Chapter 20

Chapter 20
The Nervous System
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Wolters
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Anatomy and Physiology #1
 Central nervous system

o The brain
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Left lateral view of the brain

Coronal section of the brain

 The spinal cord

o Cervical

 The spinal cord—(cont.)

o Thoracic


o Lumbar
o Sacral
o Coccyx


 Peripheral nervous
system
o The cranial nerves

 Cranial nerves—(cont.)



 Cranial nerves o VII—Facial

o I—Olfactory o VIII—Acoustic
o II—Optic o IX—
Glossopharyngeal
o III—Oculomotor
o X—Vagus
o IV—Trochlear
o XI—Spinal accessory
o V—Trigeminal
o XII—Hypoglossal
o VI—Abducens

 Peripheral nervous system

o The peripheral nerves
 Spinal nerves
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal


 Peripheral nervous system—(cont.)

o Motor pathways
 Corticospinal (pyramidal) tract
 Controls voluntary movement and integrate skilled,
complicated, or delicate movements
 Basal ganglia system
 Maintains muscle tone, controls automatic body
movements
 Cerebellar system
 Receives sensory and motor input, coordinates
motor activity, maintains equilibrium

 Motor pathways:
Corticospinal and
corticobulbar tracts

 Sensory pathways:
Spinothalamic tract and
posterior columns

 Dermatomes

 Spinal reflexes: The muscle stretch and deep tendon

reflexes
o Reflex: involuntary stereotypical response
o Briskly tap the tendon of partially stretched
muscle
o Tapping tendon activates special sensory fibers
o Each deep tendon involves specific spinal
segments, can help locate a pathologic lesion

 Spinal reflexes: The deep tendon response
Reflex Spinal Segment

Ankle reflex (Achilles) Sacral 1 primarily
Knee reflex (patellar) Lumbar 2, 3, 4
Supinator (brachioradialis) Cervical 5, 6
reflex
Biceps reflex Cervical 5, 6
Triceps reflex Cervical 6, 7

 Cutaneous stimulation reflexes
Reflex Spinal Segment

Abdominal reflexes, upper Thoracic 8, 9, 10
Abdominal reflexes, lower Thoracic 10, 11, 12
Cremasteric reflex Lumbar 1, 2
Plantar responses Lumbar 5, sacral 1
Anal reflex Sacral 2, 3, 4

Question #1
The _______ coordinates all movement and helps

maintain the body upright in space.
A. Cerebrum
B. Brain stem
C. Cerebellum
D. Thallus

Answer to Question #1
C. Cerebellum
The cerebellum, which lies at the base of the brain,
coordinates all movement and helps maintain the
body upright in space.

The Health History #1
 Common or concerning symptoms

o Headache
o Head injury
o Dizziness or vertigo
o Weakness
o Change in or loss of sensation
o Near syncope and syncope
o Seizures
o Tremors

 Headache
o Many causes, ranging from benign to life threatening
 For example, neurologic changes such as
subarachnoid hemorrhage, meningitis, or mass
lesions
 Primary headaches: migraine, tension-type
trigeminal autonomic cephalalgias and other
headaches
 Secondary headaches: arise from underlying
structural, systemic, and infectious causes or
substance withdrawal
o Assess using the OLD CART mnemonic

 Dizziness or vertigo
o Common but vague; can have many meanings
o Need to elicit the patient’s experience
o If true vertigo, establish time course of
symptoms
 Weakness
o Fatigue, apathy, drowsiness, loss of strength
o Time course and location especially relevant
 Proximal or distal?

 Change in or loss of sensation

o Clarify meaning and location
o Numbness?
o Parathesias?
o Dyesthesias?
o Pain?

 Near syncope and syncope

o Reports of fainting or “passing out” are common;
warrant a meticulous history
o Syncope: losing consciousness and postural tone
o Near syncope: lightheaded/weak, but no loss of
consciousness
o Assess for warning symptoms
o Interview those who observed the episode

 Seizures
o Caused by sudden excessive electrical discharge
in the cerebral cortex or underlying structures
o Several types (Table 20-4)
o Possible loss of consciousness
o Abnormal feelings, thought processes, or
sensations before seizure?
o Assess using the OLD CART mnemonic

 Tremors
o Involuntary movements
o Occur with or without other neurologic
manifestations
o Trembling, shakiness, uncontrollable body
movements?
o Leg restlessness?

Tremors and Involuntary Movements #1




Question #2
Vertigo is common with all of the following except:

A. Inner-ear conditions
B. Brainstem tumor
C. Diplopia

Vertigo is common with all of the following except:

C. Diplopia
Diplopia is double vision

Physical Examination Equipment #1
 Cranial nerve o Tongue depressor

examination o Gloves
o Penlight
o Scent stimuli for
o Snellen chart olfactory (vanilla,
cinnamon, coffee,
o Newspaper or hand-
lemon juice, or
held news print soap)
o Ophthalmoscope o Tuning fork
o Cotton swab

Physical Examination Equipment #2
 Sensory examination
o Objects to feel (coin, paper clip)
o Tuning fork
o Hot and cold water in test tubes/glass
o Cotton swab
 Muscle stretch response/deep tendon reflexes
o Reflex hammer
o Tongue blade

Physical Examination #1
 Important areas of examination

o Mental status
o Cranial nerves I through XII
o Motor system: coordination, gait, stance, muscle
strength, bulk, tone
o Sensory system: pain and temperature, position
and vibration, light touch, discrimination
o Deep tendon, abdominal and plantar reflexes

 Organize approach into five categories:

o Mental status, speech, and language
o Cranial nerves
o Motor system
o Sensory system
o Reflexes
 If findings are abnormal, group them into patterns
of central or peripheral disorders

 Integrate neurologic assessment with other parts of

the examination
o Mental status and speech during interview
o Cranial nerves during examination of head and
neck
o Neurologic abnormalities in the arms and legs
while evaluating peripheral vascular and
musculoskeletal systems
 Think about and describe findings in terms of the
nervous system as a unit

 Guidelines for a screening neurologic examination from

the American Academy of Neurology
o Mental status: alertness, appropriateness of
responses, orientation to date and place
o Cranial nerves: vision, pupillary light reflex, eye
movements, hearing, facial strength
o Motor system: muscle strength, bulk, and tone, gait,
coordination
o Sensory: light touch, pain/temperature,
proprioception
o Reflexes: muscle stretch response/deep tendon
reflexes, plantar responses

 The cranial nerves

o CN I: olfactory
 Present patient with familiar and nonirritating
odors
 Compress one nostril and ask patient to sniff
through the other
 Ask patient to identify odor with eyes closed
 Use different odors for testing smell on each
side
 Avoid noxious triggers that might stimulate CN
V
 The cranial nerves—(cont.)

o CN II: optic
 Visual acuity
 Inspect optic fundi with ophthalmoscope
 Test visual fields with confrontation
 Refer to Chapter 11


o CN II and III: optic and oculomotor
 Size and shape of pupils
Compare one side with the other
 Pupillary reactions to light
 Near response or accommodation


o CN III, IV, and VI: oculomotor, trochlear, and
abducens
 Extraocular movements
 Convergence of eyes
Nystagmus
 Ptosis

Nystagmus #1

Nystagmus #2

 The cranial nerves (cont.)

o CN V: trigeminal
 Palpate temporal and masseter muscles
Clench teeth, move jaw side to side

o CN V: trigeminal—(cont.)
 Sensory
o Pain sensation on
forehead, cheeks,
and chin
 “Sharp” or “dull”
o Temperature
sensation
 “Cold” or “hot”
o Light touch


o CN V: trigeminal—(cont.)
 Corneal reflex
Look up and away
Out of line of vision, touch cornea with fine
wisp of cotton
Patient should blink


o CN VII: facial
 Inspect face at rest and during conversation
Asymmetry, abnormal movements

o CN VII: facial—(cont.)
 Raise both eyebrows
 Frown, smile
 Close both eyes, test
muscular strength
 Show both upper and
lower teeth
 Smile
 Puff out cheeks

Types of Facial Paralysis #1

Types of Facial Paralysis #2
 CN VII: Central Lesion


o CN VIII: acoustic
 Whispered voice test, finger rub
 Air and bone conduction test with tuning forks
Rinne test
Weber test


o CN IX and X: glossopharyngeal and vagus
 Voice
Hoarse? Nasal quality?
 Difficulty swallowing?
 “Say ‘ah’”: movements of soft palate and
pharynx?
 Test the gag reflex

 The cranial nerves—
(cont.)
o CN XI: spinal
accessory
 Atrophy or
fasciculations in
trapezius muscles
 Shrug both
shoulders upward
against your hands
 Turn head to each
side against hand


o CN XII: hypoglossal
 Listen to articulation of words
 Tongue position in mouth
 When tongue protruded: asymmetry, atrophy,
deviation from midline
 Move tongue from side to side, note symmetry
of movement

 The motor system

o Body position
 During movement and rest
o Involuntary movements
 Tremors, tics, chorea, fasciculations
 Note location, quality, rate, rhythm, amplitude
 Relation to posture, activity, fatigue, emotion,
and other factors

 The motor system—(cont.)

o Muscle bulk, tone, and strength
 Detailed in Chapter 18
o Coordination
 Requires four areas of the nervous system:
Motor system
Cerebellar system
Vestibular system
Sensory system


o Coordination—(cont.)
 Observe performance of:
Rapid alternating movements
Point-to-point movements
Gait and other related body movements
Standing in specific ways

 The motor system

o Rapid alternating
movements
 Arms
 Legs


o Point-to-point movements
 Arms: finger-to-nose test
 Legs: heel-to-shin test


o Gait


o Stance
o The Romberg test
o Test for pronator drift

Abnormalities of Gait and Posture #1



 The sensory system

o Test the following:
 Pain and temperature (spinothalamic tracts)
 Position and vibration (posterior columns)
 Light touch (both spinothalamic and posterior)
 Discriminative sensations (cortex,
spinothalamic tracts, posterior columns)

 The sensory system—(cont.)

o Correlate abnormal findings with motor and
reflex activity
o Underlying lesion central or peripheral?
o Sensory loss bilateral or unilateral?
o Pattern suggest dermatomal distribution, a
polyneuropathy, or a spinal cord syndrome?
o Loss of pain and temperature sensation?
o Intact touch and vibration?


o Patterns of testing
 Can fatigue patient, producing unreliable
results
 Pay special attention to:
Where there are symptoms such as
numbness or pain
Where there are motor or reflex
abnormalities
Where there are trophic changes


o Patterns of testing—(cont.)
 Compare symmetric areas
 Compare distal with proximal
areas
 Test fingers and toes first for
vibration and position
 Vary the pace of your testing
 Map out boundaries if sensory
loss or hypersensitivity is
detected

o Pain
 Use broken tongue blade/cotton swab
 Sharp and dull
 Apply lightest pressure needed for stimulus to
feel sharp; do not draw blood


o Temperature
o Water, tuning fork
o Light touch
o Cotton, avoid pressure
o Vibration
o Tuning fork


o Proprioception (joint position)
o Move big toe up and down


o Discriminative sensations
o Stereognosis
o Number identification
o Two-point discrimination
o Point localization
o Extinction

 The sensory system—

(cont.)
o Dermatomes, anterior

 The sensory system—

(cont.)
o Dermatomes, posterior

 Muscle stretch reflexes (deep tendon reflexes)

o Equipment: properly weighted reflex hammer
 Pointed versus flat end
o Encourage patient to relax
o Hold reflex hammer loosely between thumb and
finger
o With wrist relaxed, strike tendon briskly
o Note the speed, force, and amplitude of reflex
response

Scale for Grading Reflexes
4+ Very brisk, hyperactive, with clonus (rhythmic oscillations

between flexion and extension)
3+ Brisker than average: possibly but not necessarily indicative
of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response

 Muscle stretch reflexes

(deep tendon reflexes)—
(cont.)

 Muscle stretch reflexes

(deep tendon reflexes)—
(cont.)
o Reinforcement
 For use if patient’s
reflexes are
symmetrically
diminished or absent
 Isometric contraction
of other muscles up
to 10 seconds, may
increase reflex
activity

 Muscle stretch reflexes (deep tendon reflexes)—

(cont.)
o The biceps reflex (C5, C6)


(cont.)
o The triceps reflex (C6, C7)

 Muscle stretch reflexes (deep tendon

reflexes)—(cont.)
o The brachioradialis reflex (C5, C6)

 Muscle stretch reflexes (deep tendon reflexes)

—(cont.)
o The quadriceps (patellar) reflex (L2, L3,
L4)


(cont.)
o The Achilles (ankle) reflex (primarily S1)

 Muscle stretch reflexes (deep tendon

reflexes)—(cont.)
o Clonus

 Cutaneous or superficial stimulation reflexes

o The abdominal reflexes

 Cutaneous or superficial stimulation reflexes—

(cont.)
o The plantar response (L5, S1)

Question #3
Extraocular movements are controlled by which of the

following cranial nerves? (Choose all that apply.)
A. III
B. IV
C. V
D. VI

A. III
B. IV
D. VI
The extraocular movements are controlled by cranial

nerves III, IV, and VI. CN V is responsible for corneal
reflexes, facial sensation, and jaw movements.

Special Techniques #1
 Assessment of the unconscious patient

o ABCDE
o Level of consciousness
 Glasgow Coma Scale
o Neurologic evaluation—focal or asymmetric
findings
o Interview relatives, friends, witnesses
 Warning symptoms, precipitating factors,
previous episodes, prior appearance and
behavior

 Assessment of the unconscious patient—(cont.)

o Airway, breathing, and circulation
 Color and breathing pattern
Rate, rhythm, and pattern of respirations
 Consider intubating if airway is obstructed
 Assess circulation by checking the remaining
vital signs
If hypotension/hemorrhage present,
establish IV access, begin IV fluids


o Level of consciousness
 Alertness: Alert patient opens eyes, looks at
you, and responds fully and appropriately
 Lethargy: Patient appears drowsy but opens
eyes, looks at you, responds to questions, and
falls asleep
 Obtunded: Patient opens eyes, looks at you,
responds slowly, and is somewhat confused


o Level of consciousness—(cont.)
 Stupor: Patient arouses from sleep only after
painful stimuli. Verbal responses are slow or
absent. Patient lapses into unresponsive state
when stimulus ceases and has minimal
awareness of self or environment
 Coma: Patient is unarousable and eyes are
closed. There is no evident response to inner
need or external stimuli

 Glasgow Coma Scale

o Points are determined to assess levels of
consciousness and coma in 3 areas: eye
opening, verbal response, and motor response
o Interpretation:
 3—no response
 3–8—comatose
 15—fully alert and functioning person

Assessment of the unconscious patient—(cont.)




Pupils in Comatose Patients #1

Pupils in Comatose Patients #2

 Assessment of the
unconscious patient—
(cont.)
o Neurologic
evaluation
 Respirations
 Pupils
 Ocular movement
 Oculocephalic
reflex


o Neurologic evaluation—(cont.)
 Posture and muscle tone
 If there is no spontaneous movement, apply
painful stimuli
 Classify results:
Normal-avoidant
Stereotypic
Flaccid paralysis or no response


o Neurologic evaluation—(cont.)

Abnormal Postures in Comatose Patients
#1

#2

#3

 Meningeal signs
o Neck
mobility/Nuchal
Rigidity
o Brudzinski sign
o Kernig sign


o “Don’ts” when assessing the unconscious patient
 Don’t dilate the pupils
 Don’t flex the neck if there is any question of
trauma to the head or neck

 Reducing risk of diabetic peripheral neuropathy

o Diabetes causes several types of peripheral
neuropathies
 Distal symmetric sensorimotor polyneuropathy
 Autonomic dysfunction
 Mononeuropathies
 Polyradiculopathies

 Reducing risk of diabetic peripheral neuropathy—

(cont.)

 Steps for the lower extremity amputation prevention

(LEAP)/Semmes–Weinstein test
o 1. Explain rationale for examination
o 2. Remove patient’s shoes and socks
o 3. Demonstrate what monofilament feels like on
hand/arm
o 4. Ask patient to respond “yes” each time feel
pressure of monofilament
o 5. Have patient close eyes and hold
monofilament perpendicular to patient’s foot

 Steps for the lower extremity amputation prevention
(LEAP)/Semmes–Weinstein test—(cont.)
o 6. Press monofilament until it bends in a “C”
shape on designated areas
o 7. Hold the monofilament in place for 1 to 2
seconds; press so it buckles one of two times;
say “time one” or “time two;” patient identifies
time foot was touched
o 8. Randomize the site sequence
o 9. Test plantar surface of distal hallux and third
toe; first, third, fifth metatarsal heads; avoid
ulcers, calluses, corns

Recording Your Findings
 Mental status
 Cranial nerves
 Motor
 Sensory
 Reflexes

Question #4
It’s important to NOT dilate the pupils in a comatose

patient
A. True
B. False

A. True
The pupils are the single most important clue to the
underlying cause of coma.

Health Promotion and Counseling #1
 Preventing stroke and transient ischemic attack

(TIA)
o Stroke
 Fourth leading cause of death in the United
States
 Leading cause of long-term disability
 Symptoms and signs depend on vascular
territory affected in brain
Table 20-19 for types of stroke
Most common: middle cerebral artery

 Stroke warning signs
AHA/ASA Stroke Warning Signs and Symptoms

F Face Drooping—Does one side of face droop or is it numb?
Is the person’s smile uneven?
A Arm Weakness—Is one arm weak or numb? Ask the
person to raise both arms; does one arm drift downward?
S Speech Difficulty—Is speech slurred? Unable to speak or
hard to understand? Can sentence be repeated correctly?
T Time to call 9-1-1—If the person shows any of these
symptoms, call 9-1-1 and get the person to the hospital

 Stroke warning signs—(cont.)
AHA/ASA Stroke Warning Signs and Symptoms

Beyond FAST:
Sudden numbness or weakness of the leg, arm, or face
Sudden confusion or trouble understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance, or coordination
Sudden severe headache with no known cause

 Stroke risk factors: primary prevention

o Hypertension
o Smoking
o Dyslipidemia
o Diabetes
o Weight
o Diet and nutrition
o Physical activity
o Alcohol use

 Stroke risk factors: disease-specific risk factors

o Atrial fibrillation
o Carotid artery disease
o Obstructive sleep apnea
 Optimal blood pressure control is essential for
preventing hemorrhagic stroke
o Most common cause of hemorrhagic stroke:
ruptured aneurysms in the circle of Willis
 Risk factors: smoking, alcohol use, oral
contraceptives, family history (first‐degree
relative)
 For patient who already suffered a TIA or stroke,

focus on:
o Identifying underlying cause
o Reducing cardiovascular risk factors
o Identifying most appropriate interventions for
secondary prevention
 Strokes in young adults have a different set of
causes

Question #5
A stroke is caused by hemorrhage in approximately

__________ of patients.
A. 13%
B. 31%
C. 69%
D. 87%

13%
A stroke is a sudden neurologic deficit caused by
cerebrovascular ischemia (87%) or hemorrhage
(13%).

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Chapter 20

The Nervous System

 Central nervous system

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Left lateral view of the brain

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Coronal section of the brain

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 The spinal cord

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 The spinal cord—(cont.)

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 The spinal cord—(cont.)

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 The spinal cord—(cont.)

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 Cranial nerves o VII—Facial

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 Peripheral nervous system

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 Peripheral nervous system—(cont.)

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 Spinal reflexes: The muscle stretch and deep tendon

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 Spinal reflexes: The deep tendon response

Reflex Spinal Segment

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 Cutaneous stimulation reflexes

Reflex Spinal Segment

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The _______ coordinates all movement and helps

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 Common or concerning symptoms

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 Change in or loss of sensation

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 Near syncope and syncope

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Vertigo is common with all of the following except:

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Vertigo is common with all of the following except:

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 Cranial nerve o Tongue depressor

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 Important areas of examination