Neurological

Nursing
Overview of the Anatomy
and Physiology of the
NERVOUS
SYSTEM
 NERVOUS
SYSTEM
CENTRAL PERIPHERAL
⮚organ system that contains a network
of specialized cells called neurons.
⮚Controller of various processes

Nervous system
 Anatomic & Physiologic Overview
• 2 major parts: CNS & PNS
• FUNCTIONS
⮚Sensory input
⮚Processing & interpreting
⮚Motor output
• Composition: 2 principal types of cells
(conducting and supportive cells)
 Cells of the Nervous System
1. Neuron
(Neurone,
Nerve cell)
⮚ Dendrites- threadlike structures that
conveys incoming electrochemical
messages toward the cell body.
⮚ Axon- long projections that
generates impulses away from the
cell body.
⮚ Cell body- center of neuron; nucleus
⮚Synapses- fundamental property of
neurons that is used to communicate
with other cells
⮚Myelin Sheath- whitish, fatty
material (covers long nerve fibers);
- has waxy appearance (protects &
insulates the fibers & increases the rate
of nerve impulses)
⮚Schwann cells- myelinate the axon
⮚Nodes of Ranvier- gaps or
indentations between myelin sheath
 NEUROTRANSMITTERS
- chemicals made by neurons
Action: to potentiate, terminate, or
modulate a specific action and can
either excite or inhibit the target cell’s
activity
How: By communicating messages from
one neuron to a specific target tissue
Types of Neurotransmitters:
1. Amines group- contains molecules of
carbon, hydrogen, and nitrogen
a. Acetylcholine- most widely used
neurotransmitter
b. Norepinephrine- major
neurotransmitter of the sympathetic
nervous system
c. Dopamine- involved in the movement
of muscles, and it controls the secretion of
the pituitary hormone prolactin
c. Serotonin-helps control mood and
sleep; inhibits pain pathways
 2. Amino Acid group- organic compound
containing both an amino group (NH2) and a
carboxylic acid group (COOH)
a. Glycine
b. Glutamic and aspartic acids
c. Gamma-amino butyric acid (GABA)
Glutamic acid and GABA- most abundant
neurotransmitters within the central nervous
system especially in the cerebral cortex
(largely responsible for such higher brain
functions as thought and interpreting
sensations)
3. Peptide group- contains at least 2,
and sometimes as many as 100
amino acids
a. Substance P- influences the
sensation of pain
2. Supporting cells- Neuroglia or
Glial cells/ non- neuronal cells
⮚Not able to transmit impulses
⮚50x ˃ neurons=40% of the brain’s bulk
⮚Types:
a. astroglia/ astrocytes- supply nutrients to
neurons; help maintain neurons’ electrical
potential; form part of the blood- brain
barrier
b. Ependymal cells- help produce CSF
c. Microglia- phagocytic cells that ingest
and digest microorganisms and waste
products from injured neurons
d. Oligodendroglia- supports and
electrically insulate CNS axons by forming
protective myelin sheaths
 Central Nervous System
• Brain & the
spinal cord.
• Surrounded by
bone-skull and
vertebrae.
• Fluid and tissue
insulate the brain
and spinal cord.
THE BRAIN • Part of CNS
contained within
the cranium
• mass of soft,
spongy pinkish gray
nerve tissue.
• accounts for
approx. 2% of the
TBW
 Main regions of the brain:
❖CEREBRUM ❖CEREBELLUM
❖DIENCEPHALON ❖BRAIN STEM
CEREBRUM
- Largest & most prominent part
- Governs higher mental processes
- Consists of the R&L hemisphere
separated by the great longitudinal
fissure
- Joined at the lower portion of the
fissure by the corpus callosum
• GYRI or GYRUS - convolutions
• SULCI or SULCUS - shallow grooves
• FISSURES- deeper groves
• Cerebral cortex
Layers of the Cerebrum:
• gray matter (muscle
control, sensory
perception, memory,
emotions, and
speech)
• white matter
• Divisions/ Lobes of Cerebral Hemispheres
1. Frontal- largest lobe
Functions: (1) concentration, abstract thought,
information storage or memory and motor
function; (2) contains Broca’s area; and (3)
responsible for an individual’s affect,
judgment, personality and inhibitions
2. Parietal- primary sensory cortex
Functions: (1) analyzes sensory
information, and relays the
interpretation of the information to the
thalamus and other areas; (2) essential
for an individuals awareness of the
body in space
3. Temporal- contains the auditory
receptive areas, interpretive area
that provides integration of
somatization, visual, and auditory
areas, Wernicke’s area,
proprioception (sense of position of
self)
4. Occipital- the posterior lobe
responsible for visual interpretation
DIENCEPHALON
STRUCTURES:
1. THALAMUS- relay station for all sensory impulses,
memory, and pain impulses
2. HYPOTHALAMUS- located anterior & inferior to the
thalamus.
- Contains nuclei very important in maintaining
homeostasis
- Regulation of visceral activities
- Regulates the pituitary secretion of hormones
3. EPITHALAMUS – located superior and posterior to
thalamus
- Involved in emotional and visceral response to odor
and contains the PINEAL BODY
BRAIN STEM
• STRUCTURES
1. MIDBRAIN - connects the pons & the
cerebellum with the cerebral hemispheres.
- acts as master coordinator for all the
messages going in & out of the brain to the
spinal cord.
2. PONS - helps regulate breathing, contains the
respiratory center.
3. MEDULLA OBLONGATA - most inferior part of
the brainstem
- contain centers that control HR, BP,
sneezing, coughing, breathing, swallowing &
vomiting
CEREBELLUM
- posterior to the midbrain & pons, &
below the occipital lobe.
- Literally means “little brain”
- Responsible for balance,
coordination and muscle tone
Structures Protecting the Brain
1. Skull- bony structure that
protects the brain from
injury
Major bones: frontal,
temporal, parietal and
occipital
Suture Lines: Coronal,
Sagittal, lambdoidal, and
squamosal
2. Meninges - fibrous connective tissue that
covers the brain and spinal cord; provides
protection, support and nourishment to the
brain and spinal cord
Layers:
a. Dura mater- outermost; covers the brain and
the spinal cord; tough, inelastic, fibrous, and
gray
Epidural space- potential space between the
dura matter and skull in the cranium, and
between periosteum and dura in the
vertebral column
b. Arachnoid Matter- middle
membrane; white; contains the
choroid plexus
- has unique fingerlike projections,
arachnoid villi
c. Pia mater- innermost membrane;
thin, transparent layer that hugs the
brain closely
 Cerebrospinal fluid
- clear & colorless fluid
- Acts as protective
cushion
- produced at rate of
about 500ml/day
- laboratory analysis:
clear color, normal
specific gravity of
1.007, protein count,
minimal WBC count,
glucose, & some
electrolytes, no RBC
 Spinal Cord
• runs along the dorsal side of
the body; links the brain to
the rest of the body.
• Carries sensory information
to & motor information
from the brain.
• encased in a series of bony
vertebrae that comprise the
vertebral column.
• 45cm/18” long & about the
thickness of a finger
• Surrounded by meninges
• Gray matter- inner
core; consists mostly
of cell bodies and
dendrites.
• White matter- made
up of fiber bundles;
ascending and
descending
• Vertebral column
consists of 7 cervical,
12 thoracic, 5 lumbar
vertebrae,
sacrum(fused mass of
5 vertebrae); coccyx
Vertebral Column
Spinal cord as H- structure
- Lower portion is broader than upper portion and
corresponds to the anterior horn
a. Anterior Horn- contains cells with fibers that
form the anterior (motor) root end; essential
for the voluntary and reflex activity of the
muscles they innervate
b. Posterior Horn - contains cells with fibers that
enter over the posterior (sensory) root end and
thus as a relay station in the sensory/ reflex
pathway
Peripheral Nervous System
• 2 Principal Subdivisions
1. Sensory or afferent division- carry information
from the outside world; sensory receptors are
located in the different parts of the body; i.e.
somatic sensory fibers, visceral sensory fibers

2. Motor or efferent division- transmit impulses

from the brain & spinal cord to the muscles; i.e.
voluntary nervous system, ANS
❖Cranial nerves; carry impulses to and from
the brain.
- 12 pairs of cranial nerves emerge from the
lower surface of the brain

❖Spinal nerves; carry impulses to and from

the spinal cord.
- 31 pairs of spinal nerves arising from the
spinal cord & passing out through the
vertebrae
- 8 cervical, 12 thoracic, 5 lumbar, 5 sacral &
1 coccygeal

**these nerves serves as the communication lines of the body**

 Autonomic Nervous System
- operates without conscious control
- regulates the activities of internal organs
- Maintenance & restoration of internal
homeostasis is largely the responsibility
of the ANS
- regulated by centers in the spinal cord,
brain stem & hypothalamus.
2 major divisions:
✔SNS; predominantly excitatory responses
(fight or flight response)
Effects: bronchioles dilate, hearts
contractions are stronger & faster, arteries to
heart & voluntary muscles dilate, peripheral
BV constrict
✔PNS; predominant during quiet, nonstressful
conditions
**Each of these subsystems operates in the
reverse of the other (antagonism).
 Cranial Nerve Type Function
I olfactory Sensory Sense of smell
II optic Sensory Visual acuity & visual fields
Muscles that move the eye & lid, (down &
III oculomotor Motor out) pupillary constriction, lens accomodation
IV trochlear Motor Muscles that move the eye , superior oblique
V trigeminal (B)Mixed Facial sensation, corneal reflex, mastication,
swallowing
VI abducens Motor Muscles that move the eye, lateral rectus
Facial expression & muscle movement,
VII facial (B)Mixed salivation & tearing, taste ant. 2/3 of tongue,
sensation in the ear
VIII acoustic Sensory Reception of hearing & equilibrium
Taste in post. 3rd of tongue, sensation in
IX glossopharyngeal (B)Mixed pharynx & tongue, pharyngeal muscles,
swallowing
Muscles of pharynx, larynx & soft palate, sensation
X vagus (B)Mixed in external ear, pharynx, larynx, thoracic &
abdominal viscera, parasympathetic innervations of
thoracic & abdominal organs
XI spinal accessory Motor Sternocleidomastoid & trapezius muscles
XII hypoglossal Motor Movement of the tongue
• TFGV-Mixed (5, 7, 9, 10)
• OOA- Sensory (1, 2, 8)
• OTASH- Motor (3, 4, 6, 11, 12)
NEUROLOGIC
ASSESSMENT
Cranial Nerve
Assessment
I Identify common odors
II Snellen Chart and peripheral vision checks
III Check for pupil constriction;
IV Check for convergence as the object is brought
near the eyes;
V Check for strength of lid closure, Identify location
of the stimulus; Check ability to feel light, dull and
sharp sensation on the face; Check jaw strength,
Check for corneal reflex

V I Check for eye movement from left to right

VII Check for symmetry of facial expressions and
muscle strength; Identify sweet, sour and salty
tastes
VIII Weber and Rinne test for hearing loss; (C-A), (S-N)
Romberg’s test for balance
IX Identify sweet, sour and salty tastes;
Check gag and swallowing reflex
X Ask the client to say “Ah” - uvula should rise
midline;
Check ability to swallow
XI Have the client shrug shoulders against resistance;
Turn the head to one side against the resistance of
the hand
XII Have the client stick out tongue – observe for
deviations/tremors;
Check for the strength of tongue movement as it
presses against tongue blade
Glasgow Coma Scale
 SAMPLE QUESTION:
A patient is admitted in the ER
presenting with head injury
following a motorcycle accident.
The nurse is going to assess the
neurologic status of the patient.
The patient open his eyes to pain,
produces incomprehensible
sounds and demonstrate abnormal
flexion. What is the patient GCS
score?
SAMPLE: The client has to be assessed every
4 hours using the GCS. The nurse notes the
following: The client does not open his eyes
to voice or pain, the client extends his arms
in response to pain, and speaks
incoherently. What is the client’s total GCS
score?
A. 3
B. 4
C. 5
D. 6
Levels of
Consciouness
- most sensitive indicator of
neurologic function; first
assessment to change when
there’s neurologic injury
Level ∙ Highest level of consciousness characterized by appropriate
1 responses to internal and external stimuli
∙ Conscious, alert, fully-awake
∙ Patient oriented to person, place and time
Level ∙ Listless, lethargic, somnolent and obtunded
2 ∙ Client can be aroused from sleep but when stimulation ceases,
tends to fall asleep again
Level ∙ Stuporous
3 ∙ Response can only be evoked from a strong and continuous
stimuli
∙ The patient elicits poor response (i.e., reflex withdrawal)
Level ∙ Semi-coma - no spontaneous movement but patient may
4 demonstrate reflex activities like coughing, swallowing and
vomiting
∙ Incontinence
Level ∙ Coma/Deep Coma – absence of involuntary responses to any
5 stimuli
∙ Reflexes are absent
∙ Pupils may be constricted/dilated and does not react to light
❖ EXAMINING THE REFLEXES;
✔ Reflexes are involuntary contractions of muscles or
muscle groups in response to a stimulus.
✔ Classified as deep tendon, superficial or pathologic
✔ Assesses the intactness of the spinal reflex arc at various
spinal cord levels. The limb should be relaxed while
applying a short and snappy blow with a reflex hammer.
Hold the hammer loosely in a relaxed manner, making a
wrist action. Allow the hammer to bounce.
✔ Patellar, Achilles, triceps, biceps
• Reflex responses:
0 no response
1+ diminished, low normal
2+ average, normal
3+ brisker than normal
4+ very brisk, hyperactive
 Oculocephalic Reflex or Doll’s Eye
Phenomenon
• Done by holding the person’s eyelids open
and rotating the head from side to side.
• The reflex is present if the eyes move in the
opposite direction of the head movements.
 Oculovestibular Reflex or Caloric ice
Water Test
• a test that uses differences in temperature to
diagnose damage to the ear or brainstem.

• Cold water = FAST phase of nystagmus to the

side Opposite from the cold water filled ear
Warm water = FAST phase of nystagmus to
the Same side as the warm water filled ear
 Pupillary Exam
– changes can indicate abnormal intracranial pressure (ICP)
Normal findings: PERRLA (Pupil, Equal, Round and Reactive to Light
and Accommodation
Sizes: Pinpoint (miotic), Dilated (mydriatic), Normal size: 2-6mm
Shapes:
Ovoid – may indicate IICP
Keyhole: patients who had iridectomy

Reaction to light
Brisk
Sluggish (Meningitis, Subarachnoid Hematoma)
Non-Reactive
Comparison of pupils
Isocoria-equal size in pupils
Anisocoria- unequal size in pupils
 AVPU SCALE – quick and easy method
Awake
✔ Alert and oriented to person, place and time
✔ Acting reasonably to stimuli
✔ Patient is aware of you approaching him/her
Verbal Stimulation (responds to)
✔ Responds to voice
✔ Unawake but will respond by speaking/moaning,
facial expressions, limb movement, eyelid blinking
Pain Stimulation (responds to)
Patient will only respond to painful stimuli such as:
✔ Suborbital pressure
✔ Pinching the fleshy part near the axilla
✔ Trapezium squeeze
✔ Shaking the shoulders
✔ Earlobe pinch
✔ Nail pinch

Unresponsive
✔ Unawake, no response to verbal and pain stimuli
ALTERED LEVEL OF CONSCIOUSNESS
• An altered level of consciousness (LOC) is apparent in the patient who is
not oriented, does not follow commands, or needs persistent stimuli to
achieve a state of alertness. LOC is gauged on a continuum, with a normal
state of alertness and full cognition (consciousness) on one end and coma
on the other end.
• Coma is a clinical state of unarousable unresponsiveness in which there
are no purposeful responses to internal or external stimuli, although
nonpurposeful responses to painful stimuli and brain stem reflexes may
be present. The usual duration of coma is 2 to 4 weeks.
• Akinetic mutism is a state of unresponsiveness to the environment in
which the patient makes no voluntary movement.
• Persistent vegetative state is a condition in which the unresponsive
patient resumes sleep–wake cycles after coma but is devoid of cognitive
or affective mental function.
• Locked-in syndrome results from a lesion affecting the pons and results in
paralysis and the inability to speak, but vertical eye movements and lid
elevation remain intact and are used to indicate responsiveness. The level
of responsiveness and consciousness is the most important indicator of
the patient’s condition.