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. Bronca’s 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 they
want to say but cant say it
b. Parietal Lobe
i. Posterior Gyrus
1. sensation
c. Occipital Lobe
i. Primary visual receptor
d. Temporal Lobe
i. Behind the ear, primary auditory reception center
ii. Wernicke’s 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 activity
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 tracts
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
 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. Babinski’s 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 sense
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 grimacing
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
 i. Screening Neurologic Examination
1. done on seemingly well people who have no significant subjective findings from
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. Size
a. 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 Romberg’s: sign of loss of balance that occurs when closing
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
 a. With eyes open ask that they use the index finger to touch your finger and
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 down
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. Temperature
a. 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 brush
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 ankle,
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 zone of
deficit for its dermatome
2. Position (Kinesthesia)
a. Test ability to perceive passive movement of extremities. Move finger or
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, cotton
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
 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 DTR’s
a. For an adequate response the limb should be relaxed and the muscle
partially stretched. Stimulate reflex by directing a short direct blow of the
reflex hammer onto the muscles insertion tendon. Use just enough force
to get a reaction. Responses should be equal. Graded on a 4 point scale
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 reflex
arc 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. Strike
tendon directly just below the patella
5. Achilles Reflex
a. Position person with the knee flexed and the hip externally rotated. Hold
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 no
further movement.
7. Abdominal Reflex
a. Person assumes a supine position with the knees slightly bent. Use handle
end of reflex hammer and stroke the skin.
8. Plantar Reflex
a. (L4 – S2) position thigh in slight external rotation. With hammer, draw a
light stroke up the lateral side of the sole of the foot and inward across the
 ball of the foot, like upside down J. Normal response is plantar flexion of
all the toes and inversion and flexion of the forefoot.
b. Abnormal: except in infancy, the dorsiflexion of the big toe and fanning of
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 age
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. Second
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 back is
straight 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 ½ years of age.
v. Rooting Reflex
1. Brush the infant’s 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 baby’s ulnar side, away from the
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 ½ 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. “fencing
position”
xi. Moro Reflex
 1. Making loud noise, they look as if they are hugging a tree. Fanning fingers and
curling of the index finger and thumb to a C position occur. Present at birth and
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 scents
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 floor
to a sitting position, and then stand. Note the muscles of the neck, abdomen, arms, and
legs.
1. weak pelvic muscles are a sign of muscular dystrophy, from the supine position
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 of
cooperation in relaxation.
c. The Aging Adult
i. 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 consciousness,
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 consensual
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
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 – muscular
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 like
ii. 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)