Chapter 56: Nursing Assessment: Nervous System

STRUCTURES AND FUNCTIONS

• The human nervous system is a highly specialized system responsible for the control and
integration of the body’s many activities.

• The nervous system can be divided into the central nervous system (CNS) and parts of the
peripheral nervous system (PNS).
o The central nervous system consists of the brain and spinal cord.
o The peripheral nervous system consists of the cranial and spinal nerves and the
autonomic nervous system (ANS).

• The nervous system is made up of two types of cells: neurons and neuroglia.
o The neurons of the nervous system come in many different shapes and sizes, but
they all share common characteristics: (1) excitability, or the ability to generate a
nerve impulse; (2) conductivity, or the ability to transmit the impulse to other
portions of the cell; and (3) the ability to influence other neurons, muscle cells, and
glandular cells by transmitting nerve impulses to them.
o Neuroglia, or glial cells, provide support, nourishment, and protection to neurons.

• Nerve impulses originate within a neuron as an action potential that moves along the body
of the cell (axon) until it reaches the end of the nerve fiber. From there, it is transmitted
across the junction between nerve cells by a chemical interaction and then, the impulse will
move across the next neuron as an action potential.
o A synapse is the structural and functional junction between two neurons. It is the
point at which the nerve impulse is transmitted from one neuron to another or from
neuron to glands or muscles.
o A neurotransmitter is a chemical agent involved in the transmission of an impulse
across the synaptic cleft.

CENTRAL NERVOUS SYSTEM

• The major structural components of the CNS are the spinal cord and brain.

Spinal Cord
• The spinal cord is continuous with the brainstem and exits from the cranial cavity through
the foramen magnum. A cross section of the spinal cord reveals gray matter that is centrally
located and is surrounded by white matter.

• Specific ascending and descending pathways in the white matter can be identified.
o In general, the ascending tracts carry specific sensory information to higher levels of
the CNS.
o Descending tracts carry impulses that are responsible for muscle movement.

• Lower motor neurons are the final common pathway through which descending motor
tracts influence skeletal muscle, the effector organ for movement. The cell bodies of these
cells are located in spinal cord and the axons innervate the skeletal muscles.
Brain
• The brain consists of the cerebral hemispheres, cerebellum, and brainstem.

• The cerebrum is composed of the right and left hemispheres. Both hemispheres can be
further divided into four major lobes.
o The frontal lobe controls higher cognitive function, memory retention, voluntary eye
movements, voluntary motor movement, and expressive speech.
o The temporal lobe contains Wernicke’s area, which is responsible for receptive
speech and for integration of somatic, visual, and auditory data.
o The parietal lobe is composed of the sensory cortex, controlling and interpreting
spatial information.
o Processing of sight take place in the occipital lobe.

• The basal ganglia, thalamus, hypothalamus, and limbic system are also located in the
cerebrum.

• The brainstem includes the midbrain, pons, and medulla. The vital centers concerned with
respiratory, vasomotor, and cardiac function are located in the medulla.

• The brainstem contains the centers for sneezing, coughing, hiccupping, vomiting, sucking,
and swallowing. Also located in the brainstem is the reticular formation, which relays
sensory information, influences excitatory and inhibitory control of spinal motor neurons,
and controls vasomotor and respiratory activity.

• The cerebellum coordinates voluntary movement and to maintains trunk stability and
equilibrium.

• Cerebrospinal fluid circulates within the subarachnoid space that surrounds the brain,
brainstem, and spinal cord. This fluid provides cushioning for the brain and spinal cord,
allows fluid shifts from the cranial cavity to the spinal cavity, and carries nutrients.

PERIPHERAL NERVOUS SYSTEM

• The PNS includes all the neuronal structures that lie outside the CNS. It consists of the
spinal and cranial nerves, their associated ganglia (groupings of cell bodies), and portions of
the ANS.

• The spinal nerve contains a pair of dorsal (afferent) sensory nerve fibers and ventral
(efferent) motor fibers, which innervate a specific region of the neck, trunk, or limbs. This
combined motor-sensory nerve is called a spinal nerve.

• The cranial nerves (CNs) are the 12 paired nerves composed of cell bodies with fibers that
exit from the cranial cavity. Unlike the spinal nerves, which always have both afferent
sensory and efferent motor fibers, some CNs have only afferent and some only efferent
fibers; others have both.

• The autonomic nervous system (ANS) governs involuntary functions of cardiac muscle,
smooth (involuntary) muscle, and glands. The ANS is divided into two components, the
sympathetic and parasympathetic nervous systems.
PROTECTIVE MECHANISMS
• The blood-brain barrier is a physiologic barrier between blood capillaries and brain tissue.
The structure of brain capillaries differs from that of other capillaries. Some substances that
normally pass readily into most tissues are prevented from entering brain tissue.

• The meninges are three layers of protective membranes that surround the brain and spinal
cord.
o The thick dura mater forms the outermost layer, with the arachnoid layer and pia
mater being the next two layers.
o The subarachnoid space lies between the arachnoid layer and the pia mater. This
space is filled with CSF.

• The bony skull protects the brain from external trauma. It is composed of 8 cranial bones
and 14 facial bones.

• The vertebral column protects the spinal cord, supports the head, and provides flexibility.
The vertebral column is made up of 33 individual vertebrae: 7 cervical, 12 thoracic, 5
lumbar, 5 sacral (fused into 1), and 4 coccygeal (fused into 1).

Assessment
• Special attention should be given to obtaining a careful medication history, especially the
use of sedatives, opioids, tranquilizers, and mood-elevating drugs.

• The nurse should ask about the patient’s health practices related to the nervous system, such
as substance abuse and smoking, maintenance of adequate nutrition, safe participation in
physical and recreational activities, use of seat belts and helmets, and control of
hypertension.

• Bowel and bladder problems are often associated with neurologic problems, such as stroke,
head injury, spinal cord injury, multiple sclerosis, and dementia. It is important to determine
if the bowel or bladder problem was present before or after the neurologic event to plan
appropriate interventions.

• Because the nervous system controls cognition and sensory integration, many neurologic
disorders affect these functions. The nurse should assess memory, language, calculation
ability, problem-solving ability, insight, and judgment.

• The ability to participate in sexual activity should be assessed because many nervous system
disorders can affect sexual response.

• The physical examination assesses six categories of functions: mental status, function of
CNs, motor function, cerebellar function, sensory function, and reflex function.
o Assessment of mental status (cerebral functioning) gives an indication of how the
patient is functioning as a whole and how the patient is adapting to the environment.
o Each CN should be assessed individually.
o The motor system examination includes assessment of bulk, tone, and power of the
major muscle groups of the body, as well as assessment of balance and coordination.
o Several modalities are tested in the somatic sensory examination. Each modality is
carried by a specific ascending pathway in the spinal cord before it reaches the
sensory cortex.
o A simple muscle stretch reflex is initiated by briskly tapping the tendon of a
 stretched muscle, usually with a reflex hammer.

Diagnostic Studies
• Lumbar puncture is the most common method of obtaining CSF for analysis. CSF analysis
provides information about a variety of CNS diseases.

• Cerebral angiography is indicated when vascular lesions or tumors are suspected.

• The technique of electroencephalography (EEG) involves the recording of the electrical

activity of the surface cortical neurons of the brain by 8 to 16 electrodes placed on specific
areas of the scalp.

• Electromyography (EMG) is the recording of electrical activity associated with innervation

of skeletal muscle.

• Nerve conduction studies involve application of a brief electrical stimulus to a distal portion
of a sensory or mixed nerve and recording the resulting wave of depolarization at some
point proximal to the stimulation.

• Evoked potentials are recordings of electrical activity associated with nerve conduction
along sensory pathways. The activity is generated by a specific sensory stimulus related to
the type of study (e.g., checkerboard patterns for visual evoked potentials, clicking sounds
for auditory evoked potentials, mild electrical pulses for somatosensory evoked potentials).