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Neurological

301 - Chapter 24

QuestionAnswer
The central nervous system contains? The brain and spinal cord.
The peripheral nervous system contains? Cranial, spinal and peripheral nerves.
What occurs in the voluntary division of the nervous system? Fibers that connect the CNS to muscles and skin facilitate deliberate actions in response to stimuli.
What occurs in the involuntary (autonomic) division of the nervous system? Fibers connect the CNS with organs, smooth muscles and glands.
Which part of the neuron serves as the control center? The cell body.
What are dendrites? Smaller receiving fibers in the neuron.
What is an axon? A long connecting fiber on a neuron.
What does the myelin sheath do? Speeds impulse conduction.
What is the cerebral cortex? It forms the outside of the cerebrum, contributes to motor and sensory function, intellect and language.
What does the precentral gyrus do and where is it located? Controls motor function on the opposite side of the body. It is located in the frontal lobe.
What does the post central gyrus do and where is it located? Receives inputs on sensory function including temperature, touch, pressure and pain from the opposite side of the body. It is located in the parietal lobe.
What is the cerebral cortex responsible for? Visual imaging, auditory processing and language comprehension and expression.
What is the frontal lobe responsible for? Complex cognition (orientation, memory, insight, judgment, arithmetic and abstraction); language (verbal and written) and voluntary motor function.
The motor function area of the frontal lobe is located where? At the foot.
What is the parietal lobe responsible for? It recognizes the shape, size and texture of objects and interprets touch, pressure and pain.
The sensory areas of the parietal lobe are located where? At the front of the parietal lobe.
What is Wernicke area? An area of the brain that integrates understanding of spoken and written words.
Where is Wernicke's area located? In the parietal lobe of the left hemisphere.
What is Broca’s area? An area of the brain that regulates verbal expression and writing ability.
Where is Broca’s area located? In the parietal lobe of the left hemisphere.
What is the occipital lobe responsible for? It is the primary visual area of the brain containing visual associative areas that interpret and integrate stimuli.
What is the temporal lobe responsible for? It registers auditory input and is responsible for hearing, speech, behavior and memory.
What is the limbic lobe? A fifth lobe identified by some scientists which consists of the hippocampus and amygdaloid nucleus.
What is the limbic load primarily concerned with? Self-preservation, recall of pleasurable, unpleasant or potentially dangerous events. Recalls emotional responses in relation to events, including aggression, interpretation of smell, feeding and sexual behavior, and autonomic emotional responses
Patients who have a stroke in the left hemisphere are more likely to have what deficits? Language due to the location of Wernicke's and Broca’s areas.
Damaged Wernicke's area may lead to what? Difficulty understanding verbal communication, called receptive aphasia.
Damaged Broca area may cause what? Problems with speaking or finding words, called expressive aphasia.
What are the basal ganglia? For paired tracts of gray matter on both sides of the thalamus deep within the brain tissue.
What do the basal ganglia do? Modulate autonomic movements, receiving input from the cerebral cortex and sending output to the brainstem and thalamus to facilitate smooth motor function.
Where is the thalamus located? Directly above the brainstem.
What is the thalamus responsible for? It is the major relay station and gatekeeper for both sensory and motor stimuli to the cerebral cortex.
What is the hypothalamus responsible for? It controls vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system and emotions. It maintains overall autonomic control.
What is the limbic system responsible for? It is more primitive and mediates survival behaviors such as fear, aggression, meeting and affection.
Afferent stimuli are? Sensory.
Afferent stimuli travel in which direction? Through the brainstem to the cerebral cortex (up).
Efferent fibers are? Motor.
Efferent stimuli travel in which direction? They leave the cortex to pass through the brainstem and spinal cord (down).
The brainstem includes what? The medulla, midbrain, pons and reticular formation.
The vital autonomic centers for respiratory, cardiac and vasomotor function are where? The medulla.
Control of voluntary functions such as sneezing, swallowing, vomiting, hiccuping and coughing occurs where? The medulla.
Describe the respiratory centers? There are two located in the pons, one controls the length of inspiration and expiration and the other controls the rate.
What does the reticular formation do? Relays sensory information, excitatory and inhibitory control of spinal motor neurons and control of vasomotor and respiratory activity.
Which part of the brain is responsible for increasing wakefulness, attention and responsiveness of cortical neurons to sensory stimuli? The reticular formation.
The cerebellum is located where? Under the occipital lobe in the posterior part of the brain.
What does the cerebellum do? It coordinates voluntary movement, posture and muscle tone and maintains special orientation and equilibrium.
What are the ventricles of the brain? Fluid filled cavities that connect with spinal cord.
What protects the brain? The meninges, skull and CSF.
What is the purpose of CSF around the brain? To supply nutrients, cushioning and allow for shifts of fluid between the brain and spinal cord.
Cranial nerve I? Olfactory.
Cranial nerve II? Optic.
Cranial nerve III? Oculomotor.
Cranial nerve IV? Troclear.
Cranial nerve V? Trigeminal.
Cranial nerve VI? Abducens.
Cranial nerve VII? Facial.
Cranial nerve VIII? Acoustic (vestibulocochlea).
Cranial nerve IX? Glossy pharyngeal.
Cranial nerve X? Vagus.
Cranial nerve XI? Spinal accessory.
Cranial nerve XII? Hypoglossal.
Cranial nerve I is responsible for? Smell and smell interpretation, including peristalsis, salivation and sexual stimulation.
Cranial nerve II is responsible for? Vision, including visual acuity and peripheral vision.
Cranial nerve III is responsible for? Extraocular movements – upward, medial, downward, up and in. Eyelid raising and pupil constriction.
Cranial nerve IV is responsible for? Extraocular movements – down and in.
The ophthalmic branch of the trigeminal nerve is responsible for? Sensation to the cornea, conjunctiva, nasal mucosa, full head and nose.
The maxillary branch of the trigeminal nerve is responsible for? Sensation to the skin of the cheek and nose, low eyelid, obligor, teeth, mouth mucosa.
The mandibular branch of the trigeminal nerve is responsible for? Sensation to lower jaw and motor function to muscles of mastication.
Cranial nerve VI is responsible for? Extraocular movements – lateral.
Cranial nerve VII is responsible for? Taste and sensation for the anterior two thirds of the tongue and soft palate; serves as the primary motor nerve for facial expression.
Cranial nerve VIII is responsible for? Hearing and equilibrium.
Cranial nerve IX is responsible for? Pharyngeal muscle elevation for swallowing and speech; parotid gland secretion; general sensory (pain, touch, temperature) function.
Cranial nerve X is responsible for? Most parasympathetic innervation to a large region; effects include digestion, defecation, slowed heart rate and reduced contraction strength.
Cranial nerve XI is responsible for? Swallowing and speaking; innervates the muscles that turn the head and elevate the shoulders (shoulder shrug).
Cranial nerve XII is responsible for? Tongue movement.
The gray matter of the spinal cord contains? The cell bodies of voluntary, autonomic and sensory neurons.
Autonomic motor neurons are located where in the spinal cord? From S2 to S4.
Sympathetic neurons are located where in the spinal cord? From T1 to L2.
The ascending tracts of the spinal cord generally carry what? Specific sensory information from the periphery to higher levels of the CNS.
Stereognosis is what? The sense of localized touch.
Proprioception is what? Deep pressure, vibration, position sense
Kinesthesia is what? Movement.
Information about stereognosis, proprioception and kinesthesia is carried where? The dorsal columns.
The crossing of fibers in the medulla leads to what related to touch sensations? Right-sided sensations are perceived on the left side of the brain and left-sided sensations are perceived on the right side of brain.
Specialized ascending tracts for pain and temperature are called what? Spinothalamic.
Specialized ascending tracts for coordination of movement are called what? Spinocerebellar.
What is Brown-Sequard’s syndrome sensory loss? It occurs when half of the spinal cord is severed. Loss of pain and temperature on the opposite side of the injury, because these fibers cross in the spinal cord. Other sensations remain on the same side because these fibers cross in the medulla.
The descending tracts carry what? Information related to motor function and muscle movement.
The descending tracts control which type of movement? Voluntary movement.
The descending tract that carries impulses from the cortex to the cranial nerves is called what? Corticobulbar tract.
The descending tract that carries impulses from the cortex to the peripheral nerves is called what? Corticospinal tract.
The corticobulbar and the corticospinal tracts are referred to as what? Pyramidal tract.
The extrapyramidal tract is where? It originates in the reticular formation and is modulated by the brainstem, basal ganglia and cerebellum. It does not directly innervate the peripheral motor system.
What does the extrapyramidal tract do? It controls gross automatic movements such as reflexes, walking, complex movements and postural control.
Some medications prescribed to patients with psychiatric illnesses may have side effects affecting which tract? The extrapyramidal tract.
Loss of neurons in the extrapyramidal tract due to Parkinson's disease may present how? Poor skeletal muscle tone, drooling, tremor and shuffling gait.
Damage to the extrapyramidal tract in patients with cerebral palsy may present how? Involuntary writhing movements.
The cranial nerves, spinal nerves and autonomic nervous system all belong to? The peripheral motor system.
The spinal nerves contain what type of fibers? Afferent sensory fibers (located in the dorsal root) and efferent motor fibers (located in the ventral root).
How many pairs of spinal nerves are there? 31 – 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal.
C1 - 3 controls movement where? In and above the neck.
C4 - 6 is at the level of? The shoulder and diaphragm for breathing independently.
C7 - 8 is at the level of? The fingers and hands grasp to perform self-care and transfers with arms.
T1 - 6 provides? Trunk stability for balance when sitting.
T6 - 12 is for? Thoracic muscles and upper back of respiratory and transfer strength.
L1 - 2 is at the level of? The legs and pelvis.
L3 - 4 is at the level of? Hamstrings and ankles.
Level of injury to the spinal cord affects function where? At and below the site trauma.
The fight or flight response is controlled by? The sympathetic nervous system.
The rest and digest response is controlled by? The parasympathetic nervous system.
The autonomic nervous system is made up of? The sympathetic and parasympathetic systems.
The sympathetic ganglia are located in the spine from? T1 to L2.
The major neurotransmitter in the sympathetic nervous system is? Epinephrine or adrenaline.
The cell bodies of the parasympathetic nervous system are located where? The brainstem and spinal segments S2 to S4.
The parasympathetic ganglia are located where? Near the structures that they innervate.
The main neurotransmitter for the parasympathetic nervous system is what? Acetylcholine.
To regulate heart rate and blood pressure the sympathetic nervous system does what? Secretes epinephrine to increase blood pressure, heart rate and contractility.
To regulate heart rate and blood pressure the parasympathetic nervous system does what? Secretes acetylcholine to reduce heart rate and force of contraction.
Four types of reflexes are? Reflex arc, superficial, visceral and neonatal.
Examples of superficial reflex include? Corneal and abdominal.
Exact example of a visceral reflex is? Pupillary response to light.
Three examples of the neonatal reflex are? Rooting, grasp, Babinski.
The knee-jerk reaction tests what? The deep tendon reflex of the patella tendon.
The reflex arc involves? A receptor sensing organ, afferent sensory neuron, efferrent motor neuron and effector motor organ.
True or false – myelination is completed birth? False.
In what directions does myelination complete through development? From head to toe and centrally to peripherally.
What are the earliest nerve tracts to develop? Sensory (taste, smell and hearing); cerebellar (balance and coordination) and extrapyramidal (pain).
Myelination of the spinal cord is nearly complete by what age? Two years.
How completed is brain growth by the age of two years? 75%.
What happens to neurons of the CNS, brain size and neurotransmitters with age? They all decrease.
Results of the decrease in neurons CNS, brain size and neurotransmitters that occur with aging are? Slower thought processing, reduced response to stimuli and delayed reflexes.
Peripheral nerve function and impulse conduction decrease with aging resulting in? Decreased proprioception and potential for Parkinson like gait.
What happens to light touch and pain sensation with aging? They are reduced, with ischemic paresthesia common in the extremities.
An abbreviated acute neurological assessment involves? Level of consciousness (Glasgow coma scale), pupillary reaction, extremity strength assessment, assessment of sensation and vital signs.
If consciousness is impaired assessing selected cranial nerves may help differentiate? Neurological from metabolic causes, particularly extraocular movements, gag reflex and corneal reflex.
Risk factors for stroke are? Older adults, males, family history, hypertension, atrial fibrillation, sickle cell disease
Criteria used to identify seizure severity include? Frequency, type, duration, postictal events, postictal duration, automatisms, seizure clusters, known patterns, warnings, tongue biting, incontinence, injuries and functional impairment.
A head injury is suspected if there is? Witnessed loss of consciousness longer than 5 min, history of amnesia longer than 5 min., abnormal drowsiness, more than 3 episodes of vomiting, suspicion of a non-accidental injury, seizure in a patient with no history of epilepsy.
Symptoms of meningitis include? High fever, stiff neck, drowsiness and photosensitivity.
Symptoms of degenerative neurological disease include? Weakness, tingling or numbness, difficulty seeing and elimination-control problems.
Why does atrial fibrillation increase the risk for stroke? Because quivering atria can need blood to stagnate and form small clots, a clot that breaks off can circulate to the brain causing an embolic stroke.
Why do sickle cell disease increase the risk for stroke? Because cells tend to be stickier, causing clots to form more easily narrowed arteries.
What is the gender difference in likelihood of traumatic brain or spinal cord injuries? Males are twice as likely as females, partly because they engage in risky activities.
Unilateral weakness, disturb speech and symptoms longer than 10 min. may indicate what? Stroke.
Neuropathy primarily occurs in which muscles? Distal muscles.
A rash and generalized weakness may indicate? Lupus.
Myasthenia gravis is exacerbated by? Repetitive actions.
Neurological causes of generalized weakness include? Demyelinating disorders, amyotrophic lateral sclerosis, Guillain-Barre’s syndrome, multiple sclerosis, myasthenia gravis and degenerative disc disease.
Which type of tremors occur with Parkinson's disease? Resting tremors, they worsen at rest in decreased with activity.
Gradual onset of positional tremors suggests? Essential tremor.
Acute onset of positional tremors suggests? A toxic or metabolic disorder.
Intention tremors are worst? With movement toward an object; they may result from multiple sclerosis.
Neurological causes of dizziness or vertigo are? Multiple sclerosis, Parkinson's disease, cerebellar ischemia or infarction, benign or malignant neoplasms and arterial venous malformation of blood vessels in the brain.
Position changes that worsen dizziness are associated with what? The inner ear.
Dysphagia associated with cranial nerve dysfunction is a common symptom of? Stroke or neuromuscular disease.
What is parasthesia? An abnormal prickly or tingly sensation most common in the hands, arms, legs and feet.
Possible causes of paresthesia include? Neurological disease or traumatic nerve damage such as carpal tunnel syndrome or cervical stenosis.
Central causes of diplopia include? Stroke, vascular malformation, tumor, mass., trauma, meningitis, hemorrhage and muscular sclerosis.
Common causes of sensorineural hearing loss include? Noise, autoimmune disorders, Ménière's disease, ototoxic medications and head trauma.
Potentially harmful fetal effects of anticonvulsants taken during pregnancy include? Neural tube deficits, cleft lip or palate, congenital heart disease, developmental delay and cognitive impairment.
Why are migraines more common during pregnancy? From increased hormones.
What effect does pregnancy have on multiple sclerosis? Hormones influence its course, the relapse rate is lower during pregnancy, especially in the third trimester, with a marked increase in the first three months postpartum.
Risk of cerebral palsy in the newborn increases with what? A history of maternal infection in pregnancy, preterm birth and multiple pregnancies.
The age groups at highest risk for traumatic brain injury are? 0 to 4 years old and 15 to 19-year-old's.
Risk for autism in the newborn increases with? Advanced maternal or paternal age, low birth weight, shortened gestation and intrapartal hypoxia.
Autism is associated with what birth conditions? Breech presentation, low five-minute Apgar score, birth before 35 weeks gestation and parental psychiatric illness.
How long does the new meningitis vaccine last? Approximately 8 years, compared to the 3 to 5 year protection that the older vaccine offered.
What are risk factors for neurovascular disease? Hypertension; atrial fibrillation; diabetes; congestive, chronic renal disease; previous cerebrovascular disease and ischemic stroke.
Which group of the population has the highest rate of traumatic brain injury related hospitalization and death? Those 75 years or older.
How does ethnicity effect multiple sclerosis risk? It is higher in temperate climates.
How does ethnicity effect stroke risk? It is more common in African-Americans than Caucasian Americans.
Hospitalization rates for traumatic brain injury are highest among which ethnic groups? African-Americans, American Indians and Alaska natives.
Which cultural group has the highest death rate from traumatic brain injury? African-Americans.
Maternal exposure to what is linked to increased incidence of anencephaly and neural tube defects? Pesticides.
Incidence of spina bifida is highest among which cultural group? Hispanic women.
Severe lead exposure can lead to? Encephalopathy.
Mild lead exposure can? Lower IQ scores and contribute to attention problems.
The correct order of stimulation in assessment of consciousness is? Spontaneous, normal voice, loud voice, tactile, noxious.
The Glasgow coma scale evaluates which behavioral responses? Motor responses, verbal responses and by opening.
Eye-opening response of the Glasgow coma scale? Spontaneous = 4, to voice = 3, 2 pain = 2, none = one.
Best verbal response of the Glasgow coma scale? Oriented = 5, confused = 4, inappropriate words = 3, incomprehensible sounds = 2, none = 1.
Best motor response of the Glasgow coma scale? Obeys command = 6, localizes pain = 5, withdraws = 4, flexion = 3, extension = 2, none = 1.
Interpretation of the Glasgow coma scale? 3 is a potato and 15 is normal.
Two tools used to assess dementia are? The Mini Mental State Examination (MMSE) And the Blessed Dementia Rating Scale.
Alert and oriented times three means? Alert to person place and time.
Deficits in articulation are referred to as? Dysarthria.
How do you test speech articulation? Ask the patient to repeat words or phrases with multiple combinations of consonants and vowels.
Possible neurological causes for nystagmus include? Medications (antiseizure), cerebellar disease, weakness in the extraocular muscles and damage to cranial nerve III.
How many pairs of cranial nerves are there? 12.
Each member of a pair of cranial nerves innervates structures on which side? The same side from which it arises (the ipsilateral side).
How do you record pupil size during the neurological assessment? Record both the initial size and response size for example R6 → 4, L6 → 4.
How is eye accommodation tested? By having the person shift gaze from a distance to near object.
A lesion of the cranial nerve or its needless results in? An ipsilateral peripheral nerve deficit.
A lesion in the cerebral cortex in the area that supplies the cranial nerve nucleus or in the tracts traveling from the cerebral cortex to the cranial nerve nucleus results in what? A contralateral CNS deficit.
Facial weakness caused by a lesion in the right frontal motor control center occurs where? On the left side of the face.
A lesion on the right facial nerve itself produces weakness where? On the entire right side of the face.
If there is no resistance of the muscles to passive stretch they are said to be? Flaccid or atonic.
If there is decreased resistance of the muscles to passive stretch they are said to be? Hypotonic.
Increased resistance of the muscles to passive stretch is called? Hypertonia.
Increased resistance of muscles to rapid passive stretch, especially in flexor muscle groups in the upper extremities is called? Spasticity.
What does the term class-knife spasticity referred to? When muscle resistance is strongest on initiation of the movement and gives way as the examiner slowly continues the movement.
In what condition is clasp knife spasticity noted in? Parkinson's disease.
Commonly tested muscle groups for bulk and tone are? Deltoids, biceps, triceps, hamstrings and quadriceps.
Is cranial nerve I sensory, motor or both? Sensory.
Is cranial nerve II sensory, motor or both? Sensory.
Is cranial nerve III sensory, motor or both? Motor.
Is cranial nerve IV sensory, motor or both? Motor.
Is cranial nerve V sensory, motor or both? Both.
Is cranial nerve VI sensory, motor or both? Motor.
Is cranial nerve VII sensory, motor or both? Both.
Is cranial nerve VIII sensory, motor or both? Sensory.
Is cranial nerve IX sensory, motor or both? Both.
Is cranial nerve X sensory, motor or both? Both.
Is cranial nerve XI sensory, motor or both? Motor.
Is cranial nerve XII sensory, motor or both? Motor.
How is cranial nerve I assessed? Patency of each nostril is assessed then scent identification is tested using common fragrances such as orange, peppermint, cinnamon and coffee.
Anosmia is what? A compromised ability to discriminate odors.
How is cranial nerve III assessed? Use the Snellen chart, ask to identify how many fingers are being held up, test visual fields using confrontation.
How are cranial nerves III, IV and VI assessed? Assess pupils for size, shape and equality. Assess the six cardinal positions of gaze, observe for nystagmus.
What elements of nystagmus should be noted? If the movement is fine or coarse, constant or intermittent, the plaintiff movement is up or down, back or forth.
How is sensory function of cranial nerve V assessed? Using sharp and dull sensations on the face - be sure to evaluate all three divisions of the nerve- at the scalp (ophthalmic), cheek (maxillary) and chin (mandibular) on each side.
How is motor function of cranial nerve V assessed? Observe the face for atrophy, deviation, fasciculations. Palpate jaw with clenched teeth for masseter muscle symmetry; open jaw against resistance. Corneal blink reflex when touched.
How is sensory function of cranial nerve VII assessed? By evaluating taste (sweet, sour, salty and bitter) on the anterior two thirds of the tongue on both sides.
How is motor function of cranial nerve VII assessed? Observe facial movements during conversation. Also raise the eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, and smile, show the teeth, purse the lips and puff out the cheeks.
How is cranial nerve VIII assessed? Evaluate hearing during normal conversation using a simple whisper test all within audio meter.
How is sensory function of cranial nerve IX assessed? Evaluates taste (sweet, sour, salty and bitter) on the posterior one third of the tongue.
How is motor function of cranial nerve IX assessed? With cranial nerve X upon swallowing.
How is motor function of cranial nerve X assessed? Stick out tongue (should be symmetric), say “ah” (uvula and soft palate should be symmetric).
Injury to the Vegas or plus a pharyngeal nerve causes what? The uvula to deviate from midline.
How is sensory function of cranial nerve X assessed? By stimulating the gag reflex.
How is cranial nerve XI assessed? Evaluate the sternocleidomastoid and trapezius muscles for bulk, tone, strength and symmetry. Press against resistance on the opposite side of the chin, shrug the shoulders.
How is cranial nerve XII assessed? With cranial nerve X. Stick out tongue and observe for symmetry, have the patient say “light, tight, dynamite” – l, t, d and n should be clear and distinct.
Lesions of the hypoglossal nerve make calls what? Fasciculations, asymmetry, atrophy or deviation from midline of the tongue.
Steady, persistent resistance to passive stretch in both flexor and extensor muscle groups is? Rigidity.
What is cogwheel rigidity? Seen in patients with Parkinson's disease and is manifested by a ratchet like jerking noted in the extremity on passive movement
How is muscle strength assessed in urological exam? By independent movement and against resistance.
Hand grasp, pronator drift, and dorsiflexion and plantar flexion all assess what? Muscle strength in a neurological exam.
Strength of muscle movement in a neurological assessment is graded how? On a scale of 4 -5 +
A grade of 0 on a muscle strength assessment means? No muscle contraction.
A grade of 1 on a muscle strength assessment means? Barely detectable, flicker.
A grade of 2 on a muscle strength assessment means? Active movement with gravity eliminated.
A grade of 3 on a muscle strength assessment means? Active movement against gravity
A grade of 4 on a muscle strength assessment means? Active movement against some resistance.
A grade of 5 on a muscle strength assessment means? Active movement against full resistance.
An early or mild upper extremity weakness can be detected now? Observing for pronator drift.
How is pronator drift assessed? Ask the patient to close the eyes and outstretch the arms with palms upward for 10 seconds. Pronation of the hands and downward drift of the arm indicate weakness.
Weakness of the lower extremities can be tested how? Press the feet against resistance to test strength or extend the leg at 30°; drift is present if the leg falls before 5 seconds.
Gait and posture combined functions of what systems? The pyramidal and extrapyramidal motor systems, other cerebellar function and sensory systems.
Points to observe when watching the patient walked to assess gait and posture are? Smoothness of gait, position of feet (narrow versus wide base), height and length of step and symmetry of arm and leg movement.
What does tandem walk mean? Heel to toe in a straight line.
What is the Romberg test? Stand with feet together and arms at side with eyes closed. Note any swaying.
Moderate swaying with eyes open and closed during the Romberg test indicates what? Vestibularcerebellar dysfunction.
Pronounced increase in swaying (sometimes with falling) with the eyes closed during the Romberg test indicates what? A lesion in the posterior columns of the spinal cord.
Assessment of finger to nose coordination or rapid alternating movements tests what? Upper extremity cerebellar function.
How do you assess rapid alternating movements? Instruct the patient to slap the FIA with first the palm of the hand and then the back as fast as possible.
What is ataxia? Unsteady, wavering movement with inability to touch the target.
What is adiadochokinesia? Lack of coordination during rapid alternating movements.
Deficits in finger to nose coordination and rapid alternating movements indicate what? Ipsilateral cerebellar lesion.
Dysarthritic speech noted with cerebellar lesion may exhibit what? A peculiar quality port scanning speech, which is characterized by alternating patterns of slowness and explosiveness as each syllable spoken.
Lower extremity cerebellar function is tested how? Heel-to-shin test.
Why do you allow 2 seconds between each stimulus when testing sensory function? To avoid summation , in which the patient perceives frequent, small stimulations as one long stimulation.
Sensory stimulation deficits should be interpreted considering what? That this testing includes the peripheral nerves, sensory tracts and cortical perception.
Sensory loss in diabetic neuropathy is? Distal.
Sensory loss in spinal cord injury generally follows? The pattern of the dermatome.
Stronger stimulation when assessing sensory function is needed where? Over the central torso and back.
Screening for sensory function moves in which direction? Testing the most distal areas and proceeding centrally if deficits are noted.
Testing for sensory function involves which areas of the body? The arms (not hands), legs, trunk and face.
What is hyperesthesia? Increased touch sensation.
What is anesthesia? Absent touch sensation.
What is hyesthesia? Reduced touch sensation.
How do you test superficial pain sensation? Lightly touched the patients skin with a sharp object, ask to state where they feel the sensation.
What is hyperalgesia? Increased pain sensation.
What is analgesia? Absent pain sensation.
What is hypalgesia? Reduced pain sensation.
When should temperature sensation be tested? Only if pain or touches abnormal.
Abnormal temperature sensation is common in? Neuropathies.
How to test point localization? Patient closes eyes, using a finger, gently touch on the hands, lower arms, abdomen, lower legs and feet. Have patient identify where they feel the sensation.
Sensory loss in a stocking glove distribution suggests? Peripheral nerves.
Sensory loss in a dermatomal distribution suggests? Isolated nerves or nerve roots.
Reduced sensory sensation below a certain level is associated with? A spinal cord injury.
Sensory loss in a crossed face-body pattern suggests? The brainstem.
Hemisensory loss suggests? A stroke.
Which type of sensory loss is more surveyed distantly and improves centrally? Peripheral neuropathy.
Which sensory cents is often the first loss in peripheral neuropathy? Vibration.
With damage to what is the line of sensory loss usually marked and specific? A specific dermatome.
How is vibration sense tested? Holding a tuning fork at the base over bony prominences such as the toes, ankles, shin, finger joints, wrist, elbow, shoulder and sternum.
How is motion and position sense tested? Have patient close eyes. Move distal joints of the fingers and then the toes up or down. If the patient cannot identify these movements, test the next most proximal joints.
What is athetosis? Involuntary writing, snakelike movements of the limb.
Athetosis results from what? Loss of position sense. The brain cannot see where the limb is in space so the limb moves on its own.
What is asterognosis? Inability to identify objects, based on touch alone, correctly.
What does stereognosis test for? Cortical sensory function.
How do you assess for stereognosis? Ask patient close the eyes and identify a familiar object (coin or key) placed in the palm.
What does graphestesia test for? It evaluates cortical sensory function.
How do you test graphestesia? Ask the patient to close their eyes and use a blunt object to trace a number on the patient's palm. Ask the patient to identify which number has been traced.
Failure of the stereognosis and graphestesia tests indicates what? Compromised cortical sensory function. Often caused by damage to the sensory cortex caused by a stroke.
How do you test two-point discrimination? Have the patient close the eyes. Hold the blunt end of two cotton swabs approximately 2 inches apart and move them together until the patient feels them at one point.
What is the minimum distance of two-point discrimination in the fingertips? 3 to 8 mm.
What is the minimum distance of two-point discrimination on the upper arms and thighs? 75 mm.
Generally there is more discrimination during the two-point discrimination test where? Distally than centrally.
How is extinction tested? Have the patient close the eyes. At the same time, touch a body area on both sides. Ask the patient to state where they feel the touch.
What is clonus? Alternating flexion/extension movements (jerking) in response to continuous muscle stretch.
What does DTR mean? Deep tendon reflex.
Which deep tendon reflexes are often tested? Biceps, triceps, brachioradialis, patella and Achilles.
How are deep tendon reflexes graded? On a scale of 0 to 4.
A grade of 4+ for a DTR means what? Very brisk, hyperactive with clonus.
A grade of 3+ for a DTR means what? Brisker than average.
A grade of 2+ for a DTR means what? Average, normal.
A grade of 1+ for a DTR means what? Diminished, low normal.
A grade of 0 for a DTR means what? No response.
How can you ensure accurate location prior to striking a tendon with a reflex hammer? Have the patient flex the muscle to find the tendon and then relax it for testing.
The reflex response depends on? The force of the stimulus, accurate location of the striking area over the tendon and the patients relaxation level.
The biceps DTR corresponds to nerves and which level? C5 and C6.
The triceps DTR corresponds to nerves at which level? C6 - C8.
The brachioradialis DTR corresponds to nerves at which level? C5 and C6.
The patella DTR corresponds to nerves at which level? L2 - L4.
The Achilles DTR corresponds to nerves at which level? S1 and S2.
Superficial reflexes are elicited by? Stimulation of the skin.
How to test the plantar response? Stroke the sole of the foot with a blunt instrument, apply the stimulus firmly but gently to the lateral aspect, beginning at the heel and stopping short of the base of the toes. The toes should flex.
Pathological reflexes while testing the plantar response include? Abnormal plantar refleses and the triple flexion response.
How do abnormal plantar reflexes manifest? The great toe extends upward and the other toes fan out. Also known as an extensor-plantar response or Babinskis sign.
What is the triple flexion response? Withdrawal of the lower extremity to plantar stimulus through flexion of the ankle, knee and hip.
What the tests for superficial reflexes? Plantar response, upper abdominal, lower abdominal, cremasteric (male), bulbocavernous (male), perianal.
How do you test the upper abdominal reflex? Stroke the upper quadrants of the abdomen with a tongue blade or reflex hammer, the umbilicus should move toward each area of the stimulation symmetrically.
What does the upper abdominal reflex test for? The integrity of T8 – T10.
Depression of the upper abdominal reflex may result from? A central lesion, obesity or lax skeletal muscles (postpartum). It also may be noted with spinal cord injury.
How do you test the lower abdominal reflex? Stroke the lower quadrants of the abdomen with a tongue blade or reflex hammer, the umbilicus should move toward each area of the stimulation symmetrically.
How do you test the cremasteric reflex? Stroke the inner thigh of the male patient, the testicle and scrotum should rise on the stroked side.
What does the upper cremasteric reflex test for? It identifies the integrity of L1 – L2 in male patients.
What does the bulbocavernous reflex test for? The integrity of S3 – S4.
How do you test the bulbocavernous reflex? Apply direct pressure over the bulbocavernous muscle behind the scrotum. The muscle should contract and elevate the scrotum.
How do you test the perianal reflex? Scratch the tissue at the side of the anus with a blunt instrument, the anus should pucker.
What does the perianal reflex test for? Helps identify the integrity of S3 – S5.
Examples of normal changes in neurological function with aging are? Lost nerve cell mass, atrophy in the CNS, decreased brain weight and fewer nerve cells and dendrites.
Normal changes in neurological function with aging lead to? Slower thought, memory and thinking. However plasticity enables the lengthening and production of dendrites to accommodate for this loss. Demyelinization of nerve fibers leads to delayed impulse transmission.
An increased latency period (period before next stimulation) with aging causes? Slowed reflexes, which may produce mobility and safety issues.
What happens to peripheral nerve conduction with aging? It slows down.
Neurological screening examination in a healthy patient includes? Vital signs, level of consciousness, communication/speech, orientation, motor, sensory, pupillary reaction.
When orders for "Neuro checks" are written what does this signify? If deterioration were to occur it would signify a critical or potentially life-threatening event.
“Neuro checks” assess for what? Level of consciousness (GCS score), pupillary size, equality and light responses, motor ability and, when appropriate, additional elements linked to location and pathology of existing deficits.
What is nuchal rigidity? A stiff neck.
Nuchal rigidity is associated with? Meningitis and intracranial hemorrhage from irritation of the meninges.
What is Brudzinski’s sign? Resistance or pain in the neck and flexion in the hips or knees.
How do you assess for Brudzinski’s sign? With the patient supine, slide your hand under and raise the patient’s head gently, flexing the neck.
What is Kernig’s sign? If there is resistance to straightening or pain radiating down the posterior leg.
How do you assess for Kernig’s sign? With the patient supine, raise the leg straight up (or flex the thigh on the abdomen) and extend the knee.
Physical examination of the unconscious patient includes the following? Level of consciousness assessment five Glascow coma score, pupillary assessment, brainstem assessment, motor function and close observation for patterns of dysfunction associated with progressing herniation.
Noxious stimulation can be categorized how? As peripheral or central.
Peripheral noxious stimulation is performed how? Using nail bed pressure.
Central noxious stimulation is performed how? By pinching the trapezius or pectoralis muscle, applying pressure to the supraorbital notch (contraindicated if a facial fracture is suspected) or using the sternal rub.
What is the oculocephalic reflex? Goals I use. Used to assess brainstem function in comatose patients – ensure the spinal cord is clear intact before performing this test.
How do you assess for the oculocephalic reflex? Hold the pts eyes open, turn head to one side quickly and then to the other. In a patient with an intact brainstem, the eyes move toward the opposite side. If brainstem or midbrain function is lost, the eyes move with the head, still pointing forward.
With unilateral herniation what is one of the first signs that signifies neurological worsening? Dilating pupil at first sluggishly reactive.
As unilateral herniation progresses what may occur? Response only to pain, contralateral (opposite-sided) posturing of extremities and brainstem abnormalities may be noticeable.
What signs may be seen with bilateral herniation? Pupil change and reflex posturing are on both sides.
With which type of herniation will the patient have fixed pupils, flaccid muscles and no response to pain? Cerebellar herniation.
Common diagnostic testing for neurological conditions include? Ct, MRI, angiography, EEG, nerve conduction studies, lumbar puncture.
Nursing considerations following lumbar puncture are? Patients must typically remain flat in bed for 6 to 8, bed rest may continue for 24 hrs if headache persists. Frequent assessment for severity of headache and LOC must occur.
Unequal pupil size in comatose patients may indicate? Anisocoria related to compression of the optic nerve. Could also be physiological aniscoria, not associated with any disease, congenital in 20% of the population.
Constricted and fixed (pinpoint) pupils in the unconscious patient may indicate? Miosis related to hemorrhage in the pons or opiate narcotics.
Pinpoint pupils suggest? Damage to the sympathetic pathways or metabolic encephalopathy.
Dilated and fixed pupils in the unconscious patient may indicate? Anoxia, sympathetic effects, atropine, tricyclics, amphetamines or pilocarpine drops for glaucoma treatment; when associated with a head injury prognosis is poor.
Horner’s syndrome in the unconscious patient may indicate? Preganglionic, central or postganglionic lesion.
Describe Horner’s syndrome Miosis (small pupil), ptosis (eyelid droop), anhydrosis (lack of sweat) and apparent enopthalmos (affected eye appears to be sunken).
Aide pupil in the unconscious patient may indicate? Denervation of the nerve supply from diabetic neuropathy or alcoholism.
Describe Aides pupil Both the pupillary response and accommodation are sluggish or impaired in one eye.
Argyll Robertson in the unconscious patient may indicate? Neurosyphilis, meningitis.
Describe Argyll Robertson Virtually no response to light, but brisk response to accommodation bilaterally. Pupils are small and frequently irregular in shape.
Describe third nerve palsy Sudden ptosis, diplopia and pain. Pupil is fixed and dilated and extraocular motility is restricted.
Decorticate posturing is? Abnormal flexion, arms adducted and flexed, wrists and fingers flexed on the chest, lower extremities extended, internally rotated with plantar flexion.
Decerebrate posturing is? Abnormal extension, arems adducted, extended and internally rotated, wrists/palms pronated, fingers flexed, lower extremities are extended, plantar flexion and hyperextension of the back.
Decorticate posturing may be caused by? Damage to the midbrain or upper pons; more serious than decrebrate posturing because the patient is posturing toward rather than away from a noxious stimulus.
Decerebrate posturing may be caused by? Damage to the cerebral cortex.
What is hemiplegia? Loss of sensation and motor strength unilaterally.
What may cause hemiplegia? Stroke.
What is flexion withdrawal? Gross movements of all body parts away from noxious stimulation. Rather than localizing pain to one side the patient may withdraw both arms when nailbed pressure is applied on one side.
What may cause flexion withdrawal? CNS depression or injury.
What is flaccid quadriplegia? Sensation and muscle tone are completely lost.
What may cause flaccid quadriplegia? Nonfunctional brainstem.
Define paralysis Loss of motor function resulting in flaccidity over the area of damage; may be total, one-sided (hemiplegia), in all four extremities (quadriplegia), or only in the legs (paraplegia).
What is a resting tremor? Tremor prominent at rest, may decrease or disappear with voluntary movement, common in Parkinson’s disease.
What is an intention tremor? Absent at rest, increase with movement; may worsen as movement progresses.
What may cause intention tremors? Multiple sclerosis with damage to the cerebellar pathways, or essential tremor.
What is fasciculation? Fine, flickering, irregular movements in small muscle groups seen under the skin; may not cause movement at the joint.
What may cause fasciculation? Deterioration of the anterior horn cells.
What is a tic? Brief, repetitive, similar but irregular movements, such as blinking or shrugging shoulders.
What may cause a tic? Tourette’s syndrome, use of psychiatric medications and use of amphetamines.
What is clonus/myoclonus? Rapid, sudden clonic spasm of a muscle that may occur regularly or intermittently.
What might cause clonus/myoclonus? Seizures, hiccups or they occur just prior to falling asleep.
What is dystonia? Slow involuntary twisting movements that often involve the trunk and larger muslces; may be accompanied by twisted postures.
What can cause dystonia? Use of some psychiatric medications.
What are choreiform movements? Brief, rapid, jerky movements that are irregular and unpredictable; commonly affect the face, head, lower arms and hands.
What may cause choreiform movements? Huntingdons disease.
What are athetoid movements? Slow. Involuntary wormlike twisting movements that involve the extremities, neck, facial muscles and tongue; may be associated with drooling and dysarthria.
What may cause athetoid movements? Cerebral palsy.
UMN lesions involve? Motor areas of cerebral cortex and white matter tracts connecting to motor nerve nuclei in brain or spinal cord.
LMN lesions involve? Brainstem or spinal cord motor nuclei, nerve roots or nerves.
UMN lesions vs LMN lesions – Strength? UMN – spastic paresis or paralysis (may be flaccid in acute phase). LMN – Flaccid paresis or paralysis.
UMN lesions vs LMN lesions – Muscle tone? UMN – Increased (spasicity). LMN – Decreased or absent (flaccidity).
UMN lesions vs LMN lesions – Muscle stretch reflexes? UMN – increased; prescence of Babinski’s sign. LMN – Present.
UMN lesions vs LMN lesions – Muscle atrophy? UMN - Absent (although disuse atrophy may occur with prolonged deficit). LMN – Present.
UMN lesions vs LMN lesions – Muscle fasciculation? UNM – Absent. LMN - Present.
Describe spastic hemiparesis One side normal. Other side flexed from spasticity. Elbow, wrist, fingers are flexed; arm is close to side. The affected leg is extended with plantar flexion. The foot is dragged, scraping the toe, or it is circled stiffly outward and forward.
Describe scissors gait? Moves the trunk to accommodate for the leg movement. Legs are extended and knees are flexed. Legs cross over each other at each step, similar to walking in water.
Describe Parkinsonian gait Stooped posture, head and neck forward and hips and knees flexed. Arms also flexed and held at waste. There is difficulty in initiating gait, often rocking to start. Once ambulating, steps are quick and shoveling. Has difficulty stopping one started.
Describe Cerebellar ataxia gait Wide-based gait. Staggers and lurches from side to side. Cannot perform Romberg because of swaying of the trunk.
Describe sensory ataxia gait Wide-based gait. Feet are loosely thrown forward, landing first on the heels and then on the toes. Patient watches the ground to help guide the feet. Positive Rothenberg from loss of position sense.
What is a dystrophic gait Waddling. Wide gait. Weight is shifted from side to side with stiff trunk movement. Abdomen protrudes and lordosis is common.
What's may cause spastic hemiparesis? Stroke.
What may cause scissors gait? Spastic diplegia associated with bilateral spasticity of the legs.
What may cause cerebellar ataxia gait? Cerebral palsy and alcohol intake.
What may cause sensory ataxia gait? Cerebral palsy.
What may cause a dystrophic gait? Weak hip abductors.
What is peripheral neuropathy? Sensory loss is distributed peripherally in a characteristic "glove" "stocking" pattern. More diffuse and less specific than injury associated with individual nerve.
What may cause peripheral neuropathy? Diabetes mellitus or peripheral vascular disease.
Abnormalities of sensory function to individual nerves through trauma or injury may present as? Following the pattern expected in the nerve, with the cutaneous distribution that follows the dermatome.
What is spinal cord hemisection? Because of how the nerves cross the spinal cord, pain and temperature are lost below the level of the lesion on the opposite side. Position sense, vibration and motor function are affected on the same side of the body.
What may cause spinal cord Hemi-section? Brown Sequards syndrome from spinal cord injury, tumor or mass.
Complete transaction of the spinal cord will cause what? All sensation and motor function is lost below the level of the lesion.
What are the pathological (primitive) reflexes? Grasp, snout, sucking, rooting, palmomental, Hoffman sign and Glabellar’s sign.
How do you initiate a grasp reflex? Apply palmar stimulation.
How do you initiate the snout reflex? By tapping a tongue blade across the lips.
How do you initiate the sucking reflex? Touch or stroke the lips, tongue or palate.
How do you initiate the rooting reflex? Stroke the lateral upper lip.
How do you initiate the palmomental reflex? Stroke the palm of the hand.
How do you initiate Hoffman’s sign? Tab the nail on the third or fourth finger.
How do you initiate Glabellar’s sign? Tap the forehead to cause the patient to blink.
What is a grasping response in an adult associated with? Dementia and diffuse brain impairment.
The snout reflex is present if? Tapping causes the lips to purse.
The rooting reflex is present if? The patient moves the mouth toward the stimulus.
The palmomental reflex is present if? Stroking of the palm causes contraction of the same sided muscle of the lower lip.
A positive Hoffman’s sign is? If tapping eliciting involuntary flexion of the distal joint of the thumb and index finger.
Describe Glabellar’s sign Normally, the first five taps cause a single blink and then the reflex diminishes. Blinking continues in patients with diffuse cerebral dysfunction.
What are Cheyne-Stokes respirations? Also called spindle pattern. Period of apnea (10 – 60 secs) followed by gradually increasing depth and frequency or respiration, gradually decreasing in depth and frequency until period of apnea.
What may cause Cheyne-Stokes respirations? Poor brain stem perfusion.
What is gasping? Rapid and quick difficult breaths; irregular respirations with varying rate and tidal volume.
What may cause gasping? Extensive pons damage, severe hypoxia.
What is apnea? Absence of breathing.
Created by: heathrow
 

 



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