitis Angular Cheilitis (Stomatitis, Perleche) - correct answer Erythema, scaling, and shallow and painful fissures at the corners of the mouth what is the acronym for a stroke? - correct answer FAST F: facial drooping A: arm weakness S: speech impairment T: time to call 911 use abbreviation of neurologic examination in the following sequence: - correct answer Level of Consciousness (LOC) Glasgow Coma Scale (GSG) Motor function Pupillary respinse Vital signs Level of Consciousness (LOC) - correct answer state of awareness of self and environment

• change in LOC is the single most important factor in this examination

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Glasgow Coma Scale (GCS) - correct answer rate patient on :

• Eye-opening response (4-1): spontaneous, to speech, to pain, no response
• Motor response (6-1): obeys verbal command, localizes pain, flexion (withdrawal), flexion (abnormal), extension (abnormal), no response
• Verbal response (5-1): oriented x3 (appropriate), conversation confused, speech inappropriate, speech incomprehensible, no response what is normal on the GCS? - correct answer 15 - AOx what is the sequence of a Nero exam - correct answer mental status cranial nerves motor system sensory system reflexes Spinothalmic Tract - correct answer pain temperature light touch posterior column tract - correct answer vibration, position, tactile discrimination normal response: biceps reflex - correct answer contraction of biceps muscle and flexion of forearm normal response: triceps reflex - correct answer extension of forearm normal response: brachioradialis reflex - correct answer flexion and supination of forearm normal response: quadriceps reflex - correct answer extension of lower leg normal response: achilles reflex - correct answer foot is plantar flexes against your hand Superficial (cutaneous) reflexes - correct answer sensory receptors in skin rather than in muscles;

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motor response is localized muscle contraction Babinski reflex - correct answer Reflex in which a newborn fans out the toes when the sole of the foot is touched

• for those 1 year old or younger otherwise its abnormal normal response: abdominal reflexes - correct answer ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward stroke normal response: planter reflex - correct answer plantar flexion of toes and inversion and flexion of forefoot dyskinesia - correct answer difficult movement older adults: repetitive stereotyped movements in jaw, lips, or tongue may accompany senile tremors; no associated rigidity present lymph node palpation technique order - correct answer - Preauricular: in front of ear
• Posterior auricular (mastoid): superficial to mastoid process
• Occipital: at base of skull
• Submental: midline, behind tip of mandible
• Submandibular: halfway between angle and tip of mandible
• Jugulodigastric (tonsillar): under angle of mandible
• Superficial cervical: overlying sternomastoid muscle
• Deep cervical: deep under sternomastoid muscle
• Posterior cervical: in posterior triangle along edge of trapezius muscle
• Supraclavicular: just above and behind clavicle, at sternomastoid muscle

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hydrocephalus - correct answer obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head objective vertigo - correct answer room is spinning subjective vertigo - correct answer Person feels like he or she spins