1. Denise Coffey MSN, RN

2. Central Nervous System (CNS)  Cerebral cortex  Frontal lobe  Parietal lobe  Occipital lobe  Wernicke’s area  Broca’s area  Basal ganglia  Thalamus  Hypothalamus  Cerebellum  Brainstem  Midbrain  Pons  Medulla  Spinal cord Slide 23-2

3. Pathways of the CNS  Crossed representation  Sensory pathways  Spinothalamic tract  Posterior (dorsal) column  Motor pathways  Corticospinal or pyramidal tract  Extrapyramidal tracts  Cerebellar system  Upper motor neurons  Lower motor neurons Slide 23-3

4. Slide 23-4

5. Slide 23-5 [PRODUCTION NOTE: Please insert Figure 23-2 (from Jarvis Physical Examination and Health Assessment, 5e, ISBN: 978-1-4160-3243-4)] © Pat Thomas, 2006.

6. Slide 23-6 © Pat Thomas, 2006.

7.  Headache  Head injury  Dizziness/vertigo  Seizures  Tremors  Weakness Slide 23-7

8.  Preparation  Screening neurologic examination  Complete neurologic examination  Neurologic recheck  Equipment needed  Penlight  Tongue blade  Cotton swab  Cotton ball  Tuning fork (128 or 256 Hz)  Percussion hammer  Occasionally need: familiar aromatic substance Slide 23-8

9. Test Cranial Nerves  I—Olfactory  II—Optic  III—Oculomotor, IV—Trochlear, VI—Abducens  V—Trigeminal  Motor function  Sensory function  Corneal reflex  VII—Facial  Motor function  Sensory function  VIII—Acoustic (vestibulocochlear)  IX—Glossopharyngeal, X—Vagus  Motor function  Sensory function  XI—Spinal accessory  XII—Hypoglossal Slide 23-9

11. Motor System— Inspect and palpate  Muscles  Size  Strength  Tone  Involuntary movements  Cerebellar function  Balance tests  Gait  Tandem walking  Romberg’s test  Shallow knee bend  Coordination and skilled movements  Rapid alternating movements  Finger-to-finger test  Finger-to-nose test  Heel-to-shin test Slide 23-11

12. Sensory System  Person is alert, cooperative, and comfortable  Guidelines for sensory testing  Spinothalamic tract  Pain  Temperature  Light touch  Posterior column tract  Vibration  Position (kinesthesia)  Tactile discrimination (fine touch)  Stereognosis  Graphesthesia  Two-point discrimination  Extinction  Point location Slide 23-12

13.  Test the stretch or deep tendon reflexes  Technique  Grading  Reinforcement  Biceps reflex  Triceps reflex  Brachioradialis reflex  Quadriceps reflex  Achilles reflex (“ankle jerk”)  Clonus  Test the superficial reflexes  Abdominal reflex  Cremasteric reflex  Plantar reflex Slide 23-13

14.  Neurologic recheck  Level of consciousness  Person  Place  Time  Motor function  Pupillary response  Vital signs  Glasgow Coma Scale (GCS) Slide 23-14

17.  Oculomotor response (Cranial nerve III)  Size, equality, and roundness of pupils assessed  Size measured in millimeters  Evaluated for symmetry in size and response to light stimulus  Brisk, sluggish, non-reactive  Consensual reaction of opposite pupil at same time

19.  Assess accommodation by holding finger 4-6 inches from client’s nose and then pull out to 18 inches.  As finger moves away pupil will accommodate by dilating, as finger moves closer, constricting  PEARLA- Pupils equal and reactive to light and accommodation

20.  Ability to follow commands  Muscle tone  Muscle strength  Coordination  Balance (Romberg test)  Posturing (Decorticate, Decerebrate)

22.  Tactile sensation  Pain  Temperature  Vibratory sensation  Tactile discrimination

23.  Superficial  Deep tendon  Biceps  Triceps  Patellar  Achilles  Plantar (Babinski Response)

25.  Clear and appropriate  Confused  Inappropriate  Garbled  Aphasia (Expressive, Receptive)  Limited hearing  Use of hearing aids

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