This document provides an overview of the central nervous system and how to perform a neurological examination. It describes the major structures of the CNS including the cerebral cortex, basal ganglia, thalamus, hypothalamus, cerebellum, and brainstem. It outlines sensory and motor pathways and lists common neurological symptoms. The document then details how to test the cranial nerves, motor system, sensory system, reflexes, and provides guidelines for the neurological exam and recheck.

1. Denise Coffey MSN, RN

2. Central Nervous System (CNS)
 Cerebral cortex
 Frontal lobe
 Parietal lobe
 Occipital lobe
 Wernicke’s area
 Broca’s area
 Basal ganglia
 Thalamus
 Hypothalamus
 Cerebellum
 Brainstem
 Midbrain
 Pons
 Medulla
 Spinal cord
Slide 23-2

3. Pathways of the CNS
 Crossed representation
 Sensory pathways
 Spinothalamic tract
 Posterior (dorsal) column
 Motor pathways
 Corticospinal or pyramidal tract
 Extrapyramidal tracts
 Cerebellar system
 Upper motor neurons
 Lower motor neurons
Slide 23-3

4. Slide 23-4

5. Slide 23-5
[PRODUCTION NOTE: Please insert Figure 23-2 (from Jarvis Physical
Examination and Health Assessment, 5e, ISBN: 978-1-4160-3243-4)]
© Pat Thomas, 2006.

6. Slide 23-6
© Pat Thomas, 2006.

7.  Headache
 Head injury
 Dizziness/vertigo
 Seizures
 Tremors
 Weakness
Slide 23-7

8.  Preparation
 Screening neurologic examination
 Complete neurologic examination
 Neurologic recheck
 Equipment needed
 Penlight
 Tongue blade
 Cotton swab
 Cotton ball
 Tuning fork (128 or 256 Hz)
 Percussion hammer
 Occasionally need: familiar aromatic substance
Slide 23-8

9. Test Cranial Nerves
 I—Olfactory
 II—Optic
 III—Oculomotor,
IV—Trochlear,
VI—Abducens
 V—Trigeminal
 Motor function
 Sensory function
 Corneal reflex
 VII—Facial
 Motor function
 Sensory function
 VIII—Acoustic
(vestibulocochlear)
 IX—Glossopharyngeal,
X—Vagus
 Motor function
 Sensory function
 XI—Spinal accessory
 XII—Hypoglossal
Slide 23-9

11. Motor System—Inspect and palpate
 Muscles
 Size
 Strength
 Tone
 Involuntary
movements
 Cerebellar function
 Balance tests
 Gait
 Tandem walking
 Romberg’s test
 Shallow knee bend
 Coordination and skilled
movements
 Rapid alternating movements
 Finger-to-finger test
 Finger-to-nose test
 Heel-to-shin test
Slide 23-11

12. Sensory System
 Person is alert,
cooperative, and
comfortable
 Guidelines for sensory
testing
 Spinothalamic tract
 Pain
 Temperature
 Light touch
 Posterior column tract
 Vibration
 Position (kinesthesia)
 Tactile discrimination
(fine touch)
 Stereognosis
 Graphesthesia
 Two-point discrimination
 Extinction
 Point location
Slide 23-12

13.  Test the stretch or deep
tendon reflexes
 Technique
 Grading
 Reinforcement
 Biceps reflex
 Triceps reflex
 Brachioradialis reflex
 Quadriceps reflex
 Achilles reflex (“ankle jerk”)
 Clonus
 Test the superficial
reflexes
 Abdominal reflex
 Cremasteric reflex
 Plantar reflex
Slide 23-13

14.  Neurologic recheck
 Level of consciousness
 Person
 Place
 Time
 Motor function
 Pupillary response
 Vital signs
 Glasgow Coma Scale (GCS)
Slide 23-14

17.  Oculomotor response (Cranial nerve III)
 Size, equality, and roundness of pupils
assessed
 Size measured in millimeters
 Evaluated for symmetry in size and response to
light stimulus
 Brisk, sluggish, non-reactive
 Consensual reaction of opposite pupil at same
time

19.  Assess accommodation by holding finger 4-6
inches from client’s nose and then pull out to
18 inches.
 As finger moves away pupil will accommodate
by dilating, as finger moves closer, constricting
 PEARLA- Pupils equal and reactive to light
and accommodation

20.  Ability to follow commands
 Muscle tone
 Muscle strength
 Coordination
 Balance (Romberg test)
 Posturing (Decorticate, Decerebrate)

22.  Tactile sensation
 Pain
 Temperature
 Vibratory sensation
 Tactile discrimination

23.  Superficial
 Deep tendon
 Biceps
 Triceps
 Patellar
 Achilles
 Plantar (Babinski Response)

25.  Clear and appropriate
 Confused
 Inappropriate
 Garbled
 Aphasia (Expressive, Receptive)
 Limited hearing
 Use of hearing aids

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