NEUROLOGICAL

SYSTEM FUNCTION,
ASSESSMENT AND
THERAPEUTIC
MEASURES
DR. MARIA LYNNE C.
PARAMBITA
 LEARNING OBJECTIVES
 Describe the normal structures and functions of the
nervous system
 Identify the effects of aging on the nervous system.

 List data to collect when caring for a patient with a

disorder of the nervous system.
 Identify tests used to diagnose disorders of the nervous
system.
 Plan nursing care for patients undergoing each of the
diagnostic tests for disorders of the nervous system.
 Describe common therapeutic measures that are used
for patients with disorders of the nervous system.
NEURON (NERVE CELL)
 Neuron: functional unit of CNS. Conducts electrical
impulses from one area of the brain to another.
 Main cell body has two branches:
1. Axons conduct impulses away from the cell body
2. Dendrites convey impulses toward the cell body
 Axons and dendrites are covered with myelin that
enhances conduction along nerve fibers
 Myelination increases conduction speed. Level of
myelination correlates to the necessity of speed
 Example: neurons for protective reflexes are heavily
myelinated, processing neurons has no myelin
 Myelin gives axons white appearance (white matter).
Cell bodies without myelin are gray (gray matter)
 NEURON (NERVE CELL)
 Classifications of neurons:
1. Sensory neurons (afferent neurons): Transmit
information from distal parts of the body or
environment toward the CNS (
2. Motor neurons (efferent neurons): Carry motor
information from the CNS to the periphery
3. Interneurons: relay stations between sensory and
motor neurons
 A well-coordinated organized function is a result of a
well integrated system of impulse transmission
 A myelinated neuron is capable of transmitting hundreds
of impulses per second and at speed of more than 100
meters per second
 IMPULSE TRANSMISSION
• A nerve impulse (action potential) is an electrical charge
brought about by movement of ions across a neuron cell
membrane:
 When dendrite is stimulated, it initiates series of
electrochemical events. Na and K exchanged resulting in
depolarization
 It continues from dendrite to end of axon until ions return to
resting state known as repolarization
 When impulse reaches end of axon, neurotransmitters are
released (acetylcholine, norepinephrine, epinephrine,
dopamine). Impulse passes from one neuron to another
across neural synapse (space between neuron to another)
 Neurotransmitter crosses synapse where it stimulates an
electrical impulse
 (CNS)
 The CNS is divided into two main parts:
1. The Brain and the Spinal cord
2. The Peripheral nervous system
 The Brain: largest, most complex portion of the CNS,
containing 100 billion multipolar neurons. It can be
divided into four principal areas:
1.Cerebellum: integrate sensory information about
position of body parts, balance, coordinates skeletal
muscle activity, maintains posture.
2.Diencephalon: thalamus and hypothalamus
3.Cerebrum: composed of left and right hemispheres. It
is the largest area associated with higher mental
functions such as:
 interprets sensory input
 initiates voluntary muscular movements, memory
 integrates information for reasoning
4.Brain stem: mid-brain, pons and medula
 THE CEREBRUM
Left hemisphere Right hemisphere
 THE CEREBRUM: THE FOUR
LOBES
1. Frontal lobe: has motor areas that control movement
on the opposite side of the body. Has Broca’s area that
control movement of speech and personality:
initiative, emotion, memory, judgment, reasoning,
conscience
2. Temporal lobe: has sensory areas for hearing and
olfaction(smell), visual recognition. On the left side,
has Wernicke’s area for speech comprehension
3. Parietal lobe: receives, perceives and interprets
somatic senses and gustation (taste)
4. Occipital lobe: contains visual areas that receive and
interprets sight
THE BRAIN
 MENINGES
 Three Layers of connective tissue that cover the CNS:
1. Dura mater: outermost thick fibrous connective tissue
2. Arachnoid: middle layer, has web-like appearance
3. Pia mater: inner layer, thin connective tissue on the
surface of brain and spinal cord
 Each 4 ventricles of the brain contains choroid plexus, a
capillary network that forms cerebrospinal fluid (CSF) and
circulates through the 4 ventricles
 CSF is composed of water, glucose, sodium chloride,
and protein. It permits exchanges of nutrients and
waste products between blood and CNS neurons. It acts
as shock absorber for brain and spinal cord
 CSF circulates through the 4 ventricles to the central
canal of the spinal cord and to the subarachnoid spaces
THE MENINGES
 SYSTEM
 Composed of cranial nerves and spinal nerves: pp 1103
 Cranial nerves: has twelve pairs arising from underside of
the brain. Function is to control sensory, motor and
autonomic activities of the head and neck: table 47.2
1.Olfactory: smell
2. Optic: vision
3. Oculomotor: eye movement
4. Trochlear: eye movement
5.Trigeminal: facial skin sensation, chewing
6. Abducens: eye movement
7. Facial: movement of facial muscles
8. Vestibulocochlear: hearing and balance
9.Glossopharyngeal: taste, salivation
10.Vagus: parasympathetic stimulation to decrease BP, HR
11. Accessory: shoulder elevation and head turning
12.Hypoglossal: tongue movement
 PERIPHERAL NERVOUS
SYSTEM
 Spinal Nerves: has 31 pairs grouped according to the
level from which they arise and numbered in sequence,
beginning with those in the cervical region. Each spinal
nerve arises from two roots: dorsal, or sensory root
1. Cervical Plexuses: lie on either side of the neck and
supply muscles and skin of the neck
2. Brachial Plexuses: arise from lower cervical and
upper thoracic nerves and lead to the upper limbs.
3. Lumbrosacral Plexuses: arise from the lower
spinal cord and lead to the lower abdomen,
external genitalia, buttocks, and legs.
 SYSTEM
 Controls involuntary activities of the viscera, including
smooth muscle, cardiac muscle, and glands
 Two major subdivisions:
1. Sympathetic Division: dominant in stressful situations
such as fear, anger, anxiety, excitement and exercise. The
responses prepare the body for physical activity
• Fight or flight response: increase HR, constricts

peripheral vessels (increase BP), vasodilatation in

skeletal muscles, bronchodilatation, glycogen to
glucose, vasoconstriction in the skin
2. Parasympathetic division: dominates during relaxed,
non-stressful situations to promote normal functioning of
organs. Acetycholine is the neurotransmitter. Bring the
body back to balance and rest. Decreased BP and HR
 AGE-RELATED CHANGES
 Number of nerve cells decreases, brain weight is
reduced; ventricles increase in size. Forgetfulness occurs
due to decreased ability for problem solving
 Lipofuscin: aging pigment deposited in nerve cells with
amyloid, a type of protein. Increased plaques and
tangled fibers in nerve tissue
 Eye pupil smaller; respond to light more slowly
 Reflexes intact except for Achilles tendon jerk, which is
often absent. Reaction time increases, especially complex
reactions
 Tremors in the head, face, and hands are common
 Some develop dizziness and problems with balance
 Low tolerance for extremes in temperature
 Common cause of mental changes: depression,
malnutrition, infection, hypotension, side-effects of
medications
NURSING ASSESSMENT
 Purpose of neurologic assessment is to establish present
function of the CNS and to detect changes from previous
assessments. Baseline should be performed
 Health history: note speech, behavior, coordination,
alertness, comprehension
Chief complaint and history of present illness
Document what prompted to seek medical attention,
describe injuries
Pain: note onset, severity, location, and duration

Past medical history: head injury, seizures, DM, HTN,

heart disease, cancer
Record dates and types of immunizations, current
medications, allergies
Family history: If immediate family members had heart
disease, stroke, DM, CA, seizure disorders, muscular
dystrophy, or Huntington’s disease
NURSING ASSESSMENT
 Review of systems: fatigue/weakness, headache, vertigo,
dizziness, changes in vision or hearing, tinnitus, drainage
from ears/nose, dysphagia, neck pain/stiffness, nausea,
vomiting, bladder/bowel function, sexual dysfunction,
fainting, paralysis, mood changes, incoordination,
memory problems, tremors, numbness or tingling
 Functional assessment: symptoms that interfere with
usual activities and occupation. Sources of stress, usual
coping strategies, sources of support
 Physical examination: Basic neurologic assessment
1. Level of consciousness
2. Vital signs
3. Pupillary response
4. Neuromuscular response: extremity strength and
movement
5. Sensation
 EXAMINATION:
1. Level of Consciousness: most accurate and reliable indicator of
neurologic status. Evaluate for:
• Orientation to person, place and time: ability to comprehend self
in relation to person, place and time. Ask to state theirnames,
where they are, what time it is.
• Responses to verbal or tactile stimulation: degree of stimulation
to evoke a response (light or vigorous), behavior in response to
stimulation (combative, agitated, lethargic)
• Altered level of consciousness:
• Somnolence: unnatural drowsiness or sleepiness

• Lethargy: excessive drowsiness

• Stupor: decreased responsiveness with lack of spontaneous

motor activity
• Semicoma: stuporous but arousable

• Coma: cannot be aroused

Figure 27-5
 BASIC NEUROLOGIC
EXAMINATION:
2. Pupillary evaluation: “PERLA”
Pupils: assess, compare size, shape, and reactivity
Pupils are normally 3mm in size, round and react briskly
to light. Changes indicate neurological deterioration
3. Neuromuscular response: to evaluate cerebral and spinal
cord function (muscle movement). Assess strength and
equality of hand drip and movement of extremities
• Determine ability to sense touch or pain in extremities
• To elicit pain, place pressure on nailbed or on trapezius
muscle. Be sure to apply stimulus long enough to elicit
response
4. Vital signs: changes in pulse, respirations and blood
pressure may indicate neurologic deterioration.
 PUPILLARY CHANGES
 PERRLA: P-upils E-qually Round and R-eactive to L-ight
and A-ccommodation

Fixed and dilated pupil(s) is a neurologic emergency

 PUPILLARY CHANGES

•If pupils are large or small ask for

any meds taken that may affect
pupil size.
•If pupils are unequal (anisocoria),
ask if normally anisocuric, maybe
congenital or due to surgery
•Unequal pupils for patient who
previously had equal pupils is an
emergency and should be reported
immediately
 NURSING ASSESSMENT
 Glasgow Coma scale (GCS): International scale to assess level
of consciousness and evaluate patients potential for rapid
deterioration in consciousness. The sum total is used to
assess coma and impaired consciousness
 Three parameters of consciousness: eye opening, verbal
response, motor response
 Scores are evaluated: range from 3-15 scores.

 To evaluate effects of head injury:

 Score of 15 indicates patient is fully alert and oriented

 Mild head injury: 13-14 points
 Moderate head injury: 9-12 points
 Severe head injury: less than 8 points
 Patients with scores less than 7 are comatose
 There is No zero score
 GLASGOW COMA SCALE (GCS)
Eye opening Verbal Response Motor
Response (E) (V) Response (M)

4 = Spontaneous 5 = Normal conversation 6 = Normal

3 = To Voice 4 = Disoriented 5 = Localizes to
conversation pain
2 = To Pain 3 = Words, but not 4 = Withdraws to
coherent pain
1 = None 2 = No words, 3 = Decorticate
only sounds posture
1 = None 2 = Decerebrate
posture
1 = None
E Score V Score M Score E+V+M=
Total Score
 NURSING ASSESSMENT
 Posturing:
Decorticate: flexion of the arms at the elbows
and bringing the hands up toward the chest with
legs extended
Indicates impairment of cerebral functioning

GCS score of 3

Decerebrate: both upper and lower extremities

are extended and the arms are internally rotated
indicates damage in the brainstem

GCS score of 2
ABNORMAL POSTURING
NEUROLOGIC EXAMINATION
 FullOutline of UnResponsiveness (FOUR): newer tool,
accurate predictor of outcome for traumatic brain
injury patient, has an advantage over GCS when
assessing intubated patients
 Uses four categories:

1. Eye response
2. Motor response
3. Brainstem reflexes
4. Respiration (breathing pattern)
 Maximum four points on each category. The lower the
FOUR score is, the worse the patient is neurologically,
the poorer the prognosis
(FOUR)
NEUROLOGIC EXAMINATION
 Cranial nerve function: to control sensory, motor, and
autonomic activities of head and neck. Vagus nerve
affects, cardiac, respiratory, gastric and gallbladder
function
 Coordination and balance: cerebellar dysfunction
creates loss of steady, balanced posture and gait.
1. Ipsilateral (cerebellar): same side of brain lesion
2. Contralateral (cerebral): opposite side of lesion
3. Romberg test: test for positioning and balance.
Romberg's test is positive if the patient sways more
than 20secs., leans to one side or falls while the
patient's eyes are closed. Observe safety in elderly
when doing this test
NEUROLOGIC EXAMINATION
 Neuromuscular function: assess muscle groups for size,
tone, strength. Tests: Hand grasp strength (firm squeeze),
arm drift (ulnar or motor drift) (weak arm rotates and
drifts downward when extended with eyes closed)
 Sensory function: Pain, Light touch, Tactile
discrimination, Vibration, Position, Temperature
 Reflexes: unconscious, involuntary response mediated at
the level of the spinal cord without input from higher
brain centers. Tests: Knee jerk (tap the patella to convey
impulse to spinal cord, cause muscle to contract);
Babinski reflex (stroke bottom of the foot to cause
plantar flexion). Abnormal Babinski is dorsiflexion of the
big toe bends upward, fanning of the other toes
BABINSKI REFLEX
 TAP)
 Insertion of spinal needle into the subarachnoid space of
the fourth or fifth lumbar vertebra (L4 or L5)
 Purpose: to obtain cerebrospinal fluid (CSF), measure
CSF fluid or pressure, or instill air, dye or medications
 Contraindicated in clients with increased intracranial
pressure, because it will cause a rapid decrease in
pressure within the CSF around the spinal cord, leading
to brain herniation
 Implementation: pre-procedure
 obtain a consent.
 Give simple clear, simple direction as this is
frightening to patient. Alleviate anxiety
 have the patient empty the bladder
 TAP)
• During the procedure:
• Two Positions:
1. Lateral recumbent
position: draw knees up
to abdomen, chin to
chest
2. sitting position leaning
over table
• Skin is cleaned, local
anesthesia by physician
• Maintain surgical aseptic
technique
• Label specimens in
sequence.
ANALYSIS OF CSF
 LUMBAR PUNCTURE (SPINAL
TAP)
 Implementation: post-procedure
Monitor VS and neurological signs. Bed rest with HOB
flat for 4-8 hours to decrease leakage of CSF from
puncture site that can result to severe spinal
headache. Check puncture site for leakage, bleeding,
hematoma and infection
Assess movement and sensation of lower extremities
frequently for the 1st 4 hours. Assess headache, give
analgesic. Force fluids, Monitor I & O
 Normal Cerebrospinal fluid:

Pressure: 50 to 175mmH₂0, pH: 7.30-7.40, clear,

colorless appearance, fasting glucose: 40-80mm/dL,
WBC: 0-5 small lymphocytes/mm³
 DIAGNOSTIC TESTS AND
PROCEDURES
 Skull
and Spinal X-ray: reveal size, shape of skull bones,
suture separation in infants, fractures or bony defects,
erosion, or calcification
identify fractures, dislocation, compression, curvature,
erosion, narrowed spinal cord, and degenerative
processes
Implementation:
 immobilize neck if spinal fracture is suspected

(trauma). Xrays are done before removal of devices

 Remove metal items from body parts

 If the client has thick and heavy hair, this should be

documented, because, it may affect interpretation

of the x-ray film
 COMPUTED TOMOGRAPHY (CT)
SCAN
 Brain scan: may or may not require injection of a dye.
 Detects intracranial bleed, space-occupying lesions,
cerebral edema, infarctions, hydrocephalus, cerebral
atrophy, and shifts of brain structures
 Implementation: Pre-procedure

Remove objects from head (wigs, barrettes, earrings,

hairpins). Assess for allergies to iodine, contrast dyes,
or shellfish
Some may be given dye even if they report an allergy,
and treated with antihistamines and corticosteroids
prior to injection, to reduce severity of a reaction.
Emergency carts standby
 COMPUTED TOMOGRAPHY (CT)
SCAN
 Intra-procedure:
Inform client there may be warm, flushed sensation in
the groin and metallic taste in the mouth when dye is
injected
Instruct client to lie still and flat during test. Assess for
claustrophobia. If in pain, give pain med. Inform client
of possible mechanical noises as the scanning occurs
 Post-procedure:
Monitor for allergic reaction to dye
Assess dye injection site for bleeding or hematoma, and
monitor extremity for color, warmth, presence of distal
pulses.
Provide replacement fluids because diuresis from the
contrast dye is expected
CT SCAN OF THE BRAIN
 (MRI)
 Non-invasive procedure to identify types of tissues,
tumors, vascular abnormalities, degenerative diseases,
hemorrhages, cerebral edema
 Provides more detailed pictures than CT scan, does not
expose client to ionizing radiation
 Implementation: pre-procedure

Remove all metal objects: pacemaker, implanted

defibrillator, or metal implants such as hip prosthesis
or vascular clips
Instruct to remain still during procedure
 Implementation: post-procedure

May resume normal activities . Expect diuresis if

contrast agent was used
MAGNETIC RESONANCE
IMAGING (MRI)
 ELECTROENCEPHALOGRAPHY
(EEG)
 Graphic recording of electrical activity of the superficial
layers of the cerebral cortex. Small electrodes placed at the
head to detect electrical signals
 Implementation: pre-procedure
Wash hair. Inform client that electrodes are attached to
the head and electricity does not enter the head.
Reassure patient that there is no electric shock, mind
cannot be read, and it does not detect mental illness
No caffeine, withhold stimulants, antidepressants,
tranquilizers, and anticonvulsants for 24 to 48 hrs prior
to the test
 Implementation: post-procedure
Wash client’s hair. Maintain side rails and safety
precautions if sedated
ELECTROENCEPHALOGRAM
(EEG)
 CEREBRAL ANGIOGRAPHY
 Injection of contrast through femoral artery into carotid
arteries to visualize cerebral arteries, assess lesions
 Pre-procedure: consent, assess for allergies to iodine
and shellfish. Remove metal items from hair. Encourage
hydration for 2 days before test. NPO 4-6 hours prior to
test. Mark peripheral pulses
 Post-procedure: monitor for neck swelling and difficulty
swallowing. Elevate HOB, 15-30 degrees. Keep bed flat
if femoral artery is used. Force fluids if not
contraindicated. Assess peripheral pulses. Immobilize
puncture site for 12 hrs. Apply sandbags and pressure
dressing to site to prevent bleeding
CALORIC TESTING
(OCULOVESTIBULAR TESTING)
 Provides information about function of vestibular
portion of the eighth cranial nerve. Aids in diagnosis of
cerebellum and brainstem lesions
 Procedure

Patency of external canal is confirmed. Cold or warm

water is introduced into external auditory canal
Stimulate auditory canal with warm water to cause
horizontal nystagmus toward side of the irrigated ear
if vestibular eighth cranial nerve is normal
Stimulate auditory canal with cold water to cause
horizontal nystagmus away from side of the irrigated
ear if brainstem is intact
THANK YOU…