Neuro Assessment Outline Fall 2024 PDF

# NEURO ASSESSMENT ## Chapter 43 ### Anatomy Review - Basic functional unit of the brain is the neuron. - It is composed of a cell body, dendrite, and an axon. - Dendrite - receiving electrochemical messages. - Axon - carries impulses away from the cell body. ### Neurotransmitters - These...

# NEURO ASSESSMENT ## Chapter 43 ### Anatomy Review - Basic functional unit of the brain is the neuron. - It is composed of a cell body, dendrite, and an axon. - Dendrite - receiving electrochemical messages. - Axon - carries impulses away from the cell body. ### Neurotransmitters - These communicate messages form one neuron to another or from a neuron to a specific target tissue. - They are responsible for all types of brain activity. - Imbalances or deficiencies of a particular neurotransmitters may cause neurologic dysfunction. #### Acetylcholine - Major transmitter of the PNS. - Many areas of the brain; autonomic nervous system. - Usually excitatory; PNS effects sometimes inhibitory (stimulation of heart by vagal nerve.) - ↓ leads to myasthenia gravis. #### Serotonin - Brainstem, hypothalamus, dorsal horn of the spinal cord. - Inhibitory, helps control mood and sleep, inhibits pain pathways. - ↓ leads to depression #### Dopamine - Substantia nigra and basal ganglia. - Usually inhibits, affects behavior (attention, emotions) and fine movement. - ↓ leads to Parkinson disease. #### Norepinephrine - Major transmitter of the SNS. - Brainstem, hypothalamus, postganglionic neurons of the SNS. - Usually excitatory; affects mood and overall activity. - Seen rarely. ### Cerebrum - **Frontal lobe** - concentration, abstract thought information storage or memory, and motor function. Contains Broca’s area and Wernicke’s area. Responsible for a person’s affect, judgement, personality, emotions, attitudes, and contributes to the formation of thought processes. - **Parietal lobe** - the primary sensory cortex. Analyzes sensory information like pressure, vibration, pain, and temperature. Essential to one’s orientation to space and special relations. - **Temporal lobe** - contains the auditory receptive areas. Responsible for receptive speech. For most people hand dominance and long-term memory recall. - **Occipital lobe** - primary visual cortex. Responsible for some visual reflexes as well as some involuntary eye movements. ### Brain - **Corpus callosum** - transmits information from one side of the brain to the other. - **Basal ganglia** - control fine motor movements. - **Thalmus** - relay station for all sensation except smell. All memory passes through this section. - **Hypothalmus** - important for endocrine system. Regulates temperature regulation. - **Pituitary gland** - responsible for hormone balance. - **Brainstem** - responsible for automatic functions. - **Cerebellum** - responsible for coordination of all movement, controls fine movement, balance and position sense or proprioception ### Protection - **Skull** - **Meninges** - dura, arachnoid, and pia matter. ### 1254 Chart 43.6 _Cerebrospinal Fluid CSF_ - Clear, colorless fluid. - The intracranial pressure within the skull results from a combination of brain tissue, blood flow, and CSF. ### Cerebral circulation - Brain does not store nutrients and has a high metabolic demand. - Has poor collateral blood flow. ### Spinal cord and Vertebral Column - Spinal cord is a continuous structure the serves as a connection between the brain and the periphery. - Vertebral column- surrounds and protects the spinal cord. Consist of 7 cervical, 12 thoracic, 5 lumbar vertebrae, sacrum (5 fused vertebrae) and the coccyx. ### Peripheral Nervous System - Includes the cranial nerves, spinal nerves, and autonomic nervous system. ### _CRANIAL NERVES_ | Cranial Nerve | Mnemoni | Mnemoni | Type | |---|---|---|---| | I - Olfactory | Only | Some | Sensory | | II - Optic | One | Say | Sensory | | III - Oculomotor | Of | Marry | Motor | | IV - Trochlear | The | Money | Motor | | V - Trigeminal | Two | But | Both | | VI - Abducens | Athletes | My | Motor | | VII - Facial | Felt | Brother | Both | | VIII - Acoustic | Amazing | Says | Sensory | | IX - Glossopharyngeal | Good | Big | Both | | X - Vagus | Victorious | Brains | Both | | XI - Spinal Accessory | And | Matter | Motor | | XII - Hypoglossal | Healthy | Most | Motor | | Cranial Nerve | Assessment | Dysfunction | |---|---|---| | I - Olfactory | - Eyes closed.<br>- ID two familiar odors.<br>- Each nostril is tested separately.<br>- Avoid using strong odors. | - Inability to ID odor. (anosmia) | | II - Optic | - Read big print to small.<br>- Have pt close one eye and focus on your nose as you assess peripheral vision. | - Decreased visual acuity. <br>- Decreased visual fields. | | III - Oculomotor | - Six cardinal positions. - Left superior, left lateral, left inferior, right superior, right lateral, right inferior.<br>- Hold position briefly to assess for nystagmus.<br>- Test for pupillary reflexes.<br>- Inspect eyelids for ptosis (drooping of the eyelid). | - Inability to move the eye in the visual field described.<br>- Ptosis of affected eye.<br>- Nonreactive or dilated pupil. | | IV - Trochlear | - Move the eye down and in (as if looking towards the nose) | - Inability to look down and in. | | V - Trigeminal | - Asses facial sensation, corneal reflex, and chewing or mastication. <br>- Have pt close eyes. Touch cotton to forehead, cheeks, and jaw. <br>- Test pain in the same areas with dull and sharp. If response is incorrect test for temp by using hot and cold test tubes.<br>- Assess chewing have pt clench the jaw and palpate the temporal and masseter muscles.<br>- Corneal reflex may be assessed by having the pt look up and away as you brush the cornea with a wisp of cotton. (both eyes should blink). | - Absence of corneal reflex.<br>- Diminished sensation to forehead, maxillary and mandibular region.<br>- Weakness of muscles responsible for chewing. | | VI - Abducens | - Moves the eye laterally (side to side or horizontally) | - Inability to look laterally, double vision. | | VII - Facial | - Symmetry of facial movement.<br>- Ask pt to smile, raise eyebrows, keep eyes and lips closed while you try to open them, and puff out cheeks.<br>- Taste is also a function of this CN. | - Facial paralysis.<br>- Facial asymmetry, droop of mouth.<br>- Absent nasolabial fold.<br>- Decreased ability to taste.<br>- Decreased hearing in affected ear. | | VIII - Acoustic | - Assess hearing by rubbing your fingers, placing a ticking watch, or whispering near each ear.<br>- Equilibrium can be assessed with the Romberg test and is usually deferred. | | | IX - Glossopharyngeal | - Is primarily innervation of the pharynx and tongue, pharyngeal muscles, and swallowing.<br>- Ask Pt to open mouth and say “Ah”.<br>- Note symmetrical elevation of the upper palate and uvula in the midline position.<br>- Assessing for gag reflex by touching the Pt posterior pharynx with a cotton swab or tongue blade. Note the quality of the Pt voice. | - Dysphagia. <br>- Absence of gag reflex. | | X - Vagus | - Assessed by swallowing and gag reflex.<br>- Note the quality of the Pt voice. | - Hoarse or nasal quality to voice.<br>- Slurred speech. <br>- Inability to shrug shoulders. | | XI - Spinal Accessory | - Have Pt shrug the shoulders and turn their head from side to side. <br>- Assess the sternocleidomastoid and trapezius muscle for symmetry. | | | XII - Hypoglossal | - Inspect the tongue for atrophy at rest.<br>- Assess movement of the tongue, have Pt stick out the tongue and move it internally from cheek to cheek | - Tongue weakness. | ### Autonomic nervous system - Regulates activities of internal organs. Maintains and restores homeostasis. Two divisions sympathetic and parasympathetic. | Structure or Activity | Parasympathetic Effects | Sympathetic Effects | |---|---|---| | Pupil of the eye | Constricted | Dilated | | Circulatory system | | | - Rate and force of heartbeat | Decreased | Increased | | Blood vessels | | | - In heart muscle | Constricted | Dilated | - In skeletal muscle | No direct effect | Dilated | - In abdominal viscera and skin | No direct effect | Constricted | - Blood pressure | Decreased | Increased | | Respiratory system | | | - Bronchioles | Constricted | Dilated | - Rate of breathing | Decreased | Increased | | Digestive System | | | - Peristaltic movements of digestive tube | Increased | Decreased | - Muscular sphincters of digestive tube | Relaxed | Contracted | - Secretion of salivary glands | Thin, watery saliva | Thick, viscid saliva | - Secretions of stomach, intestine, and pancreas | Increased | No direct effect | - Conversion of liver glycogen to glucose | No direct effect | Increased | | Genitourinary System | | | - Urinary bladder | Contracted | Relaxed | - Muscle wall | Relaxed | Contracted | - Sphincters | Relaxed, variable | Contracted under some conditions; varies with menstrual cycle and pregnancy. | - Blood vessels of external genitalia | Dilated | No direct effect | | Integumentary System | | | - Secretion of sweat | No direct effect | Increased | - Pilomotor muscles | No direct effect | Contracted (gooseflesh) | | Adrenal Medulla | No direct effect | Secretion of epinephrine and norepinephrine | ### Nervous system and Aging: Structural - Brain weight decreases as well as the number of synapses. - Cerebral blood flow and metabolism is decreased. - Temperature regulation becomes less efficient. - Deep tendon reflexes can be decreased or absent. - Sleep stages can be reduced. Sleep apnea becomes more common. - Slowing of the autonomic nervous system. - Pupillary responses may be reduced or absent in the presence of cataracts. ### Nervous system and Aging - *Motor* - flexed posture, shuffling gait, and rigidity of movement. - *Sensory* - visual and hearing loss can cause confusion, anxiety, disorientation, misinterpretation of environment, and feelings of inadequacy - *Temp and pain* - feel cold and decreased reaction to painful stimuli. - *Taste and smell* - activity of the taste buds decreases and olfactory sense may be altered. - *Tactile and visual* - dulling of tactile sensation. Sensitivity to glare and decreased peripheral vision. ### Assessment - Take a good history!! Health hx, Family hx, Social hx. - Physical Assessment- Mental status exam and Neurologic exam. ### Physical Assessment - **LOC**- the first cue to a change in neurologic function may be change in LOC. - **Mental Status** - appearance and behavior. Orientation as well as short and long term memory. - **Perception** - Agnosia (is the inability to interpret or recognize objects seen through the special senses). - **Motor ability** - Perform a skilled activity (comb hair, brush teeth). - **Language ability** - understand and communicate appropriately. Aphasia. - **Cranial nerves** - **Motor** - muscle tone, size and strength as well as coordination and balance. - Five-point scale to rate muscle strength. - 5 - indicated full power if contraction against gravity and resistance or normal muscle strength. - 4 - Indicates fair but not full strength against gravity and moderate amount of resistance or slight weakness. - 3 - Indicates just sufficient strength to overcome the force of gravity or moderate weakness. - 2- Indicates the ability to move but not overcome the force of gravity or severe weakness. - 1 - Indicates minimal contractile power (weak muscle contraction can be palpated but no movement is noted) or very severe weakness. - 0 - Indicates no movement. - **Balance and coordination** - Ataxia. - Deep tendon reflexes grading and superficial reflexes - Deep tendon reflexes graded on a scale of 0-4 - 0 = No response. - 1+ = Diminished (hypoactive). - 2+ = Normal. - 3+ = Increased (may be interpreted as normal). - 4+ = Hyperactive (Hyperreflexia) - Superficial reflexes - Reflexes include corneal, gag or swallow, upper/lower ABD, cremasteric (men only), plantar, and perianal. - *Corneal* - cotton swap lightly touching the outer corner of each eye. (Action elects a blink). - *Gag* - touching the back of the pharynx with cotton tipped applicator, first on one side of the uvula and then the other side. - *Planter* - (Babinski reflex) stroking the lateral side of the foot with a tongue blade. If toes constrict and draw together the Pt has a intact CNS, if the toes fan out the Pt has a CNS disease. - They are graded as (-) absent or (+) present. - **Sensory examination** is subjective and requires patient cooperation ### Diagnostic Evaluation - CT is the test of choice. - PET - Single-Photon Emission Computed Tomography - MRI - Cerebral Angiography Diagnostic Evaluation - Diagnostic Evaluation - Myelography - Carotid flow studies - EEG - EMG - Lumbar puncture ## Oncologic Disorders of Brain and Spinal Cord ## Chapter 44 ### Primary Brain Tumors - **Localized** - begin in brain. - These tumors or lesions may cause seizures or focal neurologic signs. - May be malignant or benign. - Benign are usually slow growing. - Malignant can grow rapidly and can spread to surrounding tissue. - Rarely spread to other areas of the body. ### Types of brain tumors - **Glioma** - originating in the brain tissue. - **Dural meningioma** - arise from the coverings of the brain. - **Acoustic neuroma** - developing in or on the cranial nerves. - **Metastatic lesions** - originating from cancer elsewhere in the body. - Pituitary and pineal glands are also considered types of brain tumors. ### Gliomas - **Box 44-1 glioma classes** - **Glioblastoma Multiforme** - most common and most aggressive. - **Meningiomas** - most common brain tumor found in adults. Women > men. - **Acoustic neuromas** - benign tumor of 8th.