N295 EXAM 4 - LONG ISLAND UNIVERSITY - LATEST VERSION, RATED A

Document Content and Description Below

N295 Exam #4 EAR ASSESSMENT A&P Ear • Three parts: external ear, middle ear and inner ear External Ear • Called the auricle or pinna and consists of movable cartilage and skin • Exter... nal auditory canal: a culde-sac 2.5-3cm long and terminates at the eardrum or tympanic membrane (TM) o Lined w/ glands that secrete cerumen Middle Ear • A tiny air-filled cavity inside the temporal bone • Contains tiny ear bones or auditory ossicles: malleus, incus and stapes • Three functions: o Conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear o Protects the inner ear by reducing the amplitude of loud sounds o Its Eustachian tube allowed equalization of air pressure on each side of the tympanic membrane so the membrane does not rupture Inner Ear • Embedded in bone • Contains bony labyrinth (holds the sensory organs for equilibrium and hearing o Vestibule, semicircular canals compose vestibular apparatus and cochlea contains central hearing apparatus • Not accessible to direct examination, can assess its functions though Hearing • Involves the auditory system at 3 levels: o Peripheral, brainstem and cerebral cortex o At peripheral level sounds  vibrations  electrical impulses Aging Adult • Cilia lining the ear canal become coarse and stiff • Cerumen is drier • Hx of frequent ear infections result in scarring on drum • Impacted cerumen common in aging adults • Person living or working in a noise-polluted area has a greater risk for sensorineural hearing loss • Presbycusis: type of hearing loss that occurs with 60% of those older than 65 y/o (even if living in a quiet environment o A gradual sensorineural loss caused by nerve degeneration in the inner ear that slowly progresses SUBJECIVE DATA • Earache, infections, discharge, hearing loss, environmental noise, tinnitus, vertigo, patient-centered care OBJECTIVE DATA INSPECT AND PALPATE THE EXTERNAL EAR NORMAL RANGE OF FINDINGS ABNORMAL FINDINGS Size and Shape • Ears are of equal shape bilaterally; no swelling or thickening • Microtia-ears smaller than 4cm vertically • Macrotia-ears larger than 10cm • Edema with infection or trauma Skin condition • Color consistent with the person’s facial skin color • Skin intact w/ no lumps or lesions • Darwin’s tubercle: small, painless nodule at the helix; congenital variation • Reddened, excessively warm skin w/ inflammation • Crusts and scaling occur with otitis externa, eczema, contact dermatitis, seborrhea • Enlarged, tender lymph nodes in the region indicate inflammation of the pinna or mastoid process • Red-blue discoloration with frostbite • Trophi, sebaceous cyst, chondrodermatitis, keloid, carcinonma Tenderness • Move pinna and push on the tragus • Should feel firm and movement should produce no pain • Palpating the mastoid process should produce no pain • Pain with movement occurs with otitis externa and furuncle • Pain at the mastoid process may indicate mastoiditis or enlarged posterior auricular node The external auditory meatus • Note size of opening to direct choice of speculum for otoscope • No swelling, redness or discharge should be present • Some cerumen is usually present; color varies from gray-yellow to light brown and black, texture varies from moist and waxy to dry and desiccated • A sticky, yellow discharge accompanies otitis externa or may indicate OM if the drum has ruptured • Impacted cerumen is a common cause of conductive hearing loss INSPECT WITH THE OTOSCOPE • Note the size of the auditory meatus • Choose the largest speculum that fits comfortable in the ear canal • Tilt the person’s head slightly away from you toward the opposite shoulder • Pull the pinna up and back on an adult or older child (helps straighten the S-shape of the canal • Hold pinna gently but firmly • Do not release traction on the ear until you have finished the examination and the otoscope is removed • Hold the otoscope “upside down” along your fingers and have the dorsa (back) of your hand along the person’s cheek braced to steady the otoscope • Insert the speculum slowly and carefully along the axis of the canal; put eye up to the otoscope • Avoid touching the inner “bony” section • Perform otoscopic examination before testing hearing NORMAL RANGE OF FINDINGS ABNORMAL FINDINGS External Canal • Note any redness and swelling, lesions, foreign bodies or discharge • Any changes: note color and odor • Person w/ hearing aid: note any irritation or the canal wall from poorly fitting ear molds • Redness and swelling occur with otitis externa; canal may be completely closed with swelling • Purulent otorrhea suggests otitis externa or OM if the drum has ruptured • Frank blood or clear, watery drainage (CSF) after trauma suggests basal skull fracture and warrants immediate referral. CSF feels oily and is positive for glucose on Tes-Tape • Foreign body, polyp, furuncle, exostosis Tympanic Membrane Color and Characteristics • Normal eardrum is shiny and translucent, w/ a pearly gray color • Cone-shaped light reflex is prominent in the anteriorinferior quadrant • Sections of the malleus are visible through the translucent drum (umbo, manubrium and short process) • At the periphery the annulus looks whiter and denser Position • Eardrum is flat and slightly pulled in at the center Integrity of Membrane • Inspect the eardrum and the entire circumference of the annulus for perforations • Normal TM is intact Color and Characteristics • Yellow-amber drum color occurs with OM with effusion (serous) • Red color with acute OM • Absent or distorted landmarks • Air/fluid level or air bubbles behind drum indicate OM with effusion Position • Retracted drum is caused by vacuum in middle ear with obstructed Eustachian tube • Bulging drum is caused by increased pressure in OM Integrity of Membrane • Perforation shows as a dark oval area or as a larger opening on the drum • Vesicles on drum TEST HEARING ACUITY NORMAL RANGE OF FINDINGS ABNORMAL FINDINGS • “Do you have difficulty hearing now?” • Pure tone audiometer gives a precise quantitative measure of hearing by assessing the person’s ability to hear sounds of varying frequency • w/ patient sitting, prop his or her elbow on the armrest of the chair w/ the hand making a gentle fist; tell patient to raise finger when sound heard and lower when no longer heard • Test each ear separately and record results • This single question in people over 50 y/o has an 83% to 90% agreement with hearing loss documented by audiometric testing Whispered Voice Test • Stand arm’s length (2 feet) behind the person • Test one ear at a time while masking hearing in the other ear to prevent sound transmission around the head (place one finger on the tragus and pushing it in and out of the auditory meatus • Whisper slowly a set of 3 random numbers and letters • Normally the person repeats each number/letter correctly after you say it • If not correct, repeat using different numbers and letters • Passing score is correct repetition of at least 3 of the possible 6 numbers/letters • Assess other ear with different numbers and letters • The person is unable to hear whispered items. A whisper is a high-frequency sound and is used to detect high-tone loss Tuning Fork Tests • Measure hearing by air conduction r bone conduction • Weber and Rinne tests do not yield precise or reliable data; these tests should not be used for general screening • With documented hearing loss, these tests may help distinguish conductive loss from sensorineural loss. But they cannot screen a conductive loss from a mixed conductive/sensorineural loss VESTRIBULAR APPARATUS • Romberg test: assess the ability of the vestibular apparatus in the inner ear to help maintain standing balance ABNORMAL FINDINGS EXTERNAL EAR ABNORMALITIES FROSTBITE Reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, the person feels pain and tenderness, and ear necrosis may ensue Otitis Externa (Swimmer’s Ear) An infection of the outer ear, w/ severe painful movement of the pinna and tragus, redness and swelling of pinna and canal, scanty purulent discharge, scaling, itching, fever and enlarged tender regional lymph nodes. Hearing normal or slightly diminished. More common in hot, humid weather. Swimming causes canal to become waterlogged and swell; skinfolds set up for infection. Prevent by using rubbing alcohol or 2% acetic acid eardrops after every swim Branchial Remnant and Ear Deformity A facial remnant or leftover of the embryologic branchial arch usually appears as a skin tag; in this case, one containing cartilage. Occurs most often in the preauricular area, in front of the tragus. When bilateral, there is increased risk for renal anomalies Cellulitis Inflammation of loose, subcutaneous connective tissue. Shows as thickening and induration of auricle with distorted contours LUMPS AND LESIONS ON THE EAR Sebaceous Cyst Location is commonly behind lobule in the postauricular fold. A nodule with central black punctum indicates blocked sebaceous gland. It is filled with waxy sebaceous material and painful if it becomes infected. Often are multiple Tophi 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 Painful nodules develop on rim of helix (where there is no cushioning subcutaneous tissue) as a result of repetitive mechanical pressure or environmental trauma (sunlight). They are small, indurated, dull red, poorly defined, and very painful Keloid Overgrowth of scar tissue, which invades original site of trauma. It is more common in dark-skinned people, although it also occurs in Whites. In the ear it is more common at lobule at site of a pierced ear. Overgrowth shown here is unusually large Battle Sign Trauma to the side of the head may lead to a basilar skill fracture involving the temporal bone. This shows as ecchymotic discoloration just posterior to the pinna and over the mastoid process. A look inside the ear canal may show hemotympanum as well Carcinoma Ulcerated, crusted nodule with indurated base that fails to heal. Bleeds intermittently. MUST REFER FOR BIOPSY. Usually occurs on the superior rim of the pinna, which has the most sun exposure. May occur also in ear canal and show chronic discharge that is either serosanguineous or bloody HEARING LOSS • May be sensorineural, conductive, or mixed • Age-related sensorineural loss affects 63% of those 70 years or older; 80% over 85 y/o • It is underscreened and undertreated • Hearing aids can improve this loss • Conductive hearing loss blocks sound transmission somewhere in the external auditory canal, tympanic membrane, or middle ear ABNORMAL VIEWS SEEN ON OTOSCOPY Appearance of Eardrum Indicates Suggested Condition Yellow-amber color Serum or pus Otitis media w/ effusion (OME) or chronic otitis media Prominent landmarks Retraction of drum Vacuum in middle ear from obstructed eustacian tube Air/fluid level or air bubbles Serous fluid Otitis media w/ effusion Absent or distorted light reflex Bulging of eardrum Acute otitis media Bright red color Infection in middle ear Acute otitis media Blue or dark red color Blood behind drum Trauma, skull fracture Dark, round or oval areas Perforation Drum rupture White dense areas Perforation Drum rupture Diminished or absent landmarks Thickened drum Chronic otitis media Black or white dots on drum or canal Colony of growth Fungal infection ABNORMAL TYMPANIC MEMBRANES Retracted Drum Landmarks look more prominent and well defined. Malleus handle looks shorter more horizontal than normal. Short process is very prominent. Light reflex is absent or distorted. The drum is dull and lusterless and does not move. These signs indicate negative pressure and middle ear vacuum from obstructed eustachian tube and serous otitis media Otitis Media w/ Effusion (OME) An amber-yellow drum suggests serum in middle ear that transudes to relieve negative pressure from the blocked eustachian tube. You may note an air/fluid level with fine black dividing line or air bubbles visible behind drum. Symptoms are feeling of fullness, transient hearing loss, popping sound with swallowing Acute Otitis Media This results when the middle ear fluid is infected. An absent light reflex from increasing middle ear pressure in an early sign. Redness and bulging are first noted in superior part of drum (pars flaccida), along with earache and fever. Then fiery red bulging of entire drum occurs along with deep throbbing pain. Accompanied by possible fever and transient hearing loss. Pneumatic otoscopy reveals drum hypomobility Perforation If the acute otitis media is not treated, the drum may rupture from increased pressure. Perforations also occur from trauma. Usually the perforation appears as a round or oval darkened area on the drum. Central perforations occur in the pars tensa. Marginal perforations occur at the annulus. Marginal perforations are called attic perforations when they occur in the superior part of the drum, the pars flaccida Insertion of Tympanostomy Tubes Polythylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and promote drainage of chronic or recurrent middle ear infections. Number of acute infections tends to decrease because of improved aeration. Tubes extrude spontaneously in 12-18 months Cholesteatoma An overgrowth of epidermal tissue in the middle ear or temporal bone may result over the years after a marginal TM perforation. It has a pearly white, cheesy appearance. Growth of cholesteatoma can erode bone and produce hearing loss. Early signs include otorrhea, otalgia, unilateral conductive hearing loss, tinnitus Scarred Drum Dense white patches on the eardrum are sequelae of repeated ear infections. They do not necessarily affect hearing Blue Drum (Hemotympanum) This indicates blood in the middle ear, as in trauma resulting in skill fracture Fungal Infection Colony of black or white dots on drum or canal wall suggest a yeast or fungal infection Bullous Myringitis Small vesicles containing blood are on the eardrum; it accompanies mycoplasma pneumonia and viral infections. Blood-tinged discharge and severe otalgia may be present TUNNING FORK TESTS Weber Test Rinne Test NORMAL—Sound is equally loud in both ears; sound does not lateralize NORMAL—sound is heard twice as long by air conduction (AC) as by done conduction (BC); a “positive” Rinne, or AC>BC Conductive Loss—Sound lateralizes to “poorer” ear from background room noise, which masks hearing in normal ear. “Poorer” ear (the one with conductive loss) is not distracted by background noise and this has a better change to hear bone-conducted sound Conductive loss—Person hears equally long by bone conduction as by air conduction (AC=BC) or even longer (AC<BC). The Rinne test is accurate to detect conductive loss, and loss can be confirmed by audiometry Sensorineural loss—Sound lateralizes to “better” ear or unaffected ear. Poor ear (the one with nerve loss) is unable to perceive the sound. However, many people with unilateral loss (conductive or sensorineural) still localize the sound in the midline. Confirm with audiometry. Sensorineural loss—Normal ration of AC>BC is intact but is reduced overall. That is, person hears poorly both ways. Confirm with audiometry NEURO ASSESSMENT A&P • Central nervous system (CNS): include the brain and spinal cord o Cerebral cortex  “Gray matter”  Each half is a hemisphere; left is dominant in most people  Each hemisphere is divided into four lobes (frontal, parietal, temporal and occipital) • Frontal lobe: personality, behavior, emotions, intellectual function; Broca’s area motor speech • Parietal lobe: sensation • Occipital lobe: visual receptor center • Temporal lobe: primary auditory reception center; hearing, taste and smell; Wernicke’s area language comprehension o Basal Ganglia  Help initiate and coordinate movement and control automatic associated movements of the body o Thalamus  An integrating center with connection that are crucial to human emotion and creativity o Hypothalamus  Major respiratory center; temperature, appetite, sex drive, heart rate, BP control, sleep center, anterior and posterior pituitary gland regulator, coordinator of autonomic nervous system activity and stress response o Cerebellum  Coiled structure concerned with motor coordination of voluntary movements, equilibrium and muscle tone o Brain Stem  Central core of the brain  Cranial nerves III-XII originate from nuclei in the brain stem  Three areas: o Midbrain: merges into the thalamus and hypothalamus; contains many motor neurons and tracts o Pons: has two respiratory centers that coordinate with the main respiratory center in the medulla o Medulla: contains all ascending and descending fiber tracts; has vital autonomic centers (respiration, heart, gastrointestinal function) and nuclei for cranial nerves VIII-XII o Spinal Cord  Myeilnated axons form main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves  Mediates reflexes of posture control, urination and pain pressure • Peripheral nervous system: includes all nerve fibers outside the brain and spinal cord (12 cranial nerves, 31 pairs of spinal nerves and their branches) o Peripheral nerves carry input TO the CNS and delivery output FROM the CNS o Reflex Arc  Reflexes are basic defense mechanisms of the nervous system  Involuntary, operating below the level of conscious control and permitting a quick reaction to potentially painful or damaging situations  Four types of reflexes: • Deep tendon reflexes: patellar (knee jerk) o Five components: an intact sensory nerve (afferent), a functional synapse in the cord, an intact motor nerve fiber (efferent) the neuromuscular junction and a competent muscle • Superficial: corneal reflex, abdominal reflex • Visceral: pupillary response to like and accommodation • Pathologic: Babinski (or extensor plantar) reflex o Cranial Nerves  Enter and exit the brain rather than the spinal cord  Cranial nerves I and II extend from the cerebrum  Cranial nerves III-XII extend from the lower diencephalon and brainstem  12 pairs of cranial nerves supply primarily the head and neck, except the vagus nerve (travels to the heart, respiratory muscles, stomach and gallbladder • Autonomic Nervous System o Mediates unconscious activity; overall function is to maintain homeostasis of the body The Aging Adult • General atrophy with a steady loss of neuron structure in the brain and spinal cord • Decrease in weight and volume with a thinning of the cerebral cortex, reduced subcortical brain structures and expansion of the ventricles • Neuron loss  general loss of muscle bulk, loss of muscle tone in the face, in the neck, and around the spine; decreased muscle strength; impaired fine coordination and agility; loss of vibratory sense at the ankle; decreased or absent Achilles reflex,; loss of position sense at the big toe; pupillary miosis; irregular pupil shape; and decreased pupillary reflexes • Nerve conduction decreases between 5% and 10%; reaction time slower • Touch and pain sensation, taste and smell may be diminished • Muscle strength and agility decrease • Muscle tremors may occur in the hands, head and jaw w/ possible repetitive facial grimacing (dyskinesias) • Decrease in cerebral blood flow and oxygen consumption dizziness and loss of balance with position change SUBJECTIVE DATA • Headache, head injury, dizziness/vertigo, seizures, tremors, weakness, incoordination, numbness or tingling, difficulty swallowing, difficulty speaking, patient-centered care (past Hx), environmental/occupational hazards • Addition Hx for aging adult: Dizziness, Mennocturia; decrease in memory, change in mental function, noticed any tremor, sudden vision changes, etc. (pg. 643) OBJECTIVE DATA TEST CRANIAL NERVES NORMAL RANGE OF FINDINGS ABNORMAL FINDINGS Cranial Nerve I—Olfactory Nerve • Do not test routinely • Test the sense of smell in those who report loss of smell, those with head trauma and those with abnormal mental status and when the presence of an intracranial lesion is suspected • Assess patency by occluding one nostril at a time and asking the person to sniff • With the person’s eyes close, occlude one nostril and present an aromatic substance (use familiar conveniently obtainable) • Normally a person can identify an odor on each of the nose • Smell normally is decreased bilaterally with aging • Any asymmetry in the sense of smell is important • One cannot test smell when air passages are occluded with upper respiratory infection or sinusitis • Anosmia—Decrease or loss of smell occurs bilaterally with tobacco smoking, allergic rhinitis, and cocaine use • Unilateral loss of smell in the absence of nasal disease is neurogenic anosmia Cranial Nerve II—Optic Nerve • Test visual acuity and visual fields by confrontation • Using ophthalmoscope, examine the ocular fundus to determine the color, size and shape of the optic disc • Visual fields • Papilledema with increased intracranial pressure; optic atrophy Cranial Nerve III, IV, and VI—Oculomotor, Trochlear, and Abducens Nerves • Palpebral fissures are usually equal in width or nearly so • Check pupils for size, regularity, equality, direct and consensual light reaction and accommodation • Assess extraocular movements by the cardinal positions of gaze • End-point nystagmus occurs normally • Assess any other nystagmus • Ptosis (drooping) occurs with myasthenia gravis, dysfunction of cranial nerve III, or Horner syndrome • Increasing intracranial pressure causes a sudden, unilateral, dilated and nonreactive pupil • Strabismus (deviated gaze) or limited movement • Nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem Cranial Nerve V—Trigeminal Nerve • Motor function: assess the muscles of mastication by palpating the temporal and masseter muscles as the person clenches the teeth; muscle should feel equally strong on both sides; next try to separate the jaws by pushing down on the chin; normally you cannot • Sensory function: with the person’s eyes closed, test light touch sensation by touching a cotton wisp to these designated areas on the person’s face: forehead, cheeks and chin; ask the person to saw “NOW” whenever the touch is felt (testing for ophthalmic, maxillary and mandibular • Decreased strength on one or both sides • Asymmetry in jaw movement • Pain with clenching of teeth • Decreased or unequal sensation. With a stroke, sensation of face and body is lost on the opposite side of the lesion Cranial Nerve VII—Facial Nerve • Motor function: Note mobility and facial symmetry as the person response to requests: smile, frown, close eyes tightly, lift eyebrows, show teeth and puff cheeks; press the person’s puffed cheeks in and note that the air should escape equally from both sides • Muscle weakness is shown by flattening of the nasolabial fold, dropping of one side of the face, lower eyelid sagging, and escape of air from only one cheek that is pressed in • Loss of movement and asymmetry of movement occur with both CNS lesions (ex. Stroke that affects lower face on one side) and peripheral nervous system lesions (ex. Bells palsy that affects the upper AND lower face on one side) Cranial Nerve VIII—Acoustic (Vestribulocochlear) Nerve • Test hearing acuity by the ability to hear normal conversation and by the whispered voice test Cranial Nerves IX and X—Glossopharyngeal and Vagus Nerves • Depress the tongue with a tongue blade and note pharyngeal movement as the person says “ahhh” or yawns; the uvula and soft palate should rise in the midline, and the tonsillar pillars should move medially • Touch the posterior pharyngeal wall with a tongue blade and note the gag reflex • Also note that the voice sounds smooth and not strained • Absence or asymmetry of soft palate movement or tonsillar pillar movement. Following a stroke, dysfunction in swallowing may increase risk for aspiration • Hoarse or brassy voice occurs with vocal cord dysfunction; nasal twang occurs with weakness of soft palate Cranial Nerve XI—Spinal Accessory Nerve • Examine the sternomastoid and trapezius muscles for equal size • Check equal strength by asking the person to rotate the head forcibly against resistance applied to the side the chin • Then ask the person to shrug the shoulders against resistance • Should feel equally strong on both sides • Atrophy • Muscle weakness or paralysis occurs with a stroke or following injury to the peripheral nerve (ex. Surgical removal of lymph nodes) Cranial Nerve XII—Hypoglossal Nerve • Inspect the tongue • No wasting or tremors should be present • Note the forward thrust in the midline as the person protrudes the tongue • Also ask the person to say “light, tight, dynamite” and note that lingual speech is clear and distinct • Atrophy. Fasciculations. • Tongue deviates to side with lesions of the hypoglossal nerve (when this occurs, deviation is toward the paralyzed side) INSPECT AND PALAPATE THE MOTOR SYSTEM NORMAL RANGE OF FINDINGS ABNORMAL FINDINGS Muscles • Size: Inspect all muscle groups for size; compare left and right; muscles should be within the normal size limits for age and symmetric bilaterally • Strength: Test the power of homologous muscles simultaneously. Test muscle groups of the extremities, neck and trunk • Tone: Move the extremities through a passive range of motion. Persuade the person to relax completely, move each extremity smoothly through a full range of motion; support the arm at the elbow and the leg at the knee; normally you will note a mild, even resistance to movement • Involuntary movements: Normally no involuntary movements occur. If present note location, frequency, rate and amplitude; note if the movements can be controlled at will • Atrophy—abnormally small muscle with a wasted appearance; occurs with disease, injury, LMN disease such as polio, diabetic neuropathy • Hypertrophy—increased size and strength; occurs with isometric exercise • Paresis or weakness is diminished strength; paralysis or plegia is absence of strength • Limited range of motion • Pain with motion • Flaccidity—Decreased resistance, hypotonia occur with peripheral weakness • Spasticity and rigidity—Types of increased resistance that occur with central weakness • Tic, tremor, fasciculation, myoclonus, chorea and athetosis Cerebellar Function Coordination and Skill movements • Rapid Alternation movements (RAM): ask the person to pat the knees with both hands, lift up turn hands over, and pat the knees with the backs of the hands; ask the person to do this faster; normally this is done with equal turning and a quick, rhythmic pace; OR ask the person to touch the thumb to each finger on the same hand, starting with the index finger then reverse direction; normally this can be done quickly and accurately • Finger-to-finger test: with the person’s eyes open, ask that he or she use the index finger to touch your finger and then his or her own nose; after a few times move your finger to a new spot; movements should be smooth and accurate • Finger-to-nose test: Ask the person to close the eyes and stretch out the arms; ask him or her to touch the tip of his or her nose with each index finger; alternating hands and increasing speed; normally accurate and smooth movement • Heel-to-Shin test: Test lower-extremity coordination by asking the person, who is in a supine position, to place the heel on the opposite knee and run it down the shin from the knee to ankle; normally the person moves the heel in a straight line down the shin • Lack of coordination • Slow, clumsy, and sloppy response is termed dysdiadochokinesia and occurs with cerebellar disease • Lack of coordination • Dysmetria is clumsy movement with overshooting the mark and occurs with cerebellar disorders or acute alcohol intoxication • Past-pointing is a constant deviation to one side • Intention tremor when reaching to a visually directed object • Misses nose. Worsening of coordination hen the eyes are closed occurs with cerebellar disease or alcohol intoxication • Lack of coordination, heel falls off shin; occurs with cerebellar disease Balance Tests • Gait: Observe as the person walks 10-20 ft, turns and returns to the starting point; normally the person moves with sense of freedom; gait is smooth, rhythmic and effortless; the opposing arm swing is coordinate, turns are smooth, step length is about 15 inches fro heel to heel • Ask the person to walk a straight line in a heel-to-toe fashion (tandem walking); normally the person can walk straight and stay balanced • Can also test for balance by asking the person to walk on his or her toes and then on the heels for a few steps; normally planter flexion and dorsiflexion are strong enough to permit this • The Romberg Test: Ask the person to stand up with feet together and arms at the sides; once in a stable position, ask him or her to close the eyes and to hold the position; wait about 20 seconds; normally a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur • Ask the person to perform to shallow knee bed or to hop in place, first on one leg and then the other • Stiff, immobile posture. Staggering or reeling. Wide base of support • Lack of arm awing or rigid arms • Unequal rhythm of steps. Slapping of foot. Scraping of toe of shoe • Ataxia—uncoordinated or unsteady gait • Crooked line of walk • Widens base to maintain balance • An ataxia that did not appear with regular gait may appear now. Inability to tandem walk is sensitive for an upper motor neuron lesion such as multiple sclerosis and for acute cerebellar dysfunction such as alcohol intoxication • Muscle weakness in the legs prevents this • Sways, falls, widens base of feet to avoid falling • Positive Romberg sign is loss of balance that occurs when closing the eyes. You eliminate the advantage of orientation with the eyes, which had compensated for sensory loss. A positive Romberg sign occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication), loss of proprioception, and loss of vestibular function • Unable to perform knee bend because of weakness in quadriceps muscle or hip extensors ASSESS THE SENSORY SYSTEM • Ask the person to identify various sensory stimuli to test the intactness of the peripheral nerve fibers, the sensory tracts, and higher cortical discrimination • You do not need to test the entire skin surface for every sensation • Compare sensation on symmetric parts of the body • When you find a definite decrease in sensation, map it out by systematic testing in that area • Proceed from the point of decreased sensation toward the sensitive area • By asking the person to tell you where the sensation changes, you can map the exact borders of the deficient area • Draw your results on a diagram • Person’s eyes should be closed during each of the tests • Note if the topographic pattern of sensory loss if distal (ex. Over the hands and feet in a “glove and stocking” distribution) or if it is over a specific dermatome NORMAL RANGE OF FINDINGS ABNORMAL FINDINGS Spinothalamic Tract • Pain: tested by the person’s ability to perceive a pinprick • Break a tongue blade lengthwise, forming a sharp point at the fractured end and a dull spot at the rounded end and a dull spot at the rounded end • Lightly apply the sharp point or the dull end to the person’s body in a random, unpredictable order • Ask the person to say “sharp” or “dull” • Let at least 2 seconds elapse between each stimulus to avoid summation • Light touch: Apply a wisp of cotton to the skin, brush it over the skin in a random order of sites and at irregular intervals • Include the arms, forearms, hands, chest, thighs and legs • Ask the person to say “now” or “yes” when touch is felt • Compare symmetric points • Hypoalgesia—Decreased pain sensation • Analgesia—Absent pain sensation • Hyperalgesia—Increased pain sensation • Hypoesthesia—Decreased touch sensation • Anesthesia—absent touch sensation • Hyperesthesia—increased touch sensation Posterior (Dorsal) Column Tract • Vibration: test the person’s ability to feel vibrations of a tuning fork over bony prominences • Strike the tuning fork on the heel of your hand and hold the base on a bony surface of the fingers and great toe • Ask the person to indicate when the vibration starts and stops • If normal vibration or buzzing sensation felt on the distal areas you may assume that proximal spots are normal and proceed no further • If not vibrations felt, move proximally and test ulnar processes and ankles, patellae and iliac crests • Position (Kinesthesia): Test the person’s ability to perceive passive movements of the extremities • Move a finger or the big toe up and down and ask the person to tell you which way it is moved, test is done w/ eyes closed; vary the order of the movement • Normally a person can detect movement of a few millimeters • Tactile Discrimination (Fine Touch): the person needs a normal or near-normal sense of touch and position sense as a prerequisite • Stereognosis: Test the person’s ability to recognize objects by feeling their forms, sized and weights • With his or her eyes closed, place a familiar object in the person’s hand and ask him or her to identify it • Normally a person will explore it with the fingers and correctly name it • Test a different object in each hand • Testing the left hand assesses right parietal lobe functioning • Graphesthesia: the ability to “read” a # by having it traced on the skin • With the person’s eyes closed, use a blunt instrument to trace a single digit # or a letter on the palm • Ask the person to tell you what it is • Graphesthesia is a good measure of sensory loss if the person cannot make the hand movements needed for stereognosis (arthritis) • Two-point discrimination: Test the person’s ability to distinguish the separation of 2 simultaneous pin points on the skin • Apply the 2 points lightly to the skin in ever-closing distances • Note the distance at which the person no longer perceives two separate points • Most sensitive in the fingertips (2-8mm) and lest sensitive on the upper arms, thighs and back (40-75mm) • Extinction: simultaneously touch both sides of the body at the same point • Ask the person to state how many sensations are felt and where they are • Normally both sensations are felt • Point location: Touch the skin and withdraw the stimulus promptly • Tell the person, “Put your finger where I touched you.” • Unable to feel vibration. Loss of vibration sense occurs with peripheral neuropathy (ex. Diabetes and alcoholism). Often this is the first sensation lost • Peripheral neuropathy is worse at the feet and gradually improves as you move up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome • Loss of position sense • Problems with tactile discrimination occur with lesions of the sensory cortex or posterior column • Astereognosis—inability to identify object correctly. Occurs in sensory cortex lesions (ex. Stroke) • Inability to distinguish # occurs with lesions of the sensory cortex • An increase in the distance it normally takes to identify two separate points occurs with sensory cortex lesions • The ability to recognize only one of the stimuli occurs with sensory cortex lesion; the stimulus is extinguished on the side opposite the cortex lesion • With a sensory cortex lesion, the person cannot localize the sensation accurately, even though light touch sensation may be retained TEST THE REFLEXES NORMAL RANGE OF FINDINGS ABNORMAL FINDINGS Stretch Reflexes or Deep Tendon Reflexes (DTRs) • For an adequate response, the limb should be relaxed and the muscle partially stretched • Stimulate the reflex by directing a short, snappy blow of the reflex hammer onto the insertion tendon of the muscle • Use a relaxed hold on the hammer; strike a brief, well-aimed blow and bounce up promptly; do not let the hammer rest on the tendon • Use just enough force to get a response; compare left and right sides—response should be equal • 4-Point scale: 4+ Very brisk, hyperactive with clonus, indicative of disease 3+ Brisker than average, may indicate disease, probably normal 2+ Average, normal 1+ Diminished, low normal, or occurs only with reinforcement 0 No response • Biceps reflex (C5-C6): Support the person’s forearm on yours; place your thumb on the biceps tendon then strike a blow on you thumb; normal response is contraction of the biceps muscle and flexion of the forearm • Triceps reflex (C7 to C8): Tell the person to let the arm “just go dead” as you suspend it by holding the upper arm; strike the triceps tendon directly just above the elbow; normal response is extension of the forearm • Brachioradialis Reflex (C5 to C6): Hold the person’s thumbs to suspend the forearms in relaxation, strike the forearm directly, about 2-3cm above the radial styloid process; normal response is flexion and supination of the forearm • Quadriceps Reflex (“Knee Jerk”) (L2 to L4): Let the lower legs dangle freely to flex the knee and stretch the tendons; strike the tendon directly just below the patella; extension of the lower leg is the expected response • For the person in the supine position, use your own arm as a lever to support the weight of one leg against the other • Achilles Reflex (“Ankle Jerk”) (L5 to S2): Position the person with the knee flexed and the hip externally rotated, hold the foot in dorsiflexion and strike the Achilles tendon directly; feel the normal response as the foot plantar flexes against your hand • For the person in supine position: flex one knee and support that lower leg against the other leg so it falls “open” • Clonus: support the lower leg in one hand, w/ your other hand move the foot up and down a few times to relax the muscle, stretch the muscle by briskly dorsiflexing the foot, hold the stretch; with a normal response you feel no further movement When clonus is present you feel and see rapid, rhythmic contractions of the calf muscle and movement of the foot • Clonus is a set of rapid, rhythmic contractions of the same muscle • Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the usually inhibiting influence of higher cortical levels. This occurs with upper motor neuron lesions (ex. Stroke) • Hyporeflexia, which is the absence of a reflex, is a lower motor neuron problem. It occurs with interruption of sensory afferents or destruction of motor efferents and anterior horn cells (ex. Spinal cord injury) • Clonus is repeated reflex muscular movements. A hyperactive reflex with sustained clonus (lasting as long as the stretch is held) occurs with UMN disease Superficial (Cutaneous) Reflexes • Plantar reflex (L4 to S2): Position the thigh in slight external rotation, with the reflex hammer draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot, like an upside down J; normal response is plantar flexion of the toes and inversion and flexion of the forefoot • Except in infancy, the abnormal response is dorsiflexion of the big toe and fanning of all toes, which is a positive Babinski sign, also called “upgoing toes.” This occurs with UMN disease of the corticospinal (or pyramidal) tract THE AGING ADULT • Use the same examination as with the younger adult • Be aware older adults show a slower response to requests • Any decrease in muscle bulk is most apparent in the hand, seen by guttering between the metacarpals, these dorsal hand muscles look wasted, even with no apparent arthropathy • Grip strength remains relatively good • Hand muscle atrophy is worsened with disuse and degenerative arthropathy • Senile tremors occasionally occurs • Benign tremors: intention tremor of the hands, head nodding and tongue protrusion • Dyskinesias are the repetitive stereotyped movements in the jaw, lips or tongue that may accompany senile tremors; no associated rigidity is present • Distinguish senile tremors from tremors of parkinsonism. The latter includes rigidity and slowness and weakness of voluntary movement • Gait may be slower and more deliberate • May deviate slightly from a midline path • Absence of a rhythmic reciprocal gait pattern is seen in parkinsonism and hemiparesis • Have more difficulty performing rapid alternating movements • After 65 y/o loss of sensation of vibration at the ankle malleolus is common and usually accompanied by a loss of the ankle jerk • Tactile sensation may be impaired • May need stronger stimuli for light touch and especially for pain • Note any difference in sensation between right and left sides, which may indicate a neurologic deficit NEUROLOGIC RECHECK • Some hospitalized people have head trauma or a neurologic deficit caused by a systemic disease process • These people must be monitored closely for any improvement or deterioration in the neurologic status and for any indication of increasing intracranial pressure • Use abbreviation of the neurologic exam in the following sequence: o Level of consciousness  A change in the level of consciousness is the single most important factor in the exam  Note the ease of arousal and the state of awareness, or orientation  Assess orientation by asking questions about person, place, time  Note the quality and content of the verbal response; articulation, fluency, manner of thinking and any deficit in language comprehension or production  A person is fully alert when his or her eyes open at your approach or spontaneously; when he or she is oriented person, place and time and when he or she is able to follow verbal commands appropriately  If the person is not fully alert, increase the amount of stimulus used in this order: • Name called • Light touch on person’s arm • Vigorous shake of shoulder • Pain applied  Record the stimulus used and the person’s response to it  A change in consciousness may be subtle. Note any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person o Motor function  Check the voluntary movement of each extremity by giving the person specific commands  Ask the person to lift the eyebrows, frown, bare teeth  Note symmetric facial movements and bilateral nasolabial folds (cranial nerve VII)  Check upper arm strength by checking hand grasps, ask the person to squeeze your fingers; offer your 2 fingers one on top of the other  A weak grip occurs with upper and lower motor neuron disease and with local hand problems (arthritis, carpal tunnel syndrome)  Alternatively, ask the person to lift each hand or to hold up one finger; you can also check upper-extremity strength by palmar driftask the person to extend both arms forward or ½ way up, palms up, eyes closed and hold for 10-20seconds; normally the arms stay steady with no downward drift  Pronator drift is a downward unilateral drift and turning in of the forearm that occurs with mild hemiparesis  Check lower extremities by asking the person to do straight leg raises; ask the person to life one leg at a time straight up off the bed; full strength shoes the leg to be lifted 90 degrees  If multiple trauma, pain, or equipment precludes this motion, ask the person to push one foot at a time against the resistance in your hand  For the person with decreased level of consciousness, note if movement occurs spontaneously and as a result of noxious stimuli such as pain or suctioning  An attempt to push away your hand after stimuli is called localizing and is characterized as purposeful movement  Any abnormal posturing, decorticate rigidity, or decerebrate rigidity indicates diffuse brain injury o Pupillary response  Note the size, shape and symmetry of both pupils  Shine a light into each pupil, and note the direct and consensual light reflex; both pupils should constrict briskly  When recording, pupil size is best expressed in millimeters  In a brain-injured person a sudden unilateral dilated and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation o Vital signs  Measure the temperature, pulse, respiration, and BP as often as the person’s condition warrants  The Cushing reflex shows signs of increasing intracranial pressure: BP—sudden elevation with widening pulse pressure; pulse—decreased rate, slow and bounding • The Glasgow Coma Scale o Scale is divided into 3 areas: eye opening, verbal response, and motor response o Each is rated separately and a number is given for the person’s best response o A fully alert, normal person has a score of 15 o a score of 7or less reflects coma ABNORMAL FINDINGS [Show More]

Last updated: 1 year ago

Preview 1 out of 19 pages