CN

https://appliedanatomy.weebly.com/
Major Brain Regions
🞂 CEREBRAL HEMISPHERES
 Major Brain Regions
🞂 DIENCEPHALON

https://www.google.com/search?q=thalamus+hypothalamus+and+limbic+system&sourc
Major Brain Regions
🞂 THE BRAIN STEM

https://www.azchironeuro.com/wp-content/uploads/2017/06/
brain-and-brainstem.jpg
Major Brain Regions
🞂 CEREBELLUM
 Medulla Oblongata

mage.slidesharecdn.com/the brain
 Areas of the Brain

https://biofeedback-
neurofeedback-
therapy.com/
Neuron https://olesyalutsenko.files.wordpress.com/
HISTORY OF PRESENT HEALTH
CONCERN -COLDSPA-
What does COLDSPA stand for?

Character-dull, achy, sharp, stabbing, shooting, burning,

or numb sensation
Onset-when did it start? abrupt and sudden or insidious
and gradual
Location-where? Does it radiate? which side of the body,
and which specific body part is experiencing pain
Duration-"acute" to pain that lasts less than 30 days,
"chronic" to pain of more than six months' duration, and
"subacute" to pain that lasts from one to six months.
 HISTORY OF PRESENT HEALTH
CONCERN -COLDSPA-
Severity- the intensity graded by the patient or the impact pain has on
function.

🞂 Pattern- represents how the individual's pain changes with time.

🞂 and Associated Factors- What are the 8 factors of pain?

🞂 Biological factors include age, existing medical conditions, medications, and
genetics. Social factors include cultural beliefs, social support, where an
injury took place, and activities of daily living. Psychological factors include
stress, coping mechanisms, beliefs about pain, mood, and expectations.
HISTORY OF PRESENT HEALTH
CONCERN -COLDSPA-
1. Numbness , tingling/Prickling (Paresthesias)
2. Seizure- occurs with epilepsy, metabolic disorders,
head injuries, high fevers
-an aura forewarns the client that a
seizure is about to occur.
-where the seizure start and what occurs
and before and after- determines the type

SAFETY MEASURES
EPILEPSY
Seizures
Types of seizure
🞂Grand mal- generalized seizure
affecting both hemisphere of the
brain.
- often has bladder incontinence
🞂Absence seizure or petit mal seizure
Types of seizure
🞂 There are six types of generalized seizures: 1.absence
seizures
2. atonic seizures,
3. myoclonic seizures,
4.clonic seizures,
5.tonic seizures, and
6.tonic-clonic seizures.
Types of seizure
1. Absence seizures, also known as petit mal seizures,
typically cause patients to adopt a blank stare with or
without blinking. This may commonly be mistaken
for daydreaming, as these episodes are usually short,
lasting less than 15 seconds.
2. Atonic seizures, or drop attacks, cause the muscles to
go limp. Falls are a major concern in these types of
seizures.
Types of seizure
3.Myoclonic seizures are the opposite of atonic seizures
and are characterized by brief, jerky movements in
different muscles of the body.
4. Clonic seizures cause similar muscle jerks and spasms
in all parts of the body and may last longer.
5. In tonic seizures, patients stiffen up and often lose
consciousness. Their eyes may roll back, and their neck
and back may arch. Patients may make gargling noises as
their chest muscles tighten, and their face may take on a
bluish color as breathing becomes more difficult.
 HISTORY OF PRESENT HEALTH
CONCERN -COLDSPA
3. Headaches
Types and Characteristics of Headaches
a. Sinus Headache-Deep constant throbbing pain; pressure
like pain in one specific area of face or head
b. Cluster Headache-Stabbing pain; may be accompanied
by tearing, eyelid drooping, reddened eye. Or runny nose
c. Tension Headache- Dull tight, diffuse
d. Migraine Headache-Accompanied by nausea, vomiting,
and sensitivity to noise or light.
e. Tumor related Headache- Aching, steady, neurologic and
mental symptoms as well as nausea and vomiting
Headaches
HISTORY OF PRESENT HEALTH
CONCERN -COLDSPA

4 dizziness /lightheadedness/problem with balance or

coordination?
5.Senses-smell/taste
6.Ringing of ears or hearing loss-cranial nerve VIII
7.Changes in vision- optic nerve dysfunction, CN II, ICP,
or tumor. CN III or VI- double or blurred vision
HISTORY OF PRESENT HEALTH
CONCERN
8. Difficulty in speaking/ understand others or difficulty
making others understand/ difficulty in forming words
or verbally interpreting thoughts.- injury to cerebral
cortex
9. Difficulty in swallowing- CVA, parkinson’s disease,
myasthenia gravis, Guillain-Barre syndrome, CN X or
XII
🞂 Myasthenia gravis (my-us-THEE-nee-uh GRAY-vis) is
characterized by weakness and rapid fatigue of any of
the muscles under your voluntary control. It's caused
by a breakdown in the normal communication between
nerves and muscles.

🞂 Parkinson's disease is a disorder of the nervous system.

It results from damage to the nerve cells that produce
dopamine, a chemical that is vital for the smooth
control of muscles and movement.
Myasthenia Gravis

Myasthenia gravis (MG)

HISTORY OF PRESENT HEALTH
CONCERN
10. Muscle control-loss of bowel/bladder control?-SCI or
tumor.
11. Muscle weakness? Where? – unilateral weakness or
paralysis results from CVA, compression of spinal
cord. Progressive weakness is a symptom of several
nervous system disease
HISTORY OF PRESENT HEALTH
CONCERN
12. tremors? Where?- degenerative disease-parkinson’s,
multiple sclerosis
13. Memory loss- recent-24hour-amnesia, korsakoff’s
syndrome, delirium and dementia.
remote memory- (past dates and historical accounts)-
impaired in cerebral cortex disorders
Multiple Sclerosis

https://www.google.com/search?q=multiple+sclerosis
Past health history
🞂 Head injury with or without loss of consciousness.
Describe any mental changes occurred. What type of
treatment receive?
🞂 Ever had meningitis, encephalitis, SCI or stroke.
Family history
🞂 High blood pressure, stroke, alziemer, epilepsy, brain
cancer, or huntington’s chorea.

🞂 Huntington's disease is a rare, inherited disease that

causes the progressive breakdown (degeneration) of
nerve cells in the brain. Huntington's disease has a
broad impact on a person's functional abilities and
usually results in movement, thinking (cognitive) and
psychiatric disorders.
Alzheimer’s Disease
Lifestyle and health practices
🞂 Medications taken/ alcohol/ use of marijuana,
tranquilizers, barbiturates or cocaine
🞂 Smoke?
🞂 Seat belt??
🞂 Daily diet-peripheral neuropathy results from a
deficiency in niacin, folic acid or vitamin B12
Lifestyle and health practices
🞂 Prolonged exposure to lead, insecticides, pollutants or
other chemicals?- alter neurologic status
🞂 Frequently lift heavy object or perform repetitive
movements-risk for intervertebral disc injuries

🞂 Can you perform normal activities of daily living?

Lifestyle and health practices
🞂 Has your neurologic problem changed the way you
view yourself?
🞂 Does neurologic problem added stress to your life?
OBJECTIVE DATA
HOW TO ASSESS THE DEEP TENDON
REFLEX USING REFLEXHAMMER
🞂 Relax- tenseness can inhibit a
normal response
🞂 Position properly
🞂 Hold the handle of the reflex
hammer between your thumb and
index finger so it swings freely
🞂 Palpate the tendon that you will
need to strike to elicit the reflex
🞂 Kindly view the link below
🞂 https://www.youtube.com/watch?
v=P98BISwkuw0
Tendons
Upper Extremities
Tendons
Assessing Deep Tendon Reflexes
HOW TO ASSESS THE DEEP TENDON
REFLEX USING REFLEXHAMMER
https://images.search.yahoo.com/yhs/search;_
HOW TO ASSESS THE DEEP TENDON
REFLEX USING REFLEXHAMMER
https://images.search.yahoo.com/yhs/search;_
REFLEX
Babinski

The cremasteric reflex is a superficial (i.e., close to the skin's

surface) reflex observed in human males. This reflex is elicited by
lightly stroking or poking the superior and medial (inner) part of the
thigh—regardless of the direction of stroke. The normal response is
an immediate contraction of the cremaster muscle that pulls up the
testis ipsilaterally (on the same side of the body)
HOW TO ASSESS THE DEEP TENDON
REFLEX USING REFLEXHAMMER
🞂 Using a rapid wrist movement, briskly strike the
tendon. Observe the response. Avoid a slow or weak
movement for striking
🞂 Compare the response of one side with the other side
🞂 To prevent pain, use the pointed end to strike a small
area, and the wider, blunt end to strike a wider area or a
more tender area.
HOW TO ASSESS THE DEEP TENDON
REFLEX USING REFLEXHAMMER
🞂 Use a reinforcement technique, which causes other
muscles to contract and thus increases reflex activity to
assist in eliciting a response if no response is elicited
Mental status and level of
consciousness
inspection
🞂 Observe level of consciousness (LOC)-call client’s
name and note for response/shake/apply painful
stimuli. Call louder if does not respond
Abnormal level of consciousness
Lethargy-opens eyes, answers questions and falls back
to sleep.
Obtunded- open eyes to loud voice, responds slowly with
confusion, seems unaware of the environment
Stupor-client awakens to vigorous shake or painful
stimuli but returns to unresponsive sleep
Abnormal level of consciousness
Coma- client remains unresponsive to all stimuli, eyes
stay closed
- client with lesions of the diencephalon, midbrain, Or
pons extends arms and legs , arches neck and rotates
hands and arms internally (decerebrate or abnormal
extensor posture)
D/D
Glasgow coma scale
Checklist of Glasgow Coma Scale
Exercises #1 :

A patient fell while rock

climbing. When you apply a
deep sternal rub, he
extends his arms and legs
and shows no other
response.
Exercises:
1. A patient fell while rock climbing. When you
apply a deep sternal rub, he extends his arms
and legs and shows no other response.
• Eye - 1
• Verbal - 1
• Motor – 2

• E1 V1 M2

• Answer 4/15
Exercises #2 :

The patient is
pulseless and
apneic.
Exercises:
2. A patient fell while rock climbing. When you
apply a deep sternal rub, he extends his arms
and legs and shows no other response.

• Eye - 1
• Verbal - 1
• Motor – 1

• E1 V1 M1

• Answer 3/15
Exercises #3 :
You are assessing a 20-year-old
male suspected of overdosing.
He is staring off into space,
writhing, and babbling. When
your partner starts an IV, he
cries out incomprehensibly but
does not pull away.
Exercises:
3. You are assessing a 20-year-old male
suspected of overdosing. He is staring off into
space, writhing, and babbling. When your
partner starts an IV, he cries out
incomprehensibly but does not pull away.
• Eye - 4
• Verbal - 2
• Motor – 1

• E4 V2 M1

• Answer 7/15
Exercises #4 :

A 75-year-old male rubs his

chest and tells you it really
hurts. He tells you he
wants to go to the hospital,
and you help him walk to
the stretcher.
Exercises:
4. A 75-year-old male rubs his chest and tells
you it really hurts. He tells you he wants to go
to the hospital, and you help him walk to the
stretcher.

• Eye - 4
• Verbal - 5
• Motor - 6

• Answer 15/15
Use the Glasgow coma scale
🞂 For clients who are at high risk for rapid deterioration
of the nervous system.
🞂 Normal score is 14
🞂 GCS score of less than 14 indicates some impairment
in the level of consciousness.
🞂 A score of 3 –deep coma
🞂 GLASGOW
https://www.youtube.com/watch?v=v6qpEQxJQO4
GLASGOW COMA SCALE
Glasgow coma scale
🞂 Eye opening -spontaneous opening- 4
- to verbal command- 3
- to pain 2
- no response 1
🞂 Most appropriate verbal response
-oriented 5
- confused 4
Glasgow coma scale
- inappropriate words 3
- incoherent 2
- no response 1
🞂 Most integral motor response (arm)
- obeys verbal commands 6
-localized pain 5
- withdraws from pain 4
- flexion (decorticate) 3
Glasgow coma scale
- extension ( decerebrate) 2
- no response 1
Total 3 to 15
Observe posture and body movements
🞂 Be alert for tense, nervous fidgety and restless
behavior.
- Slumped posture-powerlessness or hopelessness.
Characteristic of depression and organic brain disorder
🞂 Observe dress , grooming and hygiene
🞂 Observe facial expression
🞂 Observe speech
Speech problems
Dysphonia- voice volume disorder

Cerebellar dysarthria- irregular, uncoordinated speech

Dysarthria- defects in muscular control of speech (slurring)

Wernicke’s aphasia-rapid speech that lacks meaning

Brocas’s aphasia- slowed speech with difficult articulation, but fairly clear
meaning
If client has difficulty with speech

Perform Perform additional test

Ask Ask the client to name objects in the room

Ask Ask the client to read from printed material appropriate for his/her educational level

Ask Ask client to write a sentence

If client has difficulty with speech
Observe mood, feelings and expression

Observe thought process and perception

Observe cognitive activities

Orientation

Concentration-ability to focus and stay attentive

Recent memory
Memory
🞂 Memory is a complex ability that involves the recall and recognition
of previous experience.
🞂 The formation of new memory involves recognition and registration of
the initial sensory input, retention and storage of information and
recall or retrieval of stored information.
🞂 Memory functions have traditionally been divided into 3 areas:
immediate, recent and remote memory.
1. Immediate memory can be checked by asking patient to
repeat 6 digits forward and backward.
2. 2. Recent memory can be checked by asking patient about his
appetite and then about what they had for their breakfast or for
dinner the previous evening.
🞂 3.Remote memory can be tested by asking patient for
the information about their childhood that can be later
verified
- Remote memory
- Use of memory to learn new information-ask client to
report four unrelated words, words should not rhyme
and should have diff. meaning. Have client repeat it in
5 minutes, again in 10minuste and again in 30 minutes
- Abstract reasoning- ask client to compare objects
-judgment –ask what to do if having pain. Impaired
judgment-organic brain syndrome, emotional
disturbances, mental retardation and schizophrenia.
-visual perceptual and constructional ability-ask client to
draw face of clock or copy smile figures-mental
retardation, dementia
- Perform the mini-mental state examination if time is
limited and a quick standard measure is needed to
evaluate or reevaluate cognitive function
Cranial nerves
CN 1 ask client to clear the nose to remove any mucus
then to close eyes. Occlude one nostril and identify the
scented object
CN II (optic)- far and near vision, confrontation,
opthalmoscope to view the retina
CN III ,IV and V-assess extra ocular movements,
pupillary response and accomodation
Cranial Nerves
CN V-let client to clench the teeth while palpating the
temporal and masseter muscles
For contractions
- Test sensory function- touch client’s forehead with
sharp or dull object. Client closes eyes then let client
tell you if what she felt-sharp or dull.
- Test corneal reflex
Cranial Nerves
CN VII_facial
-test motor function. Ask the client to:
Smile,Frown and wrinkle forehead,Show teeth,
Puff out cheeks,Purse lips,raise eyebrows,close eyes
tightly against resistance.
-abnormal-inabality to close eyes, wrinkle forehead or
raise forehead along with paralysis of the lower part of
face-bell’s palsy
-CVA
Cranial Nerves
🞂 CN VIII-perform the weber’s test and Rinne test
(cochlear)
🞂 CN IX- ask client to open mouth and say “ah”, use
tongue depressor on the client’s tongue.
-test the gag reflex-absent-lesions
- Check ability to swallow. Note client’s voice quality
Cranial Nerves
🞂 CN XI (spinal accessory)
-ask client to shrug shoulder against resistance-abnormal-
torticollis,neck injury
-ask client to turn head-peripheral nerve disease
🞂 CN XII- (hypoglossal)-ask client to protrude
tongue,move it to each side againstthe resistance of a
tongue depressor, then put it back to the mouth-
MOTOR AND CEREBELLAR SYSTEM
🞂 Assess condition and movement of muscles-muscle
atrophy disease of lower motor neuron or muscle
disorders
🞂 Assess strength and tone of all muscle groups-soft,
limp and flaccid muscles (lower motor neuron
involvement), spastic ( involvement of the
corticospinal motor tract), rigid muscles that resist
passive movements(abnormalities of the
extrapyramidal tract)
 🞂 Note any unusual involuntary movements such as
fasciculations, tics, or tremors.
Abnormal findings:
1. Tic –twitch of the face, head or shoulder due to stress
or neurologic disorder
2. Unusual bizarre face, tongue,jaw or lip movements-
chronic psychosis or long term use of psychotropic
drugs
3. tremors-rhythmic, oscillating movements- parkinson.’s
disease, cereballar disease,MS, hyperthyrodism, or
anxiety
4. slow, twisting movements in the extremities and face
from cerebral palsy
5. Brief,rapid,irregular,jerky movements (at rest) from
huntington’s chorea
Motor and cerebellar systems
🞂 Evaluate balance-assess gait- ask client to walk across
the room
-ask client to walk in heel to toe fashion
-perform the romberg test
-ask client to bend foot and to bend the knee of the leg he
or she is standing then ask client to hop on that foot-
inability- muscle weakness or disease of the cerebellum
ASSESSMENT
🞂 Assess coordination- finger to nose test
-assess the rapid alternating movements. Have client sit
down then ask to touch each finger of the hand down to
his thumb.( cerebellar disease, upper motor neuron
weakness or extrapyramidal disease.
-ask client to put palms of both hands down on both legs,
then turn the palms up, then palms down again
increasing in speed
ASSESSMENT
-perform the heel-to-shin test- ask client to lie down
supine and to slide the heel of the right foot down the
left shin. Repeat with the other heel and shin.-deviation
of heel to one side or the other may be seen in
cerebellar disease
Assessing the sensory system integrity
🞂 Assess light touch, pain and temperature sensations,
client closes eyes and tell the nurse what sensation is
felt- (peripheral neuropathies and lesions of the
ascending spinal cord, the brain stem, cranial nerves
and cerebral cortex
Light touch- wisp of cotton
Pain sensation- safety pin the blunt and sharp
Assessing the sensory system integrity
Temperature- tubes filled with hot and cold water
Abnormal findings:
Anesthesia-insensitivity to pain
Hypesthesia- dec.sensitivity to touch
Hyperesthesia- increase sensitivity to touch
Analgesia-no pain
Hypalgesia- decrease sensitivity to pain
Hyperalgesia- inc. sensitivity to pain
🞂 Test vibratory sensation-strike a low-pitch tuning fork
on the heel of your hand and hold the base on a bony
surface of the fingers or big toe. Ask client what he
feels (posterior column disease or peripheral
neuropathy)
🞂 Test sensitivity to position- client close eyes. Move
client’s toes/fingers up or down-ask client to tell you
the direction it is moved
🞂 Assess tactile discrimination-
Stereognosis-client close eyes. Place a familiar object in
client’s hands and let client identify
Test point localization- briefly touch the client and ask
the client to identify the points touched
Test graphesthesia- use a blunt instrument to write a
number on the palm of the client’s hand
Test two-point discrimination-ask the client to identify
the number of points felt when touched with the ends
of two applicators at the same time. Touch the client on
the fingertips,forearm, dorsal hands, back and thigh
Test extinction-simultaneously touch the client in the
same area on both sides of the body at the same point.
Ask the client to identify the area touched
Assessing Reflexes
🞂 Deep tendon reflex
-hyporeflexia- SCI
-hyperactive reflex- lessions of the upper motor neurons
and when the higher cortical levels are impaired
Some older clients- dec. deep tendon reflex- numeric
dec. in nerve axons and increased demyelination of
nerve axons
Assessing Tendon Reflexes
1. Biceps reflex-ask client to partially bend arm at elbow
with palm up. Place your thumb over the biceps tendon
and strike your thumb with the reflex hammer- elbow
flexes and contraction of the biceps muscle is felt or
seen
2. Brachioradialis reflex- client flex elbow with palm
down and hand resting on the abdomen or the lap. Tap
the tendon at the radius about 2 inches above the wrist-
evaluate the functions of spinal levels C5 and C6-
forearm flexes and supinates
Assessing Tendon Reflexes
3. Triceps reflex- client hangs his arm freely while you
support it with your non dominant hand. With the
elbow flexed, tap the tendon above the olecranon
process-evaluates C6,C7, C8-elbows extends, triceps
contracts
4. Patellar reflex- let both legs hang freely off the side of
the examining table, tap the patellar tendon.located just
below the patella.-knee extends, quadriceps contracts
Assessing Tendon Reflexes
🞂 achilles reflex-client’s legs still hanging freely,
dorsiflex the foot. Tap the achilles tendon- plantar
flexion of the foot. Some older clients, may be absent
or difficult to elicit
🞂 Ankle clonus- done if all other reflexes tested have
been hyperactive.
-place one hand under the knee to support the leg then
briskly dorsiflex the foot toward the client’s head-
abnormal- repeated rapid contractions of the ankle and
calf muscle
SUPERFICIAL REFLEXES
🞂 Superficial reflexes
1. Planter reflex-stroke the lateral aspect of the sole from
the heel to the ball of the foot,curving medially across
the ball-normal- flexion of the toes occur. Abnormal-
dorsiflexion of the big toe and fanning of all toes-
lesions of upper motor neurons, unconscious from
drug, alcohol intoxication, brain injury epeliptic seizure
Assessing Tendon Reflexes
2. Abdominal reflex- lightly stroke the abdomen on each
side. Above and below the umbilicus –evaluate the fx
of spinal levels T10, T11, and T12. normal abd’l
muscle contract, umbilicus deviate towrd the side being
stimulated.
- May be concealed due to obesity or muscular stretching
Assessing Tendon Reflexes
3.Cemetric reflex-lightly stroke the inner aspect of the
upper thigh. Normal for scrotum to elevate on
stimulated side. Absence- motor neuron disorder