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Protective structures

Skull—protects brain
• Foramen magnum
• foramina
• Meninges = dura mater, arachnoid, pia mater, brain all the way down the SC
Adult = pressure
Child = swelling

Cerebrospinal fluid: what does it look like & what does it do?

-Cerebrospinal fluid = COLORLESS (cloudy = infection), ODORLESS fluid containing:
• Glucose, electrolytes, oxygen, water, carbon dioxide, and leukocytes
• Produced in choroid plexus of ventricles
• provides cushion, maintains intracranial pressure, nutrition & remove metabolic wastes

cerebral ventricular system: how many & what do they do?

• 4 interconnecting chambers or ventricles that produce & circulate CFS

The Brain is made up of?

• Cerebrum, diencephalon, cerebellum, and brainstem
- Gray matter (cell bodies)/white matter (myelinated nerve fibers)

Brain circulation: blood flow

• Blood flow
- Carotid arteries (also vertebral artery)
- Blood to cerebrum—posterior, middle, and anterior cerebral arteries
- Posterior/anterior communicating arteries— flow through circle of Willis
- Blood leaves brain through venous sinuses into jugular veins

Describe the general anatomy of the Cerebrum?

• largest part of the brain & has 2 hemispheres
• Each hemisphere divided into 4 lobes

Cerebrum: frontal lobe functions

-Frontal lobe: primary motor cortex— voluntary motor activity & personality
• Left frontal lobe— Broca's area → formation of words

cerebrum: parietal lobe function

• primary sensory cortex
• position sense, touch, shape & texture of objects

Cerebrum: Occipital lobe function

left frontal lobe - primary visual cortex

Broca's area function

Involved with formulation of words

Cerebrum: Temporal lobe function

primary auditory cortex

Wernicke's area: where is it & what is the function?

• (left temporal lobe)
• responsible for comprehension of spoken & written language

Diencephalon consist of: (4) skipped

1. Thalamus
2. Hypothalamus
3. epithalamus
4. subthalamus

Thalamus: functions (skipped)

- relay/integration station from spinal cord to cerebral cortex and other parts of brain

Hypothalamus: functions (skipped)

- maintaining homeostasis
- other functions: regulates body temp, hunger, thirst, formation of ANS responses, storage & secretion of hormones from pituitary gland

Epithalamus functions (skipped)

• (pineal gland)—causes sleepiness; regulate some endocrine function

Subthalamus function (skipped)

• part of basal ganglia
- extrapyramidal system of autonomic nervous system and basal ganglia

Basal ganglia function

- Located between cerebral cortex and midbrain, adjacent to diencephalon
- Create smooth, coordinated voluntary movement; balance production of two neurotransmitters: acetylcholine and dopamine

Brainstem consists of: (skipped)

-Midbrain, pons, and medulla oblongata
-10 of 12 cranial nerves (CNs) originate

Midbrain: function (skipped)

— relays stimuli concerning muscle movement to other brain structures

Pons: function (skipped)

- relays impulses to brain centers and lower spinal nerves

Medulla oblongata functions & what unusual thing happens?

- reflex centers for controlling involuntary functions
- * Motor/sensory tracts from frontal/parietal lobes cross to other side in medulla; *right side lesions create abnormal movement/sensation on left side and vice versa **

Cerebellum functions

- Separated from the cerebral cortex by tentorium cerebelli
• Coordinating movement, equilibrium, muscle tone, and proprioception
• Each hemisphere controls movement for same (ipsilateral) side of body

Spinal cord anatomy: general (3)

• Continuation of medulla oblongata; begins at foramen magnum and
• ends at 1st and 2nd lumbar (L 1/2) vertebrae
• At L 1/2—spinal cord branches into lumbar and sacral nerve roots

SC: What does the descending tracts do?

• (motor tracts)—impulses from frontal lobe to muscles for voluntary movement; also role in muscle tone and posture

SC: What does the Ascending tracts do?

• (sensory tracts)—sensory information from body through thalamus to parietal lobe

SC: Gray matter anatomy

• (contains nerve cell bodies)—butterfly shape with anterior and posterior horns

Cranial nerves: how many?

-12 pairs of cranial nerves
• motor fibers (5 pairs)
• sensory fibers (3 pairs)
• both motor and sensory fibers (4 pairs)

Spinal nerves: how many & where in spine

- 31 pairs emerge from segments of spinal cord
• 8 cervical
• 12 thoracic
• 5 lumbar
• 5 sacral
• 1 coccygeal nerves

Reflex arc: what is it?

• observing muscle movement, response to sensory stimuli
• deep tendon reflexes → responses to stimulation of tendon that stretches neuromuscular spindles of a muscle group

deep tendon reflexes definition

responses to stimulation of tendon that stretches neuromuscular spindles of a muscle group

Superficial reflexes: Upper abdomen are where on spine?

T7, T8, T9
Generally not tested b/c insignificant

Superficial reflexes: lower abdomen are where on spine?

T10, T11

Superficial reflexes: cremasteric are where on spine?

T12, L1, L2

Superficial reflexes: Plantar are where on spine?

L4, L5, S1, S2

Deep tendon reflexes: Biceps are where on spine?

C5, C6

Deep tendon reflexes: Brachioradial are where on spine?

C5, C6

Deep tendon reflexes: Triceps are where on spine?

C6, C7, C8

Deep tendon reflexes: Patellar are where on spine?

L2, L3, L4

Deep tendon reflexes: Achilles are where on spine?

S1. S2
Ex. If you had a L2 injury the Achilles reflex wouldn't work because it's lower. Cervical → thoracic→lumbar→sacral

Autonomic Nervous System: function and what are the 2 systems?

• Regulates body's internal environment with endocrine system
• Two components
1. Sympathetic nervous system (SNS) = thoracolumbar segments of spinal cord; activated during stress ("fight or flight" response) ↑HR (b-blocker causes HR↓)
2. Parasympathetic nervous system (PNS) = craniosacral segments of spinal cord; controls vegetative functions

Sympathetic nervous system (SNS): where on spine & what is the function?

thoracolumbar segments of spinal cord; activated during stress ("fight or flight" response) ↑HR (b-blocker causes HR↓)

Parasympathetic nervous system (PNS): where on spine & what is the function

craniosacral segments of spinal cord; controls vegetative functions

Brain attack, cerebrovascular accident (CVA) Traits (7)

aka = stroke
1. Age: older at greater risk
2. Gender: men at greater risk than women (women - more than half of deaths from brain attacks)
3. Family history: risk greater if parent, grandparent, or sibling had a brain attack
4. Race: African Americans at higher risk of death from brain attack & CVA at younger age
5. Previous brain attack or heart attack increases risk of brain attack
6. High blood pressure—undue pressure on arteries = young people with strokes
7. Smoking: nicotine constricts blood vessels; CO reduces oxygen in blood

Health History: risk factors (5)

-Atrial fibrillation = atria jiggles can move to PE & stroke
-High serum cholesterol = plaque
- Obesity = ↑ BP
-Excessive alcohol intake = >2 per day
-Cocaine use increases risk

Problem based history: Headache questions

• Describe. What do they feel like? Where? Last how long? How often?
• Recent surgeries or medical procedures such as spinal anesthesia or lumbar puncture?

Problem based history: Dizziness questions (3)

• How do you feel when dizzy or lightheaded? Feel as if you can't keep balance or may fall? How often? Is the dizziness associated with change in position/activity? What makes it worse? What relieves it?
• Ever feel like room is spinning (objective vertigo) or that you are spinning (subjective vertigo)? Suddenly or gradually? What makes it worse? What relieves it?
• most hypertension meds cause dizziness

Problem based history: seizure questions (5)

• How often are you having seizures/convulsions? Last seizure? What are they like? Become unconscious?
• Warning signs before seizure? Describe what happens.
• When client loses consciousness during seizure, ask the following questions to person observed seizure:
- Describe how feeling proceeds through body. Where did feeling begin? Travel? To Where? Observe repeated, automatic movements (e.g. lip smacking or eyelid fluttering) Loss of urine or bowels?
• Feeling after the seizure? Confused? Headache or aching muscles? Do you spend time sleeping?
• Factors that seem to start seizures—stress, fatigue, activity, or discontinuing medication, fever? Did you take actions to prevent hurting yourself?

Problem based history: Loss of consciousness questions

• When did you lose consciousness or feel you weren't aware of surroundings? Did it occur suddenly? What happened just before? Other symptoms? Have diabetes mellitus, liver failure, or kidney failure?

Problem based history: changes in movement questions & possible cause

• How long have you had a change in your mobility? Describe. continuous or intermittent? Parkinsons

Dysphagia definition & assessment questions (4)

= difficulty swallowing → stroke, MS
• How long have you had the problem?
• Were liquids or solids involved? Both?
• Have excessive saliva or drooling?
• Did you cough or choke when trying to swallow?

Routine neural examination (5)

• Assess mental status (orientation X4) and LOC (are they alert?)
• Evaluate speech
• Notice cranial nerve functions
• Observe gait
• Evaluate extremities for muscle strength/sensation (both UE & LE)

Special circumstances in neural examination (4)

• Assess cranial nerves
• Assess cerebellum (can be related to ↑ alcohol use)
• Assess peripheral nerves
• Assess altered level of consciousness

How do you assess mental status and LOC when you walk in patient's room (2)

• Say clients name
• Gather information during subjective component (ex. why are you here? How did you sleep last night?)

How do you do a speech evaluation?

• Evaluate speech—articulation, voice quality, conversation (comprehension of verbal communication)
- Voice—inflections, sufficient volume
- Responses—indicate understanding, listening, answering appropriately, are they asking questions back?

Cranial Nerve: I

• Olfactory
• Close eyes
• Occlude nostril
• Client identifies common smell (coffee, oranges)
not tested too often

Cranial Nerve: II

• Optic
• Visual acuity using snellen
• Confrontation test

Cranial Nerve: III

• Oculomotor
• Observe eyes for extra ocular movement
• Observe eyes—pupillary size, shape, equality, constriction, accommodation
• if person is awake, alert, appropriate then pupils are okay.
• elderly = constriction/pupils are smaller

Cranial Nerve: IV

• trochlear
• Observe eyes for extra ocular movement
• Observe eyes—pupillary size, shape, equality, constriction, accommodation
• if person is awake, alert, appropriate then pupils are okay.
• elderly = constriction/pupils are smaller

Cranial Nerve: V

• Trigeminal
• Evaluate face—movement/sensation
• Motion—clench teeth—palpate temporal/masseter muscles; symmetrical facial characteristics when making 'faces'
- Light touch—cotton tipped swab lightly over 3 branches
- Deep sensation—sharp/dull over same areas
- Corneal reflex—omitted if alert/blinking normally

Cranial Nerve: VI

• Abducens
• Observe eyes for extra ocular movement
• Observe eyes—pupillary size, shape, equality, constriction, accommodation
• if person is awake, alert, appropriate then pupils are okay.
• elderly = constriction/pupils are smaller

Cranial Nerve: VII

• Facial
• Evaluate face—movement/sensation
• Motion—clench teeth—palpate temporal/masseter muscles; symmetrical facial characteristics when making 'faces'
- Light touch—cotton tipped swab lightly over 3 branches
- Deep sensation—sharp/dull over same areas
- Corneal reflex—omitted if alert/blinking normally
• Anterior 2/3 of tongue CN VII (sweet & salty)

Cranial Nerve: VIII

• Acoustic (vestibulocochlear)
• Acoustic
• Rinne
• Weber's
• also whisper test or rub fingers together

Cranial Nerve: IX

• Glossopharyngeal
• Posterior 1/3 of tongue CN IX
• Movement of soft palate (is tongue midline)
- aahhhh" test (vagus)
• Gag reflex (not on someone awake & alert)

Cranial Nerve: X

• Vagus
• Movement of soft palate
- aahhhh" test (vagus)
• Gag reflex

Cranial Nerve: XI

• Spinal accessory
• Test shoulders and neck for strength and movement
• Have client shrug shoulders; turn

Cranial Nerve: XII

• Hypoglossal
• Test tongue for movement, symmetry, strength, and absence of lesions
• Test for muscle strength
-Have client protrude tongue, move
toward nose, chin, side to side
-Have client press tongue against gloved finger

Test Cerebellar Function: Balance & Coordination Tests of LE (4)

• Gait
• Tandem walking (heel to toe)
• Romberg's test
• Shallow knee bend

Test Cerebellar Function: UE - coordination & skilled movements (4)

• Rapid alternating movements
• Finger‐to‐finger test
• Finger‐to‐nose test
• Heel‐to‐shin test (lower)

Test Cerebellar Function: LE - Coordination (1)

• Heel to knee, down to shin

How do you assess for sensation both in UE & LE (8) and possible causes (2)

- Dermatome map—identify spinal nerve providing sensation
• Monofilament—peripheral sensation for peripheral neuropathy (usually LE, should feel by the time it bends in half)
• Light touch—cotton tipped swab
• Sharp/dull
• Vibration—vibrating tuning fork on bony prominence; feel vibration/when stops (usually LE)
• kinesthetic sensation
• sterognosis
• graphesthesia
• 2 point discrimination test
= DM, arterial disease

What is Kinesthetic sensation & possible causes of abnormalities?

moving finger/toe up/down
-test neuropathy = DM, arterial disease

What is Stereognosis & possible causes of abnormalities?

—identification of familiar object in hand
very difficult for dementia patients
-test neuropathy = DM, arterial disease

What is the 2 point discrimination & possible causes of abnormalities

—touch parts of body simultaneously with 2 points—how many points felt?
-test neuropathy = DM, arterial disease

what is Graphesthesia & possible cause of abnormalities

—identification of number/letter drawn on hand, back, other area
-test neuropathy = DM, arterial disease

What is evaluation of Deep Tendon Reflexes & how is it scored?

- Muscle contraction response to direct/indirect percussion of tendon
- Client relaxed; lying/sitting down
- 4+ scoring system

Reflex scoring for DTRs?

• 0 = no response
• 1+ = sluggish or diminished
• 2+ = active or expected response
• 3+ = slightly hyperactive, more brisk than normal
• 4+ = brisk, hyperactive with intermittent clonus
• 5+ = sustained clonus (continuous severe tremors)

What happens with the Triceps reflex & location on spine?

—contraction of triceps muscle; extension of elbow
• C6, C7, C8

What happens with the Biceps reflex & location on spine?

—contraction of biceps muscle; flexion of elbow
• C5, C6

What happens with the Brachioradialis reflex & location on the spine?

—pronation of forearm; flexion of elbow
• C5, C6

What happens with the Quadriceps (patellar) reflex & location on the spine?

• Contractionof quadriceps, causing extension of lower leg
• L2, L3, L4

What happens with the Achilles reflex & location on the spine?

• Flex knee & dorsiflex the ankle at 90 degrees
• Hold bottom of foot, while striking tendon
• Expect contraction of gastrocnemius muscle, causing plantar flexion (flex downward) of foot
• S1, S2

What happens with the Plantar reflex?

• Plantar: stroke lateral aspect of the sole of the
foot from heel to ball
• Expected findings = plantar flexion of all toes

What is Ankle clonus reflex & what should you expect?

• Test if other reflexes are hyperactive
• Support knee in a partly flexed position • Dorsiflex the foot
• Expect = no movement of the foot

superficial reflexes (2)

• Evaluate superficial reflexes (little clinical significance for presence/absence)
-Abdominal—stroke abdomen away from umbilicus
-Cremasteric (males)—stroke upper/inner thigh; testicle should rise slightly

How can you determine if there is an altered level of consciousness?

• can determine if client is alert/oriented by way that questions are answered during the history
• ***changes in LOC - earliest/most sensitive indicator of - Assessing awareness
• Determined by orientation, memory, attention, calculation, recall, and language, as well as judgment, insight, and abstraction
• Date/time—first orientation to disappear -Only a problem if remains disoriented
after being reoriented
• Place—2nd orientation to disappear
• Person—last orientation to disappear

What is Awareness & how to determine if it exists?

—higher level function; controlled by reticular activating system
—mental status (orientation (X4), memory, attention, calculation, recall, language, insight, dementia - pain anxiety, abstraction) alterations in cerebral function

What controls wakefulness?

controlled by brainstem

What does Glasgow coma scale mean?

assess LOC using 3-15 point scale
- done anyone semi-comatose
- pain #1 descriptor used in assessment of best eye/best motor response
Three categories
1. Best eye-opening response
2. Best verbal response
3. Best motor response

What does PERRLA mean?

pupils are
equal and
round and
reactive to
light and

What is abnormal flexion and it's technical name?

- with stimuli
- rigid holding of arms to chest (bending elbows)

What is abnormal extension & it's technical name?

- with stimuli
- rigid hold of arm to the side

What is orientation X4?


How to Assess awakening abilities in a patient?

- Determine stimulation/pain required to elicit response
- 1st stimulation—touch, normal voice tone
- Shake client on shoulder/leg; shout
- Painful stimuli begin peripherally, move centrally

How do you apply painful stimuli to awaken a patient?

Applied until client responds in some way or for at least 15 seconds, but no more than 30 seconds
- Begin by depressing nailbed at cuticle with your fingernail or length of pen or pencil
- Squeeze trapezius muscle very hard
- Push upward on supraorbital notch above eye

What is Kernig's sign & what does it test for?

flexing one leg at hip and knee, then extending knee
• No pain—negative Kernig's sign
• If inflammation of meninges—pain along vertebral column when leg is extended; positive Kernig's sign (irritation of meninges)

What is Brudzinski's sign & what does it test for?

• client supine
• Client's neck flexed
• No pain or resistance to neck flexion
• Positive Brudzinski's sign—client passively flexes hip/knee in response to head flexion; reports pain along vertebral column

older adults: What structural changes should you expect to see in the nervous system?

• effects of aging of nervous system gradual; structural and functional changes
• structural changes = dilation of ventricles
- cortical atrophy (brain gets smaller); greater in frontal/temporal lobes

older adults: What functional changes should you expect to see in the nervous system?

• Decline in sensorimotor function most noticeable
• Eye lens thickens; smaller pupil—brighter light for vision
• 50% of those >75 years report hearing difficulties
• Short‐term memory declines with age, long‐ term memory usually maintained
• Cognitive decline—modest during normal aging

What is crystallized intelligence?

acquired knowledge maintained throughout life

What is fluid intelligence?

ability to acquire new concepts, adapt to unfamiliar situations, peaks between 20-30 and then declines

What are some abnormal muscle movements?

• Paralysis
• Tic
• Myoclonus • Tremor
• Rest tremor
• Intention tremor • Chorea
• Athetosis

What are some abnormal postures?

• Flaccid quadriplegia • Opisthotonos

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