Neurological ExaminationHealth Assessment

HNI/HNC 370Professor Janet GaliczewskiProfessor Janet Galiczewski

RN,MSN,ANP,CCRNRN,MSN,ANP,CCRN

A & P of the Neurological System Central Nervous SystemCentral Nervous System: Brain & Spinal : Brain & Spinal

cordcord Peripheral Nervous System:Peripheral Nervous System:12 pairs 12 pairs

cranial nerves, 31 pairs spinal nerves.cranial nerves, 31 pairs spinal nerves. Autonomic Nervous System:Autonomic Nervous System: sympathetic & parasympathetic.sympathetic & parasympathetic.

Central Nervous System

BrainBrain protected by the skull. protected by the skull. Between brain & skull lie three connective Between brain & skull lie three connective

tissue layers called meninges.tissue layers called meninges. Outer layer - Outer layer - Dura MaterDura Mater Middle layer Middle layer - Arachnoid;- Arachnoid; between between

arachnoid & inner meningeal layer is the arachnoid & inner meningeal layer is the subarachnoid spacesubarachnoid space. CSF found here.. CSF found here.

Inner layer - Inner layer - Pia MaterPia Mater

Cerebral Spinal FluidCerebral Spinal Fluid –circulates around –circulates around the brain & spinal cord the brain & spinal cord

provides cushionprovides cushion removes metabolic wasteremoves metabolic waste provides nutritionprovides nutrition maintains normal ICPmaintains normal ICP

Brain

Consists of the Consists of the cerebrum, cerebellum, cerebrum, cerebellum, brainstem & diencephalon.brainstem & diencephalon.

Made up of Made up of gray matter & white mattergray matter & white matter.. Blood flows to the brain by two internal carotid Blood flows to the brain by two internal carotid

arteries, two vertebral arteries.arteries, two vertebral arteries. Drains away through venous sinuses that empty Drains away through venous sinuses that empty

into the jugular veins.into the jugular veins. Circle of WillisCircle of Willis (provides circulation if 1 of 4 (provides circulation if 1 of 4

main vessels interrupted.main vessels interrupted.

Cerebrum

Largest part of the brain; composed of two Largest part of the brain; composed of two hemispheres.hemispheres.

Each hemisphere divided into 4 lobes:Each hemisphere divided into 4 lobes: FrontalFrontal: personality, speech, memory, : personality, speech, memory,

behavior, emotion, intellectual function.behavior, emotion, intellectual function. ParietalParietal:sensation.:sensation. TemporalTemporal: hearing taste, smell.: hearing taste, smell. OccipitalOccipital: visual reception.: visual reception.

Diencephalon Lies on top of the brainstem; contains the Lies on top of the brainstem; contains the

Hypothalmus & ThalamusHypothalmus & Thalamus.. HypothalamusHypothalamus- maintains homeostasis, - maintains homeostasis,

body temp., hunger, thirst, storage & body temp., hunger, thirst, storage & secretion of hormones.secretion of hormones.

ThalmusThalmus – main part of Diencephalon, – main part of Diencephalon, relays info to parts of cerebral cortex, relays info to parts of cerebral cortex, regulates states of sleep & wakefulness, regulates states of sleep & wakefulness, damage can lead to “coma state”.damage can lead to “coma state”.

Brainstem consists of: Midbrain: Midbrain: processes visual & auditoryprocesses visual & auditory

info, initiates involuntary motor responses, info, initiates involuntary motor responses, maintains consciousness.maintains consciousness.

Pons: Pons: connects cerebellum to brainstem, connects cerebellum to brainstem, motor control.motor control.

Medulla OblongataMedulla Oblongata: connects brain & : connects brain & spinal cord, involuntary functions spinal cord, involuntary functions responsible for primitive life maintenance, responsible for primitive life maintenance, heart function, breathing, sneezing, heart function, breathing, sneezing, coughing, vomiting.coughing, vomiting.

Cerebellum

Coordination of voluntary movementCoordination of voluntary movement Equilibrium, balanceEquilibrium, balance Muscle ToneMuscle Tone Proprioception (without looking, knowing Proprioception (without looking, knowing

where your body parts are in space & where your body parts are in space & relationship to each other.)relationship to each other.)

Each hemisphere controls movement for the Each hemisphere controls movement for the same side of the body (ipsilateral).same side of the body (ipsilateral).

Spinal Cord Continuation of the medulla oblongataContinuation of the medulla oblongata Begins at base of the skull (foramen magnum).Begins at base of the skull (foramen magnum). Protected by the vertebraeProtected by the vertebrae Ends L1 & L2 branches into lumber & sacral Ends L1 & L2 branches into lumber & sacral

nerves roots called cauda equina.nerves roots called cauda equina. Nerve fibers grouped into tracts run through spinal Nerve fibers grouped into tracts run through spinal

cord transmit sensory, motor, autonomic impulses cord transmit sensory, motor, autonomic impulses between higher centers in the brain & body.between higher centers in the brain & body.

Peripheral Nervous System

Cranial Nerves 12 pairsCranial Nerves 12 pairs Spinal Nerves 31 pairs emerge from different Spinal Nerves 31 pairs emerge from different

segments of the spinal cord.segments of the spinal cord. 8 cervical8 cervical 12 thoracic12 thoracic 5 lumbar5 lumbar 1 coccygeal1 coccygeal 5 sacral5 sacral

Each pair of spinal nerves is formed by the union of Each pair of spinal nerves is formed by the union of an efferent or motor ventral root & an afferent or an efferent or motor ventral root & an afferent or sensory dorsal root attached to the spinal cord.sensory dorsal root attached to the spinal cord.

Motor (efferent) root carry impulses from brain to Motor (efferent) root carry impulses from brain to the spinal cord to the muscles & glands.the spinal cord to the muscles & glands.

Sensory (afferent) root carry impulses from sensory Sensory (afferent) root carry impulses from sensory receptors of the body through the spinal cord to the receptors of the body through the spinal cord to the brain.brain.

Each pair of spinal nerves & its corresponding part Each pair of spinal nerves & its corresponding part of the spinal cord innervates specific body segments.of the spinal cord innervates specific body segments.

DermatomesDermatomes - Band of skin innervated by - Band of skin innervated by the sensory nerve root of a single spinal the sensory nerve root of a single spinal segment. Distal point tested first.segment. Distal point tested first.

Hypoesthesia: decreased sensationHypoesthesia: decreased sensation Hyperesthesia: excessive sensationHyperesthesia: excessive sensation Anesthesia: loss of sensation Anesthesia: loss of sensation Paresthesia: numbness, tingling, burning.Paresthesia: numbness, tingling, burning.

Reflex ArcReflex Arc - deep tendon reflexes are - deep tendon reflexes are segmental responses to stimulation of a segmental responses to stimulation of a tendon.tendon.

Autonomic Nervous System

Considered part of the Peripheral Nervous Considered part of the Peripheral Nervous System.System.

SympatheticSympathetic: activated during stress (fight : activated during stress (fight or flight).or flight).

ParasympatheticParasympathetic: conserving energy (rest : conserving energy (rest & digest)& digest)

Cerebral Function

Brief (mini) Mental StatusBrief (mini) Mental Status LOCLOC Remote memoryRemote memory Recent memoryRecent memory Orientation (person, place, time)Orientation (person, place, time) MoodMood Thought contentThought content

Cranial Nerves

Olfactory I Olfactory I Acoustic VIII Acoustic VIII Optic IIOptic II Glossopharyngeal IX Glossopharyngeal IX Oculomotor IIIOculomotor III Vagus X Vagus X Trochlear IVTrochlear IV Spinal Accessory XI Spinal Accessory XI Trigeminal VTrigeminal V Hypoglossal XII Hypoglossal XII Abducens VIAbducens VI Facial VIIFacial VII

Cerebellar Function

Tests balance & coordinationTests balance & coordination Point to PointPoint to Point: Upper Extremities, Lower : Upper Extremities, Lower

Extremities.Extremities. Alternating MovementsAlternating Movements: Upper : Upper

Extremities. Lower Extremities.Extremities. Lower Extremities. GaitGait Tandem GaitTandem Gait RombergRomberg

Sensory

TouchTouch: Upper Extremities; Distal & : Upper Extremities; Distal & Proximal.Proximal. Lower Extremities; Distal & Proximal.Lower Extremities; Distal & Proximal. PainPain If pain response abnormal-Temperature.If pain response abnormal-Temperature.

Vibration: Upper & Lower Extremities.Vibration: Upper & Lower Extremities. Motion & PositionMotion & Position

Sensory (cont.)

Forms of Sensation: Two Point Forms of Sensation: Two Point Discrimination-Fingers & Thigh.Discrimination-Fingers & Thigh.

StereognosisStereognosis ExtinctionExtinction Point LocationPoint Location

Motor

Muscle SizeMuscle Size Muscle ToneMuscle Tone

SpasticitySpasticity RigidityRigidity FlaccidityFlaccidity

Resting or Intentional TremorsResting or Intentional Tremors Rest TremorRest Tremor Intention TremorIntention Tremor Essential tremorsEssential tremors

Motor (cont).

Choreiform MovementsChoreiform Movements TicTic MyoclonusMyoclonus FasciculationsFasciculations

Test Muscle Strength: 5/5 normalTest Muscle Strength: 5/5 normal See handout for scale of Muscle strengthSee handout for scale of Muscle strength

Sensory – Motor Deep Tendon Reflexes Deep tendon Reflexes are involuntary responses & Deep tendon Reflexes are involuntary responses &

involve afferent neurons (sensory) & efferent involve afferent neurons (sensory) & efferent neurons (motor).neurons (motor).

To Elicit a DTR briskly tap the tendon of a To Elicit a DTR briskly tap the tendon of a partially stretched muscle.partially stretched muscle.

For reflex to fire, all components of the reflex arc For reflex to fire, all components of the reflex arc must be intact – sensory nerve fibers, spinal cord must be intact – sensory nerve fibers, spinal cord synapses, motor nerve fibers, neuromuscular synapses, motor nerve fibers, neuromuscular junction, & muscle fibers.junction, & muscle fibers.

Reflexes - Spinal Cord Segment

ReflexReflex TricepsTriceps PatellarPatellar AchillesAchilles BicepsBiceps BrachioradialisBrachioradialis

Spinal Cord Seg.Spinal Cord Seg. Cervical 6, 7Cervical 6, 7 Lumbar 2, 3, 4Lumbar 2, 3, 4 Sacral 1Sacral 1 Cervical 5, 6Cervical 5, 6 Cervical 5, 6Cervical 5, 6

Sensory Motor: Deep Tendon Reflexes

BicepsBiceps TricepsTriceps BrachioradialisBrachioradialis PatellaPatella AchillesAchilles Superficial Plantar (Babinski)Superficial Plantar (Babinski)

Reflex Scale

4+ - Very brisk; hyperactive4+ - Very brisk; hyperactive 3+ - Brisker than average3+ - Brisker than average 2+ - Average2+ - Average 1+ - Diminished1+ - Diminished 0 - Absent0 - Absent