Abdomen 11/20/10 3:08 PM

Abdomen- Large oval cavity extending from the diaphragm to the brim of

the pelvis

Internal anatomy

o Inside the abdominal cavity, all the internal organs are called

viscera

Solid viscera- organs that maintain a characteristic

shape (liver, pancreas, spleen, adrenal glands, kidneys,

ovaries, and uterus)- usually palpable

Hollow viscera- shapes depend on the content

(stomach, gallbladder, small intestine, colon, bladder)-

not palpable

o Small intestines are located in all 4 quadrants

o Spleen is a soft lymphatic mass- normally not palpable

o Aorta is to the left of the midline in the upper part of abdomen

o Pancreas is behind the stomach

o Kidneys are retroperitoneal

o Costovertebral angle- where kidneys are located (11th/12th rib)

Four quadrants

RIGHT UPPER QUADRANT LEFT UPPER QUADRANT

Liver

Gallbladder

Duodenum

Head of pancreas

Right kidney and adrenal

Hepatic flexure of colon

Part of ascending and transverse

colon

Stomach

Spleen

Left lobe of liver

Body of pancreas

Left kidney and adrenal

Splenic flexure of colon

Part of transverse and

descending colon

RIGHT LOWER QUADRANT LEFT LOWER QUADRANT

Cecum

Appendix

Right ovary and tube

Right ureter

Right spermatic cord

Part of descending colon

Sigmoid colon

Left ovary and tube

Left ureter

Left spermatic cord

Epigastric- area between the costal margins

Umbilical- around the umbilicus

Hypogastric/suprapubic- above the pubic bone

The Aging Adult

Deposition o fat in the abdominal area (“bay window/sparetire”)

Salivation decreases- dry mouth, dec. sense of taste

Esophageal emptying is delayed- risk of aspiration

Gastric acid secretion decreases- risk of pernicious anemia, iron

deficiency anemia, and malabsorption of calcium

Incidence of gall stones increases

Liver sized decreases; drug metabolism is impaired due to the

decreased blood flow

Frequent constipation (dec, physical activity, inadequate intake of

water, low-fiber diet, side effects of medication, irritable bowel

syndrome, bowel obstruction, hypothyroidism, difficulty ambulating)

SUBJECTIVE DATA

Appetite

o Change? Loss? Weight? Over what period?

o Anorexia- loss of appetite that occurs with GI disease, AE of

medication, with pregnancy, or psychological

Dysphagia

o Difficulty swallowing? When?

o Dysphagia- occurs with disorders of the throat and

esophagus

Food intolerance

o Allergy? Heartburn?

o E.g. lactase deficiency- bloating or excessive gas after taking

milk products

o Pyrosis (heartburn) burning sensation in esophagus and

stomach from gastric reflux

o Eructation (belching)

Abdominal pain

o Any pain? Point! One spot? How start? How long have u had

it? Constant? Cramping? Burning? Dull? Stabbing?

Aggravating? Alleviating factors?

o Abdominal pain may be:

visceral from an internal organ (dull, general, poorly

localized)

parietal from inflammation of overlying peritoneum

(sharp, precisely localized, aggravated by movement),

referred (from disorder in another site)

Nausea/vomiting

o n/v? how often? How much comes up? Color? Odor? Blood?

What food did u eat in the last 24 hours? w/ diarrhea? Fever?

Chills? Colicky pain

o N/V is a common side effect of many medications with GI

disease, early pregnancy

o Hematemesis- blood vomiting; occurs with stomach or

duodenal ulcers and esophageal varices

o Consider food poisoning

Bowel habits

o How often? Color? Consistency? Diarrhea? Constipation?

o Assess usual bowel habits

o Black stools may be tarry due to occult blood (melena) from

GI bleed or nontarry from iron medication

o Gray stools occur with hepatitis

o Red blood stools occurs with GI bleeding or localized bleeding

around the anus

Past abdominal history

o GI problems? GB disease? Hepatitis? Jaundice? Hernia? Any

abdominal operation?

Medications

o Peptic ulcer disease occurs with frequent use of NSAIDS,

alcohol, smoking, H. pylori infection

Nutritional assessment

o Via 24-hour recall

For aging adult

o Assess risk for nutritional deficit: limited access to grocery

store, income, or cooking facilities; physical disability,

o Assess risk for nutritional deficit if living alone; may not

bother to prepare all meals; social isolation; depression

o 24- hour recall may not be sufficient bec. daily pattern may

vary; attempt week-long diary of intake

OBJECTIVE DATA

PREPARATION: empty bladder; keep the room, stethoscope, and

hands warm; person supine, head on pillow, knees bent or on pillow,

arms at side or across the chest

INSPECT

o Contour (persons side, look down the abdomen, sit to gaze

across; it describes nutritional state)

Flat

Scaphoid

Rounded

protuberant

o Symmetry (shine a light across)

Should be symmetric bilaterally

hernia- protrusion of abdominal viscera through

abnormal opening in muscle wall

enlarged liver or spleen may show

o umbilicus

nomally midline and inverted; no sign of discoloration,

inflammation, or hernia; becomes everted and pushed

upward with pregnancy

site should not be red or crusted

everted with acites or underlying mass

deeply sunken with obesity

enlarged and everted with umbilical hernia

bluish periumbilical color occurs with intraabdominal

bleeding (Cullen’s sign)

o skin

jaundice (shown best in natural daylight)

skin glistening and taut occurs with ascites

striae (lineae albicanted) – silvery white. Linear,

jagged marks about 1 to 6 cm long; occur when elastic

fibers in the reticular layer of the skin are broken

(weight gain, pregnancy); pink or blue then turn silvery

white

Cushing’s syndrome- skin is fragile and easily broken;

striate are purple-blue

Pigmented nevi (moles) are common on the abdomen

Note scar even if well-healed; surgical scar alerts

possibility of the presence of underlying adhesions and

excess fibrous tissue

Cutaneous angiomas (spider nevi)- occur with

portal hypertension or liver disease

Fine venous network may be visible in thin persons

Prominent, dilated veins occur with portal hypertension,

cirhosis, ascited, or vena caval obstruction

Veins are more visible with maltnutrition as a result of

thinned adipose tissue

Poor turgor occurs with dehydration, which often

accompanies GI disease

o Pulsation or movement

May see from the aorta in the epigastric area; esp. in

thin persons

Marked pulsation of aorta occurs with widened

pulse pressure (htn, aortic insufficiency,

thyrotoxicosis, aortic aneurism)

Respiratory movement can be seen also

Waves of peristalsis are sometimes visible (ripple slowly

and obliquely across abdomen)

If with a distended abdomen, it indicates intestinal

obstruction

o Hair distribution- patterns alter with endocrine or hormone

abnormalities, chronic liver disease

o demeanor

restlessness and constant turning to find comfor occur

with the colicy pain of gastroenteritis or bowe

obstruction

absolute stillness, resisting any movement, occurs with

the pain of peritonitis

knees flexed up; facial grimacing; and rapid, uneven

respirations also indicate pain

AUSCULTATE BOWEL SOUNDS AND VASCULAR SOUNDS

o Bowel sounds

Auscultate before percussing and palapating to because

those can increase peristalsis, which would give false

interpretation of bowel sounds;

begin in RLQ (ileocecal) bec. sounds are always present

there

o vascular sounds

bruits- vascular sounds

check aorta, renal arteries, iliac, and femoral arteries

esp. with those who have hypertension

note location, pitch, and timing

systolic bruit- pulsatile blowing sound and occurs with

stenosis or occlusion of an artery

PERCUSS GENERAL TYMPANY, LIVER SPAN, AND SPLENIC

DULLNESS

o General tympany

Percuss in all 4 quadrants clockwise

Dullness occurs over a distended bladder, adipose

tissue, fluid or a mass

Hyperresonance is present with gastreous distention

o Liver span

Right midclavicular line (acromioclavicular and

sternoclavicular)

Begin in the lung of resonance percuss down till

changes to dull (mark spot) find abdominal tympany

(percuss up) mark where sound changes to dull

Normally 6-12 cm

Hard if have pleural effusion or consolidation, ascites,

pregnancy, gas distention

Sratch test- place stethoscope over the liver, scratch

short stroke over the abdomen, if sound is magnified,

you have cross the border from over a hollow organ

o Splenic dullness

Dull note forward of the midaxillary line (9th to 11th

intercostal) indicates enlargement of the spleen

(mononucleosis, trauma, infection)

Change from tympany to dull sound with full inspiration

is a positive spleen percussion signsplenomegaly

o Costovertebral angle tenderness

Place one hand over 12th ribthumpsharp pain occurs

with inflammation of the kidney or paranephric area

o Special procedures

Differentiate ascites from gaseous distention

Fluid wave

Place patient’s own hand midline; Place your

left hand on the person’s right flank; Place

your right hand in the person’s left flank ;

Strike!

If ascites is present, blow will generate a fluid

wave, if distended from gas, there’ll be no change

Positive fluid wave test occurs with large amounts

of ascitic fluid

o Shifting dullness

If fluid is present, the note will change from tympany to

dull

Shifting dullness is positive with large volume of ascitic

fluid (it will not detect less than 500 ml)

PALPATION

o Measures to enhance complete muscle relaxation

Bend the person knees

Keep palpating hand low and parallel to abdomen

Teach person to breath slow (in through nose, out

through mouth)

Voice low and soothing

Try emotive imagery

If ticklish, keeps person’s hand under your own

Perform palpation just after auscultation (they’re not

perceived to be ticklish)

o Light and deep palpation

light

First four fingers together, depress for about 1 cm

Make gentle rotary motion, slide to next location,

lift fingers, and move clockwise

Note:

muscle guarding

o voluntary guarding- occurs when

person is cold, tense, or ticklish

o involuntary- if rigidity persists; it is a

constant board-like hardness of the

muscles; it’s a protective mechanism

rigidity, large masses, tenderness

deep

same technique, but push down 5 to 8 cm

if obese, use bimanual technique

tenderness occurs with local inflammation

normally palpable structures: xiphoid, liver edge,

right kidney lower poke, pulsatile aorta, recus

muscles, sacral promontory, cecum ascending

colon, sigmoid colon, uterus, full bladder

mild tenderness is present when palpating

sigmoid colon

liver- place left hand under person’s back, place your

right hand on the RUQ; push deeply and ask the person

to breath

liver palpated more than 1 to 2 cm below the right

costal margin (except if depressed diaphragm) is

enlarged

hooking technique: hook fingers to costal margin;

ask to breath deep

spleen- normally not palpable; left hand over the

abdomen, place right on LUQ, push down, ask the

person to breath deep

an enlarged spleen is friable and can rupture

easily with over palpation

kidneys

right kidney

duck bill position at the right flank; press 2

hands together (deeper than liver or spleen

palpation), ask to take a deep breath; you

may feel the lower pole of the right kidney

left kidney

sits 1 cm higher than the right; not palpable

normally

aorta- use opposing thumb and fingers; palpate in the

upper abdomen, slightly left to midline; it is 2.5 to 4 cm;

widened with aneurysm

special procedures

rebound tenderness (Blumberg’s sign)

done if report of abdominal pain

choose a site away from painful area

hold hand perpendicular to abdomen

push down slowly and deeply

then lift up quickly

**pain on release confirms rebound

tendernessperitoneal

inflammationmaybe appendicitis

inspiratory arrest(murphy’s sign)

pain occurs in a person with cholecystitis

when test is positive, as the descending

liver pushes the inflamed gallbladder, the

person feels sharp pain and abruptly stops

inspiration midway

iliopsoas muscle test

if appendicitis is suspected

lift right leg straight up, flexing at the hip

push down over the lower part of the right

thigh

when the iliopsoas muscle is inflamed, pain

is felt in the right lower quadrant (occurs

with appendicits)

obcturator test

also with appendicitis

lift the right leg, flexing at the hip and 90

degrees at the knee

hold ankle, and rotate leg internally and

externally

a perforated appendix irritates the obturator

muscle, producing pain

o abdominal rigidity with acute abdominal conditions is less

common in aging

o aging person often complains of less pain than a younger

person would do

ABNORMAL FINDINGS:

Hypoactive bowel sounds- may result from inflammation

(peritonitis, paralytic ileus after surgery, late bowel obstruction,

pneumonia)

Hyperactive bowel sounds- borboygmi; occur with ealhy

mechanical bowel obstruction, gastroenteritis, brisk diarrhea,

laxative use, subsiding paralytic ileus

Peritoneal friction rub (indicates peritoneal inflammation; occurs

in organ with large surface area (liver/spleen))

Vascular sounds-

o Arterial

Aortic aneurysm- harsh, systolic, or continuous and

accentuated; with HTN

Located below renal arteris80% palpable

Feels like pulsating mass just to the left of midline

Bruit; femoral pulses are present but decreased

Renal artery stenosis- murmur is midline or toward

flank, soft low to med. pitch

Partial occlusion of femoral arteries

o Venous hum- periumbilical region

Occurs with portal hypertension/cirrhotic liver

Enlarged liver

o Smooth- fatty infiltration, portal obstructin, cirrhosis, high

obstruction of vena cava, lymphocytic leukemia, HF, acute

hepatitis, hepatic abscess

o Nodular- alte portal cirrhosis, metastatic cancer, tertiary

syphilis

Enlarged gallbladder

o tender

Cholecystitis

Felt behind liver border as a smooth and firm mass like

a sausage

Painful to fist percussion

Inspiratory arrest (Murphy’s sign) present

o Nontender- if filled with stones, as with common bile duct

obstruction

Enlarged spleen

o Spleen enlarged down to the midline due to diaphragm;

retains splenic notch

o mononucleousis- moderately enlarged with soft, rounded

edges

o Chronic cause- firm, hard, sharp edges

o Usually not tender

Enlarged kidney

o Hydronephrosis, cyst, or neoplasm

o Maybe confused with spleen;

o Percussion; tympanic because of the overriding bowel

Musculoskeletal 11/20/10 3:08 PM

COMPONENTS

Bone is hard, rigid, and very dense; cells continually turning over

Joints are the functional units of the musculoskeletal system

Joints

nonsynovial

o Bones are united by fibrous tissue or cartilage

o Immovable (sutures) or slightly (vertebrae)

Synovial

o freely movable; has lubricant

o has a layer of resilient cartilage

o supported by ligaments- fibrous bands running directly from

one bone to another

o bursa- sac filled with viscous synovial fluid (like joint)- helps

muscles and tendons slide smoothly over a bone

Muscles

Skeletal

o Voluntary muscles

o Fasciculi- bundle of muscle fibers

Muscle is attached to bone by tendon-strong fibrous cord

Temporomandibular

Articulation of the mandible and the temporal bone

3 actions:

o hinge to open and close the jaw

o fliding action for protrusion and retraction

o gliding for side to side movement of the lower jaw

Spine

Vertebrae- 33 connecting bones, stacked in a vertical column

o 7 cervical

o 12 thoracic

o 5 lumbar

o 5 sacral

o 3-4 coccygeal

spinonus process of C7 to T1 are prominent at the base of the neck

inferior angle of scapula are T7 or T8

an imaginary line connecting the highest point on each iliac crest

cross L4

an imaginary line joining the 2 symmetric dimples that overlie the

posterior superior iliac spines crosses the sacrum

cervical and lumbar are concave inward

thoracic, sacrococcygeal are convex

intervertebral disks- elastic fibrocartilaginous plates that

constitue one forth of the length of the column

o has a nucleus pulsosos- made of soft, semifluid, mucoid

material that has the consistency of toothpaste

o it cushions the spine

o motions: flexion, extension, abduction, and rotation

Shoulder

Glenohumeral joint- articulation of the humerus with the glenois

fossa of the scapula

Ball and socket—allows great mobility

Joint is enclosed by 4 musclesrotator cuff

Subacromial bursa- helps during abduction of the arm

Elbow

3 bony articulations- humerus, radius, and ulna

palpable landmarks: medial and lateral epicondyles of humerus,

and olecranon process of the ulna

radioulnar join- pronation and supination

Wrist and carpals

Radiocarpal- articulation of the radius, and carpal bones; flexion

and extension, and side to side deviation

Midcarpal joint- articulation between the 2 parallel rows of carpal

bones; allows flexion, extension, and some rotations

Metacarpophalangeal and interphalangeal—permit finger

flexion and extension

Hip

Articulation between the acetabulum and the head of the femur

Also have ball and socket; has limited ROM than shoulder but has

more stability due to muscles that spread over the joint

Knee

Articulation of 3 bones: femur, tibia, patella

Largest joint in the body

Hinge joint—flexion and extension of the lower leg in single plane

Suprapatellar pouch- sac at the superior border of the patella

Medial and lateral menisci- cushion the tibia and femur

Cruciate ligaments and collateral ligament- stabilizes the joint

Prepatellar bursa- prevent friction

Infrapatellar fat pad- small, triangular fat pad below the patella

Ankle and foot

Tibiotalar joint- articularion of the tibia, fibula, and talus

Hinge joint- limited to flexion (dorsiflexion) and extension (plantar

flexion)

Medial and lateral malleolus are the 2 bony prominences

Subtalar joint- permit inversion and eversion of the foot

SUBJECTIVE DATA

Joints

o Joint pain and loss of function are the most common

musculoskeletal concerns

o Rheumatoid arthritis- involves symmetric joints

Pain is worse in morning when arising

Stiffness occurs in the morning and after rest

periods

Osteoarthritis is worse later in the day

Tendinitis is worse in the morning, improves during the

day

Movement increases most joint pain except in RA, in

which movement decreases pain

o Joint pain 10 to 14 days after an untreated strep throat

suggests rheumatic fever

o Exquisitely tender with acute inflammation

o Decreased ROM may be due to joint injury to cartilage or

capsule, or to muscle contracture

Muscles

o Myalgia- usually felt as cramping or aching

o If in calf, pain with walking, and go away with rest, it suggests

intermittent claudication

o Viral illness often includes myalgia

o Weakness may involve musculoskeletal or neurologic systems

o Atrophy- muscle gets smaller

Bones

o Fracture causes sharp pain that increases with movement,

other bone pain usually feels “dull” and “deep” and is

unrelated to movement

ADL

o Functional assessment: screens the safety of independent

living, the need for home health services, and QOL

o Assess any self-care deficit

Self-care

o Assess risk for back pain or carpal tunnel syndrome

o Assess for:

Self-esteem disturbance

Loss of independence

Body image disturbance

Role performance disturbance

Social isolation

OBJECTIVE DATA

Preparation

o Take an orderly approach- head to toe, proximal to distal

o Support each joint at rest

o Muscles must be soft and relaxed to assess accurately

Order of the examination

o Inspection

Swelling may be excess joint fluid (effusion), thickening

of the synovial lining, inflammation of surrounding soft

tissue (bursae, tendons) or bony enlargement

Deformities include dislocation

Subluxation- partial dislocation of a joint

Contracture- shortening of a muscleROM

Ankylosis- stiffness or fixation of a joint

o Palpation

Palpable fluid is abnormal

Because it is contained in an enclosed sac, if oyu push

on one side, the fluid will shift and cause a visible

bulging on another side

o ROM

If you see limitation, attempt passive motion (anchor

joint one hand, while your other slowly moves it to it

limit)- normal ranges of active and passive should be

the same

If any limitation, use goniometer to measure

Crepitation- an audible and palpable crunching or

grating that accompanies movement. It occurs when the

articular surfaces in the joints are roughened, as with

RA

o Muscle testing

Grade Description %normal assessment

5 Full ROM against gravity,

full resistance

100 normal

4 Full ROM against gravity,

some resistance

75 good

3 Full ROM with gravity 50 Fair

2 Full ROM with gravity

eliminated (passive

motion)

25 Poor

1 Slight contraction 10 Trace

0 No contraction 0 zero

TEMPOROMANDIBULAR JOINT

o Crepitus and pain occur with temporomandibular joint

o An audible and palpable snap or click occurs in many healthy

people as the mouth opens

o Lateral motion may be lost earlier and more significantly than

vertical

o Ask to move jaw forward, and laterally against resistance (test

nerve V- trigeminal)

CERVICAL SPINE

o Inspect alightment of head and neck

o Palpate the spinous process and the sternomastoid, trapezius,

and paravertebral muscle

o Normally maintain flexion against full resistance- (test nerve

XI (spinal))

UPPER EXTREMITY

o Shoulders

Check redness, inequality of bony landmarks, atropy

Dislocated shoulder loses the normal rounded shape

and looks flattened laterally

Pain from a local cause is reproducible during the

examination by palpation or motion

Swelling from excess fluid is best seen anteriorly

Swelling of subacromial bursa is localized under deltoid

muscle, and may accentuate when tries to ABDUCT

Rotator cuff lesions may cause limited ROM, apin, and

muscle spasm during abduction, whereas forward

flexion stays fairly normal

o Elbow

Check olecranon bursa

Subluxation of the elbow shows the forearm dislocated

posteriorly

Effusion or synovial thickening shows first as a bulge or

fullness in groove on either side of the olecranon

process, and it occurs with goty arthritis

Epicondyles, head of radius, and tendons are common

sites of inflammation and local tenderness, or “tennis

elbow”

Normally, present tisses and fat pads feel fairly solid

Soft, boggy, or fluctuant swelling in both grooves

occurs with synovial thickening or effusion

Palpate the area of the olecranon bursa for ehad,

swelling, tenderness, consistency, or nodules

Subcutaneous nodules- are raised, firm, and

nontender, and overlying skin moves freely

(usually in elcranon bursa, and extensor surface of

the ulna- occurs with RA)

o Wrist and hand

Ankylosis; wrist in extreme flexion; stiffness of joint

Dupuytren’s contracture-flexion contracture of

fingers; fingers bend toward the palms

Swan-neck or boutonniere deformity in fingers

(usually bent)

Heberden’s and Bouchard’s nodules are hard and

nontender and occur with osteoarhtitis

Phalen’s Test- hold both hands back to back while

flexing the wrists 90 degrees

Reproduces numbness and burnin in a person with

carpal tunnel syndrome

Tinel’s Sign- direct percussion of the location of the

median nerve at the wrist produces no smtoms in

normal hand

In carpal tunner syndrome, percussion of the

median nerves produces burning and tingling

along its distribution, which is a positive Tinel’s

sign

LOWER EXTREMITY

o Hip

Flexion flattens the lumbar spine; if this reveals a

flexion deformity in the opposite hip, it represents a

positive Thomas Test

Limited internal rotation of hip is an early and reliable

sign of hip disease

Limitation of abduction of the hip while supine is the

most common motion dysfunction found in hip disease

o Knee

Angulation deformities

Genu varum (bowlegs)

Genu valgum (knock knees)

Flexion contracture

Hollows diappear; then they may bulge with synovial

thickening or effusion

Atrophy occurs with diuse or chronic disorder

First, it appears in the medial part of the muscle

Muscles should feel solid, and the joint should feel

smooth, with no warmth, tenderness, thickening, or

nodularity

Feels fluctuant or boggy with synovitis of suprapatellar

pouch

Swelling Test- determine tissue

Bulge sign- occurs with very small amounts of

effusion, 4 to 8 ml from fluid flowing across the

joint; stroke medial (3x) then tap lateral aspect

Ballottement of the patella- reliable when

larger amounts of fluid are present;

Left hand- compress the suprapatellar

pouch to move any fluid into the knee joint

right hand- push the patella sharply against

the femur

irregular bony margins occur with osteoarthritis

pronounced crepitus is significant and it occurs with

degenerative diseases of the knee

sudden buckling, or “giving way” occurs with ligament

injyry, weakness and instbality

special tests for meniscals tears

McMurray’s Test

Perform if reported a history of trauma

If hear or feel a “click”, McMuray’s test is

positive for a torn meniscus

o ankle and fooot

inspecte while the person is in a sitting, non-weight

bearing position

hallux valgus

hammertoes/claw toes

o spine

difference in shoulder elevation and in level of scaulae

and iliac crests occur with scoliosis

thoracic curve (kyphosis)- common in aging

lumbar curve (lordosis)- common in obese people

lateral tilting and forward bending occur with a

hearniated nucleus pulposus

spinal curvature may be clearly seen when person

touches the toes

straight leg raising or LaSegue’s Test

reproduce back and leg pain and help confirm the

presence of a herniated nucleus pulposus

if lifting the unaffected leg reproduces sciatic

painherniated nucleus pulposus

measure leg length

true leg length- measure bet. Fixed poiints, from

the anterior iliac spine to the medial malleolus,

crossing the medial side of the knee

apparent leg lengths unequal- this condition

occurs with pelvic obliquity or adduction or flexion

deformity in the hip ( measure from a nonfixed

point to a fixed point)

o aging adult

decrease in height

lengthening of the arm-trunk acis

Kyphosis is common

Slight flexion of hips and knees

Neurologic System 11/20/10 3:08 PM

NERVOUS SYSTEM

CENTRAL NERVOUS SYSTEM- spinal cord and brain

o Carries efferent messages to muscles and glands

PERIPHERAL NERVOUS SYSTEM- 12 pairs of cranial verves, 31

pairs of spinal neves, and all their branches

o Carries afferent messages to CNS

CENTRAL NERVOUS SYSTEM

Cerebral cortex- cerebrum’s outer layer of nerve cell bodies,

which looks like “gray matter” because it lacks myelin

o Center for human’s highest functions, governing thought,

memory, reasoning, sensation,a nd voluntary movement

o Each half’s is hemisphere

Each hemisphere is divided into 4 lobes

Frontal- personality, behavior, emotions,

intellectual function; precentral gyrus-initiates

voluntary movement

Parietal- center for sensation

Temporal- primary auditory reception center

Wernicke’s area- language

comprehensionreceptive aphasia (hears

but doesn’t understand)

Broca’s area- mediates motor

speechexpressive aphasia (can

understand but can’t talk)

Occipital- primary visual receptor center

Basal ganglia- additional bands of gray matter; form the

subcortical associated motor system (extrapyramidal

system)control automatic associated movements (arm swinging

when walking)

Thalamus- relay station

Hypothalamus- major control center: temperature, heart rate, BP

control, sleep center, pit. Gland regulator, coordinator of ANS, and

emotional status

Cerebellum- coiled structure, concerned with motor coordination

of voluntary movements, equilibrium, and muscle tone; does not

initiate movement but coordinates and smooths it

Brain stem- consist nerve fibers

o Midbrain- contains many motor neuron and tracts

o Pons- enlarged area containing ascending and descending

fiber tracts

o Medulla- connecting the brain and SC; vital autonomic

centers (respiration, heart, GI function) as well as nucleu for

cranial nerves VII through XII; pyramidal decussation (crossing

of the motor fibers)

Spinal cord- main highway for ascending and descending fiber

tracts that connect the brain to the spinal nerves, and it mediates

reflexes; butterfly shape with anterior and posterior “horns”

PATHWAYS TO THE CNS

o Cross representation- notable feature of the nerve tracts

Left cerebral cortex receives sensory information and

controls motor function to the right side; vise versa

o Sensory pathways

Spinothalamic tract

Contains sensory fibers that transmit the

sensation of pain, temperature, and crude or light

touch

Enters dorsal root of SC sensory

neuronopposite side and ascend up to thalamus

Lateral- pain and temperature

Anterior- crude touch

Posterior (dorsal) columns

Conduct the sensations of position, vibration, and

finely localized touch

Position (proprioception)- w/out looking,

you know where your body parts are, in

space, and in relation to each other

Vibration- vibrating objects

Finely localized touch (stereognosis) –

w/out looking, you can identify familiar

objects by touch

Enters dorsal rootsame side of the SCbrain

stemmedullasecondary

neuroncrossthalamussynapsesensory

cortex

Some organs are absent form the brain map

(heart, liver, spleen)—pain originating from these

organs is referred, because no felt image; pain

from heart is pain in chest, shoulder, or left arm;

spleen is felt on top of left shoulder

o Motor pathways

Corticospinal or pyramidal tract

Motor nerve fibers (motor cortex)trabel to brain

stem cross to the opposite or contraleteral

sidethen pass down in the lateral column of the

SCeach cord leve, they synapse with a lower

motor neuron

Corticospinal fibers mediate voluntary movement,

particularly very skilled discrete, purposeful

movementswriting

Somatotopic organization; “highter” motor system

Homunculus- hanging “upside down”

Body parts are not equally representedmore

important use more space

Extrapyramidal tracts

Include all motor nerve fiber originating from

motor cortex, basal ganglia, brain stem, SC that

are outside the pyramidal tract

“lower” more primitive motor system

maintain muscle tone and control body

movement, especially gross automatic

movements (walking)

Cerebellar system

Complex motor system, coordinates movement,

maintains equilibrium, and maintain posture

UPPER AND LOWER MOTOR NEURONS

o Upper motor neurons- complex of all the descending motor

fibers that can influence or modify the lower motor neurons

Located completely in the CNS

Convey impulse from motor areacerebral

cortexlower motor neurons in anterior horn cells (e.g.

corticospinal, corticbulbar, extrapyramidal tracts)

E.g of disease: cerebrovascular accident, cerebral palsy,

multiple sclerosis

o Lower motor neurons

Located mostly in peripheral nervous system

Cell body of lower motor neuron is in anterior gray

column of the SC but the nerve fiber extends from here

to muscle

“final common pathway”

e.g. cranial nerves, spinal nerves of the PNS

e.g. of disease: spinal cord lesions, poliomyelitis,

amyotrophic lateral sclerosis

PERIPHERAL NERVOUS SYSTEM

Reflex arc

o Deep tendon reflexes (myotatic)

E.g. patellar or knee jerk

5 components

intact sensory nerve (afferent)

functional synapse in the cord

intact motor nerve fiber (efferent)

neuromuscular junction

competent muscle

o Superficial

Corneal reflex, abdominal reflex

o Visceral

Papillary response to light and accommodation

o Pathologic (abnormal)

Babinski’s or extensor plantar reflex

Cranial nerves

o Enter and exit the brain rather than the spinal cord

o Supply head and neck except the vagus nerve which travels

to the heart, respiratory muscles, stomach, and gallbladder

CRANIAL NERVE TYPE FUNCTION

I: Olfactory sensory smell

II: optic sensory vision

III: oculomotor mixed Motor: most EOM

IV: trochlear motor Down and inward movement

of eye

V: trigeminal mixed Muscles of mastication;

sensation of face and scap,

cornea, mucous membranes

of mouth and note

VI: abducens motor Lateral movement of eye

VII: facial mixed Facial muscles, taste (sweet,

salty, sour, bitter); saliva

tear secretion

VIII: acoustic sensory Hearing and equlibrium

IX:

glossopharyngeal

mixed Pharynx (phonation, and

swallowing), gag reflex,

taste on 1/3 posterior,

X: vagus mixed Pharynx, larynx (talking and

swallowing); general

sensation from carotid body,

carotid snius, carotid reflex

XI: spinal motor Movement of trapezius and

sternomastoid

XII: hypoglossal motor Movement of tongue

o

Spinal nerves

o 31 pairs

o mixed nerves

o enter and exit the cord through roots—sensory afferent fibers

through the posterior or dorsal roots, and motor efferent

fibers through the anterior or ventral roots

o dermal segmentation- Cutaneous distribution of various

spinal nerves

dermatome- circumscribed skin area the is supplied

mainly form one spinal cord segment through a

particular spinal nerve; overlap

thumb middle finger, and fifth finger: C6, C7, and

C8

axilla- T1

nipple- T4

umbilicus- T10

groin- L1

knee- L4

Autonomic nervous system

o Peripheral nervous system is composed of cranial nerves and

spinal nerves; function is homeostasis of the body

Somatic- voluntary

Autonomic- involuntary (cardiac, and glands)

THE AGING ADULT

o General atrophy with a steady loss of neurons

o 15% loss weight of brain

o absent achilles reflex, loss of position sense, papillary miosis,

decreased papillary reflexes

o velocity of nerve conduction decreases by 5%

o dyskinesias (possible repetitive facial grimacing)

SUBJECTIVE DATA

Syncope- sudden loss of strength, temporary loss of consciousness

(faint) due to lack of cerebral blood flow.

True vertigo- rotational spinning caused by neurologic disease in

the vestibular apparatus

Seizures- occur with epilepsy; paroxysmal disease characterized

by altered or loss of consciousness, involuntary muscle movement,

and sensory disturbances

Aura- subjective sensation that precedes a seizure

Tremor is an involuntary shaking, vibrating, or trembling

Paresis- partial or incomplete paralysis

Paralysis- loss of motor function due to a lesion in the neurologic

or muscular system or loss of sensory innervation

Dysmetria- inability to control range of motion of muscles

Paresthesia- abnormal sensation (burning, tingling)

Dysarthria- difficulty forming words

Dysphasia- difficulty with language comprehension and expression

In aging adult, diminished cerebral blood flow, and diminished

vestibular response may produce staggering with position change,

which increases risk of falls

Micturition syncope

Senile tremor is relieved by alcohol, though not recommended

OBJECTIVE DATA

CRANIAL NERVES

o I (Olfactory)

one cannot test smell when air passages are occluded

with upper respiratory infection or sinusitis

anosmia- decrease or loss of smell occurs bilaterally

with tobacco smoking, allergic rhinitis, and cocaine use

o II (optic nerve)

visual field loss

papilledema with increased intracranial pressure; optic

atrophy

o III, IV, VI (oculumotor, trochlear, and abducens)

Palpebral fissures are usually equal

Ptosis (drooping) occurs with myasthenia gravis,

dysfunction of cranial nerve II, or Horner’s syndrome

Increasing intracranial pressure causes a sudden,

unilateral, dilated and nonreactive pupil

Strabismus (deviated gaze) or limited movement

Nystagmus- back and forth oscillation of the eyes

Occurs with disease of the vestibular system,

cerebellum, or brain stem

o V (trigeminal nerve)

Motor function: assess muscle of mastication

Sensory function: close eyes, test light touch

sensation with cotton; this test ophalmic, maxillary, and

mandibular nerve

Corneal reflex- lightly touch cornea with cotton, no

blink occurs with a lesion of cranial nerve V or cranial

nerve VII paralysis

o VII (facial nerve)

Motor function: note mobility and facial symmetry;

Muscle weakness is shown by flattening of the

nasolabial fold, drooping of one side of the face,

lower eyelid sagging, and escape of air form only

one cheek that is pressed in

Loss of movement and asymmetry of movement

occur with both central nervous system lesions

If indicated, test sense of taste

o VIII (acoustic-vestibulochlear)

Test hearing acuity

Weber (when one ear is better) and Rinne test

(test AC>BC)

o IX and X (glossopharyngeal and vagus nerves)

Motor function- depress the tongue with a tongue

blade, note pharyngeal movement when person says

“ahh” or yawns; note gag reflex; note voice sounds

Sensory function-

o XI (spinal accessory nerve)

Examine sternomastoid and trapezius

Atrophy? Muscle weakness or paralysis?

o XII (hypoglossal nerve)

Inspect tongue; no wasting or tremors should be

present

Say “light tight dynamite”

MOTOR SYSTEMS

o Muscle groups should by symmetric bilaterally

o Atrophy- abnormally small muscle with a wasted

appearance; occurs with diuse, injury, lower motor neuron

disease such as polio, diabetic neuropathy

o Hypertrophy- increased size and strength; occurs with

isometric exercise

o Strength-test the power of homologous muscles

simultaneously

o Tone- move the extremities through a passive ROM;

normally, you will not a mild, even resistance to movement

Flaccidity-decreased resistance, hypotonic

Spasticity and rigidity- types of increased resistance

o Involuntary movements- tic, tremor, fasciculation,

myoclonus, chorea, athetosis

CEREBRAL FUNCTION

o Balance tests

Regular gait

Ataxia- uncoordinated or unsteady gait

Walk heel to heel

An ataxia that did not appear with regular gait

may appear now

Inability= upper neuron lesion (MS, acute cerebral

dysfunction, alcohol intoxication)

o Romberg Test

Stand up, feet together, arms at sides; close eyes and

hold position for 20 seconds

Positive Romberg sign is loss of balance (occurs with

cerebellar atxia, MS, AI, loss of proprioreception, loss of

vestibular function)

o Coordination or skilled movements

Rapid alternating movements

Dysdiadochokinesia- slow, clumsy, and slppy

response, occurs with cerebellar disease

Dysmetria- clumsy movement with overshooting

the mark and occurs with cerebellar disorders or

acute alcohol intoxication

Past-pointing – constant deviation to one side

Finger to finger test/ finger to nose test

misses nose; occurs with cerebellar disease or AI

heel to shin test

place heel on the opposite knee and run down the

shin form the knee to ankle

lack of coordination, heel falls off shin,

occurs with cerebellar disease

ASSESS SENSORY TRACT

o Spinothalamic tract-

Pain

Hypoalgesia- decreased pain sensation

Analgesia- absent pain sensation

Hyperalgesia- inc. pain sensation

*let at least 2 second elapse, to avoid summation

temperature

test only if pain sensation is abnormal

light touch

hypoesthesia- decreased touch sensation

anesthesia- absent touch sensation

hyperesthesia- increased touch sensation

o Posterior column tract

vibration

unable to feel? Loss of vibration occurs with

peripheral neuropathy (e.g. diabetes and

alcoholism)

peripheral neuropathy is usually worse at the feet

position (kinesthesia)

test the person’s ability to perceive passive

movements by moving their finger up and down,

and asked them which way it is moved

tactile discrimination (fine touch)

problems with tactile discrimination occur with

lesions of the sensory cortex or posterior column

stereognosis

test the person’s ability to recognize objects by

feeling their forms, sizes, and weight

astereognosis-inability to identify object

correctly; occurs with sensory cortex lesions

(brain attack)

graphesthesia- ability to read a number by having

traced on the skin

inability occurs with lesions of the sensory cortex

2-point discrimination

test person’s ability to distinguish the separation

of 2 simultaneous pin points on the skin

an increase in the distance it normally takes to

identify 2 separate points; occurs with sensory

cortex lesions

sensitive on the finger tips; least sensitive on

upper arms, thighs, and back

extinction

touch both side of the body at same time; inability

to recognize both stimuli occurs with sensory

cortex lesions; the stimulus is extinguished on the

side opposite the cortex lesion

point location

touch skin, and tell person to put their finger

where you touched them; with sensory cortex

lesion, person cannot localize sensation

REFLEXES

o NOTE IN TESTING:

Percussion technique: action takes place at the wrist

Strike brief, well-aimed, bounced up promptly

Do not let hammer rest on tendon

Use pointed end when aiming at smaller area

Use flat end when wider or diffused

Compare right and left sides

Grading:

4+ very brisk, hyperactive with clonus

3+ brisker than average,

2+ average, normal

1+ diminished, low normal

0 no response

terms:

clonus- set of rapid, rhythmic contractions of the

same muscle

hyperreflexia- exaggerated reflex seen when the

monosynaptic reflex arc is released (upper neuron

lesions; brain attack)

hyporeflexia- absence of a reflex (lower motor

neuron problem; spinal cord injury)

reinforcement- technique to relax the muscles

and enhance response; ask the person to perform

isometric exercise away from the muscle being

tested

o reflexes

Stretch or deep tendon reflexes

Biceps reflex (C5 to c6)

Triceps reflex (c7 to c8)

Brachioradialis reflex(c5 to c6)

Hold thumb

Normal response: flexion, and supination of

forearm

Quadriceps reflex (L2 to L4)

Knee jerk;

Extension is the expected response

May also be performed supine

Achilles reflex (L5 to S2)

Hold foot in dorsiflexion then strike the achilles

tendon

Plantar reflex is the response

Clonus

Support lower leg in one hand

Other hand, move the foot up and down a few

times to relax

Then stretch muscle by briskly dorsiflexing

Hold the stretch

Superficial (Cutaneous) reflexes-

Abdominal reflexes- upper (T8 to T10 ),

lower (T10 TO T12)

Normal response: ipsilateral contraction of

the abdominal muscle

Superficial reflexes are absent with diseases

of the pyramidal tract

Cremasteric reflex (L1 to L2) (male)

Lightly stroke the inner aspect of the thigh:

note elevation of the ipsilateral aspect

Absent in both UMN and LMN lesions

Plantar reflex (L4 to S2)

Draw light stroke up

Normal response: plantar flexion of toes,

and inversion and flexion of the forefoot

Except in infancy, the abnormal response is

dorsiflexion—babinsky sign (occurs with

UMN of the corticospinal/pyramidal tract)

o THE AGING ADULT

Senile tremors- intention tremor of the hands, head

nodding, tongue protrusion

Dyskinesias-repetetive stereotyped movements in the

jaw, lips, or tongue

Distingueish senile tremors and parkinsonism

Parkinsonism- rigidity and slowness and

weakness of voluntary movement

Absence of rhythmic reciprocal gait pattern

(also absent in hemiparesis)

After 65 years of age:

Loss of sensation of vibration at the ankle

melleolus

Loss of ankle jer

Position sense in big toe may be lost

Tactile sensation may be impaired

DTR’s are less brisk

Upper extremities are usually present

Knee jerks may be lost

Aging difficult to relax: always use reinforcement

o NEUROLOGIC CHECK

Level of consciousness

Person, place, time

If not alert; increase amount of stimulus (name

called, light touch, vigorous shake, pain applied)

Motor function

Check voluntary movement of each extremity by

giving specific commans

Lift eyebrow, frown, bare teeth

Check hand grasp

Ask person to lift each hand or hold up one finger

Straight leg raises

Full strength allows 90 degrees lift

Papillary response

Note size, shape, symmetry

Brain-injured- sudden, unilateral, dilated, and

nonreactive pupil is ominous

When increasing intracranial pressure pushes the

brain stem down (uncal herniation) it puts

pressure on cranial nerve III, causing pupil

dilatation

Vital signs

Measure tem, pulse, RR, BP

Cushing reflex shows signs of increasing

intracranial pressure: BP—sudden elevation with

widening PP; pulse—decreased rate, slow and

bounding

Glasgow Coma Scale

Quantitative tool

Standardized, objective assessment that defines

the level of consciousness by giving it numeric

values

3 areas:

eye opening

verbal response

motor reponse

15- fully alert

7- reflects coma