ASSESSMENT OF NEUROLOGIC FUNCTION

LEARNING OBJECTIVES
1. Describe the structure and functions of the central and peripheral nervous systems 2. Differentiate between pathologic changes that affect motor control and those that affect sensory pathways. 3. Compare the functions of the sympathetic and parasympathetic nervous systems 4. Describe the significance of physical assessment to the diagnosis of neurologic dysfunction. 5. Describe changes in neurologic function associated with aging and their impact on neurologic assessment findings. 6. Describe diagnostic tests used for assessment of suspected neurologic disorders and the related nursing implications.

GLOSSARY
Agnosia loss of ability to recognize objects through a particular sensory may be visual, auditory, tactile Ataxia Inability to coordinate muscle movements, resulting in difficulty in walking, talking, and performing self-care activities. Autonomic Nervous system division of the nervous system that regulates the involuntary body functions Axon portion of the neuron that conducts impulses away from the cell body. Babinski reflex (sign) a reflex action of the toes, indicative of abnormalities in the motor control pathways leading from the cerebral cortex.

 Clonus abnormal movement marked by alternating contraction and relaxation of a muscle occurring succession. Delirium transient loss of intellectual function, usually due to systemic problems. Dendrite portion of the neuron that conducts impulses toward the cell body. Flaccidity displaying lack of muscle tone; limp, floppy Parasympathetic Nervous system division of the autonomic nervous system active primarily during non-stressful conditions, controlling mostly visceral functions. Photophobia- inability to tolerate light Position (postural) sense awareness of position of parts of the body without looking at them; also referred to as proprioception. Reflex an automatic response to stimuli Rigidity increase in muscle tone at rest characterized by increased resistance to passive stretch

 Romberg Test test for cerebellar dysfunction requiring the patient to stand with feet together, eyes closed and arms extended; inability to maintain the position, with either significant stagger or sway, is a positive test. Spasticity sustained increase in tension of a muscle when it is passively lengthened or stretch. Sympathetic nervous system division of the autonomic nervous system with predominantly excitatory response; the fight-or-flight system Vertigo an illusion of movement, usually rotation

Anatomic and Physiologic Overview

Nervous system 2 major parts: a. Nervous system b. Peripheral nervous system Function: control motor, sensory, autonomic, cognitive, behavioral activities.

 The brain itself contains more than 100 billion cells that link the motor and sensory pathways, monitor the bodys processes, respond to the internal and external environment, maintain homeostasis, and direct all psychological, biologic and physical activity through complex chemical and electrical messages.

CELLS OF THE NERVOUS SYSTEM

Neuron- functional unit of the brain Composed of dendrites, a cell body and axon. Dendrites are branch-type structures for receiving electrochemical messages. Axon is a long projection that carries electrical impulses away from the cell body. *some neurons have a myelinated sheath that increases the speed of conduction*

NEUROTRANSMITTERS
Communicate messages from one neuron to another or from a neuron to a specific target tissue. *stored in synaptic vesicles* As an electrical action potential propagated along the axon reaches the nerve terminal, it is released into the synapse.

 Diffuses or is transported across the synapse, binding to receptors in the postsynaptic cell membrane. It potentiates, terminates, or modulates a specific action, can either excite or inhibit activity of the target cell.

MAJOR NEUROTRANSMITTERS
NEUROTRANSMITTER SOURCE ACTION

1. Acetylcholine (major transmitter of the PNS)

2. Serotonin

Many areas of the brain, ANS

Usually excitatory; PNS effects sometimes inhibitory (stimulation of heart by vagal nerve)
Inhibitory, helps control mood and sleep, inhibits pain pathways Usually inhibits, affects behavior ( attention, emotions) and fine movement Usually excitatory; affects mood and overall activity Inhibitory

Brain stem, hypothalamus, dorsal horn of the spinal cord Substantia nigra and basal ganglia Brain stem, hypothalamus, postganglionic neurons of the SNS Spinal cord, cerebellum, basal ganglia, some cortical areas Nerve terminals in the spine, brain stem, thalamus and hypothalamus, pituitary gland

3. Dopamine

4.Norepinephrine (major transmitter of the SNS) 5. Gamma-aminobutyric acid (GABA) 6. Enkephalin, Endorphin

Excitatory; pleasurable sensation, inhibits pain transmission.

 Neurologic disorder due to an imbalance in neurotransmitter Ex. Parkinsons disease develops from decreased of dopamine Myasthenia Gravis Acetylcholine binding in muscle cells is impaired

 Evaluating diagnostic tests detect abnormal levels of neurotransmitter POSITRON EMISSION TOMOGRAPHY (PET) can detect dopamine, serotonin, and acetylcholine. SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT) can detect changes in some neurotransmitter such as dopamine in Parkinsons disease

CENTRAL NERVOUS SYSTEM

THE BRAIN
Accounts approx. 2% of the total body weight (average young adult) Weighs approx: 1400 g (average adult) 1200 g (elderly persons) Divided into three major areas: 1. Cerebrum 2. Brain stem 3. Cerebellum

Cerebrum
Composed of two hemispheres: thalamus;hypothalamus and the basal ganglia

Brain stem
Includes the midbrain, pons and medulla

Cerebellum
Located under the cerebrum and behind the brain stem

CEREBRUM

 Gyri the outside surface of the hemispheres which has wrinkled appearance as a result of many folded layers or convolutions. Sulcus or Fissures which serves as an anatomic division. Great longitudinal fissures separates the cerebrum into the right and left hemispheres

 Corpus Callosum joined two hemispheres at the lower portion of the fissures. Cerebral Cortex the external or outer portion of the hemispheres which is made up of gray matter approx 2 to 5 mm in depth. Contains billions of neuron cell bodies giving it a gray appearance.

 White matter makes up the innermost layer and is composed of myelinated nerve fibers and neuroglia cells that form tracts or pathways connecting various parts of the brain with one another.

CEREBRAL HEMISPHERES (divided into pairs of lobes)

FRONTAL
Largest lobe Located in front of the brain Major functions: Concentration, abstract thought, information storage or memory and motor function. Contains brocas area left hemisphere and is critical for motor control of speech. Responsible for a persons affect, judgment, personality, and inhibitions.

PARIETAL
Predominantly sensory lobe Posterior to the frontal lobe Analyzes sensory information Relays the interpretation of this information to other cortical areas Essential to a persons awareness of body position in space, size and shape discrimination, and right-left orientation

TEMPORAL
Located inferior to the frontal and parietal Contains auditory receptive areas Plays a role in memory of sound and understanding of language and music

OCCIPITAL
Located posterior to the parietal lobe Responsible for visual interpretation and memory

Corpus Callosum
Connects the two hemispheres of the brain