Chapter 23- Neurological

8/9/2019 Chapter 23- Neurological

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Chapter 23

Neurological

I. CNS

a. Frontal Lobe

i. Areas concerned with personality, behavior, emotions, and intellectual function

ii. Precentral Gyrus of Frontal Lobe:

1. initiates voluntary movement

iii. Broncas Area

1. mediates motor speech

2. when injured in the dominant hemisphere: Expressive Aphasia results

a. person cant talk; person can understand language and knows what the

want to say but cant say it

b. Parietal Lobe

i. Posterior Gyrus

1. sensation

c. Occipital Lobei. Primary visual receptor

d. Temporal Lobe

i. Behind the ear, primary auditory reception center

ii. Wernickes Area

1. associated with language; in persons with dominant hemisphere damage:

Receptive Aphasia

a. person hears sound, but it has no meaning, like hearing a foreign

language

e. Hypothalamus

i. Major control center: temperature, HR, and BP control, sleep center, anterior and

posterior pituitary gland regulator, and coordinator of automatic nervous system acti

and emotional status

f. Brain Stem

i. Midbrain

1. Most anterior part of brain stem, has basic tubular structure, it merges into the

thalamus and hypothalamus. Contains many motor neurons and tracts

ii. Pons

1. Enlarged area containing ascending and descending fiber tracts

iii. Medulla

1. Continuation of spinal cord. Contains all ascending and descending fiber tract

connecting to the brain and spinal cord. Vital automatic centers (respiration,

heart, GI function), as well as nuclei for cranial nerves 8 and 12.

II. Peripheral Nervous System

a. Reflex Arc

i. 4 types of Reflexes


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ii. Deep Tendon Reflex (myotatic)

1. patellar or knee jerk

iii. Superficial

1. corneal reflex, abdomen reflex

iv. Visceral (organic)

1. papillary response to light and accommodations

v. Pathologic (abnormal)

1. Babinskis or extensor plantar reflex

III. Cranial Nerves

a. Look at handout

IV. Developmental Considerations

a. Infants

i. Neurological system is not completely developed at birth; neurons are not yet

myelinated

ii. Process of myelinization follows a cephalocaudal and proximodial order (head, neck,

trunk, and extremities)b. Aging Adult

i. The loss of neurons causes a decrease in weight and volume so that by 80 years, the

brain has decreased 15%

ii. General loss of muscle bulk and muscle tone in the face, neck, and around the spine,

decreased muscle strength, impaired fine coordination and agility, loss of vibratory se

at the ankle, decreased or absent Achilles reflex, loss of position sense at the big toe,

papillary miosis, irregular pupil shape, and decreased papillary reflexes

iii. Reaction time slower due to velocity of nerve conduction decrease

iv. Touch and pain sensation, taste, and smell diminished

v. Muscle tremors may occur in head, hands, and jaw along with repetitive facial grimac

vi. A decrease in cerebral blood flow and oxygen consumption and sometimes causes

dizziness and a loss of balance with position change.

V. Subjective Data

a. Headache

b. Head injury

c. Dizziness/ vertigo

d. Seizures

e. Tremors

f. Weakness

g. Incoordination

h. Numbness/ tingling

i. Difficulty swallowing

j. Difficulty speaking

k. Memory changes (older adults)

VI. Objective Data


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i. Screening Neurologic Examination

1. done on seemingly well people who have no significant subjective findings fro

the history

ii. Complete Neurological Examination

1. done on people who have neurologic concerns

2. Use following sequence for Complete Examination

a. Mental Status

b. Cranial Nerves

c. Motor System

d. Sensory System

e. Reflexes

b. Test Cranial Nerves

i. Look at handout

c. Inspect and Palpate the Motor System

i. Muscles

1. Sizea. Atrophy

i. Abnormally small muscle with a wasted appearance, occurs with

disuse, injury, lower motor neuron disease (polio, diabetic

neuropathy)

2. Strength

3. Tone

a. go loose like a rag doll procedure

4. Involuntary Movements

a. Tic: eye blinking

b. Tremor

c. Fasciculation: really little have to get close to see

d. Myoclonus, chorea, and athetosis

ii. Cerebral Function

1. Balance Test

a. Gait

i. Walk straight line heel to toe fashion

b. The Romberg Test

i. Stand with feet together and arms by side and have them close

their eyes

ii. Positive Rombergs: sign of loss of balance that occurs when clo

eyes

2. Coordination and Skilled Movements

a. Rapid Alternating Movements (RAM)

i. Pat knees with both hands, then flip hands and pat knees again

3. Finger to Finger Test


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a. With eyes open ask that they use the index finger to touch your finger

then their nose

4. Finger to Nose Test

a. Close eyes and stretch out the arms, then ask to touch their nose with

each index finger alternating hands and increasing speed

5. Heel to Shin Test

a. Person in superior position, place heel on opposite knee and run it dow

shin

b. Normally moves heel in a straight line down

d. Assess the Sensory System

i. Spinothalamic Tract

1. Pain

a. Pain tested by person being able to feel pin prick

b. Avoid asking can you feel this pin prick?

c. Let at least 2 seconds elapse b/w each stimulus to avoid summation

2. Temperaturea. Only test when pain sensation is abnormal

3. Light Touch

a. Apply a wisp of cotton to the skin, stretch it to make a long end and br

it over the skin in a random order of sites and at irregular intervals

ii. Posterior Column Tract

1. Vibration

a. Ability to feel vibrations with a tuning fork over bony prominences

b. If no vibrations felt, move proximally and test ulnar processes, and ank

patellae, and iliac crest

c. Loss of vibration sensation occurs with peripheral neuropathy

i. Is worse at the feet and gradually improves as you move up the

leg, as opposed to a specific nerve lesion, which has a clear zon

deficit for its dermatome

2. Position (Kinesthesia)

a. Test ability to perceive passive movement of extremities. Move finger

the big toe up and down, and ask person which way its moving

3. Stereognosis

a. Test persons ability to recognize objects by feeling forms, sizes, and

weights. With eyes closed place a familiar object (paperclip, coin, cotto

ball, or pencil) in the persons hand and ask the person to identify it.

4. Graphesthesia

a. Ability to read a number by having it drawn on the hand

5. Two Point Discrimination


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a. Test ability to distinguish the separation of 2 stimulus pin points on the

skin. Apply 2 points of open paper clip lightly to skin in ever closing

distances.

iii. Test Reflexes

1. Stretch or DTRs

a. For an adequate response the limb should be relaxed and the muscle

partially stretched. Stimulate reflex by directing a short direct blow of

reflex hammer onto the muscles insertion tendon. Use just enough for

to get a reaction. Responses should be equal. Graded on a 4 point sca

i. 4+ very brisk, hyperactive with clonus, indicative of disease

ii. 3+ brisker than average, may indicate disease

iii. 2+ Average

iv. +1 Diminished, low normal

v. 0 no response

b. Clonus is a set of short jerking contractions of the same muscle

c. Hyperreflexia is exaggerated reflex seen when the monosynaptic reflexarc is released from the influence of higher cortical levels

d. Hyporeflexia which is the absence of a reflex, is a lower motor neuron

problem

2. Tricepts Reflex

a. Let arm go dead, strike tricep tendon directly above the elbow

3. Brachioradialis Reflex

a. Hold persons thumbs to suspend the forearms in relaxation. Strike

forearm directly, about 2 -3 cm above the radial styloid process

4. Quad Reflex

a. Let lower leg dangle freely to flex the knee and stretch the tendon. Str

tendon directly just below the patella

5. Achilles Reflex

a. Position person with the knee flexed and the hip externally rotated. Ho

the foot in dorsiflexion, and strike Achilles tendon directly.

6. Clonus

a. Support lower leg in one hand. With other hand, move the foot up and

down a few times to relax muscle. Then stretch the muscle by briskly

dorsiflexing the foot. Hold the stretch. With normal response you feel

further movement.

7. Abdominal Reflex

a. Person assumes a supine position with the knees slightly bent. Use ha

end of reflex hammer and stroke the skin.

8. Plantar Reflex

a. (L4 S2) position thigh in slight external rotation. With hammer, draw

light stroke up the lateral side of the sole of the foot and inward across


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ball of the foot, like upside down J. Normal response is plantar flexion o

all the toes and inversion and flexion of the forefoot.

b. Abnormal: except in infancy, the dorsiflexion of the big toe and fanning

all toes, which is a positive Babinski sign, also called up going toes.

VII. Developmental Considerations

a. Infants (birth 12 months)

i. Next 2-3 days after birth spent sleeping as baby recovers from birth. By 2 months of

the baby smiles responsively and recognizes the parents face.

ii. Babbling occurs at 4 months, and one or two words. Mama and dada are used after 9

months

iii. Abnormal finding: high pitched shrill cry or cat sounding screech occurs with CNS

damage.

iv. Head Control

1. first baby is supine and pull to sit holding the wrists and not head control. Sec

life up the baby in a prone position, with one hand supporting the chest.

a. The newborn holds head at 45 degrees or less from horizontal, the bacstraight or slightly arched, and the elbows and knees are flexed.

2. At 3 months the baby raises head and arches back, as in a swan dive. This is

Landau Reflex, which persists until age 1 years of age.

v. Rooting Reflex

1. Brush the infants cheeks near the mouth. Note whether they turn their head

toward that side and opens the mouth. Appears at birth and disappears at 3-4

months

vi. Sucking Reflex

1. Touch lips and offer your gloved little finger to suck. Present at birth and

disappears at 10 12 months

vii. Palmar Grasp

1. Place head midline. Offer your finger from the babys ulnar side, away from th

thumb. Note tight grasp of all fingers.

viii. Plantar Grasp

1. Touch thumb slightly at the ball of foot. Note the toes curling down tightly.

Present at birth and disappears 8 10 months

ix. Babinski Reflex

1. Stroke your finger up the lateral edge and across the ball of foot. Not fanning

toes. Appears at birth and disappears by 24 months

2. Positive after 2 years or 2 years of age occurs with pyramidial tract disease

x. Tonic Neck Reflex

1. Supine position; turn the head to one side with the chin over shoulder. fencin

position

xi. Moro Reflex


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1. Making loud noise, they look as if they are hugging a tree. Fanning fingers an

curling of the index finger and thumb to a C position occur. Present at birth an

disappears at 1 4 months.

b. Pre School and School Age Children

i. Smell and taste are almost never tested, if you need to test for smell use familiar sce

such as peanut butter or orange peel.

ii. Child can dress and undress and manipulate buttons. Note childs gait during both

walking and running. Observe the child as they rise from a supine position on the flo

to a sitting position, and then stand. Note the muscles of the neck, abdomen, arms, a

legs.

1. weak pelvic muscles are a sign of muscular dystrophy, from the supine positio

the child will roll to one side, bend forward, plant hands on legs, and literally

climb up.

iii. the DTRs usually are not tested in children younger than 5 years of age due to lack o

cooperation in relaxation.

c. The Aging Adulti. Senile Tremors

1. Occasionally occur. Tremor of hands, head nodding, and tongue protrusion.

VIII. Neurologic Recheck

a. Level of consciousness

i. A change in consciousness may be subtle. Note any decreasing level of consciousnes

disorientation, memory loss, uncooperative behavior, or even complacency in a

previously combative person.

1. Person: own name, occupation, names of workers around person, their

occupations

2. Place: where person is, nature of building, city, state

3. Time: day of week, month, year

ii. If person is not fully alert

1. Name called

2. light touch on persons arm

3. vigorous shake of shoulder

4. pain applied

b. Motor function

c. Papillary response

i. Note the size, shape and symmetry of both pupils. Shine light and note direct consen

light reflex. When recording pupil size is best expressed in mm.

d. Vital signs

i. Cushings Reflex

1. shows signs of increasing intracranial pressure: BP sudden elevation with

widening P pressure. P decreased rate, slow and bounding

IX. Abnormals


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a. Paralysis

i. Decreased or loss of motor power due to problem with motor nerve or muscle fiber.

Causes acute trauma, spinal cord injury, brain attack. Bells Palsy- Chronic muscul

dystrophy, diabetic, neuropathy, multiple sclerosis, episodic

b. Myoclonus

i. Rapid sudden jerk or a short series of jerks at fairly regular intervals.

ii. A hiccup

c. Rest Tremor

i. coarse and slow (3 6 seconds); partly or completely disappears with voluntary

movement. pill rolling Parkinsonism

d. Spastic Hemiparesis

i. Arm immobile against the body, with flexion of shoulder, elbow, wrist, fingers, and

adduction of shoulder. Leg is stiff and extended and circumducts with each step.

ii. Causes: upper motor neuron lesion of the corticospinal tract

e. Cerebellar Ataxia

i. Staggering; drunk likeii. Causes: alcohol or barbiturate effect

f. Parkinsonian

i. Posture is stooped; trunk is pitched forward; elbows, hips, and knees are flexed.

ii. Causes: Parkinsonism

g. Scissors

i. Knees cross or are in contact, like holding orange between thighs

ii. Causes: paraparesis of legs, multiple sclerosis

h. Steppage or footdrop

i. Lifts knee and foot high and slaps it down hard and flat to compensate for footdrop

ii. Causes: weakness of peroneal and anterior tibial muscles

i. Decorticate Ridgity

i. Upper extremities- flexion of arms, wrist, and fingers

j. Decerebrate Ridgitiy

i. Upper extremities stiffly extended, abducted, internal rotation .

k. Snout

i. Method of Testing

1. gently percuss oral region

ii. Abnormal response

1. puckers lips

iii. Indications

1. frontal lobe disease, cerebral degenerative disease (Alzheimers)

Chapter 23- Neurological

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