Neurological Assessment Randa M. Albusoul Anatomy The nervous - - PowerPoint PPT Presentation

Randa M. Albusoul

Neurological Assessment

Anatomy The nervous system can be divided into:

• Central Nervous System (CNS)
• Peripheral Nervous System (PNS)

# CNS includes brain and spinal cord #PNS includes 12 pairs of Cranial Nerves (CN) and 31 pairs of spinal nerves.

The brain consists of:

• Cerebrum: vast network of interconnecting neurons.

Nerve cell = cell body and axon. Brain tissue may be gray or white matter. Gray matter (neuronal cell bodies) White matter: (neuronal axons).

• Why cerebral cortex is gray?

Because it lacks myelin

• Hemisphere: is a half of the cerebrum.
• Each hemisphere has 4 lobes.
• Each lobe mediate specific function.
• Frontal lobe:

personality, behavior, emotions, and intellectual function.

• Contains Broca’s area

that mediates motor speech; when injured lead to expressive aphasia; person cannot talk.

• Parietal lobe: primary center for sensation.
• Occipital lobe: primarily visual receptor center.
• Temporal lobe: primarily auditory reception center.
• It also contains Wernicke’s area for language

comprehension (receptive aphasia: hear sounds but have no meaning for him).

• Basal Ganglia: movement. Example; Arm and leg

swinging during movement.

• Thalamus: processes sensory impulses and relays

them to the cerebral cortex.

• Hypothalamus: maintain homeostasis, regulates

temperature, heart rate, blood pressure, sleep center, emotional behavior, pituitary gland regulator.

• Cerebellum: voluntary movements, equilibrium,

and muscle tone.

• Brain Stem: midbrain, pons, medulla (has vital

autonomic centers: respiratory, heart, gastro).

Spinal Cord:

• Long structure that connect the

brain with the spinal nerves.

• It can mediates reflexes.
• Ends at 1st or 2nd lumber

vertebra.

Pathways of the CNS: Sensory pathways:

• There are sensory

receptors in skin, mucosa, muscles, tendons, and viscera..

• The brain monitor

the organ sensation, position, function…

Sensation of position: proprioception; without looking you know where your body parts are in space and in relation to each other. Sensation of vibration: feeling vibrating objects. Localized touch: stereognosis; without looking you can identify familiar objects by touch. Note that Lt cerebral cortex receives sensory info from and controls motor function to the Rt side of the body and visa verse this is called crossed representation.

The PNS: The Cranial Nerves (CN): emerge from cranium; CN I and II from the brain. CN III to XII fro diencephalon and the brainstem.

The peripheral nerves:

• 31 nerve; 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,

1 coccygeal.

• Each nerve has an anterior root containing motor

fibers, and posterior root containing sensory fiber.

• The anterior and posterior roots merge together to

form spinal nerve.

Reflexes: involuntary mechanism that permit a quick reaction to painful or damaging situation. Types of reflexes:

• deep tendon reflex.

• Superficial reflexes: such as corneal reflex and

abdominal reflex.

• Visceral reflexes (organic): pupillary response to light

and accommodation.

• Pathologic (abnormal) reflexes: such as Babinski’s

reflex. Reflex arc: Sensory stimulus, posterior root, spinal cord, synapse with a motor neuron in the anterior horn, anterior root, muscle.

Dermatomes:

• Band of skin that is innervated by the sensory root
• f a single spinal nerve
• Help to localize the lesion to a specific spinal cord

segment.

Subjective Data Common symptoms Headache Dizziness or vertigo Weakness Numbness or loss of sensation Loss of consciousness Seizure Tremors Difficult swallowing Difficult speaking

Objective Data 1) Mental status and level of Consciousness. Is the pt oriented to time, place, and person? 2) CN: *Olfactory (I) (S): test sense of smell. *Optic (II) (S): test visual acuity and fields (by confrontation).

*Oculomotor (III), Trochlear (IV), Abducens (VI) (M): Pupils size, reflex, accommodation, & upper lid movement (III) & asses extra ocular movement.

*Trigeminal (V) (M/S):

• Assess the muscles, jaw

clenching for temporal and masseter, lateral jaw movement for lateral pterygoids.

• Assess all three devision of

the nerve (ophthalmic, maxillary, and mandibular). Compare between sharp and dull or hot and cold sensations in each side.

• Corneal reflex: make the pt look up and away

from you. Touch the cornea by cotton, the normal reaction is blinking, the sensory of this reflex is carried by CN (V), and the motor by CN (VII).

*Facial (VII) (M/S):

• M / facial expression during movements; smile, close

eyes then open, frown, lift eyebrows, show teeth, puff cheeks, close mouth.

• S / taste (sugar, salt, sour, bitter) on the anterior two

third of the tongue.

*Acoustic (VIII) (S): hearing acuity; whisper, Weber, Rinne. *Glossopharyngeal (IX) & Vagus (X) (M/S): M / uvula (in midline) & soft palate rise, positive gag reflex (CN X), S / taste on posterior 1/3 of the tongue (salty, sweet, sour, bitter) CN (IX).

*Spinal accessory (XI) (M): assess the muscles, shoulder shrug (trapezius), turn head to each side against your hand (sternomastoid).

*Hypoglossal (XII) (M): Ask the pt to protrude the tongue, look for symmetry/midline, ask pt to talk (CN V, VII, X, XII). 3) The motor system: Coordination requires muscle strength, cerebellar system, vestibular system, and sensory system (position sense).

• Assess rapid alternating movement:

Ask the pt to strike one hand on the thigh, raise the hand, turn it over, and then strike the back of the hand down n the same place.

Point-to-point movements:

• Finger to nose; smooth & accurate movement; move

your finger, or fix it and make the pt close her eyes.

• Heel to shin: moves heel in a straight line down the

shin.

• Gait:

Assess pts walking across the room (posture, balance, swinging of the arms..). Walk heel-to-toe in a straight line. Walk on the toes. Hop in place. Do a shallow knee bend. Rise from a sitting position.

• Stance:

Romberg test: ask the person to stand up with feet together and arms at sides, close eyes. Maintain posture & balance with slight swaying. Pronator drift:

4) The sensory system: To evaluate the sensory system, test the following:

• Pain and temperature (spinothalamic tracts)
• Position and vibration (posterior columns)
• Light touch (both spinothalamic and posterior)
• Discriminative sensations, which depend on

some of the above sensations but also involve the cortex. *compare symmetrical areas and proximal and distal areas. *vary the pace of your testing. *Map out the boundaries.

• Pain: you can use broken tongue blade and cotton

swap.

• Show the pt both sensations before closing his eyes.
• Use lightest pressure needed.
• If pain assessment is normal no need for temperature

assessment.

• Light touch: see if the pt feel the touch and can

compare between sides.

• Vibration: if he can feel it and when it stops.
• Proprioception: up and down.

• Discriminative sensation:
• Stereognosis:
• Graphesthesia: number identification.

• Two point discrimination:
• Find minimal distance in

different body parts.

• Point localization.
• Extinction; simultaneously

stimulate corresponding areas on both sides

• f the body and ask where

the pt feel it.

5) Dermatomes: Assess dermatomes of the pt, some landmarks may be: C3: Front of the neck T4: Nipples T10: Umbilicus L1: Inguinal 6) Tendon reflexes:

• Encourage the pt to relax before beginning the

procedure.

• In documentation, follow the following grading

scale:

The knee reflex (Patellar Reflex) (L2, L3, L4):

• The pt may be sitting or lying but knee should be

flexed.

• Tap the patellar tendon below the paterlla.
• Note contraction of the quadriceps with extension
• f the knee.

The Plantar response (L5,S1):

• Stroke the foot from the heel moving up toward the

small toe to the ball of the foot, curving medially across the ball.

• The normal response is a downward contraction of

the toes, called the plantar response.

The knee reflex (Patellar Reflex)

• The abnormal response is called Babinski response.

Plantar response Babinski response