The Brain and Nerves

2 Parts of Central Nervous System

 Brain
 Spinal cord
Peripheral Nervous System
 Cranial nerves
Afferent- motor
Efferent- sensory
Infants and Children
- The nervous system begins to form within the 1 st 3 weeks of fetal development
- When pregnant have German measles, the infant this may cause hearing and eye problem.
- CNS immature
Responses by the new born are primarily primitive reflexes that are present
- Rooting neck reflex
- Sucking
Rooting Neck Reflex
- Appears at birth
- Disappears at 4 months
Sucking Reflex
- Using tongue and hard palate
- Most important reflex of new born
Palmar Grasp
- Appears at birth
- Disappears at 3-4 months
Plantar Grasp
- Appears at birth
- Disappears at 8-10 months
Babinski Reflex
- Normal up to 2 years old
- May disappear as early as 12 months
Tonic Neck Reflex
- Appears at birth
- Disappears at 5-7 months
 Moro Reflex
- Consist of rapid abduction and extension of arms with the opening of hands. Then come together as in
embrace
- Appears at birth
- Disappears at 4-6 months
Landau Reflex
- First and initial
- Appears at 3 months after birth
- Lasts up to 12 to 24 months of age
*disappearance of these reflexes is a measurement of nervous system mature
- beginning to walk will have a wide-based gait
- 4 years of age should be able to balance as one foot about 5 seconds

Initial Milestone- lifting of head

Final Milestone- walking

Inspection
- Level of consciousness (LOC)
- Awareness is determined by the patients orientation
- Person
- Place
- Time
- Ability to follow simple commands
- Grasp finger
- Smile

Normal Findings:
The patient is aware, alert, and responses appropriately to verbal and environmental stimuli
Vasomotor- the ability of the blood vessels to constrict and dilates
Cranial nerve III is the most important because it is an indicator of brain dysfunction
- Eye movement
- Constriction of the pupil
- Upward movement of the eye
The remaining 11 cranial nerves are not generally tested unless there is a specific reason to do so
Glasgow Coma Scale (GCS)
- Measure the level of consciousness
Location of the cranial nerves
Location Cranial Nerves
Anterior brain (Frontal) 1, 2
Midbrain 3, 4
Pons 5, 6, 7,8
Medulla Oblongata 9,10, 11, 12
12 cranial nerves are part of peripheral nervous system
Sensory Cranial Nerve
Contain only afferent (sensory fibers)
I Olfactory
II Optic
VIII Vestibulocochlear
Motor Cranial Nerves
Contain only efferent (motor Fibers)
III Oculomotor
IV Trochlear
VI Abducens
XI Accessory
XII Hypoglossal
Mixed
Contain both sensory and motor fibers
V Trigeminal
VII Facial
IX Glossopharyngeal
X Vagus

Cranial Nerve I OLFACTORY

- Sensory/Afferent
- Innervates the olfactory mucosa w/in the nasal cavity
- Origin: Cerebrum
- Responsible for the sense of smell
 - Smell is an important component of the appreciation of taste
- Sense of smell may lost as a result of:
- Trauma
- Infection
- Aging

*skull must contain:

- 80 % tissue
- 10 % blood
- 10 % CSF
*increased intracranial pressure if:
- Edema or cerebral aneurysm
- Brain tumor

- Asses the patency by occluding nostril

- Use familiar, convenient, obtainable & non noxious smell such as:
- coffee, toothpaste, orange, pepper mint
- Do not use alcohol wipes because it is irritating
- Normally, a person can identify odor both side
- Smell normally decreased bilaterally with aging

Cranial Nerve II OPTIC

- Sensory
- Carries visual impulses from the eyes to the brain

Cranial Nerve III OCULOMOTOR

- Motor
- Contracts the four extra-ocular muscles of the eye (superior, inferior, medial rectus and inferior oblique),
constricts pupils and elevates eyelids

Cranial Nerve IV TROCHLEAR

- Motor
- Superior oblique muscles

Cranial Nerve V TRIGEMINAL

 - Sensory & motor
- Origin: Pons
- Lateral jaw movements (biting & chewing)
- 3 branches or divisions:
- Ophthalmic- leaves through the superior orbital fissure
- Maxillary- through the foramen rotundum
- Mandibular- exits via foramen ovale
- The temporal & masseter muscles are examined by palpating the muscles and attempt to resist the jaw by
applying pressure
- Testing pain, thermal, and other sensations in the area supplied by the trigeminal nerve
- Test: Corneal reflex test, have the patient bite down when palpating the mandible & masseter
- Touch cornea with a wisp of cotton: patient should BLINK
- Test patient with an open paperclip, ask if it is sharp or dull

Cranial Nerve VI ABDUCENS

- Motor
- Functions: lateral eye movements (lateral rectus muscle)
- Ask the patient to look to the left and right without moving the head (6 cardinal position of gaze)

Cranial Nerve VII FACIAL NERVE

- Mixed
- Origin: Pons and Medulla
- Function: Once the facial nerve reaches the face, it enables many functions such as facial expression,
stimulates secretion of glands (salivary & lacrimal) and taste sensation (2/3 anterior tongue)
- Motor Function:
- Note mobility and facial symmetry as the person responds to these requests:
 Frown
 Close eyes tightly
 Lift eyebrows
 Show teeth
 Puff cheeks
- Sensory Function:
- Do not test routinely
 - Test only when suspected facial nerve injury
- When indicated, test sense of taste by applying to the tongue a cotton applicator covered with
solution of salt, sugar, lemon juice

Cranial Nerve VIII VESTIBULOCHLEAR

- Balance and hearing
- Semilunar canals- help maintain balance when turning, spinning and tumbling
- Utricle- maintain balance horizontally
- Saccule- maintain balance vertically

Cranial Nerve X GLOSSOPHARYNGEAL

- Sensory/motor
- Location: Medulla Oblongata
- Originates from brainstem leaves the skull through jugular foramen
- Function: Enables swallowing, salivation, taste sensation as well as visceral and general sensation
- Sensory fibers of the pharynx that results in gag reflex, promotes swallowing movements
- Taste from the 1/3 posterior of tongue
- Test: Perform gag reflex
- deviation: Nerve damage, dysphagia

CN 10: VAGUS NERVE

- Mixed
- Medulla Oblongata: Originates from multiple nuclei in brainstem
- Longest cranial nerve the only one to leave the head and neck region
- Carries sensations from the throat, larynx, heart, lungs, bronchi, GI tract, and abdominal viscera.
- Promotes swallowing, talking, and production of digestive juices
- Function: Controls gland secretion, peristalsis, phonation, taste, visceral and general sensation
- Sensory function:
- CNX, paralysis of CN10: SP does not rise
- Uvula moves to the side opposite to lesion when the patient says “AH”
- Normal findings: the uvula and the soft palate will rise as the patient say “AH”
- TONGUE
 - Should be at the midline
- Many functions such as: swallowing, speech, taste buds (papillae)
- Can also feel bones for you to not swallow it

Cranial Nerve XI SPINAL ACCESSORY

- Motor/Efferent
- Medulla Oblongata: Originating from the brainstem & Spinal Cord
- Function: Acting to enable phonation and movements of the head & shoulder
- Anterior Muscle
- SCM (R & L)
- Posterior Muscle
- Trapezius
- Ask the client to turn face and place hand on their face & there should be a resistance

Cranial Nerve XII HYPOGLOSSAL

- Motor/Efferent
- Medulla Oblongata: Anterior to the olive
- Function: Enables tongue movements
- Extremely important for daily functioning of person as it plays a significant role in important mouth
functions such as speech & swallowing

Proprioception
- Conscious perceptions of movements and spatial orientation arising from stimuli within the body itself.
Finger-to-Nose Test
- Motor and coordination
- Rapid alternating movements
- Fine motor control
Test for Coordination:
- Hand Flip Test
- Thumb-to Thumb Test
- Heel-to-Shin Test
Normal Findings:
Patients’ movement should be smooth, rapid and accurate

Altered Motor Response

- DYSDIADOCHOKINESIS- inability to perform rapid alternating movements
- Common to Multiple Sclerosis- the immune system attacks the protective sheath (myelin) that
covers nerve fibers and causes communication problems between your brain and the rest of
your body.

- DYSMETRIA- inability to perform point-to-point movements by over-or-under projections of the fingers (a

type of ATAXIA)
- Improper measuring of distance

Sensory
- Superficial pain
- Lightly with sharp or dull
- Bent paper clip
- Pen
- Broken tongue depressor or tongue blade
Light touch
- Cotton balls
- Cotton tip swab
*wait for 2 sec

ASTEREOGNOSIS
- Is the inability of the patient to recognized objects that are placed on the hands while the eyes are still
closed
- Tactile gnosis
KINESTHESIA
- Sensory
- Awareness of the position, direction and movement of the parts of the body
- Passively move the client’s toes or fingers to point in a certain direction

BALANCE AND EQUILIBRIUM

 - ROMBERG TEST
- Ask the patient to stand, close feet, hands on the side and close eyes for 30 sec
- Assessing the ability to maintain upright position of the body
- Positive Romberg:
- Cerebellum Ataxia- drunken walk
- Vestibular Dysfunction
- Sensory loss
- TANDEM GAIT
- Walk a straight line in a heel-to-heel fashion
- Decrease the base of support and will accentuate any problem with coordination
- Other Maneuver
- Stand with 1 foot only for 5 sec

PALPATION
- MOTOR ACTIVITY
- Ask the patient to squeeze your finger or extend your finger
- Asses:
- Ability to follow commands
- Symmetry of the motor activity
- Muscle strength

DEEP TENDON REFLEX

- Biceps
- Triceps
- Brachioradialis
- Patellar
- Achilles
SUPERFICIAL TENDON REFLEX
- Plantar Reflex/ Babinski
- Abdominal Reflex
- Crematic Reflex
TENDON- a fibrous connective tissue which attaches muscle to bone. It serves to move the bone or structure.
LIGAMENTS- connect one bone to bone

REFLEXES
- Vital defense mechanism
- Immediate response to alert and protect
- Ex: gag reflex, coughing, blinking, sneezing
DEEP TENDON REFLEXES
BRACHIORADIALIS
- Elbow reflexion
- Flexion and supination of the forearm
- “Golfer’s Elbow”
- Antecubital Fossa- triangular depression that lines in front of the elbow for catheter insertion

PATELLAR REFLEX
- Leg extension
- Quadriceps muscles (rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius)
*Vastus medialis and Vastus Femoris are good site of injections for infants
- Striking of the patellar tendon with a reflex hammer just below the patella
- Response: sudden kicking movement

AREFLEXIA
- No reflexes in the body common to neurological disorders

ACHILLES REFLEX
- Located directly behind the ankles
- Feet are plantar flexed (normal)
- Striking the Achilles tendon causes contraction of the gastrocnemius muscle resulting in plantar flexion of
the foot

ANKLES CLONUS
- Hyperactive reflexes
- Repeated contraction of the reflex
 - Normal: no rapid contraction
- Rapidly flexing the foot into dorsiflexion (upward)

Scale Interpretation
0 Absent response
+1 Weak response
+2 Expected (normal) response
+3 Hyperactive response
+4 Hyperactive response with clonus

SUPERFICIAL
PLATAR REFLEX/ BABINSKI
- Normal reflexes in infants
- Positive Babinski when there is extension of the big toe while fanning of the others (plantar response)
- Assessing the spinal nerves
- T12, L1 & L2
- Stroking the lateral side of the foot from heel

ABDOMINAL REFLEX
- Assessing the spinal nerves T8,T9,T10 (above umbilicus), T10, T 11, T12 (below umbilicus)
- When stroking the skin of the abdomen causes the underlying abdominal wall muscle to contract,
sometimes pulling the umbilicus toward the stimulus.

CREMASTERIC REFLEX
Found in males
- Cold temperature and anxiety are two factors
- Lightly stroking or poking the superior and medial (inner) part of the thigh—regardless of the direction of
stroke.
- Normal response is an immediate contraction of the cremaster muscle that pulls up the testis ipsilaterally