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? Review of Anatomy & Physiology
? Assessment
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? ahe 2 main components of the nervous system:


J CNS & PNS
? CNS - consists of
J ahe brain and the spinal cord
? PNS - consists of
J 12 pairs of CN
J Spinal nerves
J Sympathetic & Parasympathetic NS
J autonomic NS
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? ½eight = 1.3 kg (3 lbs)

? ahere are two main types


of brain cells:
J neurons and
neuroglia..
neuroglia

J Contains
approximately more
than 20 billion nerve
cells, or Neurons
? ©ach neuron is composed of a cell body
called a soma
soma,,
? a major fiber called an axon
axon,,
? and a system of branches called
dendrites..
dendrites
? Axons, also called nerve fibers, are
covered with myelin, a protective
sheath of substance made of fats and
protein which serves as insulation
? Neuroglial cells are twice as numerous
as neurons and account for half of the
brain's weight. Neuroglia (from  
îreek for ´glueµ) provide structural
support to the neurons
Structures
Protecting the
Brain
ahe brain is contained
in the rigid skull.
Protective membranes
between the brain
and the cranium
Meninges
Layers:
ΠDura mater
ΠArachnoid
mater
ΠPia mater
Cerebrospinal
fluid A clear
liquid that
bathes the
entire brain
and fills a
series of four
cavities, called
ventricles..
ventricles
Approximately
500ml
500 ml of CSF is
produced each
day..
day
ahe BRAIN, Anatomy & Physiology
? From the outside, the brain appears as three
distinct but connected parts:

1. Cerebrum (the Latin word for brain)


J ahe 2 major subdivision which makes up approx.
85 % of the brain·s weight is known as
hemispheres
J ahe exterior surface of the cerebrum, the cerebral
cortex,, is a convoluted, or folded, grayish layer of
cortex
cell bodies known as the gray matter.
matter.
J ahis covers an underlying mass of fibers called
the white matter.
ahe Cerebrum is composed of two
large, almost symmetrical
hemispheres known as:
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ahe convolutions are
made up of ridgelike
bulges, known as gyri
separated by small grooves
called sulci and larger
grooves called Fissures
Fissures..
—     
  

       
   —
? ahe central sulcus, or Rolandic fissure
fissure,, runs
from the middle of the top of each hemisphere
downward, forward, and toward another
major sulcus, the lateral (´sideµ), or Sylvian
sulcus.. ahese and other sulci and gyri divide
sulcus
the cerebrum into four lobes
lobes::
? Frontal-      
Frontal-  
  
     
   
  
   
      
? Parietal--
Parietal        

         

          
          
           
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2. Cerebellum
J coordinates body movements
J maintains posture and balance by
controlling muscle tone and sensing
the position of the limbs.
3. Brain Stem
J regulates breathing and blood pressure.
pressure.
J It includes three main structures lying
between and below the two cerebral
hemispheres
Πthe midbrain
midbrain,,
Πpons
pons,, and
Πmedulla oblongata
oblongata..
? Running up the brain stem from the medulla
oblongata through the pons and the midbrain is
a netlike formation of nuclei known as the
J reticular formation
formation..
Πcontrols respiration, cardiovascular
function, digestion, levels of alertness, and
patterns of sleep«
sleep«
Cranial
Nerves
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IX îlossopharyngeal
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XI Spinal   a 
 
 

 
XII Hypo ² Hypoglossal 
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? ahe brain is guarded by several highly


developed protective mechanisms.
mechanisms.
J ahe bony cranium
cranium,,
J the surrounding meninges
meninges,, and
J the cerebrospinal fluid (CSF
CSF))
? In addition, a filtration system called
J the blood
blood--brain barrier protects the brain
from exposure to potentially harmful
substances carried in the bloodstream
bloodstream..
CRANIAL CONa©NaS
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Consciousness

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Consciousn
ess
Consciousness
state of awareness of self &
environment
1st and most sensitive indicator of
neurologic change U 

  
  
 2 Components:   
 
 Awareness / Content (cognition &
affect)
  
? cerebral cortex
   
  
orientation (3 spheres: aPP)
Rattention span
 
Rlanguage 
   !
Rmemory " 



 Arousal (appearance of  


wakefulness)   
   
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? Description

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? FORMS OF
SaIM LI

ü©RBAL
üOIC© LOC
SHO a
üerbal aactile
aACaIL© Pain
aO CH Conscious (+) (+) (+)
aAP/ SHAK©
Lethargic (+) (+) (+) *
PAIN Stuporous ( -) ( -) (+)
S P©RFICIAL
D©©P
Comatose ( -) ( -) ((--)
Ê  

ù NAIL B©D COMPR©SSION


ù fine pressure with thumb
over pencil on the base of
the cuticle
ù aest bilaterally
ù N=(+)Crushing pain

ù Sa©RNAL R B ù 23 )45. 6.))4)


ù DSP ù  "  ! 7 
 7 "  " 

ù use knuckle over sternum ! " 
as if ´grinding a pillµ for 5
sec. ù . 232538 2) .2)
ù N=20--30 sec. Posturing
N=20 ù  " 
(initial reaction) ù p 59 p

ù ½ait for at least 30 seconds
Oxygenation

Assess respiratory status.

Maintain patent airway & adequate


ventilation.

½atch for S/S of hypoxia & hypercapnia«


? Note for S/S of Hypoxia/
hypoxemia

  

? (-) Spontaneous respiration


? Restlessness/ irritability
? Peripheral cyanosis
? se of accessory muscles of
respiration
? Ala Nase flaring
? Angina
? aachycardia
? aachypnea
? îIa/ Renal Dysfunction (Late sx)
? Dx/ Lab results:
ΠPulse Oximetry
ΠCapnography
Œ ABî
Œ Hematology (hct; hgb)«
Motor
Function

Assess integration of consciousness


& voluntary movement.
Look for purposeful or non-
non-
purposeful response.
Also assess muscle tone, size,
strength.
Observe for symmetric,
spontaneous movement of arms &
legs«
Abn=
tics, tremors
= stress, long term use of
psychotropic drugs, neurologic
disorders (Parkinson·s, MS, or
HC)

atrophy, paresis, plegia, M SCL© SaR©NîaH


flaccidity, spasticity, rigidity = îRADINî
motor neuron or muscle
disease îrade Description

unresponsive clients 0 No contraction


Jhemiplegia - corticospinal
1 Slight contraction
tract damage
2 Full passive ROM
Jdecorticate - upper
3 Full ROM
corticospinal tract
damage 4 Full ROM against
some resistance
Jdecerebrate ² brainstem

damage 5 Full ROM against


full resistance
Pupils

        2

!   


Ê
 
? Controlled by:
J CN
CN--III
J Brainstem

J Midbrain

? Pupillary
Assessment
J Size

J Reaction

J Shape
Ê
   

´ N=1.5--6mm (3.5
1.5
avg.)
J Anisocoria

J N=17%;

J Abn=Herniation
Abn=Herniation
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ΠDirect Consensual Light -
response "#!"
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? Abn=oval ² Õ ICP (15-


Abn=oval (15-20mmHg)
 post frontal / anterior temporal
lesions
 Contusions«
Ocular
Movement

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J Pons

J Medulla

? îag/ Cough
J Medulla

J CN IX

J CN X«
©mergen
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ù Ask to count
backward from 100,
subtracting by seven
each time (µ100, 93,
86«µ).

ù N=Can count back


into the 50s within
one minute«
Memory
? aest for short-
short-term
memory

ù Name 3 unrelated
objects (e.g. car, garbage
can, alarm clock) then
ask for these words
?
again for within a few

minutes

ù !&0 0
 

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Logic, Judgment, Reasoning &
decision--making ability
decision
ù aest for Logic & Judgment

ù Ask ´½hat would you do if you were inside a burning


building?µ
ù N=sound judgment.
ù Abn=Frontal Lobe damage, dementia, psychosis,
mental retardation.

ù aest for reasoning & decision-


decision-making ability
answering questions appropriately

ù Ask the meaning of a proverb such as ´A stitch in time


saves nine.µ
ù Abn=low intellect, dementia, schizophrenia«
©motional Stability, Speech &
Language
ù 
   
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Cerebellar function
îait

ßAsk to walk a straight heel-


heel-to-
to-toe line.
J Abn=staggering, shuffling, tiptoe walking,

foot slap, leg drag.


J ncoordinated gait & loss of balance =
Πmotor, sensory, vestibular or cerebellar
dysfunction.
J Cerebellar ataxia ² unsteady gait with legs

spread wide.
J Scissors gait ² short, stiff steps with thighs

overlapping.
J Foot drop - lifts knee high then slaps foot

down
J Parkinsonian shuffle ² accompanied by

stooped posture
Spastic paralysis - arms flexed & held to the
Cerebellar function

Balance
? Romberg·s test
J arms at sides, feet together,
J eyes closed for 20 seconds.
J ½atch for loss of balance.
J Stand close enough to prevent falling.
ΠN=slight swaying.
ΠAbn
J loss of balance
J (+) Romberg
Πcerebellar ataxia, alcohol intoxication, MS,
impaired visual functioning, or loss of
proprioception.

? aest for coordination, muscle strength, & cerebellar


function
J Ask to stand on 1 foot & do a shallow knee-
knee-bend, or hop,.
Cerebellar function
#   

 
 


  
   = $

? Rapid Alternating Movement (RAM) of the hands & fingers -


J assesses coordination & dexterity. Pat knees with the
palms, then flip & do so with the back of the hands, first
slowly then faster.
J N=smooth & bilateral movement

J Abn=slow, awkward movement= cerebellar

dysfunction

? Ask to touch thumb to each finger from index to 5th


finger & back again, slowly at first then faster. Repeat on the
other hand. Abn=Dyssenergy (lack of
coordinated muscle movement) =upper neuron weakness,
cerebellar disease, ©P dysfunction.

? Finger-to
Finger-to--nose coordination test
J Ask to touch index finger to nose then to the examiner·s
outstretched vertical finger to different points.
ΠAbn=Dyssnergy, Dysmetria (misjudgment of distance,
speed & force of movement = cerebellar dysfunction«
Sensory function
ß Superficial Pain & aouch Sensation
J test distal points on arms & legs

J ©yes closed.

J ©xamine Arms, Legs & Abdomen.


J Assess sensitivity to light touch with a wisp of cotton

(distal to proximal).
J Ask to say ´nowµ when each sensation is felt.

ΠSharp object (opened paper clip). Ask whether she


feels a sharp or dull sensation.

aemperature sensitivity
- 2 test tubes (1 filled with hot & 1 with cold
water, along the same routes.
Abn=Peripheral nerve problem: paresthesia &
impairment in touch sensation (Anesthesia,
Hypoanesthesia).

Pain sensitivity ² analgesia, hypalgesia,


hyperalgesia«
Proprioception, üibratory
sensation
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? üibratory sensation   
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  2   & &
? :
Cortical sensation
(stereognosis, graphesthesia, 2- 2-point
? Stereognosisdiscrimination)
² recognizing objects by feel.
J ©yes closed. Identify familiar objects (e.g. key). Repeat on
other hand with different object.
ΠAbn=Astereognosis = parietal lobe problems

? îraphesthesia ² identify shapes, numbers, or letters traced


on the skin.
J ©yes closed. se blunt object such as closed paper clip to
draw shape, letter or number on the palm. Repeat on the
other palm.
Œ Abn=îraphanesthesia = parietal lobe problems.

? 2-point discrimination ² touching 2 identical sharp objects


(e.g. Opened paper clips) to the skin in close proximity,
while eyes closed.
J Ask whether she feels 1 or 2 points, noting distance
between 2 points. Repeat test on arms, legs, face &
abdomen, decreasing the actual distance between the
points until client feels 2 points as one.
Superficial /Cutaneous Reflexes
Abdominal, Plantar
? Abdominal Reflex
J a8--a10 spinal nerves - controls upper abdominal muscles
a8
J a10--a12 ² lower abdominals
a10
ΠDorsal Recumbent.
ΠBlunt tipped object (cotton swab).
ΠScratch each abdominal quadrant lightly (lateral to
midline, high to low)
J N=muscle contraction & slight shift of umbilicus

towards the stimulus.


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Superficial /Cutaneous Reflexes
Cremasteric, Anal

? Cremasteric Reflex
 a12 ² L2
 For genitourinary complaints only in men.
 Lightly stroke the inner thigh
ΠN=scrotal elevation on the stimulated side

? Anal Reflex
 S3
S3--S5
 îently touching around the anus with a cotton swab
or gloved finger
Œ N=contraction of rectal sphincter«
Deep aendon Reflexes
Biceps, ariceps, Patellar, Achilles,
Brachioradialis
? Requires practice & a relaxed client.
Sitting with feet dangling. ©asier if used
with distractions.
? Pointed hammer ² small tendons
? Flat end ² larger tendons
? Compare bilateral responses
DaR îRADINî
? If any of the DaRs are hyperactive = test
for ankle clonus(rhythmic contraction).
? Lift 1 of the client·s legs & support the DaR îRAD© Response
flexed knee with non-
non-dominant hand.
îrasp the foot & quickly dorsiflex the 0 Absent reflex
toes.
1+ Diminished
J N=(-)Pain & involuntary movement
N=(- 2+ Normal
J Abn= Clonus=motor neuron 3+ Slightly
dysfunction increased
4+ Hyperactive
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