Denise Coffey MSN, RN

Central Nervous System (CNS) Cerebral cortex

Frontal lobe Parietal lobe Occipital lobe Wernicke’s area Broca’s area

Basal ganglia Thalamus

Hypothalamus Cerebellum Brainstem

Midbrain Pons Medulla

Spinal cord

Slide 23-2

Pathways of the CNS Crossed representation Sensory pathways

Spinothalamic tract Posterior (dorsal) column

Motor pathways Corticospinal or pyramidal tract Extrapyramidal tracts Cerebellar system

Upper motor neurons Lower motor neurons

Slide 23-3

Slide 23-4

Slide 23-5

[PRODUCTION NOTE: Please insert Figure 23-2 (from Jarvis Physical Examination and Health Assessment, 5e, ISBN: 978-1-4160-3243-4)]

© Pat Thomas, 2006.

Slide 23-6

© Pat Thomas, 2006.

Headache Head injury Dizziness/vertigo Seizures Tremors Weakness

Slide 23-7

Preparation Screening neurologic examination Complete neurologic examination Neurologic recheck

Equipment needed Penlight Tongue blade Cotton swab Cotton ball Tuning fork (128 or 256 Hz) Percussion hammer Occasionally need: familiar aromatic substance

Slide 23-8

Test Cranial Nerves I—Olfactory II—Optic III—Oculomotor,

IV—Trochlear, VI—Abducens

V—Trigeminal Motor function

Sensory function

Corneal reflex

VII—Facial Motor function Sensory function

VIII—Acoustic (vestibulocochlear)

IX—Glossopharyngeal, X—Vagus Motor function Sensory function

XI—Spinal accessory XII—Hypoglossal

Slide 23-9

Motor System—Inspect and palpate Muscles

Size Strength Tone Involuntary

movements

Cerebellar function Balance tests

Gait Tandem walking Romberg’s test Shallow knee bend

Coordination and skilled movements Rapid alternating movements Finger-to-finger test Finger-to-nose test Heel-to-shin test

Slide 23-11

Sensory System Person is alert,

cooperative, and comfortable

Guidelines for sensory testing

Spinothalamic tract Pain Temperature Light touch

Posterior column tract Vibration Position (kinesthesia) Tactile discrimination

(fine touch) Stereognosis Graphesthesia Two-point discrimination Extinction Point location

Slide 23-12

Test the stretch or deep tendon reflexes Technique Grading Reinforcement Biceps reflex Triceps reflex Brachioradialis reflex Quadriceps reflex Achilles reflex (“ankle

jerk”) Clonus

Test the superficial reflexes Abdominal reflex Cremasteric reflex Plantar reflex

Slide 23-13

Neurologic recheck Level of consciousness

Person Place Time

Motor function Pupillary response Vital signs Glasgow Coma Scale (GCS)

Slide 23-14

Oculomotor response (Cranial nerve III) Size, equality, and roundness of pupils

assessed Size measured in millimeters Evaluated for symmetry in size and

response to light stimulus Brisk, sluggish, non-reactive Consensual reaction of opposite pupil at

same time

Assess accommodation by holding finger 4-6 inches from client’s nose and then pull out to 18 inches.

As finger moves away pupil will accommodate by dilating, as finger moves closer, constricting

PEARLA- Pupils equal and reactive to light and accommodation

Ability to follow commands Muscle tone Muscle strength Coordination Balance (Romberg test) Posturing (Decorticate, Decerebrate)

Tactile sensation Pain Temperature Vibratory sensation Tactile discrimination

Superficial Deep tendon Biceps Triceps Patellar Achilles Plantar (Babinski Response)

Clear and appropriate Confused Inappropriate Garbled Aphasia (Expressive, Receptive) Limited hearing Use of hearing aids

Slide 23-26

Slide 23-27

Slide 23-28