 Hi, welcome to nursing school explained and on this video on the peripheral neurologic assessment. Now after we've done the assessment of the cranial nerves, which I go over in a couple of different videos, we need to move on to the periphery and check the patient's sensory as well as motor function in their extremities. And the way we want to do this, we always want to go from distal to proximal. So from the further away body part, let's say the fingers, all the way up to the arms. So distal to proximal. And there are always two things that we need to assess when it comes to the neurologic assessment, which is sensory, sensation or motor movement. So let's start with motor here. So first of all, we always need to assess the muscle strength. And that is typically where you assess for equality of the patient's right and left side of their extremities by checking the muscle strength of their hands. So by doing the hand grasp and here's a little tidbit, only always give the patient two fingers to squeeze. If you give them three fingers, you can try that out. You can kind of squish the fingers and they can kind of hurt if the patient is altered or not really cooperative. It might cause you some pain. But if you give them two fingers, they really can press as hard as they want and it's not going to hurt you. So keep that in mind. So for muscle strength, we want to check their hand grasp, the bicep and the tricep muscle strength, as well as the pedal push and pull by having them press their feet against our hands and then pull the toes towards your nose while we are assessing their foot strength. And then also check the lower extremities in terms of pushing their shin out and then moving the calf back. And that can be done whether they're sitting up, standing up or laying down in bed. So motor sensation, muscle strength on both upper and lower extremities, you've probably already done that. Now, the other big part is here to check the cerebellum function, which is a big part of the brain and the back, but it has to do with our equilibrium and balance. So there are several different tests on how to assess this and depending on your skills evaluation, you might encounter a patient that is bed bound or a patient that can walk and depending on your patient's ability, also in the clinical setting, you will need to determine what test is appropriate for your patient. And then again, always check it on the upper as well as the lower extremities. So first of all, the gait, you could, if the patient is mobile, you could have them walk across the room and observe how they are doing with their balance. So walk regularly where their heel and then their toes hit the ground. And then you can ask them to walk on their tippy toes and then back on their heels, which challenges their balance in a little bit of a different way. And you can assess their gait this way. Romburg test is where you have the patients stand up with their feet together, hands by their side. And first of all, just see if they're starting to sway. If they're pretty good with their eyes open, ask them to close their eyes, which can be a little bit scary for the patient, which is why you should put your hands in a protective way close to the patient, but not on them. So just in case they start to sway, you can kind of catch them. And so as the patient closes their eyes, you would kind of observe if they're swaying. That would mean that there might be something going on with their cerebellum or if they're pretty steady. Now, a little swaying is OK, but we don't want them to go completely swaying off to one side or even having to step out with their foot to catch them from being off balance. And then so these are tests that the patient can do if they are mobile and able to stand up. Then R-A-M stands for rapid alternating movement. Rapid alternating movement means fast alternate and then moving something. And so what you can do is you can ask the patient to lay their hand on their lap and then rapidly alternate their hands from palms facing up and palms facing down. And you can either do it at the same time or you can ask them to do it one facing up, one facing down and then go this way. So rapid and alternating, whichever side looks up. Now this would be for the upper extremities, for the lower extremities. You could have them tap their foot against your hand rapidly and then the same with the other side on the other foot. Preferably maybe even both sides at the same time to see if they're equal. Now for the finger to finger test, this is where you would hold your finger out maybe 12 or 16 inches in front of the patient's face. And you ask them to touch your finger with their right index finger and then touch their nose. And then you can move your hand towards the other side. And again, the patient alternates from touching your finger, touching their nose, touching their finger, touching their nose. You can do that first with the eyes open and then keep the hand in the same position, your finger, and then ask the patient with their eyes close to move back and forth between your finger and their nose. So this is finger to finger and then finger to nose. And then the heel to shin test is where the patient uses the heel of one foot and slide it up and down on the shin of the other foot. And here we are observing if the heel moves straight up and down the shin or if the patient is unable to do that or if the heel just moves off to one side and the patient is unable to do that again to assess their balance and equilibrium. And then pronator drift. That's a very common one that we typically also think about with stroke assessment. You would ask the patient to hold their arms both out in front of you or in front of them. Palms up, eyes closed and then ask them to count out loud to 10 and see if the hands stay up or if one starts to drift. Now a positive pronator drift is indicative of something going on in their central nervous system. And mostly we have to worry about a stroke here. And this concludes the motor side of the peripheral neural assessment. So now we've done muscle strength and cerebellar function. Now for the sensory side of things, there are a few other things that we need to assess. So first of all, to assess the spinal thalamid tract has to do with touch, pain and temperature. And when we talk about touch, so this would be having the patient close their eyes, lightly touch them at some part of their body, mostly in their periphery and ask them to identify where you touch them with their eyes closed. So right forearm, left thumb, right foot, left ankle, whatever it is. And then pain response would be sharp or dull. This is mostly where you would use maybe a Q-tip with the cotton end on one side and then a wooden end on the other. So the dull side is the cotton tipped applicator and the wooden side is the sharp side. And of course, you would have to give the patient indication of what it feels like first. And again, you would touch them on their extremities and say sharp or dull and make sure they can identify it correctly. And then you can assess their temperature. Usually that's only done if the pain response is abnormal. And temperature we have to be careful with. So this would be you could, for example, use the warm palm of your hand or your warm fingers if they're truly warm. And then your set of scope, which typically is cold to have the patient distinguish between warm and cold and assess their sense of temperature in their extremities. And then we have several posterior column tests to assess. And these are sometimes a little bit funky to do. They also have funny names, but let's go over those. So position that means that you would have the patient close their eyes and maybe take their index finger and move it up. And then they tell you what position you moved their finger to. You could do that with the fingers or with the toes, typically. And just so the patient can distinguish what position their finger or their digit or their toe is in after you've moved them. Then we have sensory extinction. So we want to know, can the patient feel us touch them? Because here we're still on the sensory assessment. And we want to see if they have the same sensation on both sides. So you would lightly touch them on their extremities again and say, does this feel, can you feel me touch you here? And does it feel the same on both sides? And then again, work your way from this total proximal. And then we have point location, which is very similar to the touch that we already did where you would have rather than the patient tell you where you touched them, you would have them close your eyes and you would touch, let's say their right elbow and then they actually localize that point that you just touched. So you have their eyes closed, you touch a certain body part and then they touch the same spot again, meaning that they can localize that spot. And then we have two point discrimination, which is a little bit difficult to understand sometimes. And the story behind this is that the spinal nerves that go down our spinal column innervate along dermatome certain parts of our body. And then there are certain nerve endings that that supply a particular surface area of the skin. And typically in our fingers, this is about half a centimeter. Zero point five centimeters wide, the surface area. And so what you could do is take two toothpicks and move them or with the two toothpicks, poke the patient on their fingertips and move them so that they're together, less than zero point five centimeters together and then move the two toothpicks apart and ask the patient whether they can feel one or two toothpick pricks. And so on the finger, we don't want this discrimination to be greater than five than zero point five. So when it's within that zero point five, they might only be able to localize one because it's innervated by the same nerve, meaning that they can only feel one prick, although you're touching them with two. But as soon as you move out of that surface area, then they can feel two because now that adjacent skin area is innervated by a different nerve. So that's the two point discrimination. And then last but not least, we have graphesthesia and stereognosis. So graphesthesia, think about graphic drawing something. So you would draw something in the patient's hand with your finger only and the patient has their eyes closed. So you could do a letter, try to do something that's not confusing, like Z could be confused for an N, for example. You could do a number. Number four typically works well, or eight or five, those kind of things. And the patient being able to identify what you have drawn into their hand. And then stereognosis is the ability of the patient to identify an object that you place in their hands and things that always come handy here would be a paperclip, a pen, anything, a spoon, anything that could come on their fruit tray that's easily distinguished. And so once you have performed the peripheral neural assessment of both the motor and the sensory in the periphery and you add that to your cranial nerve assessment, now we have the full focused neural assessment and we are done with that. And the reason that I put these videos together, not only for the cranial nerves, why I go with the explanation, but also the demonstration is so that you can actually kind of make sense of how these two play together because we have the central nervous system, cranial nerves and then the periphery and they all have to come together because not only do our facial muscles react, but we also have peripheral muscles and nerves that we need to evaluate. Now, one quick tidbit here. Here's a really good resource for you that has helped me over the years. It's called Essential Health Assessment. It's by F.A. Davis. It's a very, very good book that has the details of the different focused assessments. It might be a little bit too in depth for certain R.N. requirements. But if you are planning on advancing your career, it might be a book that's going to be worth its money going through your advanced practice degree. And the nice thing about it, it has the normal and abnormal findings that you should expect. So it tells you here, for example, for the pronator drift, what a positive and a negative binding are and what it is that you should expect. It also goes into what tools you need to assess the patient's specific body parts. So thank you so much for watching this video on the peripheral neural assessment. I will put a description for you in the video in the description below where you have a link to purchase any F.A. Davis products for 20 percent off. That's a special for nursing school explained so that you can make use of these helpful resources and hopefully find the assessment portion of your clinicals a lot easier going forward. Thanks for watching. See you soon.