Neurological Examination Health Assessment HNI/HNC 370 Professor Janet Galiczewski RN,MSN,ANP,CCRN

A & P of the Neurological System Central Nervous System: Brain & Spinal cord Central Nervous System: Brain & Spinal cord Peripheral Nervous System:12 pairs cranial nerves, 31 pairs spinal nerves. Peripheral Nervous System:12 pairs cranial nerves, 31 pairs spinal nerves.  Autonomic Nervous System:  sympathetic & parasympathetic.

Central Nervous System Brain protected by the skull. Brain protected by the skull. Between brain & skull lie three connective tissue layers called meninges. Between brain & skull lie three connective tissue layers called meninges.  Outer layer - Dura Mater  Middle layer - Arachnoid; between arachnoid & inner meningeal layer is the subarachnoid space. CSF found here.  Inner layer - Pia Mater

Cerebral Spinal Fluid –circulates around the brain & spinal cord Cerebral Spinal Fluid –circulates around the brain & spinal cord provides cushion provides cushion removes metabolic waste removes metabolic waste provides nutrition provides nutrition maintains normal ICP maintains normal ICP

Brain Consists of the cerebrum, cerebellum, brainstem & diencephalon. Consists of the cerebrum, cerebellum, brainstem & diencephalon. Made up of gray matter & white matter. Made up of gray matter & white matter. Blood flows to the brain by two internal carotid arteries, two vertebral arteries. Blood flows to the brain by two internal carotid arteries, two vertebral arteries. Drains away through venous sinuses that empty into the jugular veins. Drains away through venous sinuses that empty into the jugular veins. Circle of Willis (provides circulation if 1 of 4 main vessels interrupted. Circle of Willis (provides circulation if 1 of 4 main vessels interrupted.

Cerebrum Largest part of the brain; composed of two hemispheres. Largest part of the brain; composed of two hemispheres. Each hemisphere divided into 4 lobes: Each hemisphere divided into 4 lobes:  Frontal: personality, speech, memory, behavior, emotion, intellectual function.  Parietal:sensation.  Temporal: hearing taste, smell.  Occipital: visual reception.

Diencephalon Lies on top of the brainstem; contains the Hypothalmus & Thalamus. Lies on top of the brainstem; contains the Hypothalmus & Thalamus. Hypothalamus- maintains homeostasis, body temp., hunger, thirst, storage & secretion of hormones. Hypothalamus- maintains homeostasis, body temp., hunger, thirst, storage & secretion of hormones. Thalmus – main part of Diencephalon, relays info to parts of cerebral cortex, regulates states of sleep & wakefulness, damage can lead to “coma state”. Thalmus – main part of Diencephalon, relays info to parts of cerebral cortex, regulates states of sleep & wakefulness, damage can lead to “coma state”.

Brainstem consists of:  Midbrain: processes visual & auditory info, initiates involuntary motor responses, maintains consciousness. Pons: connects cerebellum to brainstem, motor control. Pons: connects cerebellum to brainstem, motor control. Medulla Oblongata: connects brain & spinal cord, involuntary functions responsible for primitive life maintenance, heart function, breathing, sneezing, coughing, vomiting. Medulla Oblongata: connects brain & spinal cord, involuntary functions responsible for primitive life maintenance, heart function, breathing, sneezing, coughing, vomiting.

Cerebellum Coordination of voluntary movement Coordination of voluntary movement Equilibrium, balance Equilibrium, balance Muscle Tone Muscle Tone Proprioception (without looking, knowing where your body parts are in space & relationship to each other.) Proprioception (without looking, knowing where your body parts are in space & relationship to each other.) Each hemisphere controls movement for the same side of the body (ipsilateral). Each hemisphere controls movement for the same side of the body (ipsilateral).

Spinal Cord Continuation of the medulla oblongata Continuation of the medulla oblongata Begins at base of the skull (foramen magnum). Begins at base of the skull (foramen magnum). Protected by the vertebrae Protected by the vertebrae Ends L1 & L2 branches into lumber & sacral nerves roots called cauda equina. Ends L1 & L2 branches into lumber & sacral nerves roots called cauda equina. Nerve fibers grouped into tracts run through spinal cord transmit sensory, motor, autonomic impulses between higher centers in the brain & body. Nerve fibers grouped into tracts run through spinal cord transmit sensory, motor, autonomic impulses between higher centers in the brain & body.

Peripheral Nervous System Cranial Nerves 12 pairs Cranial Nerves 12 pairs Spinal Nerves 31 pairs emerge from different segments of the spinal cord. Spinal Nerves 31 pairs emerge from different segments of the spinal cord.  8 cervical  12 thoracic  5 lumbar  1 coccygeal  5 sacral

Each pair of spinal nerves is formed by the union of an efferent or motor ventral root & an afferent or sensory dorsal root attached to the spinal cord. Each pair of spinal nerves is formed by the union of an efferent or motor ventral root & an afferent or sensory dorsal root attached to the spinal cord. Motor (efferent) root carry impulses from brain to the spinal cord to the muscles & glands. Motor (efferent) root carry impulses from brain to the spinal cord to the muscles & glands. Sensory (afferent) root carry impulses from sensory receptors of the body through the spinal cord to the brain. Sensory (afferent) root carry impulses from sensory receptors of the body through the spinal cord to the brain. Each pair of spinal nerves & its corresponding part of the spinal cord innervates specific body segments. Each pair of spinal nerves & its corresponding part of the spinal cord innervates specific body segments.

Dermatomes - Band of skin innervated by the sensory nerve root of a single spinal segment. Distal point tested first. Dermatomes - Band of skin innervated by the sensory nerve root of a single spinal segment. Distal point tested first. Hypoesthesia: decreased sensation Hypoesthesia: decreased sensation Hyperesthesia: excessive sensation Hyperesthesia: excessive sensation Anesthesia: loss of sensation Anesthesia: loss of sensation Paresthesia: numbness, tingling, burning. Paresthesia: numbness, tingling, burning. Reflex Arc - deep tendon reflexes are segmental responses to stimulation of a tendon. Reflex Arc - deep tendon reflexes are segmental responses to stimulation of a tendon.

Autonomic Nervous System Considered part of the Peripheral Nervous System. Considered part of the Peripheral Nervous System. Sympathetic: activated during stress (fight or flight). Sympathetic: activated during stress (fight or flight). Parasympathetic: conserving energy (rest & digest) Parasympathetic: conserving energy (rest & digest)

Cerebral Function Brief (mini) Mental Status Brief (mini) Mental Status LOC LOC Remote memory Remote memory Recent memory Recent memory Orientation (person, place, time) Orientation (person, place, time) Mood Mood Thought content Thought content

Cranial Nerves Olfactory I Acoustic VIII Olfactory I Acoustic VIII Optic II Glossopharyngeal IX Optic II Glossopharyngeal IX Oculomotor III Vagus X Oculomotor III Vagus X Trochlear IV Spinal Accessory XI Trochlear IV Spinal Accessory XI Trigeminal V Hypoglossal XII Trigeminal V Hypoglossal XII Abducens VI Abducens VI Facial VII Facial VII

Cerebellar Function Tests balance & coordination Tests balance & coordination Point to Point: Upper Extremities, Lower Extremities. Point to Point: Upper Extremities, Lower Extremities. Alternating Movements: Upper Extremities. Lower Extremities. Alternating Movements: Upper Extremities. Lower Extremities. Gait Gait Tandem Gait Tandem Gait Romberg Romberg

Sensory Touch: Upper Extremities; Distal & Proximal. Touch: Upper Extremities; Distal & Proximal.  Lower Extremities; Distal & Proximal.  Pain  If pain response abnormal-Temperature. Vibration: Upper & Lower Extremities. Vibration: Upper & Lower Extremities. Motion & Position Motion & Position

Sensory (cont.) Forms of Sensation: Two Point Discrimination-Fingers & Thigh. Forms of Sensation: Two Point Discrimination-Fingers & Thigh. Stereognosis Stereognosis Extinction Extinction Point Location Point Location

Motor Muscle Size Muscle Size Muscle Tone Muscle Tone  Spasticity  Rigidity  Flaccidity Resting or Intentional Tremors Resting or Intentional Tremors  Rest Tremor  Intention Tremor  Essential tremors

Motor (cont). Choreiform Movements Choreiform Movements Tic Tic Myoclonus Myoclonus Fasciculations Fasciculations Test Muscle Strength: 5/5 normal Test Muscle Strength: 5/5 normal See handout for scale of Muscle strength See handout for scale of Muscle strength

Sensory – Motor Deep Tendon Reflexes Deep tendon Reflexes are involuntary responses & involve afferent neurons (sensory) & efferent neurons (motor). Deep tendon Reflexes are involuntary responses & involve afferent neurons (sensory) & efferent neurons (motor). To Elicit a DTR briskly tap the tendon of a partially stretched muscle. To Elicit a DTR briskly tap the tendon of a partially stretched muscle. For reflex to fire, all components of the reflex arc must be intact – sensory nerve fibers, spinal cord synapses, motor nerve fibers, neuromuscular junction, & muscle fibers. For reflex to fire, all components of the reflex arc must be intact – sensory nerve fibers, spinal cord synapses, motor nerve fibers, neuromuscular junction, & muscle fibers.

Reflexes - Spinal Cord Segment Reflex  Triceps  Patellar  Achilles  Biceps  Brachioradialis Spinal Cord Seg. Cervical 6, 7 Lumbar 2, 3, 4 Sacral 1 Cervical 5, 6

Sensory Motor: Deep Tendon Reflexes Biceps Biceps Triceps Triceps Brachioradialis Brachioradialis Patella Patella Achilles Achilles Superficial Plantar (Babinski) Superficial Plantar (Babinski)

Reflex Scale 4+ - Very brisk; hyperactive 4+ - Very brisk; hyperactive 3+ - Brisker than average 3+ - Brisker than average 2+ - Average 2+ - Average 1+ - Diminished 1+ - Diminished 0 - Absent 0 - Absent