The sensory exam involves evaluation of pain (or temperature), light touch, position sense, vibration, and discriminative sensations. This portion of the exam is very subjective, and may become unreliable if repeated in quick succession. Therefore, your exam should not be rushed, but must proceed efficiently. Compare symmetrical areas on both sides of the body and compare proximal to distal areas.
Nội dung chính
- Light touch:
- Temperature:
- Position sense:
- Discriminitive sense:
- Types of Neurological Examinations
- Routine Exam
- Comprehensive
- Periodic Reevaluation
- Which neurologic assessment would the nurse perform when assessing a patients cortical sensory function?
- How do you assess for the sensory aspect of the trigeminal nerve?
- How will the nurse assess the function of cranial nerve V quizlet?
- How will the nurse assess the function of cranial nerve V?
Pain:
Test pain using a sharp object. Objects frequently used include the point of a safety pin or a wooden tongue depressor broken to create a sharp edge. Take care not to puncture the skin, and remember that universal precautions require you to discard the instrument after examination. Using the sharp point, apply light pressure to the skin. At minimum, test the shoulders, arms and legs, comparing side to side and proximal to distal areas. In any area where the patient complains of sensory loss or hypersensitivity, more detailed testing may be required.
Light touch:
Using your fingertips or a wisp of cotton, lightly stroke the skin and determine if the patient feels this symmetrically in all areas tested. Again, test the areas outlined above.
Temperature:
Usually, if pain sensation has been tested and is normal, there is no need to test temperature sensation. To test cold sensation, apply the cool tines of your tuning fork to the skin in the areas outlined above. To test warm sensation, use a glass tube or other container filled with warm water.
Position sense:
With the patient's eyes closed, test his ability to determine the direction of movement as you move the great toe upward or downward. When moving a digit, it is important to grasp it on both sides, rather than on the top and bottom. This is because pressure sensation on the top or bottom of the digit will help the patient determine position sense, even if proprioception is impaired. Repeat several times on each side, and in upper extremities using the thumb. Test a more proximal joint (for example ankle or wrist) if an abnormal response is obtained.
Vibration:
Test vibratory sense on each side, using a 128 Hz or 256 Hz tuning fork, by placing the vibrating fork on the boney prominence of a finger or toe. Ask the patient to tell you what he feels. He should report this sensation as a vibration. Then ask him to tell you when he no longer feels the vibration. If there is impaired vibratory sense, test a more proximal bony prominence. With aging, vibratory sense may be diminished or lost in the feet and ankles.
A disproportionate loss of vibratory sense and proprioception (compared to pain sensation) tends to suggest disease of the dorsal columns (e.g. tabes dorsalis, Vitamin B12 deficiency, multiple sclerosis) or demyelinating neuropathies.
Discriminitive sense:
The sensory cortex is involved in correlating, analyzing, and interpreting sensations. Three tests used to evaluate these abilities are: two-point discrimination,
stereognosis and graphesthesia. These tests are dependent on the patient having a normal sense of touch, or only minimally impaired. The patient's eyes should be closed for each of these tests.
| Click on the video icon to view a demonstration of the sensory exam. |
- Last updated
- Save as PDF
The neurological exam is a clinical assessment of the functioning of the central nervous system (CNS) and peripheral nervous system (PNS). See Figure \(\PageIndex{1}\)[1] for an image of the anatomical underpinnings of the neurological exam. Several tests are available when performing a neurological assessment; the tests included in the assessment are selected based on the patient’s medical condition and the neurological symptoms they are experiencing. The range of tests that can be included in a neurological exam include evaluation of mental status, cranial nerves, sensory functioning, motor strength, cerebellar functioning, and reflexes. The mental status exam assesses the higher cognitive functions such as memory, orientation, and language associated with the cerebrum and cerebral cortex. The cranial nerve exam tests the sensory and motor functioning of the 12 cranial nerves that connect to the diencephalon and the brain stem. The sensory response and motor strength tests evaluate functions associated with the spinal nerves. The cerebellar function tests evaluate balance, muscle tone, and coordination of voluntary movements. Deep tendon reflexes may also be used to assess the health of the nervous system.[2] Each of these components of a neurological exam is further described in the remaining sections of this chapter.
Types of Neurological Examinations
The type of neurological exam performed is based on the patient’s reason for seeking care, their current medical condition, and the practice setting.
Routine Exam
Routine neurological exams performed by registered nurses during their daily clinical practice include assessing mental status and level of consciousness, pupillary response, motor strength, sensation, and gait. The Glasgow Coma Scale is also frequently used to objectively monitor level of consciousness in patients with neurological damage such as a head injury or cerebrovascular accident (i.e., stroke).[3]
Comprehensive
A comprehensive neurologic exam is performed on patients with a neurological concern. This exam is more extensive and may be performed in specialty settings or by advanced practice nurses. In addition to the components included in a routine neurological exam, the examiner may also assess cranial nerves, detailed cerebellar function, deep tendon reflexes, and complete a Mini-Mental State Exam (MMSE).
Periodic Reevaluation
Periodic reevaluations are performed by registered nurses when the patient has experienced an acute injury or illness causing neurological deficits that require frequent monitoring for change in condition. For example, a patient admitted to the hospital for an acute cerebrovascular accident (i.e., stroke) will have their neurological status rechecked and documented frequently according to agency policy. See Figure \(\PageIndex{2}\)[4] of a nurse assessing a patient’s neurological status in an intensive care unit.
Which neurologic assessment would the nurse perform when assessing a patients cortical sensory function?
Cortical sensory function is evaluated by asking the patient to identify a familiar object (eg, coin, key) placed in the palm of the hand (stereognosis) and numbers written on the palm (graphesthesia) and to distinguish between 1 and 2 simultaneous, closely placed pinpricks on the fingertips (2-point discrimination).
How do you assess for the sensory aspect of the trigeminal nerve?
For the 5th (trigeminal) nerve, the 3 sensory divisions (ophthalmic, maxillary, mandibular) are evaluated by using a pinprick to test facial sensation and by brushing a wisp of cotton against the lower or lateral cornea to evaluate the corneal reflex.
How will the nurse assess the function of cranial nerve V quizlet?
The nurse should evaluate facial sensation to assess the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face. The nurse should evaluate the strength of the jaw to assess the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face.
How will the nurse assess the function of cranial nerve V?
Cranial nerve V (trigeminal) To assess the sensory component, instruct the patient to close their eyes, and with a cotton swab lightly touch each of the three bilateral distributions of the nerve. CN V and VII (facial nerve) contribute to the corneal reflex response.