ASSESSMENT OF NEUROLOGIC FUNCTION Marichelle Delos Santos RM,RN,MAN NERVOUS SYSTEM is an organ system containing a network of specialized cells

called neurons that coordinate the actions of an animal and transmit signals between different parts of its body NETWORKmeans neural network or a circuit of biological neurons signaling NEURONS-

is an electrically excitable cell that processes and transmits information by electrical and chemical Function of the Nervous System Controls all motor, sensory, autonomic, cognitive, and behavioral activities. Structures of the Neurologic System Central Nervous System Brain and spinal cord Peripheral nervous system Includes cranial and spinal nerves

Types: Acetylcholine-muscle movement Biogenic amines (thinking process) -Dopamine -Serotonin -Histamine -Norepinephrine Amino acids -GABA -Peptides Bones and Sutures of the Skull 3 essential components of skull: Brain tissue-78% Blood -12 % . or modulate a specific action or can excite or inhibit a target cell. Many neurologic disorders are due to imbalance in neurotransmitters. biologic and physical activity through complex chemical and electrical messages Neurotransmitters Neurotransmitters can potentiate.Autonomic and somatic systems Neuron Brain cells Links the motor and sensory pathways Monitor the body s processes Respond to the internal and external environment Maintain homeostasis Direct all psychological. terminate. Communicate messages from one neuron to another or to a specific target tissue.

sleepwake cycle and thirst .CSF-10% Monro-Kellie Hypothesis If volume added to the cranial vault equals the volume displaced from it.Hypothalamus regulates endocrine and autonomic function. appetite. water metabolism.Thalamus process sensory impulses before it reaches cerebral cortex 2. temperature. the total intracranial volume will not change Normal ICP: 60-150 mmH20 or 0-15 mmHg Brain Cerebrum Consists of 2 hemisphere Corpus callosum connects two hemisphere Cerebral cortex outer surface of the cerebrum Basal ganglia located deep within cerebral hemisphere Internal capsule white matter consisting of bundle of nerve fibers carrying motor and sensory impulses to and from cerebral cortex Lobes of the Cerebrum and their Functions Diencephalon Embedded in the brain superior to brain stem 1. emotion.

Epithalamus includes pineal gland (secretes melatonin and inhibits LH). contains nuclei that controls respiration -contains pneumotaxic center controls rhythmic quality of respirations 3. maintenance of balance. affects growth and development. S1-S5. Medial View of the Brain BRAIN STEM 1. regulatory system for consciousness Cerebellum Has two hemispheres Coordination of skeletal muscle activity. posture and control of voluntary movements Spinal cord Extends from medulla up to first lumbar vertebra Gives rise to 31 pairs of spiral nerves (C1-C8.3. L1-L5. coccygeal nerve) Center for conducting messages to and from the brain. BP. T1-T12. respirators and swallowing 4. part of endocrine system. a reflex center . Reticular activating system (RAS) influence excitatory and inhibitory control of motor neuron. Medulla control cardiac rate. Midbrain center for auditory and visual reflexes 2. Pons contains the fiber tracts.

inhibited or conditioned Hyperreflexia-disease or injury of certain descending motor tracts Hyporeflexia-damage or degeneration of the sensory or motor neurons . spinal cord mediates most reflexes Automatic or perceptible.Divisions: Ascending (Spinocerebellar) Carry a specific sensory information to higher levels of CNS Spinocerebellar tracts-muscle tension and body position Spinothalamic-pain and temperature sensation Descending (Corticospinal) Pyramidal tractsfrom the cortex to cranial and peripheral nerves inhibits muscle tone Extrapyramidal tractsfrom brain stem. and cerebellum maintains muscle tone and gross body movements Upper motor neurons from cerebral cortex to anterior gray column of SC spasticity and hyperactive reflexes Lower motor neurons final common pathways from anterior gray column up to muscles flaccidity and loss of reflexes Reflex arc Reflexes-automatic action. basal ganglia.

Posterior Jugular veins-drains the brain venous blood through dural sinuses Cross Section of the Spinal Cord Showing the Major Spinal Tracts Cranial Nerves Dermatome Distribution Peripheral Nervous system Cranial nerves-innervate head and neck region. lumbar and sacral region) Dermatomes area of the skin innervated by cutaneous branches of a single spinal nerve Somatic Nervous system  Consists of motor and sensory nerves .Meninges and Related Structures Arterial Blood Supply of the Brain Sources of Blood supply: 1. arises from basilar arteries and internal carotid arteries. vascular network at the base of the brain is important to total brain circulation because it provides equal circulation bilaterally. except the vagus nerve Spinal nerves Plexuses complex cluster of nerve fibers (cervical. Vertebral arteries-posterior circulation. ipsilateral hemispheres 2. brachial. posterior fossa Circle of Willis act as a safety valve. the other side provides blood to the area normally supplied by the damaged side Cerebral arteries (2 each): Anterior. Internal carotid arteries-anterior circulation. Middle. If one side of the circle of Willis is unable to supply adequate blood.

 Controls skeletal muscles  Produces a motor response through efficient nerve fibers from CNS which transmit impulses to the skin and skeletal muscles Autonomic Nervous System Functions to regulates activities of internal organs and to maintain and restore internal homeostasis Controls involuntary or automatic body functions Has two subdivisions. cold. each system can inhibit the organ stimulated by the other Sympathetic Nervous System originates from lateral horns of first thoracic through the first lumbar of spinal cord (thoracolumbar) helps the body cope with events in the external environment Functions mainly during stress. serving same organ but have counterbalancing effects. and sweaty palms SYMPATHETIC SYNDROMES Parasympathetic Nervous System Consist of the vagus nerves originating in the medulla of the brain stem and spinal nerves originating from the sacral region of the spinal cord (craniosacral) Activates GI system Supports restorative. pupil dilation. resting body function through such actions as replenishing fluids and electrolytes Anatomy of the Autonomic Nervous System Motor and sensory pathways of the nervous system Motor pathways Upper and lower motor neurons Upper motor neuron lesion . triggering the fight or flight response Increases heart rate and respiratory rate.

Lower motor neuron lesion Coordination of movement Sensory System Function Receiving sensory impulses Integrating sensory impulses Sensory losses DIVISIONS OF THE NERVOUS SYSTEM NERVOUS SYTEM Anatomical Classification Functional Classification .

Health History ask the client about headache. personality changes. extreme fatigue. loss of or change in function of an extremity.CNS PNS Afferent/ Efferent/ Sensory Motor Brain SC SN CN Somatomotor Autonomic Cerebrum Diencephalon Brainstem Cerebellum Sympa Parasympa Thalamus Pineal Body Hypothalamus Medulla Oblongata Pons Midbrain NEUROLOGICAL NURSING ASSESSMENT 1. seizure activity. pain. clumsiness. numbness or tingling change in vision. 2. and mood swings. Neurological Assessment .

Consciousness Requires: Arousal: alertness.Involves assessment of LOC and verbal responses to specific questions. anesthetics Seizure activity: exhausts energy metabolites . system of neurons in thalamus and upper brain stem Cognition: complex process. and tactile and pain sensation of extremities for sensory screening. analgesics. motor function. controlled by cerebral hemispheres Process that affect LOC: Increased ICP Stroke. and reflexes. A complete nursing assessment of neurological function includes assessment of the following areas: cerebral function. hematoma. gait for motor function. a. muscle strength. cranial nerve function. selected cranial nerves for eye movement and visual acuity. Level of Consciousness is assessed by determining the client s awareness and orientation and is the most important indicator of change in neurological status. involving all mental activities. Cerebral function assessment includes: a.1. dependent upon reticular activating system (RAS). sensory function. movement. intracranial hemorrhage Tumors Infections Demyelinating disorders Systemic Conditions affecting LOC Hypoglycemia F/E imbalance Accumulated waste products from liver or renal failure Drugs affecting CNS: alcohol.

and facial expressions. A score of 7 is considered a state of coma. year and day of the week. A score of 3 indicates deep coma. place and time. memory. Glasgow Coma Scale an objective tool for assessing consciousness in clients. educational level and social position. -Using open-ended communication techniques. most frequently clients with head injuries. Mood is assessed by observing and asking the client about moods and feelings. Mental Status requires observation of the client s appearance. instruct the client to tell me your first and last name . day. tell me where you are . Orientation is the person s awareness of self in relation to person. The nurse compares these behaviors based on the client s age. health status. mood. GLASGOW COMA SCALE GLASGOW COMA SCALE GLASGOW COMA SCALE a. GLASGOW COMA SCALE (?) A score of 15 indicates a fully oriented person. a. tell me the month.3.2.Level of Consciousness Alert Lethargic-very sleepy Stuporous Coma Death Awareness is the person s ability to perceive stimuli and body reactions and then respond with thought and action. movements. behavior. posture. calculation and fund of knowledge. The client s awareness is assessed through four (4) components: orientation. gestures. .

Coma a. personality changes: strokes Aphasia-defective or absent language function: TIA s. p. and fund of knowledge. general term for impairment of language Dysphonia. recall. 1998.change in tone of voice Dysarthria. palate. Intellectual Function is the ability of the brain to perform thought processes.4. pharynx.g.6.Pupil reaction . memory function (long and short term memory).MENTAL STATUS ASSESSMENT WITH ABNORMAL FINDINGS Unilateral neglect (lack of caring of the other side of the body). Ability to concentrate.(different in speaking). calculation activities. a. strokes involving middle cerebral artery Poor hygiene and grooming: dementing disorders Abnormal gait and posture: transient ischemic attacks(TIAs) . muscles of the tongue. Is affect appropriate for the situation? Is affect labile (prone to rapid change)? Is affect consistent with verbal communication COGNITIVE FUNCTION ASSESSMENT WITH ABNORMAL FINDINGS Disorientation to time and place: stroke of right cerebral hemisphere Memory deficits Emotional defense a. and Parkinson s disease Emotional swings. strokes. 1901] Decreased level of consciousness Confusion. is indistinctness of words in word articulation resulting from interference with the peripheral speech mechanisms (e. or lips) [Phipps. Emotional Status is assessed by observation of the client s affect (emotional response or mood). strokes involving anterior/posterior artery.5.

and roundness of pupils are assessed. a. Cranial II (Optic) blindness in eye: strokes of internal carotid artery. p. can be caused by the inability to form words or the inability to understand written or spoken word. TIA s Homonymous hemianopia . 1998. ask the client to follow simple command such as Close your eyes . or nonreactive. equality.Communication both written and oral communication are assessed. brain tumors Note: Visual acquity-mediated by the cones of the retina Field of vision or peripheral vision-portion of space in which objects are visible during the fixation of vision in one direction.size. The receptors for peripheral fields are the rod neurons of the retina. blockage of posterior cerebral artery. To assess communication function. Have the client write his name and address on paper to evaluate the ability to write.7. During the health history. Aphasia inability to communicate verbally. 1906) . consensual reaction is also noted. ask the client about health care expectations to evaluate the client s ability for verbal expression. b. sluggish. Cranial Nerve Function Cranial I (Olfactory): -Anosmia lesions of frontal lobes impaired blood flow to middle cerebral artery. (Phipps. Reaction is assessed as being brisk. Impaired vision: strokes of anterior cerebral artery.impaired vision or blindness in one side of both eyes. Size is measured in millimeters. Pupils are evaluated for symmetry of size and for reaction to light.

superior. lesions CN V Severe facial pain: trigeminal neuralgia (tic dorlourex) Cranial VII (Facial nerve) mixed nerve concerned with facial movement and sensation of taste 1. p. 1909) Decreased hearing or deafness: strokes of vertebralbasilar arteries or tumors of CN VIII Cranial IX(Glossopharyngeal) and cranial X (Vagus) chief function of cranial nerve IX is sensory to the pharynx and taste to the posterior third of tongue. 1998. strokes of anterior. Decreased movement of facial muscles 3. IV. paralysis of lower face. Eyelid weakness. myasthenia gravis. Loss of ability to taste 2. ‡ Ptosis (eyelid falldown). pharyngeal and laryngeal muscles (Phipps. drooping of the upper eyelid over the globe strokes of posterior inferior cerebellar artery. flat nasolabial fold. paralysis of upper motor neuron 5. 1909) . inability to wrinkle the forehead 4. 1998. cerebellar arteries Constricted pupils: may signify impaired blood flow to vertebralbasilar arteries. cranial nerve X is the chief motor nerve to the soft palatal. Inability to close eyes. strokes of posterior inferior cerebral artery Lip and mouth numbness Loss of facial sensation: contraction of masseter and temporal muscles. Pain. VI (Oculomotor. inferior. Abducens)-motor nerves that arise from the brainstem Nystagmus . impaired blood flow to carotid artery Decreased sensation of face and cornea on same side of body. palsy of CN III Cranial nerve V (Trigeminal) largest cranial nerve with motor and sensory components changes in facial sensations. p. Trochlear.involuntary eye movement. paralysis. paralysis of lower face.Cranial nerve III. sagging of facial muscles: affected side in Bell s palsy Cranial VIII (Acoustic) composed of a cochlear division related to hearing and a vestibular division related to equilibrium (Phipps.

Rigid muscles may have tremors but are constantly rigid. then against the resistance. spastic. fasciculations (twitches): LMN disease Tongue deviation toward involved side of the body c. Spastic muscles are at first resistant to passive movement. The client is then asked to move the extremity. first against gravity. Motor Function c. each extremity is placed through passive movement. Muscle size and symmetry are assessed by palpating major muscle groups of the arms and legs and then comparing them to the muscle groups of the opposite side of the body. Unilateral atrophy indicates a nervous system problem. but then release resistance. Muscle Strength to assess.3. or rigid. by lifting the extremity off the bed. Muscle Tone assessed during palpation of major muscle groups for size and symmetry while at rest and during passive movement. flaccid.2. . or soft and flabby. Flaccid muscles are hypotonic. c.1. c. Rigidity is a more constant state of spasticity. with fewer periods of release of resistance. Muscle tone is described as normal.Dysphagia (difficulty swallowing) Unilateral loss of gag reflex Cranial XI (Spinal accessory) motor nerve that supplies the sternocleidomastoid muscle and upper part of trapezius muscles Muscle weakness Contralateral hemiparesis: strokes affecting middle cerebral artery and internal artery Cranial XII (Hypoglossal) Atrophy.

No movement c. Coordination is assessed by asking the client to perform repetitious movement.1.4. Lesions of the cerebral hemispheres or internal structures of the brain cause flexion posturing. Just able to overcome force of gravity 2 . Full power of contraction 4 . Comparison is done side to side. is generally done only when a dysfunction is suspected.5 . Balance is evaluated by using the Romberg s Test.5. d. Fair or moderate power of contraction 3 . The client stands with the feet together. c. The client with eyes closed. The client should close his eyes and repeatedly. Minimal contractile power 0 . backward flexion of the head. Pain and temperature .2. rapidly touch her own nose with alternate index fingers. indicated whether the cotton ball is felt. incoordination of voluntary muscle action. and extension of the feet. adduction of the upper extremities. arms extended in front and eyes closed. Inability to perform this is termed ataxia. and extension of the lower extremities. Extension posturing (formerly decerebrate posturing) is caused by brainstem injury and is characterized by an arching of the back. It represents greater dysfunction than does flexion posturing and any change from flexion to extension posturing indicates a worsening condition d. Can move but cannot overcome power of gravity 1 . hands. Sensory Function a subjective examination of sensory function. Tactile Sensation is tested by using a cotton ball to lightly touch the client s arms. upper legs. d. adduction and hyperpronation of the arms. c.6. and feet. performed with the client s eyes closed. Posturing abnormal posturing occurs with injury to the motor tract. Flexion posturing (formerly decorticate posturing) characterized by flexion of the arms.

Superficial or cutaneous reflexes are elicited by irritating the skin on the area being assessed. Place a familiar object such as a coin or key in the client s hand and ask what the object is. should occur. Vibration is tested using a tuning fork.the absence of DTR in clients is considered an abnormal finding.4.5. or shapes drawn on the skin. d. d. Plantar flexion or curling under of the toes. A paper clip or cotton-tipped applicator is used.6. Reflexes: e. move a joint of the client s finger or extremity up or down in space and ask the client to distinguish the direction of movement of the digit or extremity as being either up or down.Steriognosis is the ability to recognize an object by feel. Deep tendon reflexes (DTR) are involuntary contractions of muscles or muscle groups responding to brisk stretching near the insertion site of muscle. d. With the client s eyes remaining closed. This abnormal response indicates corticospinal disease and is the most important abnormal superficial reflex. The client s eyes should be closed during the test. the brain function of integration is abnormal. Graphesthesia is the ability to identify letters. Strike the tuning fork on the palm. e. If only one is felt. e. A two-point discrimination test is performed by touching the client simultaneously on opposite sides of the body with a sharp object and asking the client to ascertain the number of objects felt. The normal response is two. holding only the handle.7.sensation of pain and temperature are transmitted along the same pathways and are evaluated using a sharp and dull touch.3.2. d. then place the end of the handle first on the client s wrists and then on the ankles and ask whether the vibrations are felt. Integration of sensation is a higher cortical function. not of the spinal pathways. Abnormal reflexes. d. the handle of the reflex hammer is used to stroke the outer aspect of the sole of the foot from the heel and across the ball of the foot to just below the big toe. To assess the plantar reflex. The client s ability to distinguish sharp and dull is noted. Techniques Eliciting Major Reflexes Figure Used to Record Muscle Strength Gerontological Considerations . comparing both sides of the body.Proprioception is the sense of joint position in space. numbers. They are diminished or absent with dysfunction of the reflex arc. The superficial reflex generally assessed is the plantar. A fanning of the toes and dorsiflexion of the big toe in response to the assessment of the plantar reflex is called Babinski Reflex. This sensation is a function of the brain.1.

Assess mental status carefully to distinguish delirium from dementia.Important to distinguish normal aging changes from abnormal changes Determine previous mental status for comparison. Queckenstedt s test. posture and balance. ~Attributed to both Andy McIntyre and Derek Bok . changes in gait. deceased sense of taste and smell. try ignorance. changes in the perception of pain. and decreased thermoregulatory ability Diagnostic Tests Computed tomography(CT) Positron emission tomography (PET) Single photon emission computed tomography (SPECT) Magnetic resonance imaging (MRI) Cerebral angiography Myelography Noninvasive carotid flow studies Transcranial doppler Electroencephalography (EEG) Electromyography (EMG) Nerve conduction studies. Normal changes may include: Losses in strength and agility. dulling of tactile sensations. visual and hearing alterations. slowed reaction times and decreased reflexes. and analysis of cerebrospinal fluid Magnetic Resonance Imaging If you think education is expensive. evoked potential studies Lumbar puncture.

line brain cavities. may maintain chemical balance of neurons . mitotic . forms CSF Schwann cells Phagocytic cells that form myelin sheath around nerve fibers Satellite cells Found in the PNS.Neuroglia-protect and nourish neurons.do not transmit impulses Neuroglia Function A strocytes Supply nutrients to neurons Microglia Provide protection against microorganisms Oligodendrocytes Wrap tightly around nerve fibers to form myelin sheath Ependymal cells Ciliated.

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