NEUROLOGIC SYSTEM BRAIN

Division of the Nervous System - 100 billions of neurons

- 1400 grams (3 pounds)
- 20% of the cardiac output
- 750 to 900 ml of blood flow/min

Cerebral Cortex

- Outer and thin layer on the surface of the cerebral

hemisphere

CNS

At 3 weeks gestation CNS DEVELOPS FROM

EMBRYONIC NEURAL TUBE

BRAIN & SPINAL CORD

Outer layer- consists of neuron (gray matter)
Inner layer- consists of axons (white matter)
VENTRICLES
Cerebrum (Forebrain)

BASIC ANATOMY & PHYSIOLOGY - Largest part of the brain

- Right hemisphere
Cells in the Nervous system - Left hemisphere
- Nerve cell/ Neuron
- Glial cells

NEURON

Functional classification:

- Afferent neurons (sensory)

- Efferent neurons (motor)

1. Frontal
- Higher cortical thinking
- Personality development
- Motor functions

Frontal lobe- Broca’s Area

Motor (expressive) speech center

– enables the person to speak
clearly and make gestures

Expressive Aphasia- unable to talk, write

NEUROGLIA (GLIAL CELLS)

1. Microglia – play an important part in the immune 2. Temporal

system in the brain - Hearing
2. Ependymal cells- play a critical in CSF homeostasis, - Short-term memory
brain metabolism, clearance of waste from the brain
3. Oligodendrocytes- produces myelin sheath Temporal lobe- Wernicke’s Area
(covered the axon) in the CNS Sensory (Auditory) speech center –
4. Astrocytes – play an important role in the BBB enables the person to receive and
(Blood, Brain, Barrier) understand language
5. Satellite cells- wrapping around the neuronal cell
bodies Receptive Aphasia- unable to understand both written
6. Schwann cells- form/produces myelin sheath in the and spoken words
PNS
7. 3. Parietal
- Appreciation and discrimination of sensory
FUNCTIONS impulses

Neurons Glial cells 4. Occipital

To conduct electrical To provide support, - Visual center
impulses nourishment, protection
- Enables the person to read
for the neurons

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CEREBELLUM CRANIAL NERVE FUNCTION/S
I olfactory Sense of smell
- For balance, posture,
equilibrium and gait II Optic Sense of sight
Diencephalon
III Oculomotor Pupil constriction (6
- Connects cerebrum, Brain stem cardinal gaze)

Thalamus IV Trochlear Superior oblique eye

movement ( 6 cardinal
- Relay station for sensation gaze)
Hypothalamus
V Trigeminal Facial sensation,
- Temperature regulation mastication, Lateral eye
- Controls the BP movement
- Controls thirst
VI Abducens Lateral eye movement (6
cardinal gaze)

BRAIN STEM VII Facial Facial

expression/movement,
Midbrain- reflex center 2/3 anterior taste buds
Pons- respiratory
VIII Acoustic Hearing & balance
Medulla oblongata
IX Glossopharyngeal 1/3 post, taste buds,
- Respiratory center swallowing
- Cardiac center
- Vasomotor center X Vagus Gag reflex, S/Sx of
bradycardia

XI Spinal accessory Shoulder movement

Pons – Pneumotaxic center (controls the rate & rhythm
of our respiration)
XII Hypoglossal Tongue protrusion
Medulla oblongata

Controls: Cranial nerves

- Respiration Some cranial nerves:

- Heartrate - Sensory (S)
- Vomiting - Motor (M)
- Swallowing - Both (B)
- Hiccups
AUTONOMIC NERVOUS SYSTEM (ANS)
Note: the medulla oblongata is the termination point of
spinal decussation SYMPATHETIC VS PARASYMPATHETIC
Spinal cord Sympathetic nerves Parasympathetic nerves
(increase except GIT & (decrease except GIT &
- a long cylindrical structure GUT) GUT )
- encased in the spinal column
- 31 spinal nerves- c8, t12, L5,S5, C1 Dilate pupils Constrict pupils
- C,T,L are separated by disks
o Outer annulus & inner nucleus pulposus Inhibit salivation Stimulate saliva
Cervical Increase heartbeat Slow heartbeat
- Controls diaphragm
Relax airways Constrict airways
- Chest wall muscles
- Arms and shoulders
Inhibit activity of stomach Stimulate activity of
Thoracic- controls the upper body, gastric, intestinal stomach
function Inhibit gallbladder Stimulate gallbladder

Lumbar- controls the lower body Inhibit activity of Stimulate activity of

intestines intestines
Sacral – controls bowel & bladder
Secrete epinephrine &
norepinephrine
Peripheral Nervous System
Relax bladder Contract bladder
- 12 Cranial nerves
- 31 Spinal nerves
Sympathetic nervous system:

- “fight or flight”
- Excitement , Emergency
- Epinephrine & norepinephrine

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Parasympathetic nervous system:

- “rest and digest” Hydrocephalus

- Digestion, Defecation , Diuresis
- Acetylcholine

Protection of the CNS:

1. Skull – protects the brain

2. Meninges-
3. Spine
4. CSF
5. Blood-Brain Barrier
Blood-brain barrier - Protective barrier
Supporting Structures

Meninges

Epidural space

- Dura Mater

Subdural space

- Arachnoid
Assessment
(more on
arteries) - PE
- Diagnostic tests
Subarachnoid space (blood goes)
1. Sensation
- Pia Mater 2. Motor function
3. Glasgow coma scale
4. Orientation on the mental status
CEREBROSPINAL FLUID (CSF)
Motor function assessment
- bathe, nourishes, cushion and protects the brain
from jarring against the skull - Presence involuntary anprostful and
- clear, colorless, odorless uncoordinated movement

Choroid Plexus: 125 to 150 ml/day Muscle Power

Arachnoid Villi: - Weakness (paresis)

- Paralysis (plegia)
Pressure: 75 -180 mmH20
Muscle tone
Ventricles: (2) lateral v, third v, fourth v
- Flaccidity
Appearance: halo sign - Rigidity

Muscle volume

- Atrophy (less muscle vol.)

- Hypertrophy (increase muscle vol.)

Pathway Movement

- (2) lateral ventricles then to the foramen of monro - Bradykinesia (slow movement not associated w
- 3rd ventricle then travel to cerebral aqueduct weakness)
- 4th ventricle then pass to the foramen of luschka - Akinisia (absence of muscle movement)
and foramen of magendie Movement of the extremities
- Suabarachnoid space (brain & spinal cord)
Muscle strength

Evaluate CSF - Apraxia (inability to perform fine motor activities)

- Agraphia (inability to write)
Component Normal range Indications
CHON 15-45 mg% inc in tumor,
MS, GBS
Stereognosis- ability to perceive sensory stimuli
Glucose 50-80 mg% (Glycorrhachia) Agnosia-inability to perceive sensory stimuli
dec in infection

Chloride 118-132 mg% dec in infection

Reflex activity- an involuntary movement in response to
WBC 0-8 mL elevated – stimuli
pleocytosis
Pupillary reflexes
Globulin 3-9% inc in MS
- elicit a direct light to the pupils of your eyes
- this result a CONSTRICTION OF THE PUPIL
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 - a FIXED & DILATED PUPIL is a sign of Abnormal- clients falls or experiences uncoordinated
neurologic emergency movements (ATAXIA)

Cremasteric reflex

- is elicited by a downward striking of the inner

thigh of a male client
State of Consciousness
Normal: there will be an elevation of the scrotum on the
same side a. Level of consciousness
b. Glasgow Coma Scale (GCS)
Doll’s Eye Reflex or Oculocephalic Reflex
Is an OBJECTIVE measure to assess the
- to assess brain stem function in an unconscious patient’s level of Consciousness (LOC)
patient
- hold the eyelids open then quickly but gently turn Level of Consciousness
his head to the right, if there is no problem his Level I - Conscious, normal awareness, oriented
eyes will move to the center of his body, if the to time, place & person
eyes stay to the right side or remain stationary the
reflex is absent meaning deteriorating LOC or Level II - Lethargy, somnolence, drowsiness &
deep coma obtundation
- Pt responds w conclusion
Deep Tendon Reflex DTR - Pt responds briskly to painful stimuli
- biceps, triceps, brachioradialis, patellar and
Level III - Stupor
Achilles tendon
- Physical & mental activities are minimal
- strike the tendon with percussion hammer and (deterioration)
observe the ff: - Noxious or strong stimuli – pt react by
0= absent reflex withdrawal, grimace & making
unintelligible sounds
1+ = present but diminished

2+ = normal Glasgow coma scale

3+ = increase but not necessarily pathologic Category Response Points

Eye Spontaneous, open w blinking 4
4+= hyperactive or clonus (rapid contraction and opening at baseline
relaxation of skeletal muscle)
Opens to verbal command, 3
Hyporeflexia = lower motor neuron problem speech, or shout
Hyperreflexia = upper motor neuron problem
Opens to pain 2

No response 1
Reflexes to assess meningeal irritation

KERNIG’S SIGN Category Response Points

Verbal Oriented conversation 5
How:
response
- Placed in supine position Disoriented, confused 4
- Flex the knee (90 deg) conversation, able to answer
questions
Response of the AEG:
Inappropriate responses, words 3
- Attempt to extend the leg due to pain (positive- discernible
abnormal)
Incomprehensible speech 2
BRUDZINSKI’S SIGN (moaning)
How:
No response 1
- Placed in supine position
- Positively flex the hips & neck Intubated 1T

Response of the AEG:

Category Response Points
- If the hips & knees flex due to pain (positive- Motor Obeys commands for 6
abnormal) response movement
ROMBERG’S TEST Purposeful movement to painful 5
- Assess cerebellar function stimulus
- Client to stand w feet together & eyes closed
Withdraws from pain 4
Normal – client should stand erect, slightly swaying is
normal Abnormal (spastic) flexion, 3
decorticate posture

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 External (rigid) response, 2 - Assess for CLAUSTROPHOBIA
decerebrate posture - Inform client that machine drum-like or knocking
sounds
No response 1

Electroencephalogram (EEG)

- Graphing recording of spontaneous electrical

impulses of the brain from scalp by using sensors
- Lasts for 30 mins
- Painless procedure
- Lying down or sitting position

What to expect During a Routine EEG

1. wax crayon marks spots for electrodes on scalp

2. 16-25 electrodes placed on scalp
Glasgow coma scale 3. try to relax, brain waves recorded for 45-180 mins
Normal range: 9-15 Nsg. Responsibilities
Coma: 5-8 - explain procedure
Deep coma: 3-4 - check pt meds history for drugs that may interfere
w test result:
Eye opening = Pons o antidepressants
o tranquilizers
Verbal response = midbrain
o anticonvulsants
Motor response= herniation - avoid caffeine & other stimulants
- instruct pt to relax and remain still

After the procedure:

Diagnostic Exams
- wash hair, clean and dry hair
X-ray CT Scan MRI
Uses Uses Uses magnetic
electromagnetic computerized field w radio
Lumbar Puncture/ Lumbar Tap/ Spinal Tap
radiation special X-ray frequencies
beam that slices Diagnostic (examination of CSF)
the image
Therapeutic (Reduce the ICP by withdrawal of CSF)
Confirm skull Identify tumors Identify tumors,
fracture aneurysms, infarcts, - Introduction of a needle into the subarachnoid
hemorrhage, vascular spaces
hydrocephalus abnormalities - L3-L4, L4-L5, L5-S1

With radiation With radiation No radiation Contraindicated: patient w increased ICP

CT scan

Nsg. Responsibilities

Plain W dye/contrast medium

Consent Consent

Remove metallic Inform that there is a sound

object

Remain STILL during Assess for allergic reaction to

the entire procedure iodinated contrast material

Assess for NPO 4-6 hours (for the dye

CLAUSTROPHOBIA not to be diluted)

Increase fluid intake

MRI

Nsg. Responsibilities

- Obtain history of mental implants

- Remove credit cards, watches or any metal item
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 Before

- Obtain a consent
- Assess for allergies to iodine
- Premedicate for sedation as prescribes

After

- If a water-based dye is used elevate the HOB

15-30 degrees for 8 hrs. as prescribed
- If an oil-based dye is used, keep the client flat 6-
24 hrs. as prescribed
- Increased fluid intake
- Observe for any changes in neurologic status

5-10 mL only of CSF

Cerebral angiography
Nsg. Responsibilities
- Injection of contrast through the femoral artery
Before into the carotid arteries

- Position the client: (fetal position, C position, Purpose: to visualize the cerebral arteries and assess for
prawn position, side lying position w the head lesions
pressed to the chest & the knees flexed to the
chest)
- Cleanse the site to be punctured Nsg. Responsibilities
- Between L3-L4, L4-L5, L5-S1)
Before
After
- Obtain a consent
- Prone position for 30 mins right after the - Assess the client for allergies to iodine and selfish
withdrawal of the spinal needle - Encourage hydration for 2 days before the test
- Lie flat on bed for 6-8 hrs. (no leakage of CSF) - NPO 4-6 hrs. prior to the test as prescribed
- Encourage fluid if not restricted - Mark the peripheral pulses
- Headache may develop due to CSF leakage
- Observe for change in neurologic status After

Call your doctor - Assess peripheral pulses

- Keep the bed flat if the femoral artery is used, as
- A severe headache or a headache that lasts 2 or prescribed
more days - Immobilize the puncture site for 12 hrs as
- Pain at back that persists prescribed
- Tingling in the groin or legs - Apply sandbags and pressure dressing at the site
- Fever - Force fluids

Electromyography (EMG) Diagnostic and laboratory findings

- Is a test that measures and records the activity 1. CT & MRI – hemorrhage, tumor, cysts, edema,
of contracting muscles in response to electrical brain atrophy
stimulation 2. EEG – seizure, altered LOC
- This test is use to help detect neuromuscular 3. Cerebral Angiography – aneurysm,
abnormalities and muscle weakness arteriovenous malformations
- During this test, one or more small needles (also 4. LP- CSF analysis
called electrodes) are inserted through the skin in 5. EMG- muscle weakness
to the muscle

Nsg. Responsibilities

- Explain the procedure/cost small electrodes

needle will be inserted into the muscles and
causes mild discomfort
- Instruct the patient to avoid using any creams or
lotions on the day of the test

Myelogram

- It uses x-rays and a special dye called material,

injected at your back to visualize the spaces
between the bones in your spinal column
- It finds a tumor infections, problem w the spine
such as bulging disc and arthritis
- It is an invasive diagnostic test. Usually it is done
when spinal nerve are compressed and it is not
confidentiality visualized in the MRI or CT scan

Nsg. Responsibilities
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