NCM 116 – NEURO DIVISIONS OF THE NEUROLOGIC SYSTEM

CLIENTS WITH NEUROLOGIC DISORDERS

MODULE 1

I. Neurologic System: ANATOMY & PHYSIOLOGY

Overview
 Functional Unit: Neuron and Neurotransmitters
 Divisions of the Nervous System
 Central Nervous System
 Peripheral Nervous System
 Brain Circulation

NEUROLOGIC SYSTEM
 Function: Control of all functions and behavior
in the human body

NEURON
 Basic unit
 Parts:
 Cell body/ Soma - metabolic center
 Dendrites - branch-like recipients of
electrochemical impulses
 Axons - long projections carrying
electrochemical impulses away from the
body of the neuron
 Synaptic Bulb - site of communication
between neurons or between neuron and
target cell/ organ
 Myelin - fatty substance; covers some axons
in the CNS & PNS (myelinated/white
matter)
 Neurolemma - specific to the peripheral
nervous system; aids the regeneration of the
myelin sheath responsible for the
conduction of nerve impulses.
 Node of Ranvier - spaces between the
neurolemma; Saltatory conduction
 Neuroglial cells - support, protect and
nourish neurons

NEUROTRANSMITTERS
 chemicals transported within neurons or between
neurons and specific tissues/ organs that may
excite, inhibit, or modulate specific actions.
CENTRAL NERVOUS SYSTEM: The Brain

CEREBRUM
 3 Parts: cerebrum, cerebellum, brain stem
 LOBES
 Frontal - Concentration, abstract thought,
memory, motor function, speech (Broca’s
area- left, motor), affect, judgment,
personality, inhibitions

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  Parietal - sensory analysis and
interpretation, spatial awareness, size and
shape discrimination
 Temporal - auditory reception and memory,
language (Wernicke’s area- receptive) and
music comprehension
 Occipital - Visual interpretation and
memory
 Corpus callosum - connects both hemispheres
of the brain for information transmission
 Cerebral Cortex - surface; contains motor &
sensory neurons
 Basal ganglia - fine motor movement
 Thalamus - relay station of all sensation except
smell
 Hypothalamus - regulates the pituitary
secretion of hormones
PROTECTIVE STRUCTURES OF THE BRAIN
CEREBELLUM
 Important for making postural adjustments in
order to maintain balance
 Receives input from vestibular receptors and
proprioreceptors
 Sensory integration , fine movement, balance,
proprioreception
 Skull - rigid bone structure to protect from
injury
 Meninges - protect, support, and nourish the
brain and spinal cord
 Dura mater - outermost layer; tough, thick,
inelastic, fibrous
 Arachnoid mater - middle layer; extremely
thin, delicate; spider web like
 Pia mater - Innermost; thin, transparent; hugs
every fold of brain’s surface

BRAINSTEM
 Midbrain - connects the pons and cerebellum,
with the medulla oblongata ; center of auditory
and visual reflexes
 Pons - bridges the halves of the cerebellum and
the medulla and midbrain; respiration (partly)
 Medulla - decussation of motor and sensory
fibers; reflex center for vital functions (vital
signs, coughing, sneezing, swallowing,
vomiting)
 Motor Tracts - Pyramidal or Extrapyramidal
Reticular formation - arousal and sleep-wake
cycle

 Ventricles - manufacture and absorb CSF

 Cerebrospinal Fluid - Clear, colorless fluid
that nourishes, transports wastes, and cushions
the brain; produced in the choroid plexus at 500
mL/day

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CEREBRAL CIRCULATION PERIPHERAL NERVOUS SYSTEM: SPINAL
 Arterial and venous systems are not parallel NERVES
(venous system is also involved in CSF
reabsorption)
 Brain receives blood from: internal carotid
arteries and vertebral arteries
 Brain has collateral circulation through the
Circle of Willis (compensation in case of
circulatory disruption).

WHAT IS INSIDE THE CRANIUM?  Posterior/ Sensory root

1. Brain tissue - 80%  Anterior/ Motor root: voluntary and reflex
2. Blood - 10% activity of innervated muscles
3. CSF - 10%  Lateral horn: automatic (sympathetic fibers).

*Monro-Kellie hypothesis - if one or more of these AUTONOMIC NERVOUS SYSTEM

increases significantly without a decrease in either or  Internal organ activity regulation/ homeostasis
both of the other two, Intracranial pressure (ICP) and maintenance
becomes elevated.  Sympathetic (excitatory/ fight or flight) vs.
Parasympathetic (inhibitory/ rest and digest)
SPINAL CORD
 Direct continuation of the medulla; surrounded
and protected by the vertebrae (vertebral
column)
 Ends between L1 & L2
 2 main functions:
 provide centers for reflex action
 pathway for impulses to & from the brain

UPPER & LOWER MOTOR LESIONS

MOTOR VS. SENSORY PATHWAYS

 upper motor pathway lesions (preserved reflex
arc) vs. lower motor pathway lesions
(flaccidity).

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  Esteem, image - may lead to depression and
changes in role function
 Role responsibilities- impaired ability to
perform role
 Stress - can increase existing neurologic
symptoms

PHYSICAL EXAMINATION
 Consist of assessment of the cerebral, motor,
II. NURSING ASSESSMENT of Neurologic Function sensory areas
 Health History; Family History; Review of  Intellectual function - mental status
Systems  Speech pattern - note responses during
 Functional Assessment history taking
 Physical/ Neurologic Exams  Evaluate body posture - abnormal position of
the head, neck, trunk, or extremities
HISTORY OF PRESENT HEALTH CONCERNS  Head trauma - examine ears and nose (bleeding/
(Common Symptoms) drainage)
 Headaches/ Pain (Acute or Chronic)  DON’T MOVE head especially if with recent
 Seizures history of trauma
 Dizziness and Vertigo
 Numbness and Tingling PERIPHERAL NERVOUS SYSTEM: Cranial
 Senses Nerves
 Difficulty Speaking
 Difficulty Swallowing
 Muscle Control
 Memory Loss

PAST HEALTH HISTORY; FAMILY HISTORY

 Head Injuries
 Spinal cord Injuries
 Meningitis, encephalitis
 Stroke
 High BP
 Alzheimer’s
 Epilepsy
 Brain cancer PA: MOTOR FUNCTION
 Huntington’s chorea  Muscle movement, size, tone, strength,
coordination
LIFESTYLE AND HEALTH PRACTICES  Inspect large muscle areas - evidence of
 Prescription & nonprescription drugs - tremors, atrophy; opposing muscles - size and
dizziness, altered LOC, mood & temper strength equality
changes  Ask client to perform:
 Nicotine  Pushing the palm or sole against examiner’s
 Seat belts and protective gears palm
 Usual daily diet - Peripheral neuropathy:  Picking up small and large objects
deficient niacin, folic acid, B12  Grasping objects firmly
 Prolonged exposure to lead, insecticides,  Resisting removal of an object
pollutants, chemicals -malter neurologic status
 Frequent heavy lifting - intervertebral disc PA: MOTOR SYSTEMS (BALANCE AND
injury COORDINATION)
 Perform activities with repetitive motions -  Gait, movement, balance - walk away, turn,
peripheral nerve injury walk back
 ADL - neurologic symptoms & disorders  Romberg test - screening test for balance;
negatively affect the ability to perform normally negative
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  Ataxia - incoordination of voluntary muscles,
usually of the extremities
 Other tests for balance and coordination:
standing on one foot with eyes closed, Heel-toe
walking
 Motor & cerebral function: finger-to-nose test,
writing words, identifying common objects
PA: MOTOR SYSTEMS (MUSCLE STRENGTH)
MOTOR RESPONSE: COMATOSE/
UNCONSCIOUS
 Administer painful stimulus - determine
response
 Abnormal Posturing (Impaired cerebral
function)
 Decorticate - arms flexed, fist clenched, legs
extended
 Decerebrate - rigid and stiff extremities;
more serious
 Flaccidity - no motor response
PA: REflEXES
PA: SENSORY FUNCTION
a. Tactile sensation
b. Pain and temperature sensation
c. Vibration and proprioreception
Agnosia - inability to recognize objects through a
particular sensory system
PA: CONSCIOUSNESS AND COGNITION
 Mental status - appearance and behavior,
posture, gesture, movements, facial movements,
orientation to time, place, and person
 Intellectual function - serial 7s; abstract
reasoning
 Thought content - delusions, hallucinations,
illusions, preoccupations
 Emotional status - affect
 Language ability - aphasia: deficiency in
language function
 Impact on lifestyle - limitations
 Level of consciousness - earliest and most
sensitive indicator of neurologic status
ALTERATIONS IN LEVEL OF CONSCIOUSNESS
 Drowsiness - Inattention, reduced wakefulness
 Confusion - Disorientation, bewilderment,
difficulty following commands
 Somnolent or Lethargy - Severe drowsiness
wherein patient can only be aroused by
moderate stimuli, but then drifts back to sleep
 Obtundation - Less interest in the environment,
slower response to stimulation , with more sleep
than normal and drowsiness upon waking
 Stupor - Requires vigorous and continuous
stimulation to arouse the patient; else, he is
unresponsive
 Semicomatose- unresponsive except to
superficial, relatively mild painful stimuli to
which the client makes some purposeful motor
response (movement) ; spontaneous motion is
uncommon, but the client may groan or mutter.
 Coma - Unarousable , unresponsive wherein
purposeful response to external and internal
stimuli is not present; non-purposeful response
to pain and brain arc reflexes may be intact
 Akinetic mutism - Unresponsiveness to
environment; no voluntary movement
 Persistent vegetative state - Sleep-wake-cycle
remains intact after coma, however cognitive or
affective mental function are absent
 Locked-in syndrome - Patient with paralysis and
inability to speak. Responsiveness is manifested
through vertical eye movement and lid elevation.
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GLASGOW COMA SCALE
 Tool for assessing LOC
 15 - normal response
 8 or less - comatose client 3 -totally
unresponsive

NECK
 Examined for stiffness or abnormal position
 Rigidity - checked by moving the head and chin
toward the chest
 No maneuver: head and neck injury
suspected; evident trauma to any body part
 Older adults - ROM affected due to arthritic
RANCHO LOS AMIGOS SCALE changes
 Describes cognitive & behavioral patterns
Originally 8 levels VITAL SIGNS
 9-10 – revised  Closely monitored on all clients with potential
or actual neurologic disorder
 Temperature - needs to be monitored Hourly;
affect hypothalamus
 Sudden increase or decrease - indicates change
in neurologic status; notify physician
immediately

III. DIAGNOSTIC TESTS/ PROCEDURES

 IMAGING PROCEDURES: CT, MRI, PET,
SPECT
 Lumbar Puncture
 CONTRAST STUDIES: Cerebral Angiography;
Myelogram
 EEG
 Electromyelogram
 Nerve Conduction studies
PUPILS  Echoencephalogram
 Size & equality; reaction to light - CN III  Non-invasive Carotid Flow Studies
 Size: normal, pinpoint, dilated  Transcranial Doppler
 Equality: equal, unequal size  Evoked Potential Studies
 Reaction to bright light: normal, sluggish, no
reaction, fixed BRAIN SCAN
 Any abnormal movement or position  Identifies tumors, hematomas in or around the
 Unequal, dilated or pinpoint, failure to respond brain, cerebral abscesses, cerebral infarctions,
quickly to light or displaced ventricles
 Morphine; pain narcotic depressants - affect  A radioactive material is injected before the
light response, pinpoint procedure
 Older adults - sluggish; Cataracts - no pupillary  Length of procedure - few minutes to an hour
response  CT scans and MRI are replacing this procedure

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COMPUTED TOMOGRAPHY (CT) SCAN
 Narrow X-ray beams to scan body parts in
successive layers
 Instruct patient to lie still throughout the
procedure
 Relaxation techniques or sedation as needed
 Ongoing monitoring
 Assess for shellfish/ iodine allergy if with dye
 Renal clearance prior if with die
 IV line and fasting for 4 hours pre-procedure
MAGNETIC RESONANCE IMAGING
 ALL metallic implants, metal fragments in
body, and medication patches with metal
backing must be removed pre-procedure.
 Open MRI’s - anxious, claustrophobic, obese
 Orthopedic patients - non ferromagnetic
implants (titanium, stainless steel, ceramics);
can have test
POSITRON EMISSION TOMOGRAPHY (PET)
 Shows metabolic changes, biochemical
alterations and blood flow; locates and
differentiates lesions by use of radioactive
substance
 Tracers - given intravenous, oral, inhalation
 Test after an hour
 Medications taken
 Pregnant - radiation unsafe for fetus
 Medical conditions – Diabetes
SINGLE-PHOTON EMISSION COMPUTED
TOMOGRAPHY
 Provides information about the brain’s cerebral
blood flow and the status of receptors for
neurotransmitters
 Identifies lesions before they are visible with
other imaging techniques.
 Locate the site causing epileptic seizures, help
diagnose Alzheimer’s and Parkinson’s diseases,
and detect brain tumors and changes in blood
flow
 IV radiopharmaceuticals and radioisotope 1H
prior to test - allergy risk.
LUMBAR PUNCTURE & CSF EXAMINATION
 Withdrawing CSF from the lumbar
subarachnoid space (between L3 and L4 or L4
and L5) to test CSF components, measure and
reduce CSF pressure, and administer
medications intrathecally.
 Post procedure- recline, increase fluid intake
(caffeine), limit activity for 24H
 Cisternal puncture below occipital bone;
removed CSF (children).
CONTRAST STUDIES: Cerebral Angiography;
Myelogram
 X-ray with contrast dye on selected arteries to
identify vascular diseases or anomalies
 Renal clearance
 Clear liquids until time of test
 Void immediately before the test
 Instruct that a brief feeling of warmth in the
head area and metallic taste in mouth as dye is
injected
 Myelogram - radiopaque substance is injected
into the spinal canal by means of a lumbar
puncture
ELECTROENCEPHALOGRAPHY
 Assessment of cerebral electrical activity
 Anti-seizure medications, tranquilizers,
stimulants, and depressants are withheld 24-48
hours prior to procedure
 Coffee, tea, chocolates, and cola drinks are
omitted on meal prior to procedure because of
their stimulating effect
 Sometimes, patients may be deprived of sleep
the night before the procedure to stimulate
possible seizure activity
ELECTROMYELOGRAPHY (EMG)
 Studies changes in the electrical potential of
muscles and nerves
 Identification of neuromuscular disorders and
myopathies
 Needle electrodes are placed into one or more
skeletal muscles and recorded on an
oscilloscope
 Pain may occur at needle insertion sites; muscle
soreness may last for some time
NERVE CONDUCTION STUDIES
 Nerve Conduction Velocity (NCV) Test
 performed by applying surface electrodes to the
skin over locations of various nerves
 may be combined with EMG
 aid in the diagnosis of nerve injury and
compression or neurologic disorders affecting
peripheral nerves (carpal tunnel syndrome and
the peripheral neuropathy).
ECHOENCEPHALOGRAPHY
 Ultrasound of the brain
 Detect abnormalities in the ventricles and
location of Intracranial bleeding
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NON-INVASIVE CAROTID FLOW STUDIES 2. Hemorrhagic - occur when a cerebral blood
 Use UTZ imagery and Doppler measurements vessel ruptures and blood is released in brain
of arterial blood flow to evaluate carotid and tissue
deep orbital circulation
 Blockage cause by blood clot, plaque,
inflammation

TRANSCRANIAL DOPPLER (TCD)

 Painless test that uses sound waves to detect
problems affecting blood flow in the brain
 Detect: stroke, narrowed blood vessels,
vasospasm due to subarachnoid hemorrhage,
blood clots

EVOKED POTENTIAL STUDIES

 Measures the time it takes for the brain to
respond to sensory stimulation either through
sight, sound or touch
 Diagnose Multiple Sclerosis, other conditions
the can cause a person’s reactions to slow,
unusual responses to stimulation PATHOPHYSIOLOGY (ISCHEMIC STROKE)

CEREBROVASCULAR ACCIDENT (STROKE)

 Prolonged interruption in the flow of blood
through one of the arteries supplying the brain.
 3-7 minutes during stroke - both brain and
nerve cells begin to die
 Cellular damage located in the brain but
consequence is widespread
 ⅓ die; survivors with permanent disabilities
 Permanent neurologic deficits have profound
physical, emotional, financial effect on client
and family

RISK FACTORS FOR CVA

PATHOPHYSIOLOGY (HEMORRHAGIC
Gerontologic Considerations - older adults with STROKE)
Hypertension may not adhere to the medication regimen
because of financial constraint, increasing CVA risk.

PATHOPHYSIOLOGY & ETIOLOGY

2 main Types of Stroke
1. Ischemic - occurs when thrombus or embolus
obstructs an artery carrying blood to the brain

Common: cerebellum, brain stem

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TRANSIENT ISCHEMIC ATTACK (TIA)
 A sudden, brief attack of neurologic impairment
caused by a temporary
 interruption in cerebral blood flow
 Lightheadedness, confusion, speech disturbance,
vision loss, diplopia, variable changes in
consciousness, numbness, weakness, impaired
muscle coordination, one sided paralysis
 Symptoms (short-lived) may disappear within 1
hour - day
 Stroke warning
ASSESSMENT FINDINGS
Signs of Impending Stroke:
 Numbness or weakness of one side of the face,
arm, leg
 Mental confusion
 Difficulty speaking or understanding
 Impaired walking or coordination
 Severe headache
In some instances, clients may experience one or
more TIAs days, weeks, or years before a CVA;
some no warning and symptoms develop suddenly
ASSESSMENT FINDINGS (Large Cerebral
Hemorrhage)
 Unconscious - after a large cerebral hemorrhage
 Noisy and labored breathing
 Pulse - slow, full, and bounding; BP - initially
elevated; T - elevated (acute phase), may persist
for several days
 Cheek on the side of CVA blows out on
exhalation
 Eyes deviate toward the affected side of the
brain
 LOC - ranges from lethargy, mental confusion,
deep coma
 Manifestations are varied & depending on:
area of the cerebral cortex and affected
hemisphere, the degree of blockage, presence or
absence of collateral circulation
 Hemiplegia (arm severely affected than leg)
 Expressive/ Receptive aphasia
o For most, speech center is in the dominant
hemisphere
 Confusion and emotional lability
 Hemianopia - ability to see only half of the
normal visual field
DIAGNOSTIC FINDINGS
 CT Scan or MRI - differentiates CVA from
other disorders; shows size and location of
infarcted area
 SPECT - determines blood flow
 Transcranial Doppler Ultrasonography -
determines size of intracranial vessel, direction
of blood flow, locates the obstructed cerebral
vessel
 Electroencephalogram - reveals reduced
electrical activity in the involved area
 Lumbar Puncture - is subarachnoid bleeding
suspected
 Cerebral angiography - shows displacement or
blockage of cerebral vessels
SIGNS AND SYMPTOMS OF RIGHT-SIDED
VERSUS LEFT-SIDED HEMIPLEGIA
MEDICAL & SURGICAL MANAGEMENT
 Tissue Plasminogen Activator (TPA) -
thrombolytic agent; limit neurologic deficits when
given within 3 hours after onset of ischemic CVA
 Neuroprotective agents: NMDA receptor
blockers,calcium and glutamate antagonists,
antioxidants (ongoing clinical trials)
 Hypothermia - protect damaged cells by reducing
 metabolic need for oxygen
 Carotid endarterectomy - if atherosclerosis of
carotid artery is the cause of stroke
 Surgery - ruptured cerebral aneurysm
 Supportive Treatment - damaged brain tissue
cannot be repaired
 Best Treatment - Intensive medical program aimed
at rehabilitation and prevention of future CVAs.
INCLUSION CRITERIA FOR TPA THERAPY
 Clinical evidence of an ischemic attack
 Age > 18 years
 Signed consent, if possible
 Onset of stroke within 3 hours of initiation of
therapy
 Normal prothrombin and partial thromboplastin
 Time
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NURSING MANAGEMENT
 Administer medications as directed and
understand the potential side and adverse effects
 Implement eating and swallowing techniques to
reduce potential for aspiration
 Heimlich maneuver
 Continue follow-up care with the speech
pathologist and dietitian
 Contact community resources (medical
companies) - hospital bed, commode, walker,
tripod cane
 Remove throw rugs, clutter, electrical cords -
reduce fall potential
 Perform regular exercises, frequent position
change, apply brace/ splints
 Encourage overweight clients to reduce weight
OLDER ADULTS
 More susceptible to complications of prolonged
bed rest & inactivity: hypostatic pneumonia,
pressure ulcers, contractures
 Rehabilitation is subject to more complications
 Facilitate with family and social service
agencies transfer to rehabilitation center or
long-term care facility
 Avoid stereotypes; encourage family and friends
to overcome
DIET
 Individualized according to ability to chew and
swallow
 Easiest to swallow - pudding, scrambled eggs,
cooked cereals, thickened liquids
 Cold foods stimulate swallowing
 Avoid tepid foods - difficult to locate in the
mouth; Extremely hot - overreaction
 Avoid foods most likely to cause choking -
peanut butter, bread, tart foods, dry or crisp
foods, chewy meats
 Decrease salivation - add gravies and sauces;
dill pickles, sucking on lemon slices
 Normal diet resumed - “Heart Healthy” less
saturated and trans fats; more fruits, vegetables
and whole grains
 Sodium restriction - Hypertensive clients

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