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Neurologic Assessment
Neurologic Assessment
Neurologic Assessment
INTRODUCTION
The human nervous system is a unique system that allows the body to interact with the environment as well as to maintain the activities of internal organs. The nervous system acts as the main circuit board for every body system. Because the nervous system works so closely with every other system, a problem within another system or within the nervous system itself can cause the nervous system to short-circuit. (Dillon,2007)
INTRODUCTION
A major goal of nursing is early detection to prevent or slow the progression of disease. So it is important for nurses to accurately perform a thorough neurologic assessment and to understand the implications of subtle changes in assessment findings. By doing so, we can initiate timely interventions that can save lives.
Function
Responsible for many functions including initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought process control of speech and storage of memory
CEREBRUM
Cerebrum
It consists of two hemispheres that are incompletely separated by the great longitudinal fissure It is separated into right and left hemispheres by sulcus It is joined at the lower portion by corpus callosum It has wrinkled appearance due to presence of folded layers or convolutions called gyri It has an external of outer portion made up of gray matter approx. 2 to 5 mm in depth and is made up of billions of neurons and cell bodies It has an innermost layer made up of white matter and is composed of nerve fibers and neuroglia
Frontal Lobe
Parietal Lobe
Predominantly a sensory lobe Contains primary sensory cortex, which analyzes sensory information and relays the interpretation of this information to the thalamus and other cortical areas Controls awareness of the body in space, orientation in space and spatial relations
Parietal Lobe
Temporal Lobe
Contains auditory receptive areas Contains a vital area called interpretative area, which provides integration of somatization, visual and auditory areas
Temporal Lobe
Occipital Lobe
Contains visual areas, which play important role in visual interpretation
Corpus Callosum
Basal Ganglia
Masses of nuclie located deep in the cerebral hemispheres Responsible for motor control of fine body movements
Thalamus
Lies on either side of the third ventricle Acts primarily as a relay station for all sensation except smell All memory, sensation and pain impulses pass through this section
Thalamus
Hypothalamus
Located anterior and inferior to the thalamus It includes the optic chiasm and mamillary bodies Plays a role in the regulation of pituitary secretion of hormones that influence metabolism, reproduction, stress response and urine production Called as hunger and satiety centers Regulates sleep-wake cycle, blood pressure, aggressive and sexual behaviors, and emotional responses
Hypothalamus
Brain Stem
Brain Stem
Contains the midbrain, pons and medulla oblongata The midbrain contains sensory and motor pathways and serves as the center for auditory and visual reflexes The pons contains motor and sensory pathways, and controls the heart, respiration and blood pressure The medulla oblongata transmits both sensory and motor fibers, and is the bodys respiratory center
Cerebellum
Cerebellum
Separated from the cerebral hemispheres by a fold of dura matter, the tentorium cerebelli Has both excitatory and inhibitory actions and is largely responsible for coordination of movement Controls fine movement, balance, position sense and integration of sensory input
Dura mater Outermost layer Arachnoid Middle membrane Extremely thin, delicate membrane which resembles a spider web Appears white because of absence of blood supply Contains the choroid plexus, which produces the cerebrospinal fluid (CSF) Contains arachnoid villi, which absorb CSF Pia mater Innermost membrane Thin, transparent layer that hugs the brain closely and extends into every fold of the brains surface
Meninges
Cerebrospinal Fluid
Cerebral Circulation
The brain requires 20% of the oxygen of the body The brain requires 65-70% of the glucose in the body The brain requires 1/3 of the cardiac output The brain does not store nutrients and has a high metabolic demand that requires high blood flow The brain lacks additional collateral blood flow, which may result in irreversible damage when blood flow is occluded
Cerebral Circulation
Arterial Supply
The arterial blood supply to the brain is provided by two internal carotid arteries and two vertebral arteries At the base of the brain, a ring is formed between the vertebral and internal carotid arterial chains called circle of Willis The arterial anastomosis along the circle of Willis is a frequent site of aneurysms
Arterial Supply
Venous Drainage
The veins of the brain reach the brains surface and join larger veins which empty into the dural sinuses Dural sinuses are vascular channels lying within the tough dura mater The network of the sinuses carries venous outflow for the brain and empties into the internal jugular veins, which return the blood into the heart Cerebral veins and sinuses are unique because they dont have valves
Blood-Brain Barrier
Formed by the endothelial cells of the brain capillaries, which form continuous tight junctions, creating a barrier to macro molecules and many compounds All substances entering the CSF must filter through the capillary membranes of the choroid plexus Often altered by trauma,cerebral edema And cerebral hypoxemia
Spinal Cord
Spinal Cord
Serves as a connection between the brain and the periphery Approx. 45 cm (18 in) long and about the thickness of a finger Extends from the foramen magnum at the base of the skull to the lower border of the first lumbar vertebra, where it tapers to a fibrous band conus medullaris Below the second lumbar space are nerve roots that extend beyond the conus, which are called cauda equina Contains gray matter, located at the center, and white matter on its sides
There are eight (8) ascending tracts, seven of which are engaged in motor function Examples: 1. Corticospinal tracts(2)- voluntary muscle activity 2. Vestibulospinal tracts(3)- autonomic functions such as sweating, pupil dilation and circulation 3. Corticobulbar tract- voluntary head and facial muscle movement 4. Rubrospinal and reticulospinal tractsinvoluntary muscle movement
Vertebral Column
Surrounds and protects the spinal cord and consists of7cervical, 12 thoracic, 5 lumbar and 5 sacral Nerve roots exit from the vertebral column through the intervertebral foramina Separated by disks, except for the first and second cervical, sacral and coccygeal vertebrae Each vertebra has a ventral solid body and a dorsal segment or arch, which is posterior to the body
Vertebral Column
Cranial Nerves
Cranial Nerves
Cranial Nerves I. Olfactory Functions Smell Abnormal Findings Anosmia (absence of smell) Papilledema; blurred vision; scotoma; blindness Anisucuria; pinpoint pupils; fixed, dilated pupils Nystagmus
II. Optic
Vision
III. Oculomotor
Pupil constriction; elevation of upper lid Eye movement; controls superior oblique
IV. Trochlear
Cranial Nerves
V. Trigeminal
Functions
Control muscles of mastication; sensations for the entire face Eye movements; controls the lateral rectus muscle Controls muscles for facial expression; anterior 2/3 of the tongue Cochlear branch permits hearing; vestibular branch helps maintain equilibrium
Abnormal Findings
Trigeminal neuralgia (Tic douloureux)
VI. Abducens
VII. Facial
Bells palsy; ageusia (loss of sense of taste) on the anterior 2/3 of the tongue Tinnitus; vertigo
Functions Controls muscles of the throat; taste of posterior 1/3 of the tongue Controls muscles of the throat; PNS stimulation of thoracic and abdominal organs Controls sternocleidomastoid and trapezius muscles
Abnormal Findings Loss of gag reflex; drooling of saliva; dysphagia; dysphonia; posterior third ageusia Loss of gag reflex; drooling of saliva; dysphagia; dysarthria; bradycardia; increased HCl secretion Inability to rotate the head and move the shoulders
X.Vagus
XII. Hypoglossal
Protrusion of the tongue; deviation of the tongue to one side of the mouth
Spinal Nerves
Composed of 31 pairs of spinal nerves: 8 cervical; 12 thoracic; 5 lumbar; 5 sacral; and 1 coccygeal The dorsal roots are sensory and transmit impulses from specific areas of the body, known as dermatomes, to the dorsal ganglia The sensory fibers maybe somatic, carrying information about pain, temperature, touch, and position sense (proprioception) from the tendons, joints and body surfaces Fibers can also bevisceral, carrying information from the visceral organs
Spinal Nerves
The ventral roots are motor and transmit impulses from the spinal cord to the body These fibers can either be somatic or visceral The visceral fibers include autonomic fibers that control the cardiac muscles and glandular secretions
Spinal Nerves
AUTONOMIC NERVOUS SYSTEM: Sympathetic Nervous System vs. Parasympathetic Nervous System
Structure or Activity Pupil of the Eye Circulatory System: Rate and force of heart beat Blood Vessels In the heart muscle In skeletal muscle In abdominal viscera and skin Blood pressure Respiratory System: Bronchioles Rate of breathing PNS Constricted Decreased SNS Dilated Increased
Structure or Activity Digestive System: Peristalsis Muscular sphincters Secretion of salivary gland Secretions of stomach, intestine and pancreas Conversion of liver glycogen to glucose Genitourinary System: Urinary bladder Muscular walls Sphincters
PNS
SNS
Contracted Relaxed
Relaxed Contracted
Structure or Activity Integumentary System: Secretion of sweat Pilomotor muscles Adrenal Medullae
PNS
SNS
* * *
Developmental consideration
Infants and Children The growth of the nervous system is rapid during the fetal period During infancy, the neurons mature, which allows more complete actions to take place 1. cerebral cortex thickens 2. brain size increases 3. myelinization occurs The advances in the nervous system are responsible for the cephalocaudal and proximodistal refinement of development, control and movement
Developmental consideration
The neonate has several reflexes at birth: sucking, stepping, startle (Moro) and Babinski reflexes Babinski and tonic neck reflexes are normal until two (2) years of age By about one (1) month of age, the reflexes begin to disappear
Developmental consideration
Pregnant Women The pressure of the growing uterus on the nerves of the pelvic cavity produces neurologic changes in the legs As pressure is relieved in the pelvis, the changes in the lower extremities are resolved As the fetus grows, the center of gravity of the female shifts, and the lumbar curvature of the spine is accentuated This change in posture can place pressure on roots of nerves, causing sensory changes in the lower extremities Hyperactive reflexes may indicatepregnancyinduced hypertension (PIH)
Developmental consideration
Older Adults Impulse transmission decreases Reflexes diminish and coordination weakens Senses decrease (hearing, vision, smell, taste and touch) Muscle mass decreases Gait becomes short, shuffling, uncertain and unsteady
Neurologic Assessment
Health History
Biographical and demographic data - it includes personal profile of the patient, source of history and the clients mental status
Health History
Current health a. Chief complaint- obtains a detailed description of the event that have led the client to seek care. Use open ended question. b. Symptom analysis-
Health History
Past health history a. Childhood infectious disease and immunizations Rubella and rubeola Meningitis Herpes simplex virus cytomegalovirus influenza
Health History
b. Major illnesses and hospitalizations Pernicious anemia Cancer DM Infections Hypertension Liver and renal disease F & E imbalances Acid-Base Imbalances Head trauma Seizures and stroke c. Medications CNS stimulants Sedatives and hypnotics Antidepressives Analgesics Anti hypertensive and stroke d. Growth and development
Homonymous hemianopia
Cranial XI (Spinal accessory)motor nerve that supplies the sternocleidomastoid muscle and upper part of trapezius muscles 1. Muscle weakness 2.Contralateral hemiparesis: strokes affecting middle cerebral artery and internal artery Cranial XII (Hypoglossal) 1.Atrophy, fasciculations (twitches): LMN disease 2.Tongue deviation toward involved side of the body
Sensory Function
The center for sensory perception is located in the parietal lobe, which enables us to perceive pressure, temperature, texture and pain The ability to perceive sensory stimuli is Called stereognosis The inability to perceive sensory stimuli is called agnosia
Rapid Alternating Action Test Inability to perform the task may indicate upper motor neuron weakness Heel-to-shin Test Inability to perform the test may indicate disease or lesion of the posterior spinal tract
Parkinsonian gait
Rombergs test
REFLEX
Evaluates the integrity of specific sensory & motor pathways Info. On the natures, location and progression of nuerologic d/o 2 type: Superficial Deep tendon Reflex
Superficial cutaneous Stoking a sensory zone Abdominal Plantar Corneal Pharyngeal (gag) Cremasteric Anal
Deep tendon mycotactic Rapid muscle contraction that results from rapid stretching of the muscle Sharply striking a muscle tendons point of insertion with a sudden brief blow of a reflex hammer Biceps, triceps, brachoradial, patella, ankle jerk (achilles tendon)
Assessment Tech. Light touch at corneoscleral junction Light touch to soft palate and pharynx Stroke skin of upper, middle and lower abdomen toward umbilicus Stroke medial of upper thigh
CN IX,X
Cremasteric Reflex
Elevation of epsilateral scrotum and testicle Contraction of external sphincter Plantar Flexion of the toes
T12-L2
Anal Reflex
S3-5
L4-S2
Reflex Biceps
Assessment Tech. Blow on examiners thumb placed over biceps tendon Styloid process of radius is tapped while forearm is in semiflexion and semipronation Strike on tricep tendon just above olecranon Tap on patellar tendon
Brachoradial (Supinator)
Extension of elbow C6-8 (primarily C7) Leg extends L2-4 Plantiflexion of foot
Tricep
S1-2
Abnormal reflex pathologic Indicates nuerologic d/o Often related to spinal cord injury/higher centers Babanski Snout Rooting Sucking Glabella Grasp Chewing reflex
Level of Consciousness
Level I: Conscious, cognitive, coherent ( 3 Cs) Level II: Confused, drowsy, lethargic, obtunded, somnolent Level III: Stuporous, responds only to noxious, strong or intense stimuli (e.g. sternal pressure, trapezius pinch, pressure at the base of the nail, and very strong light or very loud sound) Level IV: Light Coma: Response is only grimace or withdrawing of limb from pain; primitive and disorganized response to painful stimuli Deep Coma: Absence of response to even the most painful stimuli
The GCS scores is the sum of the three scores received for the eye, verbal and motor responses. In the case of an intubated patient (one with a tube in their trachea to help them breath), verbal function cannot be tested. These patients are given the worst score, a !, but a modifier is usually attached to indicate this. For example, a T (for tube) or V (for ventilated) is added, such as GCS 8T Remember the lowest score attainable is a 3 and this person would be comatose.
Reflex Testing
Reflexes are fast, predictable, unlearned, innate, and involuntary responses to stimuli Occurs at the level of the spinal cord but interpreted a the brain The center for reflex act is the spinal cord The cerebral cortex determines the motor response
Interpretation of Reflexes
0 = No response 1+= Diminished 2+= Normal 3+= Brisk, above normal 4+=Hyperactive