Neurological assessment Flashcards
(65 cards)
1
Q
Central nervous system (CNS)
A
- Brain and spinal cord
- Meninges; outer layer that covers the CNS to protect it
- Cerebrospinal fluid; nourish the brain and a cushion
2
Q
Peripheral nervous system (PNS)
A
- Cranial nerves, spinal nerves and branches
- Sensory (afferent) messages to CNS
- Motor (efferent) messages from CNS
- 12 cranial nerves
- 31 spinal nerves and many branches
- Some nerves can be both sensory and motor (mixed nerves)
3
Q
Cerebral cortex
A
Outer layer in humans, tightly folded, divided into 2 hemispheres (right/left)
4
Q
Basal ganglia
A
Deep within the cerebral hemispheres, associated with motor movements (autonomic and occur involuntarily)
5
Q
Thalamus
A
Relay station, all sensory information from the periphery to the cerebral cortex
6
Q
Hypothalamus
A
Vital section, controlling body temperature, coordination HR, BP, helps regulate sleep , actions happen in the background (not conscious)
7
Q
Pituitary gland
A
Regulated by hypothalamus, master gland of the body, below the hypothalamus, released many hormones that direct different processes
8
Q
Cerebellum
A
Back of brain, maintains equilibrium, coordination/smoothing out of more complex movements, role in maintaining muscle tone
9
Q
Brain stem
A
Part of brain right before the spinal cord, many fibre tracts that send message to/from the brain, coordinated vital centre activity (HR, BP, respirations)
10
Q
Spinal cord
A
Long structure that runs down column, continuous with brains stem, down until L1-L2, highway for motor/sensory messages, ascending/descending tract, nerve conduction
11
Q
Frontal lobe
A
- Personality
- Behaviour
- Emotion
- Intellectual functions
12
Q
Broca’s area
A
- In frontal lobe
- Motor speech
- Expressive aphasia; if injured cannot say words
13
Q
Temporal lobe
A
- Hearing
- Taste
- Smell
14
Q
Wernicke’s area
A
- Temporal lobe
- Speech comprehension
- Receptive aphasia; if injuired cannot comprehend speech
15
Q
Occipital lobe
A
- Visual reception
16
Q
Parietal lobe
A
- Sensation
17
Q
Precentral gyrus
A
- Primary motor area
- Near frontal and parietal lobe meeting (central sulcus)
18
Q
Sensory pathways
A
- Up to brain
- Detect things in peripheral and send it to the brain
- Spinothalamic tract
- Posterior (dorsal) column
- Depends on type of message
19
Q
Spinothalamic tract
A
- Pain
- Temperature
- Light (crude) touch
20
Q
Posterior (dorsal) column
A
- Proprioception; where body parts are in relation to each other without visual aid
- Vibration
- Stereognosis; ability to identify familiar objects without visual aid
21
Q
Motor pathways
A
- Descending path from brain to periphery
- Corticospinal (Pyramidal) tract
- Extrapyramidal tract
- Cerebellar system
22
Q
Cortiospinal (Pyramidal) Tract
A
- Skilled, purposeful voluntarily movements
- Higher motor system
- Fine muscles tone
- i.e. playing the piano
23
Q
Extrapyramidal tract
A
- Muscle tone
- Gross body movements
- Older more primitive system
24
Q
Cerebellar system
A
- Coordinates movement
- Maintains equilibrium
- Posture
- Unconscious level
- Makes things smooth
25
Motor neurons
Upper motor neurons
- Located in the CNS
- Descending neurons
- Influence LMN
- i.e. stoke is a UMN disorder
Lower motor neurons
- Located in PNS
- Final pathway before innervating a muscle
- i.e. spinal cord lesion is . LMN disorder
26
Cranial nerces
- 12 Cranial Nerves
- Exit the brain rather than the spinal cord
- Mainly supply the head and neck (with a few exceptions)
- Can be sensory nerves, motor nerves, or both
27
Spinal nerves
- 31 pairs of spinal nerves
- Named for region of spine with there exit
- All mixed nerves – can sensory and motor impulses
28
Dermatomes
- Area on the skin that in innervated by one’s spinal nerve
| - They overlap a little bit
29
Reflex arc
- PNS functioning
| - Basic defence system of the body
30
Autonomic nervous system
Sympathetic nervous system - fight or flight
| Parasympathetic nervous system - rest and digest
31
PNS afferent vs. efferent
Afferent
- Sensory division
- From sensory organs to brain
efferent
- Motor divison
- From brain to effectors
32
Cranial nerves
```
i - olfactory
ii - optic
iii - oculomotor
iv - trochlear
v - trigeminal
vi - abducens
vii - facial
viii - acoustic
ix - glossopharyngeal
x - vagus
xi - spinal accessory
xii - hypoglossal
```
33
Cranial nerve i
- Olfactory
- Type: sensory
- Function: smell
34
Cranial nerve ii
- Optic
- Type: sensory
- Function: vision
35
Cranial nerve iii
- Oculomotor
- Type: mixed
- Function:
motor; most EOM movement, opening of the eyelids
parasympathetic; pupil constriction, lens shape
36
Cranial nerve iv
- Trochlear
- Type: motor
- Function: down and inward movement of the eye
37
Cranial nerve v
- Trigeminal
- Type: mixed
- Function:
motor; muscles of mastication
sensory; sensation of face and scalp, cornea, mucous membranes
38
Cranial nerve vi
- Abducens
- Type: motor
- Function: lateral movement of eye
39
Cranial nerve vii
- Facial
- Type: mixed
- Function:
motor; facial muscles, close eye, labial speech, close moth
sensory; taste (sweet, salty, sour, bitter) on anterior 2/3 of tongue
parasympathetic; saliva and tear secretion
40
Cranial nerve viii
- Acoustic
- Type: sensory
- Function: hearing and equilibrium
41
Cranial nerve ix
- Glossopharyngeal
- Type: mixed
- Function:
motor; pharynx (phonation and swallowing)
sensory; taste on posterior 1/3 of tongue, pharynx (gag reflex)
parasympathetic; parotid gland, carotid reflex
42
Cranial nerve x
- Vagus
- Type: mixed
- Function:
motor; pharynx and larynx (talking and swallowing)
sensory; general sensation from carotid body, carotid sinus, pharynx, viscera
parasympathetic; carotid reflex
43
Cranial nerve xi
- Spinal accessory
- Type: motor
- Function: movement of trapezius and sternomastoid muscles
44
Cranial nerve xii
- Hypoglossal
- Type: motor
- Function: movement of the tongue
45
Types of reflex arcs
1) Deep Tendon Reflexes (DTRs)
- i.e. hit tendon with a tool
2) Superficial Reflexes
- Exist within the skin
3) Visceral Reflexes
- Involuntary reflex that happen organically
4) Pathologic Reflexes
- Unexpected reflexive response
46
Neurological developmental considerations: infants
- Dramatic growth and development of neurological system during 1st year of life
- Initially, movements directed primarily by primitive reflexes
- Sensory and motor system develops during process of myelinization (helps transmit signals faster)
- Cephalocaudal (head to toe) and proximal to distal order
47
Neurological developmental considerations: older adults
- General atrophy; impaired fine coordination and agility, correction, and balance.
- Cranial/spinal nerves; velocity of nerve conduction decreases, slows reaction time in some individuals
- Sensory changes
- Motor system; slowing down of movement (motor system atrophy)
- Progressive decrease in cerebral blood flow and oxygen consumption; may cause dizziness, loss of balance
- Changes in intellectual functioning depend on the individual
48
Subjective assessment of the neurological system
- Headache
- Head injury
- Dizziness/vertigo/ syncope
- Seizures
- Tremors
- Weakness
- Coordination/balance
- Numbness or tingling; Paraesthesia’s
- Difficulty swallowing; dysphagia
- Difficulty speaking; Dysarthria/dysphasia
- Significant past history
- Environmental and occupational hazards
- Sleep, nutrition, medications, substance abuse can throw off findings; ensure accurate picture
49
Sequence of complete neurological examination
1) Cranial nerves
2) Motor system
3) Sensory system
4) Reflexes
50
Testing cranial nerve i
Assess patency and sense of smell
Patency
- Want both nostrils open; not blocked by secretion – occlude one nostril and sniff
Sense of smell
- Use a familiar smell, i.e. mint, coffee, etc.
- Have them let you know when they smell it with eyes closed
51
Assessing cranial nerve ii
Assess visual acuity, visual fields, fundus
Visual acuity
- Snellen chart – optimistrist, letters on the wall
- Last line the patient can read with 2 or less errors
- 20/20 in healthy visual acuity
- Top number is distance standing from chart/bottom number is the number of letters the patient can read accurately
Visual field
- Peripheral vision
- Confrontation test
- Testing assuming the examiner has healthy peripheral vision
- Very gross assessment of peripheral vision
- Cover same eye and work with finger to see
52
Assessing cranial nerves iii, iv, and vi
Assess:
Palpebral fissures
- Symmetry, signs of infection, etc.
- Ptosis; drooping of one side of an eyelid, worried about nerve iii
Pupils
- PERRLA; Pupils Equal Round, Reactive to Light, and Accommodate
- Use pen light from side and then in front, pupil will constrict in response to light
- Inspect for roundness
- Accommodation means change in pupil size as someone changes from focusing on something close to something far away
Eye movements (EOM)
- Extra ocular movements
- Both eyes move together in a coordinated, smooth fashion
- Nystagmus – vibration of the eyes
- Test using a 6-points star
- Look straight ahead, with just eyes follow your finger movement
53
Assessing cranial nerve v
Sensory Function
- Assess light touch; use a wisp of cotton or gauze
3 spots on the face; chin, cheek, and forehead
Corneal reflex – touching the cotton towards the eye, expect the eyes to blink
- Assess corneal reflex only if necessary
Motor Function
- Assess temporal and masseter muscles, lower jaw movement
54
Assessing cranial nerve vii
Motor Function
- Assess mobility & symmetry with facial expressions
- Have them make faces, blow up cheeks and push air looking for symmetry
Sensory Function
- Assess sense of taste
- Not routinely tested (only when suspect injury)
Parasympathetic Functions
- Saliva and tear production
- Ask if mouth is dry and if they are producing tears or not
55
Assessing cranial nerve viii
- Assess hearing acuity; ability to hear
- Hear regular conversation; just while talking
- Whispered voice test; stand 2ft behind client, assess one ear at a time
- Occlude the tragus (one at a time)
- Whisper something abscure, then test the other side
56
Assessing cranial nerves ix and x
Motor Function
- Assess movement of pharynx
- Assess for gag reflex
- Only if observed no movement of the pharynx
Sensory Function
- Difficult to assess posterior
one third of tongue for taste
57
Assessing cranial nerve xi
- Trapeus and sternomastoid muscles
- Assess against resistance of examinor
- Equal resistance on both side
58
Assessing cranial nerce xii
- Assess movement of the tongue
- Assess movement of the tongue and person’s ability to articulate “light, tight, dynamite”
- Assessing strength of voice, enunciation
59
Motor system assessment: muscles
- Gross screening
- GO head to toe
- Size; equal on both sides
- Strength; equal on both sides
- Symmetry
- Tone; engage the client in passive ROM
- Involuntary movements; tremors, twitches, etc.
60
Motor system assessment: cerebellar function
Balance test
- Gait; smooth, steady, coordinated walking
- Ataxia; uncoordinated, unsteady gait
- Tandem walking; walking on line, heal to toe – any issue of coordination is increased when we decrease base of support
- Romberg test; feet together, arms at side, ask them to close their eyes (20 secs, positive test is if they completely lose balance
Coordination and skilled movements
- Rapid alternating movements; take finger and touch it to thumb, perform smoothly; OR hand son thighs alternate back and forth smoothly
- Finger to finger test; able to mostly do it; your finger, touch their nose then touch tour finger while you move your finger around
- Finger to nose test; eyes close, touching their nose with alternating finger
- Heel to shin test; lying or sitting on bed, have opposite heel touching shin, and slide down; should do smoothly on both sides
61
Sensory system assessment: spinothalamic tract
- Pain; break tongue blade and have them assess with eyes closed to feel sharp or dull sensation on skin
- Temperature; done if abnormal pain sensation test
- Light touch; points on periphery with light touch to assess
62
Sensory system assessment: posterior column tract
- Vibration; tuning fork
- Position; close eyes and move limbs in different positions
- Fine touch;
- Stereognosis – eyes closed put something familiar in hand, should be able to detect what it is
- Graphesthesia; use finger to write in hand letter or number
- 2 point discrimination; take paper clip and unfold it (2 pointy ends) and can alter the distance; fingertips can detect that it’s two distinct pints but not in gross areas such as back
63
Deep tendon reflex testing
- Test the reflex arc at a specific spinal level
- Biceps, Triceps, Brachioradialis, Quadriceps (patellar, knee jerk), Achilles
- Grade the response on a 4 point scale
- To elicit a good response; limb needs to be slightly bent, patient completely relaxed, if they know you will strike them they may tense (good to distract them)
- Examinor needs to be relaxed holding the hammer, relaxed wrist, strike in a quick gentle way
64
Grading a deep tendon reflex
```
+4 - Very brisk, hyperactive with clonus (rhythmic jerking of muscles after reflex is elicited)
+3 - Brisker than average
+2 - Average, normal
+1 - Diminished, low normal
0 - No response
```
65
Superficial reflex testing
- Sensory receptors in the skin rather than muscles
- Plantar reflex; bottom of foot with back of hammer, draw and upside down 'J'
- Expect tickle and toes turn over
- Unexpected finding is a full Babskini fan out of toes (only seen in infants)
