1. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Assessment of the Neurologic System Health Assessment Across the Lifespan

2. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-2  Structure and Function  Subjective Data—Health History Questions  Objective Data—The Physical Exam  Abnormal Findings

3. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-3 Structure and Function 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

4. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-4 Cerebral Cortex

5. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-5 Components of the Central Nervous System [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. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-6 Structure and Function (cont.) 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

7. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-7 Sensory Pathways © Pat Thomas, 2006.

8. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-8 Motor Pathways © Pat Thomas, 2006.

9. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-9 Structure and Function (cont.) Peripheral Nervous System  Cranial nerves  Spinal nerves  Autonomic nervous system  Reflex arc

10. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-10 Reflex Arc

11. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-11 Subjective Data— Health History Questions  Headache  Head injury  Dizziness/vertigo  Seizures  Tremors  Weakness

12. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-12 Health History Questions (cont.)  Incoordination  Numbness or tingling  Difficulty swallowing  Difficulty speaking  Significant history  Environmental/occupational hazards

13. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-13 Objective Data— The Physical Exam  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

14. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-14 Objective Data—The Physical Exam (cont.) 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

15. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-15 Objective Data—The Physical Exam (cont.) Motor System—Inspect and palpate  Muscles  Size  Strength  Tone  Involuntary movements  Cerebellar function  Balance tests Gait Gait Tandem walking Tandem walking Romberg’s test Romberg’s test Shallow knee bend Shallow knee bend  Coordination and skilled movements Rapid alternating movements Rapid alternating movements Finger-to-finger test Finger-to-finger test Finger-to-nose test Finger-to-nose test Heel-to-shin test Heel-to-shin test

16. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-16 Objective Data—The Physical Exam (cont.) 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 Stereognosis Graphesthesia Graphesthesia Two-point discrimination Two-point discrimination Extinction Extinction Point location Point location

17. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-17 Objective Data—The Physical Exam (cont.)  Test the stretch or deep tendon reflexes  Technique  Grading  Reinforcement  Biceps reflex  Triceps reflex  Brachioradialis reflex  Quadriceps reflex  Achilles reflex (“ankle jerk”) Clonus Clonus  Test the superficial reflexes  Abdominal reflex  Cremasteric reflex  Plantar reflex

18. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-18 Objective Data—The Physical Exam (cont.)  Neurologic recheck  Level of consciousness  Person  Place  Time  Motor function  Pupillary response  Vital signs  Glasgow Coma Scale (GCS)

19. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System

20. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System

21. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Pupillary Changes  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

22. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Pupillary Changes to Light

23. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Pupillary Changes  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

24. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Motor Function  Ability to follow commands  Muscle tone  Muscle strength  Coordination  Balance (Romberg test)  Posturing (Decorticate, Decerebrate)

25. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Decorticate/Decerebrate

26. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Sensory Function  Tactile sensation  Pain  Temperature  Vibratory sensation  Tactile discrimination

27. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Reflexes  Superficial  Deep tendon  Biceps  Triceps  Patellar  Achilles  Plantar (Babinski Response)

28. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System

29. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Assess Speech and Hearing  Clear and appropriate  Confused  Inappropriate  Garbled  Aphasia (Expressive, Receptive)  Limited hearing  Use of hearing aids

30. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-30 Sample Charting

31. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-31 Sample Charting (cont.)

32. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-32 Sample Charting (cont.)

33. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-33 Abnormal Findings Abnormalities in Muscle Movement  Paralysis  Fasciculations  Tic  Myoclonus  Tremor  Rest tremor  Intention tremor  Chorea  Athetosis

34. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-34 Abnormal Findings for Advanced Practice Abnormal Gaits  Spastic hemiparesis  Cerebellar ataxia  Parkinsonian (festinating)  Scissors  Steppage or footdrop  Waddling  Short leg

35. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-35 Abnormal Findings Common Patterns of Sensory Loss  Peripheral neuropathy  Individual nerves or roots  Spinal cord hemisection (Brown-Séquard syndrome)  Complete transection of spinal cord  Thalamus  Cortex

36. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-36 Abnormal Findings Abnormal Postures  Decorticate rigidity  Decerebrate rigidity  Flaccid quadriplegia  Opisthotonos

37. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-37 Which area of the brain is most likely affected if the patient is having trouble with the finger-to-nose test? A.Cerebellum B.Cerebrum C.Hypothalmus D.Brain stem

38. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 23: Neurologic System Slide 23-38 Vibratory sense is most frequently affected in cases of A.Heart disease B.Crohns’ disease C.Lung Cancer D.Diabetes