Neurologic System Chapter 22

Neurologic System The nervous system Central and peripheral divisions Maintains and controls all body functions by its voluntary and autonomic responses 2

Neurologic System (Cont.) The physical examination of the nervous system assesses the following elements: Motor Sensory Autonomic Cognitive Behavioral 3

Anatomy and Physiology Central nervous system Main network of coordination and control for the body Brain Spinal cord Peripheral nervous system Carries information to and from the central nervous system Cranial nerves Spinal nerves 4

Anatomy and Physiology (Cont.) Autonomic nervous system Coordinates and regulates the internal organs of the body Two divisions that balance the impulses of each other Sympathetic Parasympathetic 5

Brain (Cont.) Three major units Cerebrum Cerebellum Brainstem 6

Cerebrum (Cont.)  Uses sensory data for reflexive control of muscle tone, equilibrium, and posture  Frontal lobe  Voluntary skeletal movement  Parietal lobe  Interpretation and recognition of body parts and awareness of body position (proprioception)  Senses  Occipital lobe  Vision  Temporal lobe  Perception and interpretation of sounds 7

Brainstem Involuntary functions 12 cranial nerves Medulla oblongata Midbrain Pons Transmits information between the brainstem and the cerebellum Diencephalon Thalamus: perception of various sensations (pain) Hypothalmus: Controls temperature 8

Cranial Nerves 12 nerves that rise from brain I- Olfactory II- Optic III- Oculomotor IV- Trochlear V- Trigeminal VI- Abducens VII- Facial VIII- Acoustic IX- Glossopharyngeal X- Vagus XI- Spinal acessory XII- Hypoglossal 9

Spinal Cord and Spinal Nerves  Each of 31 pairs supply and receive information from specific body parts 10

Infants and Children  Major brain growth and myelinization in first year of life  Brain growth continues until 12 to 15 years of age 11

Older Adults The number of cerebral neurons decreases with aging, but this is not necessarily associated with deteriorating mental function. Velocity of nerve impulse conduction declines. Slowed response time Diminished touch and pain perception 12

History of Present Illness Seizures Pain Gait coordination Weakness/ parasthesia Tremor Trauma Circulatory function 13

Family History Hereditary disease Alcoholism Mental disabilities Epilepsy, seizure disorder, or headaches Alzheimer disease or other dementia Learning disorders Weakness or gait disorders Medical or metabolic disorder 14

Personal and Social History Environmental or occupational hazards Ability to care for self Use of alcohol and drugs 15

Infants Prenatal history Birth history RespiCongenital anomalies Developmental delay 16

Children Developmental milestones Hyperactive or impulsive behavior Health problems 17

Older Adults Pattern of increased stumbling, falls, unsteadiness, or decreased agility Interference with performance of ADLs Hearing loss, vision deficit Transient neurologic deficits 18

Neurologic Examination Components Cranial nerves Proprioception and cerebellar function Sensory function Reflex function 19

Cranial Nerves Olfactory (CN I) Sensory and smell Test for odor identification Optic (CN II) sensory and visual acuity Test for visual acuity Test visual fields Perform ophthalmologic examination Oculomotor(CN III), Trochlear (CN IV), and Abducens (CN VI) Inspect eyelids for drooping Inspect pupils for size and equality Consensual response and accomadation Extraocular eye movements 20

Cranial Nerves (Cont.) Trigeminal (CN V) Muscle tone and sensation Inspect face for atrophy or tremors Palpate jaw for tone and strength Assess for pain Corneal reflex Facial (CN VII) Facial symmetry Taste (salty and sweet) 21

Cranial Nerves (Cont.) Acoustic (CN VIII) Hearing Bone and air conduction Sound lateralization Glossopharyngeal (CN IX) Sour and bitter taste Gag reflex and swallowing Vagus (CN X) Uvula symmetrical Swallowing 22

Cranial Nerves (Cont.) Spinal accessory (CN XI) motor and muscle strength in trapezius and sternocleidomastoid Shrug shoulder Hypoglossal (CNXII) Tongue strength Speech sounds 23

Proprioception and Cerebellar Function Coordination and fine motor skills Touching thumb to finger Finger to nose Heel to shin Balance Equilibrium Romberg Stand on one foot Gait Heel to toe walking 24

Sensory Function Test with the patient’s eyes closed. Observe all sensory function tests Superficial touch and pain Vibration Position of joints 25

Sensory Function (Cont.) Cortical sensory function Stereognosis Familiar object (key, coin) Tactile agnosia is an inability to recognize objects by touch Graphesthesia Draw letter on palm of hand Point location Where they are being touched 26

Reflexes Superficial reflexes (Cont.) Plantar reflex Babinski Deep tendon reflexes Biceps: elbow flexion Brachioradial: forearm pronation and elbow flexion Triceps: elbow extension Patellar: lower leg extension Achilles: foot flexion 27

Reflexes (Cont.) Deep tendon reflexes (Cont.) Symmetric visible or palpable responses should be noted. Clonus Involuntary movemnt Associated with stroke Scoring deep tendon reflexes: 0 No response 1  Sluggish or diminished 2  Active or expected response 3  More brisk than expected, slightly hyperactive 4  Brisk, hyperactive, with intermittent or transient clonus 28

Additional Procedures  Meningeal signs (Cont.)  Brudzinski Involuntary flexion of the hips and knees when flexing the neck is a positive Brudzinski sign.  Kernig Pain in the lower back and resistance to straightening the leg at the knee constitute positive Kernig sign 29

Infants Cranial nerves indirectly assessed by observing: CN II, III, IV, and VI Optical blink reflex Gaze and tracking CN V Rooting and sucking CNVII Smile CN VIII Acoustic blink 30

Infants (Cont.) Cranial nerves CN IX and X Swallow and gag reflex CN XII Sucking and swallowing ability 31

Infants (Cont.) Relexes Palmar grasp Moro Stepping 32

Older Adults Test gait for decreases in speed, balance, and grace Check tactile and vibratory sense for impairment Check deep tendon reflexes for diminished response 33

Abnormalities (CNS) Multiple sclerosis Progressive autoimmune disorder obstructed transmission of nerve impulses Seizure disorder Electrical discharges (excessive concurrent firing) of cerebral neurons Encephalitis Inflammation of the brain and spinal cord Meningitis Inflammation of the meninges 34

Abnormalities (CNS) Stoke (brain attack or cerebrovascular accident) Sudden interruption of blood supply to a part of the brain or the rupture of a blood vessel, spilling blood into spaces around brain cells Myasthenia gravis Disorder of neuromuscular transmission Muscle weakness Guillain-Barre’ 1-3 weeks after a virus or or immunization 35

Abnormalities (PNS) Bell palsy Temporary acute paralysis or weakness of one side of the face Peripheral neuropathy Disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves Diabetes mellitus B 12 or folate deficiency Lyme disease HIV infection 36

Abnormalities (Children) Cerebral palsy Permanent disorder of movement and posture development 37

Abnormalities (Older Adults) Parkinson disease Slowly progressive, degenerative neurologic disorder Poor communication between parts of the brain that coordinate and control movement and balance 38