Week 9: Assessing the Neurologic System

Question 1

Risk factors for stroke

Answer 1

Stroke risk factors:
1. High BP

2. High cholesterol – development of atherosclerosis
3. Cigarette smoking – increases BP and BV hardening
4. DM
5. Poor diet and physical inactivity – avoid “saturated fats” and “partially/hydrogenated fats”
6. Overweight and obesity
7. Untreated atrial fibrillation – thrombus development in heart
8. Postmenopausal hormone therapy
9. Oral contraceptive use – especially women >35 who smoke
10. Drug and alcohol abuse – limit 2 drinks/day (men) and 1 drink/day (women)
11. Sleep disordered breathing
12. Ethnic and racial minorities

Question 2

Warning signs of stroke

Answer 2

Medical emergency, requiring time-limited treatment (call EMS immediately); do NOT wait for symptoms to worsen

Symptoms:
1. Sudden numbness or weakness of the face, arm or leg (especially on one side)

2. Sudden confusion, trouble speaking, or understanding speech
3. Sudden trouble seeing in one or both eyes
4. Sudden trouble walking, dizziness, loss of balance or coordination
5. Sudden severe HA with no known cause (known as “thunderclap HA”)

Question 3

Objective data: neurologic examination

Answer 3

Neuro exams:
1. MENTAL STATUS – Cerebral function of the brain (AAOx4? Able to interpret instructions properly?)

2. CRANIAL NERVES – Transmission of motor and sensory messages primarily to the head and neck
3. MOTOR AND CEREBELLAR SYSTEMS – Functioning of the pyramidal and extrapyramidal tracts
4. SENSORY SYSTEMS – Integrity of the spinothalamic track, posterior column of the spinal cord, and the parietal lobes of the brain
5. REFLEXES – Deep and superficial reflexes

Question 4

Cranial nerves

Answer 4

CNs:
CN I – Olfactory

CN II – Optic

CN III, IV, and VI – Oculomotor, trochlear, and abducens

CN V – Trigeminal

CN VII – Facial

CN VIII – Acoustic vestibulocohlear

CN IX and X – Glossopharyngeal and Vagus

CN XI – Spinal accessory

CN XII – Hypoglossal

Question 5

Motor and cerebellar systems

Answer 5

Assess:
1. Condition and movement of muscles

2. Evaluate balance
3. Romberg test
4. Coordination – finger-to-nose test

Question 6

Sensory system

Answer 6

Assess:
1. Light touch, pain, and temperature sensations (spinothalamic tract)

2. Vibratory sensation and sensitivity position (posterior columns)
3. Tactile discrimination – STEREOGENESIS (correctly identifies object), GRAPHESTHESIA (correctly recognizes writing on skin), and two-point discrimination

Question 7

Reflexes

Answer 7

Test DTRs – bicep, tricep, brachioradialis, patellar, and Achille’s reflex

Test superficial reflexes:

1. Plantar – BABINSKI (Abnormal = Fanning of toes)
2. Abdominal
3. Cremastueric reflex – the scrotum contracts and testicles elevate upon stroke of inner thigh (Abnormality indicates defect to T12, L1, or L2)

REFLEX GRADING SCALE:
4+: Hyperactive, brisk, abnormal (indicative of disorder)

3+: More brisk or active than normal (not indicative of disorder; possibly due to meds./electrolyte imbalance)

2+: Normal, usual response

1+: Decreased, less active than normal

0: No response

Question 8

Meningeal irritation or inflammation

Answer 8

Assess neck ROM

Tests:
1. BRUDZINSKI’S SIGN: Flex neck when supine; Abnormal = Pain in neck as evidence by bending/flexion of hips and knees

2. KERNIG’S SIGN: Flex knees when supine, and then straighten; Abnormal = Pain and resistance to knee extension bilaterally

Question 9

Abnormal muscle movements

Answer 9

Abnormalities:
1. Atrophy and fasciculations of tongue

2. Tics
3. Postural tremors
4. Intention tremors

Question 10

Gait

Answer 10

Gait abnormalities:
1. CEREBELLAR ATAXIA – Wide-based, staggering, unsteady gait (positive Romberg); Cerebellar diseases or alcohol/drug intoxication

2. PARKINSONIAN GAIT – Shuffling gait, turning in very stiff manner, stooped-over posture with flexed hips and knees; Parkinson’s disease and drug-induced parkinsonian because of effects on the basal ganglia
3. SCISSORS GAIT – Stiff, short gait, and thighs overlap each other with each step; Partial paralysis of the legs
4. SPASTIC HEMIPARESIS – Flexed arm held close to body while dragging/circling toes forward; Lesions of the upper motor neurons in the cortical spinal tract (and stroke)
5. FOOTDROP – Foot and knee are lifted high with each step, and then slammed hard (cannot walk on heels); Disease of lower motor neurons

Question 11

Older clients

Answer 11

Common variables:
1. Normal decreased taste/scent/sight/hearing sensations

2. May experience intention tremors (involuntary contractions during voluntary movement)
3. May have reduced muscle mass from degeneration of muscle fibers
4. May have hand or head tremors or dyskinesia (repetitive movements of the lips/jaw/tongue)
5. Slow and uncertain gait – wider/shorter, hips/knees may be flexed for a bent-forward appearance
6. Light touch/pain sensations may be decreased; vibratory sensation at ankles may decrease >70
7. Sense of position of great toe may be reduced
8. Intact DTRs, but decrease in reaction time may slow the response
9. Achille’s reflex and flexion of toes may be absent or difficult to elicit