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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