NEUROLOGIC

©Concept Media 2005

NEUROLOGIC ASSESSMENT

Series 106 CEREBELLAR FUNCTION AND SENSORY EVALUATIONS (106.3)

This Instructor’s Guide contains: Brief Description, Objectives, Discussion Questions, Pretest, Post-test, Answer Keys, Glossary, and Handouts for this program, Neurologic Assessment: Cerebellar Function and Sensory Evaluations. The questions included in this Guide follow the NCLEX model. Institutions that have purchased this program from Concept Media have permission to duplicate any of the contents of this Instructor’s Guide for teaching purposes.


Neurologic Assessment: Cerebellar Function and Sensory Evaluations

Program Description:

Cerebellar Function and Sensory Evaluations, the third program in the four-part series Neurologic Assessment, uses real-time footage of a healthcare professional performing two of the components of a complete neurologic examination. It starts with a brief description of the functions of the cerebellum and then shows how to assess balance and coordination. The second part of the program begins with an explanation of the two types of sensory pathways as well as the significance of sensory dermatomes. It concludes by demonstrating how to assess a patient’s ability to discriminate between various sensory stimuli.

Objectives: Upon completion of this program, the learner will be able to:

1. List the functions of the cerebellum.

2. Explain how to assess a patient’s proprioception, coordination, and balance.

3. Compare and contrast the dorsal column and spinothalamic pathways.

4. Define a sensory dermatome. Explain its significance when performing a sensory examination.

5. Demonstrate how to evaluate sensory nerve function.



Previewing Questions:

True or False 1. The right cerebellar lobe controls the right side of the body.

2. The cerebellum controls cognition and balance.

3. Moving the heel of one foot up and down the shin of the other leg is a technique used to assess coordination.

4. The ability to stand from a sitting position and walk is dependent on cerebral function.

5. Wide-spread gait is normal for elders.

6. To perform the Romberg test, ask the patient to lie prone on a bed.

7. Nerves in the spinothalamic pathway detect crude touch, pain, and temperature.

8. Nerves in the dorsal column detect crude touch, pain, and temperature.

9. Nerves in the spinothalamic pathway cross to the other side of the spinal cord at the brainstem.

10. Dermatomes refer to the distribution of sensory nerves near the skin which are responsible for pain and tingling.

11. Proprioception is defined as the ability of a person to recognize the position, location, orientation, and movement of his body.

12. Cortical sensory input is processed in the frontal lobe of the brain.

13. The ability to identify an object by touch is stereognosis.

14. Graphesthesia is the inability to read.



Previewing Questions: Answer Key

Correct Answer Blacked Out 1. True False

2. True False

3. True False

4. True False

5. True False

6. True False

7. True False

8. True False

9. True False

10. True False

11. True False

12. True False

13. True False

14. True False



Discussion Questions: 1. Why is it important to have patient cooperation while testing cerebellar and sensory functions?

2. How can the patient be encouraged to participate in these examinations?

3. Compare and contrast sensory and cerebellar functions.



Post-Test Questions:

1. The cerebrum:

a. interprets visual data. b. fine tunes motor activity. c. assists with balance. d. b and c e. All of the above

2. The left cerebellar hemisphere controls:

a. the right side of the body. b. the left side of the body. c. both sides of the body. d. language interpretation.

3. Coordination can be assessed by asking a patient to:

a. rapidly touch each of his fingers with the thumb of the same hand. b. stand still with his eyes closed for 30 seconds. c. press down on the evaluator’s hand as if it were a gas pedal. d. All of the above e. None of the above

4. The ability to stand from a sitting position and then walk is dependent upon information from:

a. visual stimuli. b. the vestibular system. c. the sensory system. d. b and c e. All of the above

5. A wide-spread gait:

a. is normal for elders. b. usually accompanies fast-paced walking or running. c. is a compensatory measure for unsteadiness. d. None of the above



Post-Test Questions: continued 6. Crude touch, pain, and temperature are detected in the:

a. dorsal column nerves. b. spinothalamics. c. coruna. d. cerebrum.

7. Dorsal column nerves:

a. cross to the opposite side of the body in the brain stem. b. cross to the opposite side of the body in the vertebral column. c. do not cross to the opposite side of the body.

8. Sensory dermatomes:

a. refer to distribution of sensory nerves near the skin. b. are innervated by a single spinal nerve root. c. are responsible for pain, tingling, and other sensations. d. a and c e. All of the above

9. To assess proprioception ask the patient to:

a. differentiate between a soft and sharp object on his arm. b. tell you where he feels two different pressure points on his thigh. c. close his eyes and tell you in what position you are holding his great toe. d. let you know when he feels vibration from a tuning fork placed on his middle finger.

10. Cortical sensory input is interpreted by the:

a. cerebellum. b. left temporal lobe. c. occipital lobe. d. parietal lobes.

11. Stereognosis is the ability to identify an object by:

a. taste. b. smell. c. sound. d. touch.



Post-Test Questions: continued 12. Graphesthesia is:

a. the ability to identify an object by sight. b. the ability to identify an object by its shape. c. the ability to identify letters or numbers which are written on the skin with a dull-pointed object. d. a form of dyslexia.



Post-Test Questions Answer Key: 1. a b c d e

2. a b c d e

3. a b c d e

4. a b c d e

5. a b c d e

6. a b c d e

7. a b c d e

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11. a b c d e

12. a b c d e



Glossary: Afferent nerve: nerve that carries impulses toward the central nervous system. Clonus: involuntary movement of rapidly alternating contraction and relaxation of a muscle. Coma: condition where a patient does not respond to either continuous or painful stimulation. He does not move except for reflex actions, and he does not verbalize. Consensual constriction: constriction of the pupil of the eye when a light is directly shone in the other eye. Decerebrate posturing: extensor posturing where a patient has clenched teeth, rigidly extended and hyperpronated arms, stiffly extended legs, and plantar extended feet. Decorticate posturing: flexor posturing where a patient’s arms, wrists, and fingers flex, his arms adduct, his legs stiffly extend and internally rotate, and his feet plantar extend. Dermatome, sensory: localized area of skin that is innervated by a segment of the spinal cord. Dilated pupil: pupil greater than 4 millimeters in diameter. Dorsal column nerves: detect proprioception, vibratory sensation, and light touch. The impulses travel from the periphery, entering the spinal cord and moving to the brainstem, where they cross to the opposite side terminating in the cerebral hemisphere on the opposite side of the body from where they began. Efferent nerve: nerve that carries impulses away from the central nervous system. Fasciculation: involuntary contractions or twitching of groups of muscle fibers. Graphesthesia: the sense by which letters or numbers are recognized when written on the skin with a dull-pointed object. Lethargy: drowsy state in which a patient can awaken, although not completely, to stimulation. He may also follow commands; however, his responses may be slow and inattentive. Lower motor neurons: nerve fibers which originate in the spinal cord and travel out of the central nervous system to muscles in the body.


Neurologic Assessment: Cerebellar Function and Sensory Evaluations Glossary: continued Obtundation: condition where a patient is difficult to arouse and needs constant stimulation to follow commands. He may verbally respond to stimuli with a few words, but will drift back to sleep when the stimulus is removed. PERRLA: acronym for pupils equal, round, reactive to light and accommodation.

Proprioception: perception of position, location, orientation, and movement of the body.

Reflex arc: route followed by nerve impulses to produce a reflex act, from the periphery through the afferent nerve to the nervous system, and back through the efferent nerve to an organ that produces an effect such as contraction or secretion.

Reinforcement: distraction technique (such as having a patient clench his teeth or hook his fingers together and then try to pull them apart) to elicit reflex activity in the upper or lower extremities. Spinothalamic nerves: detect crude touch, pain, and temperature. Impulses travel from the periphery, enter the spinal cord, and cross to the other side of the cord within one or two vertebral levels of their point of entry. They continue on that side up to the brain, terminating in the cerebral hemisphere on the opposite side of the body from where they began. Stereognosis: ability to recognize an object placed in the hands without looking at it. Stupor: state where a patient arouses to vigorous and continuous stimulation, which is typically painful in nature. He may moan briefly, but does not follow commands. His only response may be withdrawal from the painful stimulus. Subluxation: Incomplete or partial dislocation of a joint. Upper motor neurons: nerve fibers that start in the motor cortex of the brain and terminate within the medulla or spinal cord.



Handouts: CRANIAL NERVES

Number Nerve Function Structures Innervated I Olfactory Smell Olfactory bulb II Optic Vision Retina III Oculomotor Eyeball movement

Lens Accommodation 4 eyeball muscles and 1 eyelid muscle

Pupil constriction IV Trochlear Eyeball movement Superior oblique muscles V Trigeminal Sensations Face, scalp, teeth, lips, eyeballs, nose, throat lining General sensory from tongue Anterior 2/3 of tongue Proprioception Muscles of mastication Chewing Muscles of mastication VI Abducens Eyeball movement Lateral rectus muscle VII Facial Taste Face and scalp Proprioception Face and scalp Facial expressions Muscles of face Salivation and lacrimation Salivary and lacrimal glands VIII Acoustic Balance Vestibular apparatus (Vestibulocochlear) Hearing Cochlea IX Glossopharyngeal Taste Posterior 2/3 tongue Proprioception for swallowing Throat muscles Blood pressure receptors Carotid sinuses Swallowing and gag reflex Throat muscles Tear production Lacrimal glands Saliva production Parotid glands X Vagus Chemoreceptors Blood oxygen concentration, aortic bodies Pain receptors Respiratory and digestive tracts Sensations External ear, larynx, pharynx Taste Tongue Heart rate and stroke volume Pacemaker and ventricular muscles Peristalsis Smooth muscles of digestive tract Air flow Smooth muscles in bronchial tubes Speech and swallowing Muscles of larynx and pharynx XI Spinal Accessory Head rotation, upright position

Shrugging shoulders

Trapezius and sternocleidomastoid muscles

XII Hypoglossal Speech and swallowing Tongue and throat muscles



Handouts: continued SCORING FOR PUPIL REACTION TIME

Score Descriptor

4+ Brisk

3+ Less than brisk

2+ Slow

1+ Very sluggish

0 Absent

SCORING FOR STRENGTH OF REFLEX REACTION

Value Descriptor

0 Reflex absent

1+ Reflex slight, trace response or response brought on by reinforcement

2+ Reflex in lower half of normal range

3+ Reflex in upper half of normal range

4+ Reflex enhanced, more than normal, includes clonus

National Institute of Neurological Disorders and Stroke Scale



Handouts: continued SCORING OF MUSCLE STRENGTH

Value Descriptor

0 No muscle contraction

1+ Trace contraction, though not enough to move structure to which it is attached

2+ Voluntary movement which is not enough to overcome force of gravity

3+ Voluntary movement capable of overcoming gravity, but not applied resistance

4+ Voluntary movement capable of overcoming some resistance

5+ Normal strength

CONTINUUM OF LEVELS OF CONSCIOUSNESS

Full Consciousness Lethargy Obtundation Stupor Coma



Handouts: continued GLASGOW COMA SCALE

Category Criteria Score

Eye opening spontaneously 4

Eye opening to verbal response

3

Eye opening to pain 2

Eye Response

No eye opening 1

Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

Verbal Response

No verbal response 1

Obeys commands 6

Localizing pain 5

Withdrawal from pain 4

Flexion to pain (decorticate posturing)

3

Extension to pain (decerebrate posturing)

2

Motor Response

No motor response 1

NEUROLOGIC

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