CHAPTER 47:

NEUROLOGICAL
SYSTEM FUNCTION,
ASSESSMENT AND
THERAPEUTIC
Beth
Campos
MSN
MEASURES
RN
Instructor

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

CENTRAL
NERVOUS
SYSTEM
The CNS is divided into two main parts:
(CNS)
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

1.LOBES
Frontal lobe: has motor areas that control

movement on the opposite side of the body.

Has Brocas 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 Wernickes
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

PERIPHERAL
NERVOUS
of cranial nerves
and spinal nerves: pp
1103
SYSTEM
Cranial nerves: has twelve pairs arising from

Composed

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
Spinal
SYSTEM
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.

AUTONOMIC NERVOUS
Controls involuntary activities of the viscera,
SYSTEM
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 Huntingtons 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

BASIC
NEUROLOGIC
1. Level of Consciousness: most accurate and reliable
indicator
of neurologic status. Evaluate for:
EXAMINATION:

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 Reactive 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

NURSING
ASSESSMENT
Coma scale
(GCS): International scale to

Glasgow

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

Eye
Verbal
Motor
(GCS) Response
opening
Response
Response
(E)

(V)

(M)

4=
Spontaneou
s

5 = Normal
conversation

6 = Normal

3 = To Voice 4 = Disoriented
conversation

5 = Localizes
to pain

2 = To Pain

3 = Words, but not

coherent

4=
Withdraws to
pain

1 = None

2 = No words,
only sounds

3=
Decorticate
posture

1 = None

2=
Decerebrat

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
Full Outline of UnResponsiveness
EXAMINATION
(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

FULL OUTLINE OF
UNRESPONSIVENESS (FOUR)

NEUROLOGIC
nerve function:EXAMINATION
to control sensory, motor,

Cranial

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

LUMBAR
PUNCTURE
Insertion of spinal needle into the subarachnoid
(SPINAL
TAP)
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

LUMBAR PUNCTURE
During the
(SPINAL TAP)
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
Implementation: post-procedure
(SPINAL
TAP)
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 175mmH0, pH: 7.30-7.40, clear,
colorless appearance, fasting glucose: 4080mm/dL, WBC: 0-5 small lymphocytes/mm

DIAGNOSTIC
TESTS
AND
and Spinal X-ray: reveal size, shape of
PROCEDURES
skull bones, suture separation in infants, fractures

Skull

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
Brain scan: may or may not require injection of a
(CT)
SCAN
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
Intra-procedure:
(CT) SCAN
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

MAGNETIC RESONANCE
Non-invasive procedure to identify types of
IMAGING (MRI)

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)

ELECTROENCEPHALOGRAPH
Graphic recording of electrical activity of the superficial
Y
(EEG)
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 clients 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
Provides information about function of vestibular
(OCULOVESTIBULAR
TESTING)
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