Lecture 2: Neurologic Asssessment Flashcards

1
Q

Learning Objectivess

A
  1. Describe the structure and the function of the central and peripheral nervous system
  2. Discuss risk factors associated with a cerebral vascular accident (CVA) commonly known as stroke
  3. Perform a physical assessment of the neurologic system using the correct techniques
  4. Differentiate between normal and abnormal findings of the neurologic system
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2
Q

Central Nervous System CNS

A

brain and spinal cord

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3
Q

Peripheral Nervous System (PNS)

A

all the nerve fibers existing outside the brain and spinal cord

  • 12 cranial nerves
  • 31 pairs of spinal nerves and their branches (2 nerve roots)

either sensory (Afferent) or motor (Efferent)
“motors are Efficient”

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4
Q

Cerebral Cortex

A
  • thought, memory, reasoning, sensation, and voluntary movement

Each half of cerebrum is a hemisphere
Each hemisphere divided into four lobes: frontal, parietal, temporal, and occipital

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5
Q

Frontal Lobe

A
  • personality, behavior, emotions, and

*intellectual function
initiates voluntary movement

*Broca’s area: Motor speech
-Damage causes expressive aphasia (BROCen speech)

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6
Q

Parietal Lobe

A

sensation

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7
Q

Occipital Lobe

A

primary visual receptor

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8
Q

Temporal Lobe

A

*primary auditory reception center, taste, and smell

*Wernicke’s area: Language comprehension
-Damage causes receptive aphasia

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9
Q

What happens when the cerebral cortex is damaged

A

produces a corresponding loss of function:
Motor weakness
Paralysis
Loss of sensation
Impaired ability to understand and process language

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10
Q

Basal Ganglia

A

Large bands of gray matter in two cerebral hemispheres that form the extrapyramidal system

  • Initiate and coordinate movement
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11
Q

Thalamus

A

Main relay station where sensory pathways of spinal cord, cerebellum, and brain stem form synapses

located in between the basal ganglia

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12
Q

Hypothalamus

A

Major respiratory center
appetite
sex drive
temperature
heart rate
blood pressure
sleep
anterior and posterior pituitary gland regulation
coordination of autonomic nervous system

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13
Q

Cerebellum

A

-located under occipital lobe

-coordination of voluntary movements, equilibrium, and muscle tone

-Does not initiate movement, but coordinates movements
*Coordinates many different muscles needed in playing piano, swimming, or juggling

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14
Q

Crossed Representation (decussation) in the pathways of the CNS

A

the crossing over of tracts such as the left and right cerebral cortex

L cortex: receives sensory information from and controls motor function to right side of the body

R cortex: receives sensory information from and controls motor function to left side of the body

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15
Q

Cerebrovascular Accident (CVA)

A

Stroke

the 5th leading COD

leading cause of disability

Blood flow to a portion of the brain is interrupted or stops, depriving the brain cells of oxygen. If blood flow is blocked for more than a few seconds, brain cells begin to die and permanent damage may result

Major risk factors- HTN (Silent Killer- importance of BP screenings), DM, Smoking

Stroke belt (dietary factors) NC, SC, GA, AL, MS, LA, AK, TN

if we can identify the risks, we can intervene more early in the process

F: facial Drooping
(smooth nasal labial fold)
A: arm Swaying
S: speech (garbled, slurred)
T: time to call 911

dizziness= most missed symptom

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16
Q

Sensory pathways

(how does sensation travel and what roots can it take)

A

sensation travels in Afferent fibers in peripheral nerves
>
through the posterior (dorsal) root
>
into the spinal cord

Can take one of 2 roots:
1. spinothalamic tract
2. posterior (dorsal) columns

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17
Q

Spinothalamic tract sensory pathway

A

pain, temperature, and crude or light touch

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18
Q

Posterior (dorsal) columns sensory pathway

A

position, vibration, finely localized touch

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19
Q

what are Motor Pathways and what tracts can messages take?

A

carry Efferent messages from the CNS to the muscles

  • pyramidal (corticospinal) tract
    *mediate skilled, discrete, voluntary momement (ie: writing)
  • Extrapyramidal tracts (motor nerve fibers outside the pyramidal tract)
    *maintain muscle tone
    *controls gross body movements such as walking
  • cerebellar system
    *movement, equilibrium, posture
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20
Q

Reflexes

A

basic defense mechanisms of the nervous system
- Involuntary
- below level of conscious control
- permits quick reaction to potentially painful or damaging situations

Four types of reflexes:
*Deep tendon reflexes (DTRs)
*Superficial (i.e., corneal reflex)
*Visceral (i.e., pupillary response to light)
*Pathologic (i.e., Babinski’s)

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21
Q

What are the 4 types of reflexes

A

Deep tendon reflexes (DTRs)

Superficial (i.e., corneal reflex)

Visceral (i.e., pupillary response to light)

Pathologic (i.e., Babinski’s)

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22
Q

Reflex Arc

A

Tapping the tendon stretches the muscle spindles which:

  1. Activates afferent sensory fibers
  2. Travels to dorsal root
  3. Synapse in spinal cord with the motor neuron
  4. Motor efferent fibers leave via the ventral root
  5. Travel to the muscle
  6. Stimulates muscle contraction
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23
Q

Dermatomes (PNS)

general definition

A

Each area of body sensation is supplied by nerves at a specific level.

Overlapping and somewhat variable.

Compression of a nerve will lead to a pattern of loss specific to a dermatome.

Sensory changes often precede motor loss.

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24
Q

Useful Landmarks of Dermatomes

memorize

A

Thumb at C6
Middle finger at C7
Fifth finger at C8
Axilla at T1-T2
Nipple at T4
Umbilicus at T10
Groin in region of L1
Knee at L4

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25
Q

Cranial Nerves (PNS)

general definition

A

Enter and exit brain rather than spinal cord
*CN I and II extend from cerebrum
*CN III to XII extend from lower diencephalon and brain stem

12 pairs of cranial nerves supply primarily head and neck
*except vagus nerve, which travels to heart, respiratory muscles, stomach, and gallbladder

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26
Q

Names of the Cranial Nerves

A
  1. Olfactory (sensory)
  2. Optic (sensory)
  3. Oculomotor (motor)
  4. Trochlear (motor)
  5. Trigeminal (both)
  6. Absucens (motor)
  7. Facial (both)
  8. Acoustic (sensory)
  9. Glossopharyngeal (both)
  10. Vagus (both)
  11. Spinal Accessory (sensory)
  12. Hypoglossal (motor)
27
Q

Spinal Nerves

A

31 pairs of spinal nerves arise from spinal cord

Named for region of spine from which they exit:8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and1 coccygeal

“Mixed” nerves
*contain both sensory and motor fibers

28
Q

Examples of subjective data

A

Headaches (worst headache of your life?)
Head injury (concussions)
LOC- level of consciousness (awareness of one’s own existence, feelings, and thoughts of the environment)
Dizziness (#1 symptom missed in CVAs)
Seizures
Tremors
Weakness
Incoordination
Numbness/tingling
Difficulty walking/speaking/swallowing (dysphagia)

29
Q

Pertinent Information in Past Medical History

A

Significant illness: CVA (residual?), spinal cord injury, meningitis, encephalitis, congenital defect

Environmental hazards: exposure to insecticides, lead paint/water (Flint, MI) and train derailment with haz mat (Palestine, OH)

30
Q

Objective Data

A

Penlight
Tongue blade
Cotton swab
Cotton ball
Tuning fork: 128 Hz or 256 Hz
Percussion hammer

31
Q

Sequence of Events for Neurologic Examination
(objective data)

A

Use following sequence for complete neurologic examination:

1 Mental status
2 Cranial nerves
3 Motor system
4 Sensory system
5 Reflexes

32
Q

CNI
(cranial nerve 1) of the PNS

A

Olfactory
- sensory

*sense of smell (choice of odors)

33
Q

CNII of the PNS

A

Optic
- sensory

Central vision (Snellen (eye dr. chart) ; Jaeger)
- what we use in LRC
Peripheral vision (confrontation)
Visualize optic disc

34
Q

CNIII of the PNS

A

Oculomotor
- sensory and motor

Parasympathetic
- pupillary constriction
Motor
- EOMs
- opening of eyelids

35
Q

CNIV of the PNS

A

Trochlear
- motor

Downward medial movement of eye (EOM)

36
Q

CNVI of the PNS

A

Abducens
- motor

lateral movement of eye (EOM)

37
Q

which cranial nerves are tested together and how

A

CNIII, CNIV, and CNVI

oculomotor, trochlear, and absucens

tested by “sky writing”

38
Q

CNV of the PNS

A

Trigeminal
- motor: muscles of mastication

  • sensory: Ophthalmic (forehead)
    Maxillary (cheeks)
    Mandibular (chin)
39
Q

CNVII of the PNS

A

Facial
- motor: facial expressions /symmetry
Smile, raise eyebrows, puff cheeks

  • sensory: taste on anterior 2/3 tongue
40
Q

CNVIII of the PNS

A

Acoustic / Auditory (hearing)

  • sensory: Whisper test
    Stand behind patient
    Occlude ear not being tested by pressing on tragus
    Whisper, two, two-syllable words- baseball, soccer,
    Client should be able to repeat back
41
Q

CNIX of the PNS

A

Glossopharyngeal

  • motor: phonation “aah”, swallowing
    Uvula and soft palate rise bilaterally

-Sensory:
taste posterior 1/3 tongue
pharynx (gag reflex)

42
Q

CNX of the
PNS

A

Vagus

Motor:
- phonation “aah”, swallowing
- Uvula and soft palate rise bilaterally

Sensory:
- general sensation from carotid body and sinus, pharynx, viscera

43
Q

CNXI of the PNS

A

Spinal Accessory
- motor:
Sternomastoid:
Rotate head against resistance

Trapezius muscle:
Shrug shoulders against resistance

44
Q

CNXII of the
PNS

A

Hypoglossal
- motor:

Tongue
Stick out tongue, move side to side
“light, tight, dynamite” to check for lingual speech

45
Q

Mnemonic for naming cranial nerves

A

,,,

46
Q

Overall Neuro Cranial Nerve Physical Exam Recap

A

1 smell
2 eyes
3. 3, 4 & 6 EOM
5 face sensation
7 puff cheeks, raise eyebrows
8 Ears – whisper
9 Say “ahhh”
10 Say “ahhh”
11 Shrug shoulders
12 Stick out tongue

47
Q

Motor Exam

A

Strength:
- Test muscle groups of extremities, neck, and trunk
- Grading muscle strength

Tone:
-Persuade person to relax completely
-Move each extremity smoothly through a full ROM
*Normal: mild, even resistance to movement

Involuntary movements
-Normally none occur
- If present, note location, frequency, rate, and amplitude

48
Q

Cerebellar Function Tests

A

Tandem walk:

Ask person to walk straight line in heel-to-toe fashion
- this decreases base of support

normal: person can walk straight and stay balanced
Abnormal: crooked line of walk, staggering, loss of balance

Romberg Test:

Ask person to stand up with feet together and arms at sides
when in stable position, ask person to close eyes and to hold position for about 20 seconds
Normally person can maintain posture and balance, even with visual orienting information blocked
+ Romberg: client sways or falls

49
Q

Sensory Exam of the Spinothalamic Tract

A

Pain:
tested by person’s ability to perceive pinprick (sharp vs dull)

Temperature:
test temperature sensation only when pain sensation is abnormal
test tubes filled with hot and cold water

Light Touch: apply wisp of cotton to skin in random order of sites and at irregular intervals
include arms, forearms, hands, chest, thighs, and legs
ask person to say “now” or “yes” when touch is felt

50
Q

Sensory Exam of the Posterior Column

A

Vibration:
test person’s ability to feel vibrations of tuning fork over bony prominences
Compare right side with left side
Reduced ability to sense vibrations of a tuning fork may be present with peripheral neuropathy or EtoH abuse

Kinesthesia (position):
test person’s ability to perceive passive movements of extremities
Move toes or finger up and down while client closes eyes

Stereognosis:
test person’s ability to recognize objects by feeling their forms, sizes, and weights

Graphesthesia:
ability to “read” a number by having it traced on skin

Extinction:
simultaneously touch both sides of body at same point
normally both sensations are felt

Point location:
touch skin and withdraw stimulus promptly
ask person to put finger where you touched

51
Q

Best Practices for Deep Tendon Reflexes

A

Joint in flexion, limb relaxed, muscle partially stretched, supported by examiner as needed,

Apply short, snappy blow onto muscle’s insertion site with reflex hammer

Pointed end of hammer for smaller target; flat end for wider target

Just enough force to get response

Compare both sides-responses should be equal

52
Q

Deep Tendon Reflexes: Biceps

A

C5 & C6 nerves innervates tendon

Elbow flexed at 45°.
With your thumb, press the biceps brachii tendon.
Strike your thumb with the reflex hammer.

Need to know normal reflex is contraction of biceps which causes visible or palpable flexion of elbow.

Checking the intactness of the reflex arc at specific spinal levels.

53
Q

Deep Tendon Reflexes: Brachioradialis

A

C5 & C6

Strike brachioradialis tendon approximately 2-4 inches above base of the thumb over radius

Need to know reflex should cause slight wrist extension and/or radial deviation, supination and slight elbow flexion

Checking the intactness of the reflex arc at specific spinal levels.

54
Q

Deep Tendon Reflexes: Triceps

A

C7 & C8

Relax the patient’s elbow in your hand at 90°.
Tap the triceps brachii tendon proximal to the olecranon process.
Need to know normal response is elbow extension.
Checking the intactness of the reflex arc at specific spinal levels.

55
Q

Deep Tendon Reflexes: Patellar

A

L2 to L4

Have the patient sit on a table or high bed to allow his legs to swing freely
Tap the patellar tendon, inferior to the patellar, directly with a rubber hammer
Need to know normal reflex is knee extension
Checking the intactness of the reflex arc at specific spinal levels.

56
Q

Deep Tendon Reflexes: Achilles

A

S1
Have the patient sit on a table or bed so that legs dangle
Grasp the patient’s foot and pull it in dorsiflexion
Tap the tendon directly
Need to know normal response is contraction of the gastrocnemius and plantar flexion of the foot.
Checking the intactness of the reflex arc at specific spinal levels.
Need to know which nerve innervates tendon

57
Q

Deep Tendon Reflexes: Grading

A

four point scale
0 No response
1+ Diminished, low normal
2+ Average, normal
3+ Brisker than average, possible disease
4+ Very brisk, hyperactive with clonus=disease

58
Q

Deep Tendon Reflexes: Reinforcement

A

Ask person to perform isometric exercise in muscle group away from one being tested

-Causes muscles to contract and increase reflex activity
-Ask client to clench jaw for arm reflexes
-Ask client to the lock the fingers of both hands and pull them against each other for leg reflexes

59
Q

Superficial Reflexes:
Babinski or Plantar reflex

A

L4-S2

With reflex hammer, draw a light stroke up lateral side of sole of foot and inward across ball of foot, like an upside-down “J”
- Normal response: plantar flexion of toes
- Abnormal response: dorsiflexion of big toe and fanning of all toes

  • Positive Babinski is normal in infant up to 2 years
60
Q

Neurologic Recheck

A
  1. LOC (awareness of one’s own existence)-change in LOC is earliest & most sensitive change
  2. Note ease of arousal & state of awareness, or orientation
    - If person not fully alert, ↑ amount of stimulus used in this order:
    a. Name called
    b. Light touch on arm
    c. Vigorous shake of shoulder
    d. Pain applied (pinch nail bed, trapezius muscle, sternal rub)
  3. Motor Function-check hand grasps
  4. Pupillary Response-PERRLA (brain injury, brain dead- pupils dilated and fixed, no longer reacting to light)
  5. Vital signs
  6. Blood glucose check
61
Q

Pupillary Light Reflex procedure

A

Darken room
Ask person to gaze into distance
(this dilates pupils)
Advance a light in from side and note response

Normal:
* constriction of same-sided pupil (direct light reflex)
* simultaneous constriction of the other pupil (consensual light reflex)

62
Q

Accommodation check procedure

A

Ask person to focus on a distant object
(This dilates pupils)

Have person shift gaze to near object, such as your finger held about 7 to 8 cm (3 inches) from nose

Normal response includes:
Pupillary constriction
Convergence of axes of eyes

63
Q

PERRLA recording

A

Pupils
Equal
Round
Reactive to
Light and
Accommodation

Ex. Documentation: PERRLA 4/3, react briskly

64
Q

Documentation example

A

9/9/2020 0730 Patient A&OX3. Responds to questions appropriately. PERRLA 4/3 with direct and consensual reaction. CN grossly1-12 intact. Romberg negative. DTRs 2+ throughout. Babinski negative. ——————————N. Nurse, UANS