Académique Documents
Professionnel Documents
Culture Documents
NERVOUS SYSTEM
is an organ system containing a network of specialized cells called neurons that coordinate the actions of
an animal and transmit signals between different parts of its body
NETWORK-
NEURONS-
is an electrically excitable cell that processes and transmits information by electrical and chemical
Neuron
Brain cells
Maintain homeostasis
Direct all psychological, biologic and physical activity through complex chemical and electrical messages
Neurotransmitters
Neurotransmitters can potentiate, terminate, or modulate a specific action or can excite or inhibit a
target cell.
Types:
Acetylcholine-muscle movement
-Dopamine -Serotonin
-Norepinephrine -Histamine
Amino acids
-GABA
-Peptides
Brain tissue-78%
Blood -12 %
CSF-10%
Monro-Kellie Hypothesis
If volume added to the cranial vault equals the volume displaced from it, the total intracranial
volume will not change
Brain
Cerebrum
Consists of 2 hemisphere
Corpus callosum
Cerebral cortex
Basal ganglia
Internal capsule
white matter consisting of bundle of nerve fibers carrying motor and sensory impulses to and from
cerebral cortex
Diencephalon
1.Thalamus
2.Hypothalamus
regulates endocrine and autonomic function, temperature, water metabolism, appetite, emotion, sleep-
wake cycle and thirst
3.Epithalamus
includes pineal gland (secretes melatonin and inhibits LH), part of endocrine system, affects growth and
development.
BRAIN STEM
1. Midbrain
2. Pons
3. Medulla
influence excitatory and inhibitory control of motor neuron; regulatory system for consciousness
Cerebellum
Coordination of skeletal muscle activity, maintenance of balance, posture and control of voluntary
movements
Spinal cord
Gives rise to 31 pairs of spiral nerves (C1-C8, T1-T12, L1-L5, S1-S5, coccygeal nerve)
Center for conducting messages to and from the brain; a reflex center
Divisions:
Ascending (Spinocerebellar)
Descending (Corticospinal)
Pyramidal tracts-
Extrapyramidal tracts-
Reflex arc
Meninges and Related Structures
Circle of Willis
act as a safety valve; arises from basilar arteries and internal carotid arteries; vascular network at the
base of the brain
is important to total brain circulation because it provides equal circulation bilaterally. If one side of the
circle of Willis is unable to supply adequate blood, the other side provides blood to the area normally
supplied by the damaged side
Cross Section of the Spinal Cord Showing the Major Spinal Tracts
Cranial Nerves
Dermatome Distribution
Cranial nerves-innervate head and neck region, except the vagus nerve
Spinal nerves
Plexuses
complex cluster of nerve fibers (cervical, brachial, lumbar and sacral region)
Dermatomes
Functions to regulates activities of internal organs and to maintain and restore internal homeostasis
Has two subdivisions, serving same organ but have counterbalancing effects; each system can inhibit the
organ stimulated by the other
originates from lateral horns of first thoracic through the first lumbar of spinal cord (thoracolumbar)
Increases heart rate and respiratory rate, pupil dilation, cold, and sweaty palms
SYMPATHETIC SYNDROMES
Consist of the vagus nerves originating in the medulla of the brain stem and spinal nerves originating
from the sacral region of the spinal cord (craniosacral)
Activates GI system
Supports restorative, resting body function through such actions as replenishing fluids and electrolytes
Motor pathways
Coordination of movement
Sensory losses
NERVOUS SYTEM
Sensory Motor
Brain SC SN CN
Somatomotor Autonomic
Sympa Parasympa
Pons
Midbrain
1. Health History
☺ headache;
☺ clumsiness;
☺ seizure activity;
☺ numbness or tingling
☺ change in vision;
☺ pain;
☺ extreme fatigue;
☺ personality changes;
2. Neurological Assessment
☺ Involves assessment of LOC and verbal responses to specific questions; selected cranial nerves for
eye movement and visual acuity; muscle strength; movement; gait for motor function; and tactile and
pain sensation of extremities for sensory screening.
☺ A complete nursing assessment of neurological function includes assessment of the following areas:
cerebral function, cranial nerve function, motor function, sensory function, and reflexes.
a.1. Level of Consciousness is assessed by determining the client’s awareness and orientation and is the
most important indicator of change in neurological status.
Consciousness Requires:
Arousal:
alertness; dependent upon reticular activating system (RAS); system of neurons in thalamus and upper
brain stem
Cognition:
Increased ICP
Tumors
Infections
Demyelinating disorders
Hypoglycemia
F/E imbalance
Alert
Lethargic-very sleepy
Stuporous
Coma
Death
☺Awareness
–is the person’s ability to perceive stimuli and body reactions and then respond with thought and action.
The client’s awareness is assessed through four (4) components: orientation, memory, calculation and
fund of knowledge.
–an objective tool for assessing consciousness in clients, most frequently clients with head injuries.
☺A score of 15 indicates a fully oriented person. A score of 3 indicates deep coma. A score of 7 is
considered a state of coma.
a.2. Orientation
–is the person’s awareness of self in relation to person, place and time.
-Using open-ended communication techniques, instruct the client to “tell me your first and last name”,
“tell me the month, day, year and day of the week,” “tell me where you are”.
requires observation of the client’s appearance, behavior, posture, mood, gestures, movements, and
facial expressions.
The nurse compares these behaviors based on the client’s age, health status, educational level and
social position. Mood is assessed by observing and asking the client about moods and feelings.
MENTAL STATUS ASSESSMENT WITH ABNORMAL FINDINGS
Unilateral neglect (lack of caring of the other side of the body); strokes involving middle cerebral artery
Abnormal gait and posture: transient ischemic attacks(TIAs) , strokes, and Parkinson’s disease
Aphasia-defective or absent language function: TIA’s, strokes involving anterior/posterior artery; general
term for impairment of language
Confusion, Coma
is the ability of the brain to perform thought processes. Ability to concentrate, memory function (long
and short term memory), recall, calculation activities, and fund of knowledge.
Memory deficits
Emotional defense
a.6.Pupil reaction
size, equality, and roundness of pupils are assessed. Size is measured in millimeters. Pupils are
evaluated for symmetry of size and for reaction to light. Reaction is assessed as being brisk, sluggish, or
nonreactive; consensual reaction is also noted.
a.7.Communication –
☺ Aphasia
inability to communicate verbally, can be caused by the inability to form words or the inability
to understand written or spoken word.
☺ To assess communication function, ask the client to follow simple command such as “Close your
eyes”. During the health history, ask the client about health care expectations to evaluate the client’s
ability for verbal expression. Have the client write his name and address on paper to evaluate the ability
to write.
Cranial I (Olfactory):
-Anosmia
Cranial II (Optic)
Homonymous hemianopia - impaired vision or blindness in one side of both eyes; blockage of posterior
cerebral artery.
Note:
Field of vision or peripheral vision-portion of space in which objects are visible during the fixation of
vision in one direction. The receptors for peripheral fields are the rod neurons of the retina. (Phipps,
1998, p. 1906)
Cranial nerve III, IV, VI (Oculomotor, Trochlear, Abducens)-motor nerves that arise from the brainstem
Nystagmus –- involuntary eye movement; strokes of anterior, inferior, superior, cerebellar arteries
• Ptosis (eyelid falldown); drooping of the upper eyelid over the globe—strokes of
posterior inferior cerebellar artery; myasthenia gravis, palsy of CN III
Cranial nerve V (Trigeminal)—largest cranial nerve with motor and sensory components
Decreased sensation of face and cornea on same side of body; strokes of posterior inferior cerebral
artery
Cranial VII (Facial nerve)—mixed nerve concerned with facial movement and sensation of taste
3. Inability to close eyes, flat nasolabial fold, paralysis of lower face, inability to wrinkle the forehead
Cranial VIII (Acoustic)—composed of a cochlear division related to hearing and a vestibular division
related to equilibrium (Phipps, 1998, p. 1909)
Cranial IX(Glossopharyngeal) and cranial X (Vagus)—chief function of cranial nerve IX is sensory to the
pharynx and taste to the posterior third of tongue; cranial nerve X is the chief motor nerve to the soft
palatal, pharyngeal and laryngeal muscles (Phipps, 1998, p. 1909)
Dysphagia (difficulty swallowing)
Cranial XI (Spinal accessory)—motor nerve that supplies the sternocleidomastoid muscle and upper part
of trapezius muscles
Muscle weakness
Contralateral hemiparesis: strokes affecting middle cerebral artery and internal artery
c. Motor Function
are assessed by palpating major muscle groups of the arms and legs and then comparing them
to the muscle groups of the opposite side of the body.
c.2. Muscle Tone – assessed during palpation of major muscle groups for size and symmetry while at
rest and during passive movement.
☺ Spastic muscles are at first resistant to passive movement, but then release resistance.
Rigid muscles may have tremors but are constantly rigid. Rigidity is a more constant state of spasticity,
with fewer periods of release of resistance.
The client is then asked to move the extremity, first against gravity, by lifting the extremity off
the bed, then against the resistance.
5….…Full power of contraction
0….…No movement
c.4. Coordination –
is assessed by asking the client to perform repetitious movement. The client should close his
eyes and repeatedly, rapidly touch her own nose with alternate index fingers. Inability to perform this is
termed ataxia, incoordination of voluntary muscle action.
c.5. Balance –
is evaluated by using the Romberg’s Test. The client stands with the feet together; arms
extended in front and eyes closed.
c.6. Posturing
☺ Flexion posturing (formerly decorticate posturing) – characterized by flexion of the arms, adduction
of the upper extremities, and extension of the lower extremities. Lesions of the cerebral hemispheres or
internal structures of the brain cause flexion posturing.
d. Sensory Function – a subjective examination of sensory function, performed with the client’s eyes
closed, is generally done only when a dysfunction is suspected.
is tested by using a cotton ball to lightly touch the client’s arms, hands, upper legs, and feet. Comparison
is done side to side. The client with eyes closed, indicated whether the cotton ball is felt.
d.3. Vibration
is tested using a tuning fork. Strike the tuning fork on the palm, holding only the handle, then
place the end of the handle first on the client’s wrists and then on the ankles and ask whether the
vibrations are felt. The client’s eyes should be closed during the test.
d.4.Proprioception – is the sense of joint position in space. With the client’s eyes remaining closed,
move a joint of the client’s finger or extremity up or down in space and ask the client to distinguish the
direction of movement of the digit or extremity as being either up or down.
d.5.Steriognosis – is the ability to recognize an object by feel. Place a familiar object such as a coin or
key in the client’s hand and ask what the object is. This sensation is a function of the brain, not of the
spinal pathways.
d.6. Graphesthesia – is the ability to identify letters, numbers, or shapes drawn on the skin.
d.7. Integration of sensation – is a higher cortical function. A two-point discrimination test is performed
by touching the client simultaneously on opposite sides of the body with a sharp object and asking the
client to ascertain the number of objects felt. The normal response is two. If only one is felt, the brain
function of integration is abnormal.
e. Reflexes:
e.1. Deep tendon reflexes (DTR) – are involuntary contractions of muscles or muscle groups responding
to brisk stretching near the insertion site of muscle.
e.2. Superficial or cutaneous reflexes – are elicited by irritating the skin on the area being assessed.
They are diminished or absent with dysfunction of the reflex arc.
☺ The superficial reflex generally assessed is the plantar. To assess the plantar reflex, the handle of the
reflex hammer is used to stroke the outer aspect of the sole of the foot from the heel and across the ball
of the foot to just below the big toe. Plantar flexion or curling under of the toes, should occur.
☺ Abnormal reflexes- the absence of DTR in clients is considered an abnormal finding. A fanning of the
toes and dorsiflexion of the big toe in response to the assessment of the plantar reflex is called Babinski
Reflex. This abnormal response indicates corticospinal disease and is the most important abnormal
superficial reflex.
Gerontological Considerations
Important to distinguish normal aging changes from abnormal changes
Determine previous mental status for comparison. Assess mental status carefully to distinguish delirium
from dementia.
Losses in strength and agility; changes in gait, posture and balance; slowed reaction times and
decreased reflexes; visual and hearing alterations; deceased sense of taste and smell; dulling of tactile
sensations; changes in the perception of pain; and decreased thermoregulatory ability
Diagnostic Tests
Computed tomography(CT)
Cerebral angiography
Myelography
Transcranial doppler
Electroencephalography (EEG)
Electromyography (EMG)
Neuroglia Function
Schwann cells Phagocytic cells that form myelin sheath around nerve fibers
Satellite cells Found in the PNS; may maintain chemical balance of neurons