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Central Nervous System

Encompasses the brain and spinal cord Covered by meninges, three layers of connective tissue that protect and nourish the CNS

Peripheral Nervous System

Carrying information to and from the CNS Consist of 12 pairs of cranial nerves and 31 pairs of spinal nerves

Autonomic Nervous System

Maintains the internal homeostasis of the body Incorporates the sympathetic and parasympathetic nervous system

The Frontal Lobe

the most recent evolutionary addition to the brain. White House of the brain. true center for command and control in your body responsible for functions such as reasoning, problem solving, judgement, impulse control.

The Occipital Lobe


controls visual sensation and processing. The Visual Cortex is resides here.

The Parietal Lobe


involved in processing pain and touch sensation. It's where the Somatosensory (from your skin and internal organs) Cortex resides. associated with cognition (including calculating location and speed of objects), movement, orientation, recognition and speech.

The Temporal Lobe

involved in auditory (sound) sensation and is where the Primary Auditory Cortex and on the left hemisphere, Wernicke's Area (language recognition) are located. also involved in emotion, memory and speech.

Broca's Area

part of the cortex controls speech, language recognition and facial nerves.

The Corpus Callosum  the neural bridge that connects the two hemispheres to each other, located centrally in brain. The Medulla Oblongata  Helps control the body's autonomic functions (things you don't need to think about to perform) like respiration, digestion and heart rate.  acts as a relay station for nerve signals going to/from the brain

The Pons

Has roles in your level of arousal or conciousness and sleep. Relays sensory information to/from the brain. involved in controlling autonomic body functions.

The Cerebellum

Mostly deals with movement. It regulates and coordinates movement, posture and balance. involved in learning movement.


This is the infomation superhighway of the body. It carries information up to the brain and instructions back down.

Cranial Nerve Olfactory (I)

Fibres Sensory

Origin: mucosa of the nasal cavity. Terminates: olfactory bulb. Origin: retina of the eyeball. Terminates: lateral geniculate body of the thalamus. Origin: midbrain. Terminates: extrinsic muscles of the eye.

y Smell.

Optic (II)



Oculomotor (III) Predominantly motor

yExtrinsic muscles of the eyeball (superior, medial and inferior rectus and inferior oblique and levator palpebrae superioris). yParasympathetic: intrinsic muscles of the eyeball (sphincter of the pupil and the ciliary muscle of the lens).

Trochlear (IV)

Predominantly Motor

Origin: midbrain Terminates: extrinsic muscle of the eye.

yExtrinsic muscle of the eyeball (superior oblique).

Trigeminal (V)


Origin: middle and upper face and the pons. Terminates: pons and the muscles of mastication.

Sensory (ophthalmic, maxillary and mandibular nerves): scalp, face and mouth. Motor (mandibular nerve): muscles of mastication (chewing) and soft palate and the middle ear.

Abducens (VI)


Origin: pons. Terminates: extrinsic muscle of the eye.

yExtrinsic muscle of the eyeball (lateral rectus).

Facial (VII)


Origin: taste buds and pons. Terminates: thalamus and muscles of facial expression and salivary glands.

Sensory: taste, external ear and palate. Motor (temporal, zygomatic, buccal, mandibular and cervical nerves): muscles of facial expression and middle ear. Parasympathetic: salivary and lacrimal glands.

Vestibulocochl ear (VIII)

Predominantly sensory

Origin: cochlear and semicircular canals of the inner ear. Terminates: pons and medulla oblongata. Origin: pharynx, middle ear and tongue and the medulla oblongata. Terminates: medulla oblongata, parotid gland and pharynx.

Hearing Balance
Sensory: taste, tongue, pharynx, tonsils and middle ear. Motor: muscles of the pharynx (swallowing). Parasympathetic: parotid gland.

Glossopharyng Mixed eal (IX)

Vagus (X)


Origin: viscera, tongue, pharynx and larynx; medulla oblongata. Terminates: medulla oblongata; viscera, tongue, pharynx and larynx.

Sensory: pharynx, larynx, thoracic and abdominal organs and taste. Motor: soft palate, pharynx, intrinsic laryngeal muscles (voice) and extrinsic tongue muscle. Parasympathetic: to the thoracic and abdominal viscera digestive tract, heart and lungs, kidneys, spleen liver and pancreas. Neck muscles (sternocleidomastoid and trapezius). Muscles of swallowing (pharynx and soft palate).
yExtrinsic and intrinsic muscles of the tongue and hyoid muscles.

Accessory (XI)


Origin: medulla oblongata Terminates: muscles of the neck and swallowing Origin: medulla oblongata Terminates: tongue and hyoid muscles.

Hypoglossal (XII)


SPINAL NERVES  Comprising 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal nerves  Each nerve is attached to the spinal cord by two nerve roots.

Organized into 6 major areas:  Mental Status provide information about cerebral cortex function ( abnormalities = intellectual, communication and emotional abilities are affected)  Cranial Nerves provides information regarding the transmission of motor and sensory messages.  Motor & Cerebellar System to determine the functioning of he pyramidal and extrapyramidal tracts. Cerebellar system is assessed to determine the clients level of balance and coordination.  Sensory System provides information regarding the integrity of the spinothalamic tract, posterior columns of the spinal cord and the parietal lobes of the brain.  Reflexes -provides clues of the integrity of the deep and superficial reflexes.

Assessment procedure a. Observe level of conscious ness b. Observe posture and body movement c. Observe dress, grooming, and hygiene d. Observe facial expression e. Observe speech f. Observe mood, feelings and expression g. Observe thought processes and perception s

Normal Findings alert; GCS score 14-15

Abnormal Findings lethargic, obtunded, stupor, coma

Relaxed with shoulders and back erect when standing or sitting

Slumped posture,mania=prolonged euphoric laughing, bizarre body movements=schizophrenia

Clean, appropriate for weather

OCD=meticulous grooming; depression & schizophrenia= poor grooming inappropriate clothes;

Good eye contact, smiles and frowns appropriately Moderate tone, clear and with moderate pace Cooperative, expresses feelings appropriately, verbalizes positive feelings

Poor eye contact, extreme facial expression, mask- like= parkinsons dse Slow repetitive speech=depression/ parkinsons; loud rapid speech=manic phases of bipolar d/o Prolonged negative, gloomy, despairing feelings; elation and grandiosity; high energy level; excessive worry; eccentric moods not appropriate to the situation.

Expresses free-flowing thoughts; follows directions appropriately; expresses realistic perception; easy to understand, does not voice suicidal thoughts

Persistent repetition of ideas, illogical thoughts, interruption of ideas; invention of words; rapid flight of ideas

h. Observe cognitive abilities: orientation, concentration, abstract reasoning, judgment, visual perceptual and constructional ability.

Aware of self, others ,time, home address, and current location; listens and can follow directions without difficulty; Recent memory= recalls recent events without difficulty; remote memory= correctly recalls past events Abstract reasoning: explains similarities and differences of 2 objects. Judgment: answers to questions are based on sound rationale

Reduced degree of orientation, hallucinations, distraction and inability to focus, inability to recall recent events or past events; inability o compare and contrast objects, impaired judgment

Cranial Nerve I (Olfactory)

After assessing patency of both nares, have client close eyes, obstruct one nare, and sniff. Use common, easily identifiable substances such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Use different substances for each side. Bilateral decreased sense of smell occurs with age, tobacco smoking, allergic rhinitis, cocaine use. Unilateral loss of sense of smell (neurologic anosmia) can indicate a frontal lobe lesion.

Cranial Nerve II (Optic)

Check visual acuity (have the patient read newspaper print) and visual fields for each eye. Unilateral blindness can indicate a lesion or pressure in the globe or optic nerve. Loss of the same half of the visual field in both eyes (homonymous hemianopsia) can indicate a lesion of the opposite side optic tract as in a CVA.

Cranial Nerve III (Oculomotor)

Assess pupil size and light reflex. A unilaterally dilated pupil with unilateral absent light reflex and/or if the eye will not turn upwards could indicate an internal carotid aneurysm or uncal herniation with increased intracranial pressure.

Cranial Nerve IV (Trochlear) and Cranial Nerve VI (Abducens) Have patient turn eyes downward, temporally, and nasally. If the eyes will not do this the patient may have a fracture of the eye orbit or a brain stem tumor. (Note: Cranial Nerves III, IV, and VI are examined together because they control eyelid elevation, eye movement, and pupillary constriction.) Cranial Nerve V (Trigeminal) Motor Palpate jaws and temples while patient clenches teeth. Sensory Have patient close eyes, touch cotton ball to all areas of face. Unilateral deficit seen with trauma and tumors. Cranial Nerve VII (Facial) Check symmetry and mobility of face by having patient frown, close eyes, lift eyebrows, and puff cheeks. Sensory Asses the patients ability to identify taste (sugar, salt, lemon juice)An asymmetrical deficit can be found in trauma, Bells palsy, CVA, tumor, and inflammation.

Cranial Nerve VIII (Acoustic or Vestibulocochlear)

This tests hearing acuity. Impairment indicates inflammation or occlusion of the ear canal, drug toxicity, or a possible tumor.

Cranial Nerve IX (Glossopharyngeal) and X (Vagus)

Depress the tongue with a tongue blade and have the patient say ahh or yawn. Uvula and soft palate should rise. Gag reflex should be present and the voice should sound smooth. Deficits can indicate a brain stem tumor or neck injury.

Cranial Nerve XI (Spinal Accessory)

Have the patient rotate the head and shrug shoulders against resistance. If the patient is unable to do this it may indicate a neck injury.

Cranial Nerve XII (Hypoglossal)

Assess tongue control. Wasting of the tongue, deviation to one side, tremors, and an inability to distinctly say l,t,d,n sounds can indicate a lower or upper motor neuron lesion.

bedside neurologic assessment almost always includes an evaluation of motor function.


you'll be assessing the ability to move on command, the patient must be awake, willing to cooperate, and able to understand what you are asking her.

With the patient in bed, assess motor strength bilaterally: Have the patient flex and extend her arm against your hand, squeeze your fingers, lift her leg while you press down on her thigh, hold her leg straight and lift it against gravity, and flex and extend her foot against your hand. Grade each extremity using a motor scale like the one below. +5 - full ROM, full strength +4 - full ROM, less than normal strength +3 - can raise extremity but not against resistance +2 - can move extremity but not lift it +1 - slight movement 0 - no movement

As part of the motor assessment, also check for arm pronation or drift. Have the patient hold her arms out in front of her with her palms facing the ceiling. If you observe pronationa turning inwardof the palm or the arm or the arm drifts downward, it means the limb is weak. Assess motor response in an unconscious patient by applying a noxious stimulus and observing the patient's response to it. Another approach is central stimulation, such as sternal pressure. Central stimulation produces an overall body response and is more reliable than peripheral stimulation for this purpose. The reason: In an unconscious patient, peripheral stimulation, such as nail bed pressure, can elicit a reflex response, which is not a true indicator of motor activity.

you use central stimulation, however, do so judiciously because deep sternal pressure can easily bruise the soft tissue above the sternum. We can also squeeze the trapezius muscle because it's less traumatic. Supraorbital pressure is another option for central stimulation. Don't, however, use it on patients with facial fractures or vagal nerve sensitivity.


sensory exam evaluates the patient's ability, to perceive and identify specific sensations with her eyes closed. Include it in your neuro assessment if there's a specific need, as in spinal cord injury. The patient must be able to cooperate with the exam. She'll need to tell you whether she feels the sensation and whether both sides of her body feel it equally.

Begin with the feet and move up the body to the face, comparing one side with the other. Assess sensation to light touch using your fingertips or cotton. Test superficial pain sensation with a clean, unused safety pin. Be sure not to break the skin, and discard the pin appropriately after you've finished using it on the patient. If you prefer to use something less invasive, snap a wooden, cotton-tipped swab in two and use one of the broken ends; again, take care not to scratch or puncture the skin. Also, test sensation using a dull object. The patient should be able to distinguish sharp from dull. If you need to test temperature sensation, you can use a specimen tube of ice or cold water or the chilled handle of a reflex hammer. To test vibratory sensation, use a tuning fork.

Test proprioception, or position sense, by moving the patient's toes and fingers up or down. Grasp the digit by its sides and have the patient tell you which way it's pointing. Remember, guessing will yield correct answers 50% of the time. Move on to the cerebellar assessment, if indicated. It may not be necessary in a problem-focused exam, and it can't be done if the patient can't or won't follow commands. If the patient is in bed, you may not be expected to assess her balance and gait. In that case, limiting testing to coordination is acceptable. Hold up your finger and have the patient quickly and repeatedly move her finger back and forth from your finger to her nose. Then have her alternately touch her nose with her right and left index fingers. Finally, have her repeat these tasks with her eyes closed. The movements should be precise and smooth.

To assess the lower extremities, have the patient bend her leg and slide that heel along the opposite shin, from the knee to the ankle. This movement, too, should be accurate, smooth, and without tremors. If the patient is able to stand and she's not restricted to bed, you can assess her balance using the Romberg test. Have her stand with her feet together, arms at her sides, and eyes open; she should be able to stand upright with no swaying. If she can do that, have her close her eyes and stand the same way. If she falls or breaks her stance after closing her eyes, the Romberg test is positive, indicating proprioceptive or vestibular dysfunction.

Reflex assessment encompasses deep tendon, superficial, and brain stem reflexes. Deep tendon reflexes include the triceps, biceps, brachioradialis, patellar, and the Achilles tendon. Although deep tendon reflexes aren't routinely assessed, they should be tested in any patient with a spinal cord injury. The plantar reflex is the only superficial reflex that's commonly assessed and should be tested in comatose patients and in those with suspected injury to the lumbar 4 5 or sacral 1 2 areas of the spinal cord. Stimulate the sole of the foot with a tongue blade or the handle of a reflex hammer. Begin at the heel and move up the foot, in a continuous motion, along the outer aspect of the sole and then across the ball to the base of the big toe.

The normal response is plantar flexion (curling under) of the toes. Extension of the big toe Babinski's signis abnormal, except in children younger than 2 years. Assess brain stem reflexes in stuporous or comatose patients to determine if the brain stem is intact. (You'll check for the protective reflexescoughing, gagging, and the corneal responseas part of the cranial nerve assessment.) To test the oculocephalic, or doll's eye, reflex, turn the patient's head briskly from side to side; the eyes should move to the left while the head is turned to the right, and vice versa. If this reflex is absent, there will be no eye movement.


test the oculovestibular reflex, also known as the ice caloric or cold caloric reflex, a physician will instill at least 20 ml of ice water into the patient's ear. In patients with an intact brain stem, the eyes will move laterally toward the affected ear. In patients with severe brain stem injury, the gaze will remain at midline.

Disorder caused by damage to the parts of the brain that control language. It can make it hard for you to read, write and say what you mean to say.


aphasia you know what you want to say, but you have trouble saying or writing what you mean Receptive aphasia you hear the voice or see the print, but you can't make sense of the words Anomic aphasia you have trouble using the correct word for objects, places or events Global aphasia you can't speak, understand speech, read or write

stroke Brain tumors infections injuries dementia

Speech Fluency, vocal quality, and loudness How clearly the person speaks Strength and coordination of the speech muscles (tongue, lips)


Understanding and use of vocabulary (semantics) and grammar (syntax) Understanding and answering both yes-no (e.g., Is your name Bob?) and Wh-questions (e.g., What do you do with a hammer?) Understanding extended speech-the person listens to a short story or factual passage and answers fact-based (the answers are in the passage) and inferential (the patient must arrive at a conclusion based on information gathered from the reading) questions about the material Ability to follow directions that increase in both length and complexity Ability to tell an extended story (language sample) both verbally and in written form

Expressing Can the person tell the steps needed to complete a task or can he or she tell a story, centering on a topic and chaining a sequence of events together? Can he or she describe the "plot" in an action picture? Is his or her narrative coherent or is it difficult to follow? Can the person recall the words he or she needs to express ideas? Is the person expressing himself or herself in complete sentences, telegraphic sentences or phrases, or single words?

Social Communication Social communication skills (pragmatic language) Ability to interpret or explain jokes, sarcastic comments, absurdities in stories or pictures (e.g., What is strange about a person using an umbrella on a sunny day?) Ability to initiate conversation, take turns during a discussion, and express thoughts clearly using a variety of words and sentences Ability to clarify or restate when his or her conversational partner does not understand

Reading and Writing Reading and writing of letters, words, phrases, sentences, and paragraphs Other Swallowing (as needed) Ability to use an augmentative or alternative communication aid (as needed)

Neurological disorder that is characterized by a constellation of symptoms that suggests the presence of a lesion in a particular area of the brain. It is named after Josef Gerstmann


associated with brain lesions in the dominant (usually left) hemisphere including the angulrar and supramarginal gyrinnear the temporal and parietal lobe junction. occur after a stroke or in association with damage to the parietal lob Brain damage

Dysgraphia/agraphia: deficiency

in the

ability to write Dyscalculia/acalculia: difficulty in learning or comprehending mathematics Finger agnosia: inability to distinguish the fingers on the hand Left-right disorientation

Ask the patient to perform simple calculations with pen and paper. Serial 7s is to take 7 from 100, then 7 from the answer and so forth. Finger agnosia - Ask the patient to name his or her fingers and/or examiner's fingers; inability to do so is called finger agnosia.

Ask the patient to write; inability is called agraphia. L-R confusion Test for left-right confusion is to ask the patient to show his or her right and then left hand. If this is correctly performed, then further ask the patient to touch his or her left ear with the right hand and vice versa. Inability to do this is called left-right disorientation if the right hand is affected.

a perceptual disorder in which sensation is preserved but the ability to recognize a stimulus or know its meaning is lost. Agnosia means without knowledge
- is

Agnosia results from lesions that disconnect and isolate visual, auditory and somatosensory input from higher level processing

VISUAL AGNOSIA -"Apperceptive visual agnosia" refers to a disturbance in perceptual and visual-motor integration, such that patients have difficulty copying or matching various objects. This latter form of agnosia has been associated with lesions to the parietal occipital cortex as well as to bilateral damage to the inferior-occipital cortex -"associative visual agnosia," is due to disconnection from the language area, such that auditory equivalents (or the names of) visual items cannot be matched to a visual perception. This is usually associated with left inferior and middle temporal occipital abnormalities, and to lesions to and atrophy of the parietal occipital cortex.

AGNOSIA- Auditory agnosics fail to ascribe values to verbal or non-verbal sounds. TACTILE AGNOSIA - Tactile agnosia, also called astereognosis, is often difficult to recognize as we rarely identify objects solely by feel. Information about the object, including its weight, size, and texture are not given any value.


neurological disorders

Lobe focal, occurring personality disorders, disorder

effects, motor system dysfunction, seizures, aphasia. In the occipital lobe, visual disturbances occur and can not recognize or name or anything visible. In the temporal lobe, auditory hallucinations are common. In the parietal lobe, can be found the inability to distinguish left and right, personality changes The decline in memory, decreased ability to make decisions.

Basis of assessment data

Activity Inability to mention again what is seen Impaired motor skills The inability to do things that have been done before. Ego integrity Misperceptions of the environment Misidentification of the object Changes in body image and self-perceived Hygiene
Need help / depend on others.

Neuro Sensory
Denial of symptoms that are primarily cognitive

change and or a blurred picture. Decrease in ability, cognitive remember the new passes. Decrease in communication, difficulty in determining the correct words. Asked repeatedly by substance word has no meaning. Lose the ability to read or write. Difficulties in the complex and abstract thinking. Impaired memory Visual changes Ability to calculate simple

High risk of injury

Social interaction
Feeling lost power Loss of social control

Food / fluid
Changes in taste Decreased appetite Weight loss



The main complaint : Loss of perception History of present illness : Memory loss,

impaired perception Past history of disease : History had suffered head trauma, stroke Family history of disease : Families may be suffering from a tumor

disorder caused by damage to specific areas of the cerebrum. It is characterized by loss of the ability to execute or carry out learned purposeful movements despite having the desire and the physical ability to perform the movements. It is a disorder of motor planning, which may be acquired or developmental, but may not be caused by incoordination, sensory loss, or failure to comprehend simple commands

Buccofacial or orofacial apraxia: Cannot carry out movements of the face on demand, such as licking the lips, sticking out the tongue, or whistling. Ideational apraxia: Cannnot carry out learned complex tasks in the proper order, such as putting on socks before putting on shoes. Ideomotor apraxia: Cannot voluntarily perform a learned task when given the necessary objects. For instance, if given a screwdriver, the person may try to write with it as if it were a pen. Limb-kinetic apraxia: This condition involves difficulty making precise movements with an arm or leg.

tumor Condition that causes gradual worsening of the brain and nervous system (neurodegenerative illness) Dementia Stroke Traumatic brain injury

An oral-motor assessment involves: checking for signs of weakness or low muscle tone in the lips, jaw, and tongue, called dysarthria. seeing how well the child can coordinate the movement of the mouth by having him or her imitate nonspeech actions (e.g., moving the tongue from side to side, smiling, frowning, puckering the lips) evaluating the coordination and sequencing of muscle movements for speech while the child performs tasks such as the diadochokinetic rate, which requires the child to repeat strings of sounds (e.g., puh-tuh-kuh) as fast as possible examining rote abilities by testing the child's skills in functional or "real-life" situations (e.g., licking a lollipop) and comparing this to skills in nonfunctional or "pretend" situations (e.g., pretending to lick a lollipop)

A melody of speech (intonation) assessment involves: listening to the child to make sure that he or she is able to appropriately stress syllables in words and words in sentences determining whether the child can use pitch and pauses to mark different types of sentences (e.g., questions vs. statements) and to mark off different portions of the sentence (e.g., to pause between phrases, not in the middle of them)

A speech sound (pronunciation of sounds in words) assessment involves: Evaluating both vowel and consonant sounds Checking how well the child says individual sounds and sound combinations (syllables and word shapes) Determining how well others can understand the child when they use single words, phrases, and conversational speech.