Week 5 (Class 2) - Neurological Assessment Flashcards
(43 cards)
The Central Nervous System consists of?
What is it responsible for?
The Brain and Spinal Cord
- Cerebrum (2 hemispheres; (L) analytical and (R) creative) - largest part that controls 80%
- Cerebral cortex (frontal, parietal, temporal, occipital, Wenicke’s area, Broca’s area) - thinking and processing; movement; language
- Basal ganglia
- Thalamus
- Hypothalamus
- Cerebellum - movement and coordination, balance
- Amygdala - emotions
- Forebrain - body temp, reproductive function, eating, sleeping, emotion
- Midbrain - Motor movement (eye), auditory, visual processing
- Brainstem (pons, medulla) - basic functions; breathing, HR, BP
- Spinal cord
Control and coordination of body
What does the frontal lobe control?
Motor function for the contralateral side
What does the PNS consist of?
Cranial, spinal and peripheral nerves
- Connect CNS to rest of body
PNS:
- Cranial Nerves
- How many pairs?
- Order?
- Types
- Myelination?
- Example?
- Aging adults
12 pairs that enter and exit (no spinal cord involvement)
Order:
I and II from the cerebral hemisphere
III and IV from the midbrain
V, VI, VII, VIII from the pons
IX, X, XI, XII from the medulla
Types:
- Sensory
- Motor
- Mixed (Sensory and motor)
Myelination starts after birth = why they have unsophisticated movements
- Core outwards; fine motor skill of arms and legs comes along later once myelinated
Ex. MS
- Chews up myelin on nerves
- Results in jerky, uncoordinated movements
Aging adults
- 80y brain is decreased in weight by 15%
What is the Mnemonic to remembering the cranial nerves (PNS)?
On / Some = Olfactory / Sensory Old / Say = Optic / Sensory Olympus / Marry = Oculomotor / Motor Towering / Money = Trochlear / Motor Top / But = Trigeminal / Both A / My = Abducens / Motor Fin / Brother = Facial / Both And / Says = Auditory / Sensory German / Big = Glossopharyngeal / Both Viewed / Brains = Vagus / Both Some / Matter = Spinal accessory / Motor Hops / More = Hypogloassal / Motor
PNS:
- Spinal Nerves
- How many?
- Categories?
- Afferent/Efferent
- Nerve?
31 spinal nerves
- 8 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 1 coccygeal
Afferent = Arrive - Input coming in
Efferent = Exit - Message away out to body
Nerve: Where the fibers come together
What is a dermatome?
area of skin supplied by one particular spinal nerve
PNS:
- Spinal Nerves
- Name what each nerve innervates
- C1-C3
- C1
- C4-C6
- C7-T1
- T1-T6
- T6-T12
- T12-L4
- L4-S4
C1-C3: innervate movement in and above the neck including the larynx;
C1 has no dermatome/sensory responsibilities, mostly motor
C4-C6: innervate the neck and shoulder and diaphragm (C3-C5 for breathing independently)
C7 – T1: innervate arms, fingers, hand grasp (think self-care, transfers with arms)
T1-T6: provide trunk stability for balance when sitting (thinking getting patients up and out of bed), innervate intercostal muscles for respirations
T6-T12: innvervate intercostals and abdominal muscles for respirations and transfer strength
T12-L4: innervate muscles of the abdomen, and upper leg (quads and hip abductors)
L4-S4: innervate hip abductors and extensors (hamstrings), muscles of knee, ankles, and feet, and the perineum for leg strength and bowel and bladder control
PNS:
- Autonomic Nervous System
- What is it?
- Sympathetic?
- Parasympathetic?
- What is a reflex?
Autonomic Nervous system: Maintains involuntary functions of cardiac and smooth muscle of the viscera and glands
The autonomic nervous system is divided into these two types
a) Sympathetic
- ‘Fight or Flight’ produces body-to-action during periods of physiologic and psychologic stress neurotransmitter of significance here: epinephrine (adrenaline)
b) Parasympathetic
- ‘Rest & Digest’ functions in a complementary and counterbalancing manner to conserve body resources and day-to-day functions (e.g., rest, digest) neurotransmitter
Reflexes: involuntary responses
What are a few neurological disease entities you can think of?
- Degenerative – aging: cognitive disorders (memory), Alzheimer’s, autoimmune/progressive such as MS, Parkinson’s
- Genetic – Spina bifida, MD, ALS
- Injury – Traumatic Brain Injury (TBI), concussions (this is a hot topic)
falls, MVA - Cardiovascular - stroke – risk ↑ with ↑BP, age, DM, smoking, obesity & CVD which are widely experienced by population
- Headaches
- Vertigo
- Brain tumours
- Epilepsy
- Neuropathy/peripheral neuropathy as seem in DM
What are health promotion / injury prevention for neuro?
Ex. Stroke prevention
- Smoking
- Smoking and oral contraception
- FAST to recognize strokes
Ex. Injury Prevention
- Balance and falls
Ex. Prevention of Meningeal Infections
- Vaccinations
Ex. Reduction for risk - Seizures
- Meds
- Sudden changes to meds
- Sleep deprivation
- Other illness
- Stress
Ex. Folic Acid
- Women of child bearing years should take a multivitamin
What subjective data would be required in a health history pertaining to a neurological assessment?
- Presenting with headaches
- Presenting with facial drooping
- Presenting with head injury from a fall
- Presenting with dizziness
- Presenting with limb weakness
- Presenting with difficulty speaking
- Ex. Seizures, tremors, incoordination, numbness/tingling, pain, difficulty swallowing/speaking
Do you want a whole history during a health history pertaining to a neurological assessment?
- Environmental/Occupational Hazards?
- Current Health Status?
- Past Medical History?
YES
You want a whole history, family history if relevant, but significant history might include:
- History of stroke “CVA” (cerebrovascular accident), spinal cord injury, meningitis or encephalitis, congenital defect, or alcoholism (Korsakoff syndrome caused by severe thiamine deficiency which is often due to chronic alcohol misuse).
YES
Environmental/Occupational Hazards:
- Are you exposed to any environmental/occupational hazards: insecticides, organic solvents, lead, toxic inhalants, etc.?
YES
Current Health Status: (include all medications, dose, and frequency)
YES
Past Medical and Surgical
- History
- Family History
- Social Habits
What objective data might be needed in a neurological assessment?
Equipment you (might) need:
- Penlight with pupil scale*
- Everyday objects*
- Tongue blade
- Cotton ball
- Pin
- Tuning fork (128 or 256 Hz)
- Percussion hammer
What are the 8 components of a neurological assessment?
- Vital Signs*
- Tells us about intracranial pressure (ICP) - Level of Consciousness (LOC) using GCS*
- Glascow Coma Scale has 3 parts to measure the level of consciousness - Cranial Nerves 1 – 12 (concentrate on 3, 7, 9, 12)*
- Speech*
- Strength testing*
- Cerebellar function
- Sensation testing
- Reflexes** (advanced)
What should you watch out for during a neurological assessment?
Vital Signs
- Decreasing pulse
- Decreasing respirations
- Decreasing oxygen saturation level
- Increasing BP
- Widening pulse pressure (This is the difference between systolic & diastolic values - This happens with increased intracranial pressure (ICP))
- Cushing’s Triad (symptom of increased ICP): Bradycardia, Hypertension with widening pulse pressure, Bradypnea/irregular respirations
What is LOC?
- How is it measured?
- 3 components?
- Score range?
LOC = Level of Consciousness
- Measured by the Glascow Coma Scale (GCS)
3 components:
- Eye opening
- Verbal response
- Motor response
Score range:
- 3-15
- Severe, with GCS ≤ 8 cannot protect their airway
- Moderate, GCS 9 - 12
- Minor, GCS 13-14
- Perfect score 15
What are the 3 dimensions of best verbal response (orientation)?
- What must be considered?
- Person
- Place
- Time
*To be considered oriented, all 3 must be correct
What is the sequence for eye opening?
- How long do you apply stimulus?
- Speak
- Shout
- Shake
- Pain
You want to allow the stimulus a good 15-30 SEC MIN/MAX before deciding they have “no response.” No response is a weighty finding. You want to be sure.
What if there is no eye opening?
- Round 1?
- No response?
- Eye Orbit?
- Rationale?
Then the first round pain stimulus is peripheral in the form of pressure on the nail bed with something like a pencil
- Grab a pen or a pencil, hold it across your nail bed perpendicular to your finger, and firmly press.
If no response, move to something central such as the trapezius squeeze.
- You grasp the trapezius muscle, give a squeeze and a twist.
- Moving more centrally is a more powerful stimulus for the brain, so you might get a response centrally but nothing peripherally.
Alternatively, you can take your thumb and apply pressure to the orbit of the patient’s eye. Try this on yourself too. It hurts.
The reason you’re doing this is to coax a response out of the patient’s brain by doing something that the brain should perceive as unpleasant or irritating
- The more severe the impairment, the less reaction you’ll get from the patient
- At a certain point, the patient’s brain will react in ‘reflexive’ ways to pain and discomfort that are demonstrative of a desperate brain under too much stress to cope.
What has fallen out of favour for eye opening? Why?
The sternal rub has fallen out of favour as a method for eliciting a response to pain
- You’ll still read about it in places, and you’ll still see clinicians doing it on occasion, usually because they have always done it and don’t want to try something new.
- The sternal rub is a central pain stimulus that involves forming a fist with your hand and then firmly rubbing your knuckles up and down the patient’s sternum
- In the stress of the moment and desperation to see some sort of response from the patient, clinicians end up rubbing so hard for so long that they rub layers of the patient’s skin off and cause a great deal of superficial damage
- Since we have better methods that do the same thing without all the damage, the sternal rub is now considered abuse and should be replaced with one of the other central stimulation methods
What is the best motor response (LOC)?
- What does it reflect?
What do you ask?
- What if they do not obey?
Patient’s ability to receive the simple command, and produce the action
- Ability reflects LOC, not motor impairment (though motor impairment may interfere, more on that later)
Ask the PT to follow 3 simple motor commands
- If unable to obey commands, may observe some spontaneous movement, localization = remove discomfort
- If unable to obey commands, no movement, normal flexion = attempt to move away from discomfort
What is decerebrate and decorticate postures?
- What can cause this?
These postures are so specific, and always alarming to see - When you observe these postures, you understand that the patient’s brain is in severe distress
Decerebrate
- Results from damage to upper brain stem
- Arms are adducted and extended with the wrists pronated and fingers flexed
- Legs stiffly extended with plantar flexion of feet
Decorticate
- Results from damage to one or both corticospinal tracts
- Arms adducted and flexed with wrists and fingers flexed on chest
- Legs stiffly extended and internally rotated with plantar flexion of feet
Causes:
- Your exam
- These patients may be unresponsive/in coma and this posture is this is the only observable movement
What are 4 aspects of a CN II optic (incoming light) and CN III oculomotor (muscle control) pupillary assessment?
- Pupil Size, equality, & shape:
- Measure pupil size in mm using measuring guide. Both pupils should be the same size & shape. - Direct light reflex:
- Pupil should constrict briskly & immediately in response to the light source. - Consensual light reflex:
- Pupils should constrict when light source is aimed at the opposite pupil - Accommodation:
- Hold finger/penlight 12 inches from client’s face, and bring it toward their nose
- Both pupils should constrict equally and turn inward (converge) simultaneously.
