Neurological system


LEARNINGOBJECTIVES
After completed this chapter, you should be able to: 
• Describe the structures neurological system.
• Enumerate functions of neurological system.
• Identify pertinent sensory-neurologic system history
questions.
• Obtain a sensory-neurologic system history.
• Perform a physical assessment of the sensory-
neurologic system.
• Document sensory-neurologic system findings.
• Identify actual/potential health problems stated as
nursing diagnoses
• Differentiate between normal and abnormal findings.
 The neurological system is responsible
for all human function.
 It exerts unconscious control over basic
body functions, and it also enables
complex interactions with others and the
environment
 Examination of the neurologic system
includes assessment of
(a) Mental status including level of
consciousness
(b) The cranial nerves
(c) Reflexes
(d) Motor function
(e) Sensory function
 Mental Status
 Assessment of mental status reveals the
client’s general cerebral function.
 These functions include intellectual
(cognitive) as well as emotional
(affective) functions.
 Level of consciousness (LOC)
 A fully alert client responds to questions
spontaneously; a comatose client may
not respond to verbal stimuli.
 The Glasgow Coma Scale was tests in
three major areas: eye response, motor
response, and verbal response.
 An assessment totaling 15 points
indicates the client is alert and
completely oriented. A comatose client
scores 7 or less
 Cranial Nerves
 The nurse needs to be aware of specific
nerve functions and assessment
methods for each cranial nerve to detect
abnormalities.
 In some cases, each nerve is assessed;
in other cases only selected nerve
functions are evaluated.
Cranial Nerve Type Function

I Olfactory Sensory Smell

II Optic Sensory Vision

III Oculomotor Mixed Motor: most EOM

movement, opening of
eyelids
Parasympathetic: pupil
constriction, lens shape

IVTrochlear Motor Down and inward

movement of eye

VTrigeminal Mixed Motor: muscles of

mastication
Sensory: sensation of face
and scalp, cornea, mucous
membranes of mouth and
nose
Cranial Nerve Type Function

VI Abducens Motor Lateral movement of eye

II Facial Mixed Motor: facial muscles, close

eye, labial speech, close
mouth
Sensory: taste (sweet, salty,
sour, bitter) on anterior two-
thirds of tongue
Parasympathetic: saliva
and tear secretion
VIII Acoustic Sensory Hearing and equilibrium

IXGlossopharyngeal Mixed Motor: pharynx (phonation

and swallowing)
Sensory: taste on posterior
one-third of tongue, pharynx
(gag reflex)
Parasympathetic: parotid
gland, carotid reflex
Cranial Nerve Type Function

X Vagus Mixed Motor: pharynx and

larynx (talking and
swallowing)
Sensory: general
sensation from carotid
body, carotid sinus,
pharynx, viscera
Parasympathetic:
carotid reflex

XI Accessory or Motor Movement of

Spinal trapezius and
sternomastoid
muscles (Contraction
of neck and shoulder
muscles; motor to
larynx (speaking)

XII Hypoglossal Motor Movement of tongue

 Reflexes
 A reflex is an automatic response of the
body to a stimulus.
 It is not voluntarily learned or
conscious.
 Reflexes are tested using a percussion
hammer
 Motor Function
 Neurologic assessment of the motor
system evaluates proprioception and
cerebellar function.
 Structures involved in proprioception are
the proprioceptors, the posterior
columns of the spinal cord, the
cerebellum, and the vestibular
apparatus (which is innervated by
cranial nerve VIII)
 Proprioceptors
 are sensory nerve terminals that occur
chiefly in the muscles, tendons, joints, and
internal ear, it give information about
movements and the position of the body.
 Stimuli from the proprioceptors travel
through the posterior columns of the spinal
cord.
 Deficits of function of the posterior columns
of the spinal cord result in impairment of
muscle and position sense.
 Clients with such impairment often must
watch their own arm and leg movements to
ascertain the position of the limbs.
 The cerebellum
 (a) helps to control posture
 (b) acts with the cerebral cortex to
make body movements smooth and
coordinated
 (c) controls skeletal muscles to maintain
equilibrium.
 Sensory Function
 Sensory functions include touch, pain,
temperature, position, and tactile
discrimination.
 A focused neurological assessment
includes: collecting subjective data
about the client’s history of head injury
or dysfunction, collecting the client’s and
the patient’s family’s history of
neurological disease, and asking the
client about signs and symptoms of
neurological conditions, such as
seizures, memory loss (amnesia), and
visual disturbances.
 A change in the level of orientation can
be an early indicator that an individual’s
health status is declining.
 If a client is experiencing a neurological
decline, short-term memory will be lost
first.
 This means that the client will first lose
orientation to place and time.
 Long-term memory is lost last.
 A loss of orientation to person (name,
birth date, etc.), therefore, is a late sign
of neurological decline.
 Memory
 The nurse assesses the client’s recall of
information presented, events or
information from earlier in the day or
examination (recent memory), and
knowledge recalled from months or
years ago (remote or long-term
memory).
 It may not be necessary to perform the
entire neurological exam on a patient
with no feeling of neurological disorders.
 When examining the nervous system,
ask the following:
 • Any past history of head injury?
(location, loss of consciousness)
 • Do you have frequent or severe
headaches? (when, where, how often)
 • Any dizziness or vertigo? (frequency,
precipitating factors, gradual or sudden)
 • Ever had/or do you have seizures?
(when did they start, frequency, course
and duration,
 motor activity associated with,
associated signs, postictal phase,
precipitating factors,
 medications, coping strategies)
 Neurological Assessment
 When examining the nervous system, also
ask the following:
 • Any difficulty swallowing? (solids or
liquids, excessive saliva)
 • Any difficulty speaking? (forming words or
actually saying what you intended)
 • Do you have any coordination problems?
(describe)
 • Do you have any numbness or tingling?
(describe)
 • Any significant past neurologic history?
(cerebral vascular accident, spinal cord
injuries, neurologic infections, congenital
disorders)
 • Environmental or occupational
hazards? (insecticides, lead, organic
solvents, illicit drugs,
 alcohol)
 A change in level of orientation can be
caused by the following:
 • Increased intracranial pressure from
swelling of the meninges or brain tissue
 • Bleeding from an injury or an aneurysm
 • A buildup of cerebral spinal fluid (CSF)
within the ventricles of the brain
(hydrocephalus)
 • Hypoxia
 • Hypoglycemia
 • Dehydration • Toxic drug levels
 • Infection
 • Electrolyte imbalance
 Cranial Nerve Examination
 CN I (olfactory) Test ability to identify
familiar aromatic odors, one naris at a
time with eyes closed
 CN II (optic)
 Test distant and near vision
 Perform ophthalmoscopic
examination of fundi
 Test visual fields by confrontation and
extinction of vision
 CN III (oculomotor), CN IV (trochlear),
and CN VI (abducens)
 Inspect eyelids for drooping
 Inspect pupils’ size for equality and
their direct and consensual response to
light and
 accommodation.
 Test extraocular eye movements
 CN V (trigeminal)
 Inspect face for muscle atrophy and
tremors
 Palpate jaw muscles for tone and
strength when patient clenches teeth
 Test superficial pain and touch
sensation in each branch (test
temperature sensation if
 there are unexpected findings to
pain or touch)
 Test corneal reflex
 CN VII (facial)
 Inspect symmetry of facial features
with various expressions (e.g., smile,
frown, puffed
 cheeks, wrinkled forehead)
 Test ability to identify sweet and salty
tastes on each side of tongue
 CN VIII (acoustic)
 Test sense of hearing with whisper
screening tests or by audiometry
 Compare bone and air conduction of
sound
 Test for lateralization of sound
 CN IX (glossopharyngeal), and X
(vagus)
 Test ability to identify sour and bitter
tastes on each side of tongue
 Test gag reflex and ability to swallow
 Inspect palate and uvula for
symmetry with speech sounds and gag
reflex
 Observe for swallowing difficulty
 Evaluate quality of guttural speech
sounds (presence of nasal or hoarse
quality to voice)
 CN XI (spinal accessory)
 Test trapezius muscle strength (shrug
shoulders against resistance)
 Test sternocleidomastoid muscle
strength (turn head to each side against
resistance)
 CN XII (hypoglossal)
 Inspect tongue in mouth and while
protruded for symmetry, tremors, and
atrophy
 Inspect tongue movement toward nose
and chin
 Test tongue strength with index finger
when tongue is pressed against cheek
 Evaluate quality of lingual speech
sounds (l, t, d, n)