Neurological System

Development

 The formation begins in the 3rd week, at

24week all nerve cell, neurons are
developed.
 At birth the brain weights an average of
325g, at 1 year the weight will tripled.
 Head circumference is the best indicator for
brain growth.
Anatomy & Physiology

 Brain: Covered by protective layers that

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

 Hemisphere divided into 4 lobes:

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

 Cerebellum: maintain body equilibrium,

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

 Evaluation of motor function

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

 involuntary, controlled by brainstem,

diminished by 3-4 mon, disappear by 4-
6mon..
 Symmetry ( abnormal if asymmetrical,
absent, persist).
 Diminished if the infant very sleepy, irritable,
satiated after feeding.
Reflex How initiated Response

Palmar With infant head midline, touch Fingers clasp examiner

grasp palm of infant hand on ulnar thumb
surface with examiner thumb

Planter Touch infant on plantar surface Toes cur downward

grasp of foot at base of toes

Rooting Touch stroke check Infants head turns

toward stimulus &
mouth should open

Sucking Gently stroke the lips Mouth open, sucking

begins
Truncal Hold infant firmly suspended in Hips& buttocks
incurvatio prone position with examiner curve/turn toward
n or hand supporting chest, with stimulus side
Gallant’s opposite hand stroke along spine
lightly with fingernail just
adjacent to vertebra from
shoulder to coccyx
Postural Reflexes

 Appear when primitive reflexes disappear,

between 5-6mon & progress in a
cephalocaudal direction from head control to
grasping objects
Reflex How initiated
Landau Hold infant firmly suspended in
prone position with examiner
hand supporting abdomen &
head legs should extend over
Parachute head
Hold infant prone & firmly
supported, slowly lower infant
toward flat surface
Lateral Suspend infant in prone
Forward position with arms/legs
extended, support with both
hands over flat surface
Positive Hold infant in upright & firmly
support supported underarms while
over exam table, touch infant
feet to surface
Response
Infant should lift head,
extend spine/lower
extremities
Should try protect
themselves by
extending arms/legs
Will lift head & extend
spine along horizontal
plane
Infant should extend
legs & bear some
weight
Involuntary Motor Function

 Tremors: coarse repetitive shaking

 Clonus: rhythmic tonic-clonic movement of
the foot
 Tics: involuntary muscle contraction and/or
audible sounds or words
Evaluation of Sensory Function

 Touch, deep pressure, pain, Tem, & vibration

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

 Discrimination: tested by following tests:

 Stereognosis: the ability to recognize an
object by its feel.
 Graphesthesia: the ability to identify shapes
traced on the palm
 Two-point discrimination: a test of spatial
discrimination of the body, with child eyes
closed touch lightly on the skin with 2 points
in close proximity on the body, ask if he felt
one or 2 points
Cranial Nerves in Newborn &
Infants
 1 Olfactory: pass strong smelling substance
under nose. Observe for startle response,
grimace, sniffing.
 2Optic: light source/ophthalmoscope. Pupil
constrict in response to light, able to fix on
object & follow for 60-90 degree
 3Oculomotor: elicit pupillary response to test
optic nerve by shining pen light toward pupil.
Evaluate shape, size, symmetry,
spontaneous movement of pupil.
Cranial Nerves in Newborn &
Infants
 4 Trochlear, &5 Abducent: “doll’s eyes”
maneuver rotate head from side to side
observe eyes moving away from direction of
rotation. Eyes should deviate Lt when
turning head to Rt, if remain fixed or don’t
track in opposite direction, (brain stem
dysfunction).
 6 Trigeminal: touch cheek area test jaw
muscles by placing gloved finger in infants
mouth. infant turns cheek toward touch
stimulus 7 bit down on gloved finger & start
sucking.
Cranial Nerves in Newborn &
Infants
 7 Facial: observe face for symmetry of
movement. Asymmetrical indicate nerve
palsy.
 8 Acoustic: with infant lying supine ring bell
sharply within a few inches of his ears.
Observe response such as mild startle/blink
reflex.
 9Glossopharyngeal: use tongue blade to
apply pressure on mid-tongue area to
overcome tongue thrust. Elicit gag reflex
observe tongue movement, strength.
Cranial Nerves in Newborn &
Infants
 10 Vagus; observe while crying. Evaluate
pitch, shrill penetrating cry indicate
intracranial hemorrhage; whiny-high pitched
cry indicate CNS dysfunction.
 11 Accessory: with infant lying supine, turn
head to one side. Should work to bring head
to midline.
 12 Hypoglossal: observe when feeding.
Sucking, swallowing should be efficient,
coordinated.
Cranial Nerves in Preschool to
School age
 2 Optic: Allen picture card, Senellen chart
 3 Oculomotor, 4trochlear,5 abducencs:
follow toy, light source, index of finger.
 Trigeminal: chewing & swallowing, touch
facial area with cotton swab
 Facial: aske to smile, puff cheek
 Acoustic: repeat words whispered from
behind
 Glossopharyngeal & Vagus: observe tongue
& gag reflex with tongue blade
 Accessory & hypoglossal: stick tongue out
&shrug shoulders
Deep Tendon Reflex

 Biceps reflex: with examiner thumb pressed

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

 Plantar reflex: stroke sole of foot from

heel to ball of foot curving medially with
flat object. Movement of toes
 Abdominal reflex: stroke briskly above &
below umbilicus. Abdominal muscle
contract & umbilicus deviates toward
stimuli
 Graded of deep tendon reflex
4. 4+: brisk, hyperactive
5. 3+:active, brisker than normal
6. 2+: normal response
7. 1+: diminished response
8. 0: no response
Evaluation of Cerebellar Function

 Evaluation balance & coordination

 Finger-to-nose test: with eyes closed ask
child to touch his nose with finger of one
hand then with first finger of other hand,
then with eyes open have child touch his
nose with first finger then touch examiner
finger held about 18 inches in front of the
child, then increase the speed of the
movement with examiner finger changing
position.
 Finger-to-thumb test; using one hand aske
the child to touch each finger to the thumb
in rapid succession, coordination aske him to
pat knee with the palm of the hand then
Evaluation of Cerebellar
Function
 Romberg test: assess for balance &
equilibrium. Aske the child to stand erect
with eyes closed & hands touching the sides
observe the child balance for several
seconds.
 Tandem walking: assess balance &
coordination. Aske the child to walk heel to
toe in straight line
 Hopping in place & heel-toe walking
Evaluation of Cerebral Function

 Evaluate
2. The level of consciousness,
3. Mood & affect
4. Thought
5. Memory
6. Judgment
7. Communication
Glasgow Coma Scale

 Eye opening

Birth to 1 >1 year Score

year
Spontaneous Spontaneously 4
ly
To loud noise To verbal 3
command
To pain To pain 2

No response No response 1
Glasgow Coma Scale

 Motor Response
Birth to 1 year > 1 year Score

Spontaneous Obeys 6
response
Localize pain Localize pain 5

Withdrawal to pain Withdrawal to pain 4

Involuntary flexion Involuntary flexion 3

Involuntary Involuntary 2
extension extension
No response No response 1
Glasgow Coma Scale

 Verbal Response

Birth to 2 year 2-5 year > 5 year Score

Cries as Purposeful Oriented & 5

response, words responds
vocalizes
cries Incoherent Disoriented & 4
words converses
Inappropriate Cries or Inappropriate 3
crying scream words
Grunts Grunts Incomprehensibl 2
e words
No response No No response 1
response
Glasgow Coma Scale

 Severity of Injury
2. Mild head injury: 13-15
3. Moderate head injury: 9-12
4. Sever head injury: <8