Jarvis Chapter 25 (p.

687-747)

STRUCTURE AND FUNCTION:

Category Description/Summary
THE CENTRAL NERVOUS SYSTEM Cerebral Cortex:
 Frontal lobe (personality, behavior,
emotions, and intellectual function
 Parietal lobe (sensation)
 Occipital lobe (visual)
 Temporal lobe (audio, language, motor
speech)

Basal Ganglia
 Automatic associated movements of body

Thalamus
 Relay for nervous system

Hypothalamus
 Temperature, HR, BP, sleep, emotions

Cerebellum
 Motor coordination of voluntary
movements, equilibrium

Brain Stem
 Midbrain (Motor neurons and tracts)
 Pons (Fibre tracts)
 Medulla (Vital autonomic centres)

Spinal Cord
 Nerve cell bodies

PATHWAYS OF THE CNS Crossed representation

 Left to right/ Right to left

Sensory pathways
 Spinothalamic Tract (transmit sensations
of pain, temp, crude or light touch
 Posterior Columns (Position, vibration,
finely localized touch)

Motor Pathways
  Corticospinal/Pyramidal Tract (motor
nerve fibres – voluntary movements)
 Extrapyramidal Tract (muscle tone, body
movements, gross automatic movements)
 Cerebellar System (coordinate movement,
equilibrium, maintain posture)

Upper and Lower Motor Neurons

 Upper motor neurons (convey impulses
from the motor areas of the cerebral
cortex to the lower motor neurons in
anterior horn cells of the spinal cord)
 Lower motor neurons (movement
translated into action by lower motor
neuron fibres)

Reflex Arc
PERIPHERAL NERVOUS SYSTEM  Deep tend reflex (patellar knee jerk)
 Superficial (corneal, abdominal)
 Visceral (pupillary response)
 Pathological (abnormal, extensor plantar)

Cranial Nerves
 12 pairs (heart, respiratory muscles,
stomach, gallbladder)

Spinal Nerves
 31 spinal nerves
- 8 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 1 coccygeal

Somatic and Autonomic Nerve Fibres

 Somatic (skeletal muscles, autonomic
fibres for smooth muscles)
 Autonomic (unconscious activity)

Infants:
DEVELOPMENTAL CONSIDERATIONS  Neurological system not completely
developed
 Sensory and motor development proceeds
with acquisition of myelin
 Older Adults:
 General atrophy with steady loss of
neurons in the brain and spinal cord
 Loss of muscle bulk
 Muscle tone in face
 Velocity of nerve conduction decreases
 Decrease in cerebral blood flow
 Better integrity in good health

SUBJECTIVE DATA:

Category Description/Summary
1. HEADACHE  Unusually frequent or severe headaches?
 Onset? How often does this occur?
 Where do you feel?
 Association?

2. HEAD INJURY  Ever had head injury?

 What part of your head was hit?
 Did you experience LOC? How long?
 Do you use helmet?

3. DIZZINESS OR  Lightheaded or faint?

VERTIGO  When have you noticed? How often? Occur with activity?
 Rotational spinning sensation? Room spinning? You are
spinning? Suddenly or gradually?

 ABNORMAL:
 Syncope: sudden loss of strength and temporary LOC
caused by lack of cerebral blood flow
 Vertigo: sensation of rotational spinning

 Had any before? Onset? How often?

4. SEIZURES  Course and duration (Warning signs?)
 Motor activity (Which part of body? One side or both?
Tense or limp?)
 Colour change in face or lips, LOC, automatisms,
incontinence
  Postictal Phase (Sleep after seizure, confusion, weakness,
headache, muscle ache)
 Precipitating factors (anything antagonize?)
 Meds?
 Coping strategies (How has affected your life?)

 ABNORMAL
 Occur with epilepsy.

 Tremors in hands or face? Onset?

 Worse with anxiety? Rest?
 Relieved with rest activity? Alcohol? Affecting daily
5. TREMORS activities?

 Problem moving a body part? Generalized or local?

 Difficulty with certain movements
6. WEAKNESS
 ABNORMAL
 Paresis (weakness of voluntary movements)
 Paralysis (loss of motor function/sensory innervation)

 Problem with coordination?

 Balance?
 One side? Falling? Problem with legs?
7. INCOORDINATION
 ABNORMAL
 Dysmetria (inability to control ROM)

 Any body part? Feel like pins or needles?

 Onset? Where you feel it? Occur with activity?

8. NUMBNESS OR  ABNORMAL
TINGLING  Paraesthesia (abnormal sensation – burning or tingling)
SENSATION

 Problem swallowing (dysphasia)

 Occur with solids or liquids? Excessive salivation,
drooling?
9. DIFFICULTY
SWALLOWING  Problem speaking? Forming words or with intention to
 say? First notice? How long it lasts?

10. DIFFICULTY  ABNORMAL

SPEAKING  Dysarthria (difficulty forming words, aphasia)

 Ever had a stroke?

 Spinal cord injury?
 Meningitis/encephalitis
11. SIGNIFICANT PAST  Congenital defect? Alcoholism?
HISTORY

 Insecticides? Organic solvents? Lead?

 Any meds?
 Alcohol?
12. ENVIRONMENTAL  Mood altering drugs (marijuana, cocaine, barbiturates,
AND tranquilizers)
OCCUPATIONAL
HAZARDS
1. Maternal health
2. Neonatal period
3. Reflexes
ADDITIONAL HISTORY 4. Weakness and balance (muscular atrophy)
FOR INFANTS AND 5. Seizures
CHILDREN 6. Physical development
7. Environmental hazards
8. Cognitive development
9. Family history

1. Risk for falls

2. Cognitive function
3. Tremor
ADDITIONAL HISTORY 4. Vision
FOR OLDER ADULTS

OBJECTIVE DATA:
Category Description/Summary
ORDER FOR COMPLETE 1. Mental health
NEUROLOGICAL EXAMINATION 2. Cranial nerves
3. Motor system
4. Sensory system
5. Reflexes

TEST CRANIAL NERVES CN I: Olfactory Nerve

 Not tested routinely – only for loss of
smell, head trauma, abnormal mental
status and intracranial lesion suspected
 One nostril at time – present aromatic
substance (coffee, toothpaste, orange)
 Asymmetry in sense of smell important

CN II: Optic Nerve

 Test visual acuity and fields by
confrontation (ophthalmoscope)

CN III, IV, VI: Oculomotor, Trochlear,

Abducens Nerves
 Palpebral fissures usually = in width
 Check pupils
 Presence of nystagmus (one or both eyes)
 Pendular movement or jerk
 Amplitude (degree of movement fine,
medium or coarse)
 Frequency (nystagmus constant or fades)
 Plane of movement (nystagmus
horizontal, vertical, rotary, combination)

CN V: Trigeminal Nerve
 Motor Function (palpate temporal and
masseter muscles as patient clenches teeth
– must be equal) (separate jaws by
pushing down on chin – normally you
cannot)

 Sensory Function (Eyes closed –

forehead, cheeks, chin) say now.

 Corneal Reflex (only for abnormal facial

sensation or facial movement – wisp of
cotton and lightly touch cornea, normally
person blink bilaterally
 CN VII: Facial Nerve
 Motor Function (mobility and facial
symmetry)
- Smile, frown, close eyes tight, lift eyebrows,
show teeth, puff cheeks

 Sensory Function (not routinely – identify

taste

CN VIII: Acoustic (Vestibulocochlear)

Nerve
 Able to hear conversation

CN IX, X: Glossopharyngeal and Vagus

Nerves
 Motor Function (depress tongue with
blade, say ah – uvula and soft palate
should rise in the midline, tonsillar pillars
should move medially

 Sensory Function (Cranial nerve IX

mediate taste to posterior 1/3 of tongue)

CN XI: Spinal Accessory Nerve

 Check sternomastoid and trapezius
muscles for = size
 Check = strength ask patient to rotate
head forcibly against resistance applied to
side of the brain
 Shrug shoulders against resistance

CN XII: Hypoglossal Nerve

 Inspect tongue – no tremors should be
present
 Light tight dynamite

Muscles
 Size (inspect all muscle groups for size)
INSPECT AND PALPATE THE MOTOR - Compare bilaterally
SYSTEM - Record difference in cm (1cm or less not
significant)

 Strength (test homologous muscles

simultaneously) extremities, neck, trunk

 Tone (contract in voluntary relaxed

muscles
- move extremities through passive ROM
(full), even resistance to movement

 Involuntary movements (no involuntary

movements occur)

Cerebellar Function

Balance Tests

 Gait (patient walks 3 to 6m, turns and

returns to starting point)
 Walk in heel to toe manner – normally
walk straight and stay balanced

 Romberg Test
 Feet together and arms at sides
 Close eyes and hold position – wait 20 sec
 Should maintain posture and balance
 Shallow knee bend/hop in place (separate
leg)

Coordination and Skilled Movements

 Rapid Alternating Movements

 Pat knees with both hands back and front
 Thumb to each finger on same hand

 Finger to Finger Test

 Touch my finger then your nose

 Finger to Nose Test

 Touch nose with each index finger
 Heel to Shin Test
 Supine position – place heel on opposite
knee and move down from knee to ankle
 Spinothalamic Tract

 Pain
ASSESS THE SENSORY SYSTEM  Break tongue blade lengthwise (sharp and
dull end)
 Note if patient can tell difference when
touched with either ends

 Temperature
 Ask which temperature is felt with test
tube water

 Light Touch
 Apply cotton wisp to skin (ask when
touch is felt)

Posterior Column Tract

 Vibration (tuning fork)

 Position (Kinaesthesia)
 Ask which way extremity is moved when
manipulated

 Tactile Discrimination (Fine Touch)

 Stereognosis (recognize objects feeling it
with eyes closed) ask to identify it
 Both hands

 Graphaethesia (read number traced on

skin) – unable to read means sensory
cortex lesions

 Two point discrimination (distinguish

separation of 2 simultaneous pinpoints on
skin)
 Extinction (Touch both sides of body at
same point) Note sensations
 Point location (Touch skin, and point
where sensation felt)
Stretch (Deep Tendon) Reflexes
 Reflex response
 4+ (very brisk) - disease
 3+ (brisker than average) – disease
TEST REFLEXES  2+ (average) – normal
 1+ (diminished) – low normal
  0 (no response)

Biceps Reflex
 Thumb on bicep tendon, strike thumb
 Flexion of forearm

Triceps Reflex
 Limp forearm, strike tricep tendon
 Extension of forearm

Brachioradialis Reflex
 Hold patient thumb suspend forearm,
strike forearm approx. 2-3 cm above
radial process
 Flexion and supination of forearm

Quadriceps/Patellar (Knee Jerk) Reflex

 Dangle leg, strike tendon below patella
 Extension of lower leg expected response

Achilles (Ankle Jerk) Reflex

 Knee flex, dorsiflex foot, strike achilles
tendon
 Plantar flexion

Clonus (for hyperactive reflex)

 Support lower leg in supine, dorsi flex
foot
 Normally no movement
 Abnormally rapid contractions of calf
muscle and movement of foot

Abdominal Reflexes
 Supine position (split tongue blade to
strok skin)
 Side of abdomen toward midline of both
upper and lower abdomen)
SUPERFICIAL (CUTANEOUS) REFLEXES
Cremasteric Reflex
 Lightly stroke inner aspect of thigh
 Elevate testicle

Plantar Reflex
 Thigh slight external rotation
 Stroke sole of foot upside down J shape
 Normally plantar flexion of toes and
inversion and flexion of forefoot