Neurological System

Neurological System

Development  The formation begins in the 3rd week, at 24week all nerve cell, neurons are developed.  At birth the brain weights an average of 325g, at 1 year the weight will tripled.  Head circumference is the best indicator for brain growth.

Anatomy & Physiology  Brain: Covered by protective layers that cushion & lubricate the outer surface.  Dura Mater: lies beneath the skull bone & periostenum & consist of layers of fibrous connective tissue.  Arachnoid: vascular, weblike membrane that cushions the cortex.  Pia Mater: highly vascular area, attach to the gray matter.  Cortex: the outmost part of the brain (gray mater)  Cerebrum: includes the cortex  Corpus callosum: Connect the 2 hemispheres

Anatomy & Physiology  Hemisphere divided into 4 lobes:  Frontal: initiate voluntary musculoskeletal movement, mediate motor speech.  Parietal: control processing & interpretation of sensory input, pain, Tem & pressure.  Occipital: primary center of receiving & interpretation of visual data.  Temporal: primary center for perception & interpretation of sound

Anatomy & Physiology   3. 4.

5. 6. 

Cerebellum: maintain body equilibrium, coordinates movement, relays signals to the muscles Brainstem: includes: Pons: act as neural transmission center Medulla oblongata: transmit impulse along the spinal cord & aids in the life center of respiration & circulation (coughing, sneezing, yawing). Diencephalon: contain thalamus & pineal body Hypothalamus & pituitary gland arise from the diencephalons Spinal Cord: extension of medulla

Physical Assessment  Evaluation of motor function  Muscle tone: is the normal degree of tension maintained by muscle while rest (change over time). Observing resting posture in young infant. Tone in the neck & trunk by gently pulling the infant to sitting position (head lag), strength in extremities by pulling the infant from sitting to standing position. Balance & normal gait assessment through walking. Symmetry of muscle tone.

Primitive reflexes  involuntary, controlled by brainstem, diminished by 3-4 mon, disappear by 46mon..  Symmetry ( abnormal if asymmetrical, absent, persist).  Diminished if the infant very sleepy, irritable, satiated after feeding.

Reflex

How initiated

Response

Palmar grasp

With infant head midline, touch palm of infant hand on ulnar surface with examiner thumb

Fingers clasp examiner thumb

Planter grasp

Touch infant on plantar surface of foot at base of toes

Toes cur downward

Rooting

Touch stroke check

Infants head turns toward stimulus & mouth should open

Sucking

Gently stroke the lips

Mouth open, sucking begins

Truncal incurvatio n or Gallant’s

Hold infant firmly suspended in prone position with examiner hand supporting chest, with opposite hand stroke along spine lightly with fingernail just adjacent to vertebra from shoulder to coccyx

Hips& buttocks curve/turn toward stimulus side

Postural Reflexes  Appear when primitive reflexes disappear, between 5-6mon & progress in a cephalocaudal direction from head control to grasping objects

Reflex

How initiated

Landau

Response

Hold infant firmly suspended in prone position with examiner hand supporting abdomen & head legs should extend over Parachute head Hold infant prone & firmly supported, slowly lower infant toward flat surface

Infant should lift head, extend spine/lower extremities

Lateral Forward

Suspend infant in prone position with arms/legs extended, support with both hands over flat surface

Will lift head & extend spine along horizontal plane

Positive support

Hold infant in upright & firmly supported underarms while over exam table, touch infant feet to surface

Infant should extend legs & bear some weight

Should try protect themselves by extending arms/legs

Involuntary Motor Function  Tremors: coarse repetitive shaking  Clonus: rhythmic tonic-clonic movement of the foot  Tics: involuntary muscle contraction and/or audible sounds or words

Evaluation of Sensory Function  Touch, deep pressure, pain, Tem, & vibration  Tactile sensation: tested in the verbal child by gently touching different area of the body with cotton swab when eyes closed, should be able to identify the area.  Pain: by touching the body with sharp or dull ends of a reflex hammer.  Tem & vibration: (not usually elicited), but vibration can be tested with tuning fork on different area of the body.

Evaluation of Sensory Function  Discrimination: tested by following tests:  Stereognosis: the ability to recognize an object by its feel.  Graphesthesia: the ability to identify shapes traced on the palm  Two-point discrimination: a test of spatial discrimination of the body, with child eyes closed touch lightly on the skin with 2 points in close proximity on the body, ask if he felt one or 2 points

Cranial Nerves in Newborn & Infants  1 Olfactory: pass strong smelling substance under nose. Observe for startle response, grimace, sniffing.  2Optic: light source/ophthalmoscope. Pupil constrict in response to light, able to fix on object & follow for 60-90 degree  3Oculomotor: elicit pupillary response to test optic nerve by shining pen light toward pupil. Evaluate shape, size, symmetry, spontaneous movement of pupil.

Cranial Nerves in Newborn & Infants  4 Trochlear, &5 Abducent: “doll’s eyes” maneuver rotate head from side to side observe eyes moving away from direction of rotation. Eyes should deviate Lt when turning head to Rt, if remain fixed or don’t track in opposite direction, (brain stem dysfunction).  6 Trigeminal: touch cheek area test jaw muscles by placing gloved finger in infants mouth. infant turns cheek toward touch stimulus 7 bit down on gloved finger & start sucking.

Cranial Nerves in Newborn & Infants  7 Facial: observe face for symmetry of movement. Asymmetrical indicate nerve palsy.  8 Acoustic: with infant lying supine ring bell sharply within a few inches of his ears. Observe response such as mild startle/blink reflex.  9Glossopharyngeal: use tongue blade to apply pressure on mid-tongue area to overcome tongue thrust. Elicit gag reflex observe tongue movement, strength.

Cranial Nerves in Newborn & Infants  10 Vagus; observe while crying. Evaluate pitch, shrill penetrating cry indicate intracranial hemorrhage; whiny-high pitched cry indicate CNS dysfunction.  11 Accessory: with infant lying supine, turn head to one side. Should work to bring head to midline.  12 Hypoglossal: observe when feeding. Sucking, swallowing should be efficient, coordinated.

Cranial Nerves in Preschool to School age  2 Optic: Allen picture card, Senellen chart  3 Oculomotor, 4trochlear,5 abducencs: follow toy, light source, index of finger.  Trigeminal: chewing & swallowing, touch facial area with cotton swab  Facial: aske to smile, puff cheek  Acoustic: repeat words whispered from behind  Glossopharyngeal & Vagus: observe tongue & gag reflex with tongue blade  Accessory & hypoglossal: stick tongue out &shrug shoulders

Deep Tendon Reflex  Biceps reflex: with examiner thumb pressed against biceps tendon in antecupital space, support arm with palm prone; tap thumb briskly, tendon should respond by tightening. Response flexion of forearm  Triceps reflex: hold arm in flexed position slightly forward toward chest with forearm dangling downward, tap directly behind elbow on triceps tendon. Contraction of triceps & elbow should extend slightly.  Patellar reflex: support child forearm with palm resting down, tap briskly on radius about 2 inches above rest. Contraction of quadriceps & extension of knee

Superficial reflexes 



 4. 5. 6. 7. 8.

Plantar reflex: stroke sole of foot from heel to ball of foot curving medially with flat object. Movement of toes Abdominal reflex: stroke briskly above & below umbilicus. Abdominal muscle contract & umbilicus deviates toward stimuli Graded of deep tendon reflex 4+: brisk, hyperactive 3+:active, brisker than normal 2+: normal response 1+: diminished response 0: no response

Evaluation of Cerebellar Function  Evaluation balance & coordination  Finger-to-nose test: with eyes closed ask child to touch his nose with finger of one hand then with first finger of other hand, then with eyes open have child touch his nose with first finger then touch examiner finger held about 18 inches in front of the child, then increase the speed of the movement with examiner finger changing position.  Finger-to-thumb test; using one hand aske the child to touch each finger to the thumb in rapid succession, coordination aske him to pat knee with the palm of the hand then

Evaluation of Cerebellar Function  Romberg test: assess for balance & equilibrium. Aske the child to stand erect with eyes closed & hands touching the sides observe the child balance for several seconds.  Tandem walking: assess balance & coordination. Aske the child to walk heel to toe in straight line  Hopping in place & heel-toe walking

Evaluation of Cerebral Function  2. 3. 4. 5. 6. 7.

Evaluate The level of consciousness, Mood & affect Thought Memory Judgment Communication

Glasgow Coma Scale  Eye opening Birth to 1 >1 year year Spontaneous Spontaneously ly

Score

To loud noise To verbal command

3

To pain

To pain

2

No response

No response

1

4

Glasgow Coma Scale  Motor Response Birth to 1 year

> 1 year

Score

Spontaneous response Localize pain

Obeys

6

Localize pain

5

Withdrawal to pain

Withdrawal to pain

4

Involuntary flexion

Involuntary flexion

3

Involuntary extension No response

Involuntary extension No response

2 1

Glasgow Coma Scale  Verbal Response Birth to 2 year

2-5 year

> 5 year

Score

Cries as response, vocalizes cries

Purposeful words

Oriented & responds

5

Incoherent words

Disoriented & converses

4

Inappropriate crying

Cries or scream

Inappropriate words

3

Grunts

Grunts

Incomprehensibl e words

2

No response

No response

No response

1

Glasgow Coma Scale  2. 3. 4.

Severity of Injury Mild head injury: 13-15 Moderate head injury: 9-12 Sever head injury: <8