Neurologic System: Learning Objectives & Structure

Learning Objectives At the end of this lecture, the student will be able to: ❑Identify pertinent neurologic system history questions ❑Obtain neurologic system history ❑Perform a physical assessment of the neurologic system ❑Differentiate between normal and abnormal findings ❑ Document neurologi...

Learning Objectives At the end of this lecture, the student will be able to: ❑Identify pertinent neurologic system history questions ❑Obtain neurologic system history ❑Perform a physical assessment of the neurologic system ❑Differentiate between normal and abnormal findings ❑ Document neurologic system findings  Structure and Function ❑ Nervous system divided into: Central nervous Peripheral nervous Autonomic nervous system (brain and system (12 pairs of system (sympathetic spinal cord) cranial nerves, 31 pairs and parasympathetic) of spinal nerves) ❑ Nerves carry information to and from CNS: Sensory (afferent) messages from sensory receptors to CNS Motor (efferent) messages from CNS to muscles and glands ❑ Brain Central Nervous System Consists of: 1) cerebrum (or cerebral cortex), 2) brainstem, and 3) cerebellum 1) Cerebral cortex ❑ Center for a human's highest functions, memory, reasoning, sensation & voluntary movement ❑ Each half of cerebrum is a hemisphere  Central Nervous System (Cont….) ❑ Each hemisphere is divided into four lobes: i. Frontal Personality, behavior, emotions & intellectual function ii. Parietal Sensation iii. Temporal hearing, taste & smell iv. Occipital Vision  Central Nervous System (Cont….) 2)Brainstem ❑ It has three areas: i. Midbrain—Most anterior part of brainstem. It contains many motor neurons and tracts ii. Pons— Containing ascending sensory and descending motor tracts iii.Medulla—It has vital autonomic centers (respiration, heart, gastrointestinal function) and nuclei for cranial nerves VIII through XII  Central Nervous System (Cont….) 3) Cerebellum ❑ Located under occipital lobe concerned with coordination of voluntary movements, equilibrium & muscle tone  Central Nervous System (Cont….) ❑ Spinal cord Extends from upper border of first cervical vertebra lower border of first lumbar vertebra Primary pathway for messages traveling between peripheral areas of body and brain It’s encased & protected by a continuation of meninges and cerebrospinal fluid of brain It’s also protected by bony vertebrae of spine  Peripheral Nervous System ❑ Consists of: 1) Spinal nerves 31 pairs (efferent and afferent nerves) Named after region of spine they exit (8 cervical, 12 thoracic, 5 lumbar, 5 sacral,1 coccygeal) 2) Cranial nerves 12 pairs  Autonomic Nervous System ❑ Contains motor neurons that regulate activities of visceral organs and affect smooth, cardiac muscles & glands ❑ It consists of two parts: i. Sympathetic division, which controls fight-or-flight reactions ii. Parasympathetic division, which restore and maintains normal body functions  Subjective Data ❑ Headache? ❑ Head injury? ❑ Dizziness (lightheaded)/ Vertigo (spinning)/Syncope, a temporary loss of consciousness? ❑ Seizures (altered or loss of consciousness, involuntary muscle movements)?  Subjective Data (Cont….) ❑ Tremors (involuntary shaking, vibrating or trembling)? ❑ Weakness? Paresis: partial or incomplete paralysis Paralysis: total loss of motor function due to lesion in the neurologic or muscular system ❑ Incoordination. Any problem with balance when walking? Dysmetria: inability to control distance, power and speed of muscular action  Subjective Data (Cont….) ❑ Numbness or tingling (Does it feel like pins and needles) Paresthesia: abnormal sensation, e.g., burning & tingling ❑ Difficulty speaking? Dysarthria: difficulty forming words Dysphasia: difficulty with language comprehension or expression ❑ Past history of stroke, spinal cord injury, meningitis, encephalitis or congenital defect?  Objective Data ❑ Sequence for complete neurologic examination: 1) Mental status 2) Cranial nerve function 3) Sensory function 4) Motor function 5) Reflexes  Objective Data (Cont….) 1)Mental Status- ABCT ❑ Appearance: posture, body movements, dress, grooming & hygiene ❑ Behavior: level of consciousness (awake, alert, aware), facial expression, speech, mood & affect ❑ Cognitive function: orientation (time, place, person), attention span, recent & remote memory ❑ Thought process and perception: thought process and content, perceptions, screen for anxiety disorders, depression & suicidal thoughts  Objective Data (Cont….) 2) Cranial Nerves (CNs) ✓ I-Olfactory ✓ II-Optic ✓ III-Oculomotor ✓ IV-Trochlear ✓ V-Trigeminal ✓ VI-Abducens ✓ VII-Facial ✓ VIII-Vestibulocochlear ✓ IX-Glossopharyngeal ✓ X-Vagus ✓ XI-Spinal accessory ✓ XII-Hypoglossal  Objective Data (Cont….) ❑ Test Cranial Nerves I-Olfactory nerve (sensory) / smell i. With client's eyes closed, occlude one nostril and present an aromatic substance ii. Use familiar, obtainable and nonnoxious smells such as coffee, toothpaste, orange, vanilla or soap iii. Ask client to sniff and identify it. Normally, a client can identify an odor on each side of the nose II-Optic nerve (sensory) / vision i. Assess visual acuity (Snellen chart & Rosenbaum card) ii. Assess visual field (confrontation)  Objective Data (Cont….) III-Oculomotor nerve (motor) IV-Trochlear nerve (motor) Eye movement VI-Abducens nerve(motor) ❑ Assess extraocular muscle function i. Corneal light reflex (Hirschberg test) ii. Diagnostic position test (Cardinal fields of gaze) ❑ Assess pupils PERRLA (Pupils, Equal, Round, React to Light, Accommodation)  Objective Data (Cont….) V-Trigeminal nerve (motor and sensory) ❑ Assess motor function i. Palpating temporal and masseter muscles as client clenches teeth; muscles should feel equally strong on both sides ii.Next try to separate jaws by pushing down on chin; normally you cannot ❑ Assess sensory function i. With client's eyes closed, test light touch sensation by touching 1 a cotton 2 wisp on 3 client's face: forehead, cheeks & chin ii. Ask client to say “Now” whenever the touch is felt  Objective Data (Cont….) VII-Facial nerve (motor and sensory) / facial expression and taste ❑ Assess motor function i. Note mobility & facial symmetry as client responds to these requests: smile, frown, close eyes tightly, lift eyebrows, show teeth and puff cheeks ii. Press client 's puffed cheeks in; note that the air should escape equally from both sides ❑ Assess sensory Function i. Placing items with various tastes on anterior portion of client’s tongue (e.g., sweet, sour & bitter)  Objective Data (Cont….) VIII-Vestibulocochlear nerve [Acoustic] (sensory) / hearing ❑ To assess this nerve, use whispered voice test, Weber’s test and Rinne test IX-Glossopharyngeal nerve and X-Vagus nerve (motor and sensory) i. Depress tongue with a tongue blade and note pharyngeal movement as client says “ahhh”; uvula and soft palate should rise in the midline ii. Then, check gag reflex by touching the tip of a tongue blade against posterior pharynx iii. Ask client to drink water & note swallowing  Objective Data (Cont….) XI-Spinal accessory nerve (motor) / neck muscles i. Check equal strength by asking client to rotate head forcibly against resistance applied to side of chin ii. Then, ask client to shrug shoulders against resistance ▪ Normally, these movements should feel equally strong on both sides  Objective Data (Cont….) XII-Hypoglossal nerve (motor) / Tongue i. Inspect the tongue. No wasting or tremors should be present ii. Note the forward thrust in the midline as client protrudes tongue iii. Ask client to say “light, tight, dynamite”. Note that lingual speech (l, t, d,n) is clear and distinct  Objective Data (Cont….) 3) Sensory function 3.1. Pain i. Break a tongue blade lengthwise, forming a sharp point at fractured end and a dull spot at rounded end ii. Lightly apply sharp point or dull end to client 's body in a random iii. Ask client to say “sharp” or “dull,” depending on sensation felt. Let at least 2 seconds elapse between each stimulus (Why ??)  Objective Data (Cont….) 3) Sensory function (Cont….) 3.2. Light Touch i. Stretch a cotton ball to make a long end and brush it over skin in a random order of sites (arms, forearms, hands, chest, thighs &legs) ii. Ask client to say “now” or “yes” when touch is felt iii.Compare symmetric points  Objective 3) Sensory function (Cont….) Data (Cont….) 3.3.Vibration i. Strike tuning fork on heel of your hand and hold base on a bony surface of fingers and great toe ii. Ask client to indicate when vibration starts and stops iii. Compare the right side with the left side 3.4. Position (Kinesthesia) i. The test is done with eyes closed ii. Move a finger or big toe up and down and ask client to tell you which way it is moved ▪ Normally, a client can detect movement  Objective Data (Cont….) 3) Sensory function (Cont….) 3.5. Stereognosis i.With his or her eyes closed, place a familiar object (paper clip, key, coin, or pencil) in client's hand ii.Ask him or her to identify it iii. Test a different object in each hand 3.6. Graphesthesia i. With client's eyes closed, use a blunt instrument to trace a single digit number or a letter on palm ii. Ask client to tell you what it is  Objective Data (Cont….) 3) Sensory function (Cont….) 3.7. Extinction i. Ask the client to close the eyes ii. Simultaneously touch both sides of body at same point iii. Ask client to state how many sensations are felt and where they are ▪ Normally, both sensations are felt Objective Data (Cont….) 4) Motor function 1) Assess muscles for size, strength, tone and involuntary movement 2) Cerebellar function (Coordination and skilled movements tests and balance tests)  Objective Data (Cont….) ❑ Assess muscles for 1) size, 2) strength, 3) tone and 4) involuntary movement 1) Size i. Assess all muscle groups and compare left to right side ▪ Atrophy: small muscles occurs with disease & in-activity ▪ Hypertrophy: increased size exercise 2) Strength i. Test power of muscles groups simultaneously ▪ Paresis: weakness ▪ Paralysis or plegia: absence of strength  Objective Data (Cont….) 3) Tone (Normal degree of tension [contraction]) i. Instruct client to “go loose”, move each extremity smoothly through a full range of motion ii. Note pain or limited range of motion ▪ Normally, you will note a mild, even resistance to movement 4) Involuntary movements Normally not occur, if present note location, rate, frequency and amplitude (tic, tremor)  Objective Data (Cont….) ❑ Coordination and skilled movement i. Rapid alternating movements test ii. Finger-to-finger test iii.Finger-nose-finger test iv.Heel-to-shin test  Objective Data (Cont….) ❑ Balance tests 1) Gait i. Observe as client walks 10 to 20 feet, turns and returns to starting point. Normally, client moves with a sense of freedom ii. Ask client to walk a straight line in a heel-to-toe fashion (tandem walking). Normally, client can walk straight and stay balanced Ataxia: uncoordinated, unsteady gait  Objective Data (Cont….) ❑ Balance tests (Cont….) 2) Romberg Test i. Ask client to stand up with feet together and arms at sides ii. Once in a stable position, ask him or her to close eyes and to hold position iii.Wait about 20 seconds ▪ Normally, a client can maintain posture & balance  Objective Data (Cont….) 5) Reflexes ( Deep and superficial) ❑ Reflex response scale 4+ = Very brisk, hyperactive 3+ = Brisker than average 2+ = Average, normal 1+ = Diminished 0 = No response Hyperreflexia: Exaggerated reflex occurs with upper motor neuron lesions (stroke) Hyporeflexia: Minimal of reflex (Spinal cord injury)  Objective Data (Cont….) ❑ Deep tendon reflexes 1- Biceps reflex (C5 to C6) Support client 's forearm on yours; this position relaxes and partially flexes client's arm Place your thumb on the biceps tendon and strike a blow on your thumb ▪ Normally, contraction of biceps muscle and flexion of forearm  Objective Data (Cont….) ❑ Deep tendon reflexes (Cont….) 2- Triceps reflex (C7 to C8) Tell client to let arm “just go dead” as you suspend it by holding upper arm Strike triceps tendon directly just above elbow ▪ Normally, extension of forearm  Objective Data (Cont….) ❑ Deep tendon reflexes (Cont….) 3- Brachioradialis reflex (C5 to C6) Hold client ’s thumb to suspend forearm in relaxation Strike forearm directly about 2-3 cm above the radial styloid process ▪ Normally, flexion and supination of forearm  Objective Data (Cont….) ❑ Deep tendon reflexes (Cont….) 4- Quadriceps reflex (Knee Jerk) (L2 to L4) Let lower legs dangle freely to flex the knee and stretch the tendons Strike tendon directly just below patella ▪ Normally, extension of lower legs. You will feel contraction of quadriceps  Objective Data (Cont….) ❑ Deep tendon reflexes (Cont….) 5- Achilles reflex (Ankle Jerk) (L5 to S2) Position the client with knee flexed and hip externally rotated Hold foot in dorsiflexion and strike Achilles tendon directly Dorsiflex foot and tap the tendon ▪ Normally, Foot planter flexes against your hand  Objective Data (Cont….) ❑ Superficial reflexes 1- Plantar reflex (L4 to S2) With reflex hammer, draw a slow stroke up lateral side of sole of foot and inward across ball of foot, like an upside-down J ▪ Normally, plantar flexion of toes and inversion and flexion of forefoot  Objective Data (Cont….) 41 Neurologic re-check Level of consciousness (LOC) Motor function Pupillary response Vital signs Glasgow coma scale (GCS)  Objective Data (Cont….) 1) Level of consciousness: Ask question about: ❑ Person. What’s your name?/ What’s your father’s name? ❑ Place. Where are you now? ❑ Time. What year is it? 2) Motor function ❑ Give specific commands & check voluntary movement of each extremity  Objective Data (Cont….) 3) Pupillary response ❑ PERRLA (Pupils, Equal, Round, React to Light, Accommodation) 4) Vital signs ❑ Measure Temp, RR, HR & BP 5) Glasgow coma scale (GCS) ❑ Accurate and reliable quantitative tool and objective assessment that defines level of consciousness by giving it a numeric value ❑ Divided into three areas: 1) eye opening, 2)verbal response and 3) motor response; fully alert person has a score of 15  Abnormalities in Muscle Tone 1)Flaccidity 2)Spasticity Decreased Increased muscle tone muscle tone or or hypotonia hypertonia Associated with lower Associated motor neuron with upper injury motor neuron injury  Abnormalities in Muscle Movement ❑Paralysis: Decreased or loss of motor power caused by problem with motor nerve Patterns of paralysis ❑Tremor: Involuntary contraction of opposing muscle groups Abnormal Gaits Abnormal Postures A. Decerebrate rigidity B. Decorticate rigidity Abnormal Finding: Meningeal irritation Brudzinski’s sign Kernig’s sign Positive Brudzinski’s and Kernig’s signs indicate meningeal irritation (which occur with meningitis)  Sample Charting: Subjective Data ❑No unusually frequent or severe headaches; no head injury, dizziness or vertigo, seizures, or tremors. No weakness, numbness or tingling, or difficulty swallowing or speaking. Has no past history of stroke, spinal cord injury, meningitis, or alcohol disorder. Sample Charting: Objective Data ❑ Mental status: Appearance, behavior, and speech appropriate; alert and oriented to person, place, and time; recent and remote memory intact ❑ Motor: No atrophy, weakness, or tremors. Rapid alternating movements— finger-to-nose smoothly intact. Gait smooth and coordinated, able to tandem walk, negative Romberg ❑ Sensory: Sharp and dull, light touch, vibration intact. Stereognosis—able to identify key ❑ Reflexes: No Babinski sign, DTRs 2+ and = bilaterally with downgoing toes  Sample Charting: Objective Data ❑ Cranial nerves: II: Vision 20/20 left eye, 20/20 right eye; peripheral fields intact by confrontation; fundi normal. III, IV, VI: EOMs intact, no ptosis or nystagmus; pupils equal, round, react to light and accommodation (PERRLA). V: Sensation intact and equal bilaterally; jaw strength equal bilaterally. VII: Facial muscles intact and symmetric. VIII: Hearing—whispered words heard bilaterally. IX, X: Swallowing intact, uvula rises in midline on phonation. XI: Shoulder shrug, head movement intact and equal bilaterally. XII: Tongue protrudes midline, no tremors.