objective 12 Flashcards
includes the brain and spinal cord
CNS
dura, arachnoid, and pia mater Along with the cerebrospinal fluid protect the CNS
meninges
12 pairs of cranial nerves; 31 pairs of spinal nerves; and all the
branches
PNS
what does the PNS carry?
1.Sensory (efferent) messages
2.Motor (efferent) messages
3.Autonomic messages
cerebrums outer later of the nerve cell bodies
centre for humans highest functions and governs: Thought, memory, reasoning, sensation, voluntary movement
cerebral cortex
what are the 4 lobes?
frontal, parietal, temporal, occipital
Form the “extrapyramidal system”. Control automatic
associated body movements
basal gangila
Main “relay station” for the nervous system
thalamus
Controls many vital functions (Blood pressure,
temperature, respirations etc.)
hypothalamus
Motor coordination of voluntary movements,
equilibrium, and muscle tone
cerebellum
central core of the brain
brainstem
what are the 3 areas of the brainstem?
midbrain, pons, medulla
Main pathway for ascending and descending fiber tracts
that connect the brain to spinal nerves
spinal cord
“The left cerebral cortex receives sensory information from, and controls
motor function to, the rights side of the body…” (p. 689)
* “The right cerebral cortex interacts with the left side of the body.”
crossed representation
Sensory fibers transmit the sensations of pain,
temperature, and crude or light touch
spinothalamic tract
Fibers conduct the sensations of position,
vibration, and finely localized touch
posterior columns
what are the sensory pathways?
spinothalamic tract
posterior columns
“Higher” motor
system, allows for very skilled and purposeful
movement
corticospinal or pyramidal tract
Maintain muscle tone and
control body movements
extrapyramidal tracts
Coordinates movement, maintains
posture and equilibrium
cerebellar system
what are the motor pathways?
corticospinal tract
extrapyramidal tracts
cerebellar system
Located completely within the CNS,
* Complex of all the descending motor fibres that influence the
lower motor neurons
upper motor neurons
Located mostly in the PNS,
* The “final common pathway”, provides final direct contact to
the muscles
lower motor neurons
Basic defense mechanism of the nervous system
* Involuntary
* Help maintain balance and muscle tone
reflexes
what are the types of reflexes
deep tendon, superficial, visceral, pathological
Enter and exit the brain
* 12 pairs of cranial nerves supply primarily the head and
neck (exception: Vagus nerve)
crainal nerves
31 pairs of spinal nerves
* Arise from the length of the spinal cord and named for the
region of the spine where they exit
spinal nerves
contain sensory and motor fibers
mixed nerves
Skin area that is supplied mainly from one spinal
cord segment through a particular spinal nerve
dermatome
if one nerve is severed most of the sensations will continue to be
transmitted by the nerve above and below
dermatomes overlap
what are the key landmarks?
C6,7,8 – thumb, middle finger, fifth finger
* T1 – axilla
* T4 – nipple
* T10 – umbilicus
* L1 – groin
* L4 - knee
what are the cultural considerations for infants?
The neurological system - not completely developed at birth
* Primitive reflexes direct movement in newborns
* During the first year the cerebral cortex develops and these reflexes
become inhibited and disappear
* Review the most commonly tested infant reflexes - Jarvis (2024), pp.
732-736
* Neurons are not yet myelinated
* Sensory and motor developments occur with the gradual acquisition of
myelin
* Myelinization follows a cephalocaudal order and a proximal to distal
order
what are the cultural considerations for older adults?
General atrophy occurs with aging, there is a steady
loss of neurons in the brain and spinal cord
* Results in: thinning of the cerebral cortex, reduced subcortical
brain structures, expansion of the ventricles
* Decreased muscle strength and impaired fine motor
coordination
* Dizziness and loss of balance with position change
Perform this examination for clients who seem healthy
and whose histories reveal no significant subjective
findings
neurological screening
Perform this examination for clients who have
neurological concerns such as headache or weakness,
or for clients who have shown signs of neurological
dysfunction.
complete neurological exam
Perform this examination for clients with demonstrated neurological
deficits who require periodic assessments.
* Hospitalized clients diagnosed with neurological deficits, such as
those caused by brain injury or disease, must be closely monitored
neurological recheck
what does monitoring of neurological recheck include?
Assessment for improvement or deterioration
* Assessment for signs of increased intracranial pressure
* An abbreviated neurological examination for hospitalized clients include the
following (please review pp. 738-741):
* Level of consciousnesses
* Motor function
* Pupillary response
* Vital signs
Used to asses the functional state of the brain as a whole
* Standardized assessment that defines level of consciousnesses
by giving it a numerical value
* Scale is divided into 3 areas: eye opening, motor response,
verbal response
* Each section scored separately and then all 3 numbers are
added together to give the total score which reflects the brain’s
function
glasgow coma scale
Valid, reliable, standardized neurological assessment tool
* Used to evaluate and monitor mentation (mental activity)
and motor function
* Can be used to predict client outcomes such as length of stay,
death, and dependency
canadian neurological scale
what equipment do we need to assess the neuro system?
Penlight
* Tongue blade
* Cotton swab
* Cotton ball
* Tuning fork (128 Hz or 256 Hz)
* Percussion hammer
* Familiar aromatic substances such as
peppermint and coffee
* Not routinely used (only used in certain
circumstances)
Not routinely tested
olfactory nerve (1)
how do we test the olfactory nerve (1)?
Assess the patency of each nostril first
* Ask the client to close their eyes and occlude one nostril
* Ask the client to smell a familiar aromatic substance through the open nostril
what are the normal and abnormal findings when assessing the olfactory nerve?
Normal: Aromatic substance can be identified through each nostril
* Abnormal: Unilateral loss of smell when there is no nasal disease
what do we review from the visual sensory system? (optic nerve)
Test visual acuity
* Test visual fields by confrontation
* Examine the ocular fundus
what do we review when assessing nerves III, IV, VI (oculomotor, trochlear, abducens)?
Assess palpebral fissures
* Assess PERRLA
* Assess extraocular movements
* Assess for nystagmus
how do we assess the trigeminal nerve motor function (V)?
Ask the client to clench their teeth
* The examiner palpates the temporal and masseter muscles
* The examiner tries to separate the jaws by pushing down on
the chin
what are the normal and abnormal findings for the trigeminal nerve (V)?
Normal: Muscles equal in strength bilaterally, examiner
cannot separate the jaws by pushing down on the chin
* Abnormal: Decreased strength on one/both sides, asymmetry
of jaw movement, pain with clenching of the teeth
how do we assess the trigeminal nerve (v) sensory function?
Tests all 3 divisions of the nerve – ophthalmic, maxillary,
mandibular
* To Test light touch sensation:
* Ask the client to close their eyes
* Brush a cotton wisp on the client’s forehead, cheeks, and
chin
* Ask the client to say “now” whenever the touch is felt
Only perform this test if the client has abnormal facial sensation or
abnormal facial movements
corneal reflex?
how do we test corneal reflex?
If the client is wearing contact lens, ask the client to remove them
* Ask client to look forward
* Using a cotton wisp, approach from the side and lightly touch the
cornea (careful - do not touch the conjunctiva)
what are the normal and abnormal findings for the corneal reflex?
Normal: Bilateral blinking
* Consideration: Reflex may be decreased in persons who wear
contact lens
* Abnormal: No blink occurs
how do we test motor function of the facial nerve (VII)?
Ask the client to smile, frown, close eyes tightly (against examiner’s
attempt to open them), lift eyebrows, show teeth, puff cheeks
* The examiner presses the puffed cheeks in – note the escape of air
what are the normal and abnormal findings when testing the motor function of the facial nerve (VII)?
Normal - Symmetry and mobility in all movements, air escapes
equally from both sides when puffed cheeks pressed in
* Abnormal: muscle weakness (i.e. facial drooping on one side, escape
of air form only one cheek that is pressed in), loss of
movement/asymmetry of movement
how do we test the sensory function of the facial nerve (VII)?
Only performed when facial nerve injury suspected
* To test sense of taste:
* Apply a cotton tipped applicator soaked in a solution of
sugar, salt, or lemon juice, to the tongue
* Ask the client to identify the taste
how do we test acoustic vestibulocochlear (VII) cranial nerve?
Review the following from the auditory sensory system:
* Test hearing acuity (client’s ability to hear normal
conversation)
* Whispered voice test
how do we test motor function of the glossopharyngeal and vagus nerves (IX X)?
Depress the client’s tongue with the tongue blade
* Ask the client to say “ahh” - assess pharyngeal movement
* Check gag reflex by touching the posterior pharyngeal wall
* Assess the client’s voice for smoothness and strain
what are the normal and abnormal findings when testing the motor function of the glossopharyngeal and vagus nerves?
Normal - Uvula and soft palpate rise in the midline and tonsillar pillars move
medially when client says “ahh”, presence of gag reflex, voice is smooth and not
strained
* Abnormal - Absence or asymmetry of soft palpate movement, uvula deviates to
one side, asymmetry of tonsillar pillar movement, hoarseness of the voice etc
how do we test the spinal accessory (XI) nerve?
Review the following from the musculoskeletal system:
* Assess sternomastoid and trapezius muscles for
equal size
* Assess equal strength bilaterally through resistance
* Rotate head against resistance
* Shrug shoulders against resistance
how do we assess the hypoglossal (XII) nerve?
Inspect the client’s tongue for wasting and tremors
* Ask client to stick out tongue - assess for forward thrust in
midline
* Ask client to say “light, tight, dynamite” – assess lingual
speech
what are the normal and abnormal findings for assessing the hypoglossal nerve?
Normal - no wasting or tremors present, forward thrust of
tongue in midline, sounds of letters l, t, d are clear and
distinct
* Abnormal - atrophy, fasciculation’s, tongue deviation, lingual
speech is not clear or distinct
how do we assess the size of the musculoskeletal system?
Assess all muscle groups for bilateral symmetry, and whether
within normal size limits for age
* Measure size if appear asymmetrical
what are the normal and abnormal findings when assessing the size of the musculoskeletal system?
Normal - bilateral symmetry, size within normal limits for
age
* Abnormal - atrophy, hypertrophy
how do we test strength of the musculoskeletal system and what are the normal and abnormal findings?
est the following muscle groups: Extremities, neck, and trunk
* Findings:
* Normal - equal bilaterally, fully resist opposing force
* Abnormal - paresis, paralysis (plegia)
how do we test tone of the musculoskeletal system and what are the normal and abnormal findings?
To test:
* Ask the client to relax
* Move the client’s extremities through passive ROM
* Findings:
* Normal - mild resistance to movement
* Abnormal - flaccidity, spasticity, and rigidity
how do we test involuntary movements and what are the normal and abnormal findings?
If present, note the location, frequency, rate, amplitude,
and whether they can be controlled by the client
* Findings:
* Normal: none present
* Abnormal - presence of tic, tremor, fasciculation,
myoclonus etc.
how to we assess gait?
Observe the client walk 3-6 meters, turn, and return to
where they started
* Ask the client to perform tandem walking (walking a
straight line, heel-to-toe)
* Ask the client to walk on their toes and then on their
heels for a few seconds
what are the normal and abnormal findings when assessing gait?
Normal
* Gait: Gait and turn is smooth; gait is rhythmic, effortless,
opposing arm swing is coordinated, step length 30 cm from heel
to heel
* Tandem walking: Client walks straight and maintains their
balance
* Client is able to walk on their toes and heels
* Abnormal findings
* Gait: Stiff immobile posture, lack of arm swing, staggering,
requires a wide base of support, ataxia
* Tandem walking: Crooked line of the walk, staggering, widening
of base for support, ataxia
* Unable to toe and heel walk
how do we do the Romberg test?
Ask the client to stand with their feet together and arms at their sides
* Ensure the client is in a stable position
* Instruct client to close their eyes and hold their position for
approximately 20 seconds
what are the normal and abnormal findings for the Romberg test?
Normal - client can maintain their balance even with their eyes closed
* Normal variation - slight swaying may occur
* Abnormal - swaying, widening base of feet to avoid falling
what is the shallow knee bend test?
Ask client to perform a shallow knee bend or to hop in place,
one leg at a time
what are the normal and abnormal findings for the shallow knee test?
Normal - normal position sense, muscle strength, cerebellar
function
* Consideration - some clients may not be able to do this due to
aging or obesity
* Abnormal: Inability to perform knee bend related to weakness
in quadriceps muscle or hip extensors
how do we assess rapid alternating movements, what are the normal findings?
Pat the knees with both hands, lift up and turn over the
hands, then pat knees with back of the hands
* Ask the client to increase the speed
Normal - Client is able to perform the actions with equal
turning and quick rhythmic pace
what is another way to test rapid alternating movements? what are the normal and abnormal findings?
Touch their thumb to each finger on the same hand
* Instruct the client to start with the index finger then reverse
direction
* Findings:
* Normal - performed quickly and accurately
* Abnormal: Lack of coordination
what is the finger-to-finger test? what are the normal and abnormal findings?
Keep their eyes open
* Instruct the client to touch their index finger to the
examiner’s finger and then to their nose
* After a few times, the examiner moves their finger to a
different spot
* Findings:
* Normal - movement is smooth and accurate
* Abnormal: Dysmetria and past pointing
what is the finger-to-nose test? what are the normal and abnormal findings?
Ask the client to close their eyes and stretch out their arms
* Instruct the client to touch the tip of their nose with each
index finger, alternating hands
* Ask the client to increase the speed
* Findings:
* Normal - movement is smooth and accurate
* Abnormal - client’s finger misses their nose
what is the heel-to-shin test? what are the normal and abnormal findings?
Ask client to lie supine and to place their heel on the opposite
knee
* Instruct the client to run their heel down the shin from the
knee to the ankle
* Findings:
* Normal - client can move their heel down their shin in a
straight line
* Abnormal - the client’s heel falls off their shin (lack of
coordination)
how do we test pain? what are the normal and abnormal findings?
Lightly touch the sharp point or dull end in a random order
* Leave 2 seconds between each application to avoid summation
* The sharp point tests for pain, the dull edge is a general test of the client’s
responses
* Ask the client to say “sharp” or “dull” to indicate the sensation felt
* Findings:
* Normal - able to perceive the stimulus of pain (correct identification)
* If this assessment reveals abnormal findings, perform an assessment of
temperature (p. 720)
how to we test light touch? what are the normal an abnormal findings?
Brush a cotton wisp over the skin
* Use random sites at irregular intervals
* Include the forearms, hands, chest, thighs, and legs
* Ask client to say “now” when the touch is felt
* Findings:
* Normal - correct identification
how do we test vibration? what are the normal and abnormal findings?
The examiner activates the tuning fork by striking it on the heel of
their hand
* Use a 128 or 256 Hz tuning fork because vibration has a slower
decay
* Hold the tuning fork over a bony surface on the client’s great toe or
fingers
* Ask client to state when the vibration starts and stops
* Findings:
* Normal - client feels vibration in these areas, no need to test
further
* Abnormal: inability to feel vibration
how do we test tactile discrimination?
These tests also measure discrimination ability of the sensory
cortex
* Important prerequisite for testing: Client must have a normal
(or near normal) sense of touch and a normal position sense
how do we test kinaesthesia? what are the normal and abnormal findings?
The examiner moves the client’s finger or great toe up and
down
* Vary the order of movement
* Hold the finger/great toe by the sides
* Ask the client to tell state which way it moved
* Findings:
* Normal - client can detect movement of a few millimeters
* Abnormal - loss of position sense
how do we test stereognosis? what are the normal and abnormal findings?
Place a familiar object in the client’s hand and ask the
client to identify it
* Test a different object in each hand
* Findings:
* Normal - the client can identify the object by feeling it with
their fingers
* Abnormal - problems with tactile discrimination
how do we test graphesthesia? what are the normal and abnormal findings?
Use a blunt instrument to trace a single-digit number or a
letter on the client’s palm
* Ask the client to identify the number or letter
* Findings:
* Normal - correct identification of the number or letter
* Abnormal: Inability to identify the number or letter
what is two-point discrimination? what are the normal and abnormal findings?
Touch 2 points of an opened paper clip lightly to the skin
* Keep narrowing the distance between the 2 points
* Note the distance that the client no longer perceives the 2 separate
points
* The level of perception varies with the area being tested
* Fingertips (2-8 mm) most sensitive region
* Thigh/upper arms/back (40-75 mm) least sensitive regions
* Findings:
* Normal - Distance to identify two separate points within expected
range
* Abnormal - Distance to identify two separate points is increased
how do we test extinction? what are the normal and abnormal findings?
At the same time, touch both sides of the body at the same
point
* Ask the client to state where and how many sensations are
felt
* Findings:
* Normal - both sensations are felt
* Abnormal - client only recognizes one sensation
how do we test point location? what are the normal and abnormal findings?
Touch the client’s skin, then withdraw immediately
* Ask client to put their finger on the place where the
examiner touched their skin
* Findings:
* Normal - client correctly identifies the area
* Abnormal - client incorrectly identifies the area
how do we test deep tendon reflexes?
Ensure the client’s limb is relaxed with the muscle partially
stretched
* Use the reflex hammer to deliver a short, snappy blow onto
the muscle’s insertion tendon
* Use a relaxed hold on the hammer with action taking place at
the wrist
* Strike a brief blow and bounce up promptly
* Use the appropriate part of the hammer for the target:
* Use the pointed end for aiming at smaller targets
* Use the flat end for aiming at a wider target, or to diffuse
impact and prevent pain
what is the 5 point scale for deep tendon reflexes?
4+ Very brisk, hyperactive with clonus, indicates disease
3+ Brisker than average, may indicate disease
2+ Average, normal
1+ Diminished, low normal
0 No response
there is a wide range of normal responses.
Therefore, the results of this test should be used in
conjunction with other results obtained during the
neurological exam
normal response of deep tendone reflex
exaggerated reflex, upper motor neuron
disease
hyperreflexia
reduced functioning of the reflex, lower motor
neuron disease
hyporeflexia
used to relax the muscles and enhance the
response
reinforcement
how do we use reinforcement?
1.Ask the client to perform an isometric exercise (this should be performed in a
muscle group away from the one being tested)
2.Once the client is performing the exercise, strike the tendon
* Examples:
* To enhance a biceps response, ask client to clench their teeth
* To enhance a patellar response, ask client to lock their fingers together and
pull
how do we test biceps reflex? what are the normal and abnormal findings?
Support client’s forearm on their forearm
* Place their thumb on the client’s biceps tendon
* Strikes their thumb with the reflex hammer
* Findings:
* Normal response - contraction of the client’s biceps muscle
and flexion of the client’s forearm
how do we test triceps reflex? what are the normal and abnormal findings?
Hold the client’s upper arm to suspend it
* Instruct the client to let their arm “go limp”
* Strike the triceps tendon directly (location is just above the
elbow)
* Method Two (alternate method)
* To test, the examiner should:
* Hold the client’s wrist across their chest to flex the client’s
arm at the elbow
* Strike the triceps tendon directly
* Findings:
* Normal response - extension of the client’s forearm
12.8 Deep Tendon Reflexes
how do we test brachioradialis reflex? what are the normal and abnormal findings?
Hold the client’s thumb to suspend and relax the forearm
* Strike the forearm directly 2-3 cm above the radial styloid
process
* Findings:
* Normal response - flexion and supination of the forearm
how do we test quadriceps and archilles reflex? what are the normal and abnormal findings?
Ask the client to dangle their legs freely (this flexes the
client’s knee and stretches the tendon)
* Strike the quadriceps tendon directly (location is just below
the patella)
* Findings:
* Normal - extension of the lower leg; contraction of the
quadriceps muscle palpable
how do we test achilles reflex? what are the normal and abnormal findings?
Position the client so their knee is flexed and their hip is
externally rotated
* Hold the client’s foot in dorsiflexion
* Strike the Achilles tendon directly
* Findings:
* Normal response - the examiner can feel the client’s foot
plantar flex against their hand
located in the skin
sensory receptors
localized muscle contraction
motor response
how do we test abdominal reflex? what are the normal and abnormal findings?
Ask the client to lie in the supine position with their knees slightly
bent
* Use the handle of the reflex hammer to stroke the skin from the side
of the abdomen toward the midline
* This is performed at the upper level and lower level of the
abdomen
* Findings:
* Normal response - ipsilateral contraction of the client’s abdominal
muscle and an observed deviation of the umbilicus toward the stroke
* Abnormal response- absence of the reflex
how do we test cremasteric reflex? what are the normal and abnormal findings?
Lightly stroke the inner aspect of the client’s thigh with the
reflex hammer
* Findings:
* Normal response - elevation of the ipsilateral testicle
* Abnormal response - absent reflex
how do we test the plantar reflex? what are the normal and abnormal findings?
Place the client’s thigh in slight external rotation
* Use the handle of the reflex hammer (bottom part) to lightly stroke an upside
down J shape on the bottom of the foot
* Lightly stroke up the lateral side of the sole of the foot and continue inward
across the ball of the foot
* Findings:
* Normal response - plantar flexion of the toes; inversion and flexion of the
forefoot
* Abnormal response - positive Babinski sign
* A positive Babinski sign is dorsiflexion of the big toe and fanning of all toes
