NERVOUS SYSTEM ANATOMY AND PHYSIOLOGY

Nervous System
integrates and monitors the countless actions occurring simultaneously throughout the entire human body

The nervous system consists of two parts: a. Central Nervous System (CNS) consists of the brain and spinal cord.
b. Peripheral Nervous System (PNS) consists of nerves outside the CNS

PNS are classified by the direction of nerve propagation Sensory(afferent)neurons

transmit impulses from skin and other sensory organs or from various places within the body to the CNS.
Motor(efferent) neurons

transmit impulses from the CNS to effectors (muscles or glands)

Motor Neurons are further classified according to the effectors they target. somatic nervous system (SNS) directs the contraction of skeletal muscles autonomic nervous system (ANS) controls the activities of organs, glands, and various involuntary muscles, such as cardiac and smooth muscles.

Autonomic Nervous System has two divisions:

The sympathetic nervous system

involved in the stimulation of activities that prepare the body for action such as:
increasing the heart rate increasing the release of sugar from the liver into the blood, and other activities generally considered as fight-or-flight responses (responses that serve to fight off or retreat from danger).

 The parasympathetic nervous system

activates tranquil functions such as:

stimulating the secretion of saliva or digestive enzymes into the stomach and small intestine.

 Generally, both sympathetic and parasympathetic systems target the same organs, but often work antagonistically. For example:
sympathetic system accelerates the heartbeat while the parasympathetic slows the heartbeat. Each system is stimulated as is appropriate to maintain homeostasis.

CNS
(central nervous system) is made up of the: spinal cord

brain

The spinal cord conducts sensory information from the peripheral nervous system (both somatic and autonomic) to the brain conducts motor information from the brain to our various effectors

skeletal muscles
cardiac muscle smooth muscle glands serves as a minor reflex center

The brain receives sensory input from the spinal cord as well as from its own nerves (e.g., olfactory and optic nerves) devotes most of its volume (and computational power) to processing its various sensory inputs and initiating appropriate and coordinated motor outputs.

White Matter vs. Gray Matter

Both the spinal cord and the brain consist of

white matter = bundles of axons each coated with a sheath of myelin gray matter = masses of the cell bodies and dendrites each covered with synapses.

 In the spinal cord white matter is at the surface gray matter inside In the brain of mammals, this pattern is reversed.

However, the brains of "lower" vertebrates like fishes and amphibians have their white matter on the outside of their brain as well as their spinal cord.

Meninges Both the spinal cord and brain are covered in three continuous sheets of connective tissue, the meninges. From outside in, these are the: dura mater pressed against the bony surface of the interior of the vertebrae and the cranium the arachnoid the pia mater The region between the arachnoid and pia mater is filled with cerebrospinal fluid (CSF).

The Extracellular Fluid (ECF) of the Central Nervous System The cells of the CNS are bathed in a fluid that differs from that serving as the ECF of the cells in the rest of the body. The fluid that leaves the capillaries in the brain contains far less protein than "normal" because of the blood-brain barrier, a system of tight junctions between the endothelial cells of the capillaries. This barrier creates problems in medicine as it prevents many therapeutic drugs from reaching the brain. cerebrospinal fluid (CSF), a secretion of the choroid plexus. CSF flows uninterrupted throughout the central nervous system through the central cerebrospinal canal of the spinal cord and through an interconnected system of four ventricles in the brain. CSF returns to the blood through veins draining the brain.

The Spinal Cord 31 pairs of spinal nerves arise along the spinal cord. These are "mixed" nerves because each contain both sensory and motor axons. However, within the spinal column, all the sensory axons pass into the dorsal root ganglion where their cell bodies are located and then on into the spinal cord itself. all the motor axons pass into the ventral roots before uniting with the sensory axons to form the mixed nerves.

Spinal cord has two main functions:

It connects a large part of the peripheral nervous system to the brain. Information (nerve impulses) reaching the spinal cord through sensory neurons are transmitted up into the brain. Signals arising in the motor areas of the brain travel back down the cord and leave in the motor neurons.
The spinal cord also acts as a minor coordinating center responsible for some simple reflexes like the withdrawal reflex. The interneurons carrying impulses to and from specific receptors and effectors are grouped together in spinal tracts.

The Brain The brain of all vertebrates develops from three swellings at the anterior end of the neural tube of the embryo. From front to back these develop into the forebrain (prosencephalon shown in light color) midbrain (mesencephalon gray) hindbrain (rhombencephalon dark color) The human brain is shown from behind so that the cerebellum can be seen .

The human brain receives nerve impulses from the spinal cord and 12 pairs of cranial nerves Some of the cranial nerves are "mixed", containing both sensory and motor axons Some, e.g., the optic and olfactory nerves (numbers I and II) contain sensory axons only Some, e.g. number III that controls eyeball muscles, contain motor axons only.

Sensory-Somatic Nervous System The sensory-somatic system consists of12 pairs of cranial nerves and 31 pairs of spinal nerves.

The Hindbrain
The main structures of the hindbrain (rhombencephalon) are the medulla oblongata pons cerebellum

Medulla oblongata
The medulla looks like a swollen tip to the spinal cord. Nerve impulses arising here
rhythmically stimulate the intercostal muscles and diaphragm making breathing possible regulate heartbeat regulate the diameter of arterioles thus adjusting blood flow

The neurons controlling breathing have mu () receptors, the receptors to which opiates, like heroin, bind.
This accounts for the suppressive effect of opiates on breathing

Destruction of the medulla causes instant death.

Pons

serve as a relay station carrying signals from various parts of the cerebral cortex to the cerebellum.
Nerve impulses coming from the eyes, ears, and touch receptors are sent on the cerebellum. The pons also participates in the reflexes that regulate breathing

Pons cont The reticular formation is a region running through the middle of the hindbrain (and on into the midbrain). It receives sensory input (e.g., sound) from higher in the brain and passes these back up to the thalamus. The reticular formation is involved in sleep, arousal (and vomiting).

Cerebellum

The cerebellum consists of two deeply-convoluted hemispheres.

Although it represents only 10% of the weight of the brain, it contains as many neurons as all the rest of the brain combined. Its function is to coordinate body movements. People with damage to their cerebellum are able to perceive the world as before and to contract their muscles, but their motions are jerky and uncoordinated.

Cerebellum cont.. So the cerebellum appears to be a center for learning motor skills (implicit memory).

Laboratory studies have demonstrated both longterm potentiation (LTP) and long-term depression (LTD) in the cerebellum

The Midbrain

The midbrain (mesencephalon) occupies only a small region in humans (it is relatively much larger in "lower" vertebrates).

We shall look at only three features:

1. the reticular formation: collects input from higher brain centers and passes it on to motor neurons.
2. the substantia nigra: helps "smooth" out body movements; damage to the substantia nigra causes Parkinson's disease.

3. the ventral tegmental area (VTA): packed with dopamine-releasing neurons that are activated by nicotinic acetylcholine receptors and

whose projections synapse deep within the forebrain.

The VTA seems to be involved in pleasure: nicotine, amphetamines and cocaine bind to and activate its dopamine-releasing neurons and this may account for their addictive qualities.

Drugs and the Nervous System The activity of the nervous system is mediated by many kinds of interneurons releasing one or another neurotransmitter such as: noradrenaline gamma aminobutyric acid(GABA)

dopamine
glutamate (Glu) acetylcholine (ACh) serotonin

 The midbrain along with the medulla and pons are often referred to as the "brainstem".

The Forebrain The human forebrain (prosencephalon) is made up of a pair of large cerebral hemispheres, called the telencephalon. Because of crossing over of the spinal tracts, the left hemisphere of the forebrain deals with the right side of the body and vice versa. a group of structures located deep within the cerebrum, that make up the diencephalon.

Diencephalon

We shall consider four of its structures:

1. Thalamus. All sensory input (except for olfaction) passes through these paired structures on the way up to the somatic-sensory regions of the cerebral cortex and then returns to them from there. signals from the cerebellum pass through them on the way to the motor areas of the cerebral cortex. 2. Lateral geniculate nucleus (LGN).

All signals entering the brain from each optic nerve enter a LGN and undergo some processing before moving on the various visual areas of the cerebral cortex.

Diencephalon 3. Hypothalamus. The seat of the autonomic nervous system. Damage to the hypothalamus is quickly fatal as the normal homeostasis of body temperature, blood chemistry, etc. goes out of control. The source of 8 hormones, two of which pass into the posterior lobe of the pituitary gland. 4. Posterior lobe of the pituitary. Receives vasopressin Oxytocin from the hypothalamus and releases them into the blood.

The Cerebral Hemispheres

Each hemisphere of the cerebrum is subdivided into four lobes visible from the outside: frontal
parietal

occipital
temporal

Hidden beneath these regions of each cerebral cortex is 1.an olfactory bulb; they receive input from the olfactory epithelia. 2.a striatum; they receive input from the frontal lobes and also from the limbic system (below). At the base of each striatum is a 3.nucleus accumbens (NA). The pleasurable (and addictive) effects of amphetamines, cocaine, and perhaps other psychoactive drugs seem to depend on their producing increasing levels of dopamine at the synapses in the nucleus accumbens (as well as the VTA).

4. a limbic system; they receives input from various association areas in the cerebral cortex and pass signals on to the nucleus accumbens. Each limbic system is made up of a: a. hippocampus. It is essential for the formation of long-term memories..

b. an amygdala
The amygdala appears to be a center of emotions (e.g., fear). It sends signals to the hypothalamus and medulla which can activate the flight or fight response of the autonomic nervous system.

NEUROLOGICAL ASSESSMENT

Components of a Neurological Assessment: 1. Interview 2. Level of Consciousness 3. Pupillary Assessment 4. Cranial Nerve Testing

5. Vital signs
6. Motor Function 7. Sensory Function 8. Tone 9. Cerebral Function

INTERVIEW

The patient/family interview will allow the nurse to:

gather data: both subjective and objective about the patient's previous/present health state provide information to patient/family

clarify information
make appropriate referrals develop a good working relationship with

both the patient and the family

initiate the development of a written plan of care which is patient specific

Interview to identify presence of:

headache
difficulty with speech

inability to read or write

alteration in memory

altered consciousness
confusion or change in thinking disorientation decrease in sensation, tingling or pain

Interview to identify presence of: cont..

motor weakness or decreased strength

decreased sense of smell or taste

change in vision or diplopia

difficulty with swallowing

decreased hearing
difficulty with swallowing altered gait or balance dizziness tremors, twitches or increased tone

LEVEL OF CONSCIOUSNESS

***Consciousness is the most sensitive indicator of neurological change**

Consciousness can be defined as a state of general awareness of oneself and the environment. Consciousness is difficult to measure directly but it is estimated by observing how patients respond to certain stimuli.

Physiologic Basis for Consciousness

1. Reticular Activating System (RAS)

Loose network of neurons and fibers in the brainstem which receive input from spinothalamic (sensory) pathways and project to the entire cerebral cortex.

Arousal is dependent on the adequate functioning of the RAS. Arousal is purely a function of the brain stem. It does not have anything to do with the thinking parts of the brain.

 The fact that your patient opens his/her eyes when you call their name is an indication that their RAS (brainstem) functioning is intact but it does not tell you if they are awake or aware.

2.Cortex Modulates incoming information via connections to the RAS. Therefore, the cortex requires functioning of the RAS to function itself. Awareness, means that the cerebral cortex is working and that the patient can interact with and interpret his environment. We evaluate awareness in many ways but tend to focus on four areas of cortical functioning: orientation, attention span, language, and memory.

 Consciousness will be disturbed if a lesion of the RAS is present or if there is diffuse damage to the cortex (both hemispheres).

Some mechanisms by which consciousness is disturbed: Diffuse cortical dysfunction: decreased cerebral metabolism: hypoxia, hypoglycemia, acidosis/alkalosis, hyponatremia

drugs:
alcohol, barbiturates, phenytoin, phenothiazines, benzodiazepines, methanol, ethylene glycol, paraldehyde

hypotension:

hypotension: decreased cerebral blood flow

structural lesions:
infarctions, hemorrhages, tumors

Assessment of Level of Consciousness A. Stimulate with progressively stronger stimuli: i) normal voice ii) shout iii) light touch iv) pain

 Alert:
o awake, looks about
o responds in a meaningful manner to verbal instructions or gestures

Drowsy:
o oriented when awake but if left alone will sleep Confused: o disoriented to time, place, or person

o memory difficulty is common

o has difficulty with commands o exhibits alteration in perception of

 Stuporous:

o generally unresponsive except to vigorous stimulation

o may make attempt at verbalization to vigorous/repeated stimuli o Opens eyes to deep pain Comatose: o unarousable and unresponsive o some localization or movement may be acceptable within the comatose category depending on the coma definitions e.g. light coma to deep coma o Does not open eyes to deep pain

 The difference between Coma and Sleep: o sleeping persons respond to unaccustomed stimuli o sleeping persons are capable of mental activity (dreams) o sleeping persons can be roused to normal consciousness o cerebral oxygen uptake does not decrease during sleep as it often does in coma

Special States of Altered Levels of Consciousness

Brain Death:
An irreversible loss of cortical and brain stem activity. Persistent Vegetative State: A condition that follows severe cerebral injury in which the altered state becomes chronic or persistent. Locked-in Syndrome:

A state of muscle paralysis, involving voluntary muscles, while there is preservation of full consciousness and cognition.

PUPILLARY ASSESSMENT
When assessing pupils (eyes) it is important to assess the following: size shape reactivity to light comparison of one pupil to the other

Size

Normally, both pupils are the same size, from 2-6 mm. Size of pupils should be assessed after the eyelids have opened and the pupils have accommodated to room light. Seventeen percent of the population have unequal pupils and this is a normal finding for them. Direct eye injury or past surgery can affect size.

Extraocular eye movement

What to expect in a normal healthy person:

the eyes blink periodically the eyes move together in the orbital sockets

no nystagmus or abnormal eye movements the eyeball neither protrudes or is sunken into the eye socket
the eyelids do not droop

 CRANIAL NERVE ASSESSMENT

VITAL SIGNS
MOTOR FUNCTION When assessing motor function, from a neurological perspective, the assessment should focus on arm and leg movement. You should consider the following: 1. muscle size 2. muscle tone

3. muscle strength
4. involuntary movements 5. posture, gait

 SENSORY FUNCTION When assessing sensory function remember that there are three main pathways for sensation and they should be compared bilaterally: 1. pain and temperature sensation 2. position sense (proprioception) 3. light touch

 Pain can be assessed using a sterile pin. Light touch can be assessed with a cotton wisp. To test proprioception, grasp the patient's index finger from the middle joint and move it side to side and up and down.

Have the patient identify the direction of movement. Repeat this using the great toe.

Sensory Tests:

A number of tests for lesions of the sensory cortex can be done. Examples include:
Stereognosis: The ability to recognize an object by feel. Place a common object in the persons hand and ask them to identify the object.

Graphesthesis: Draw a number in the palm of the persons hand and ask them to identify the number.

 Two-Point Discrimination: Simultaneously apply two pin pricks to the skin surface. Continually repeat the test while bringing the two pins closer together, until the individual can no longer identify two separate stimuli. The finger tips are the most sensitive location for recognizing two point differences while the upper arms, thighs and back are the least sensitive.

 Extinction: Touch the same spot on both sides of the body at the same time (e.g. the left & right forearms). Ask the individual to describe how many spots are being touched. Normally, both sides are felt; with sensory lesions the individual will sense only one.

Point Locations: Touch surface of skin & remove the stimulus quickly. Ask the individual to touch the spot where the sensation was felt. Sensory lesions can impair accurate identification, even if they retain their sensation of light touch

CEREBELLAR FUNCTION

The cerebellum is responsible for muscle coordination & balance on the same side. To test cerebellar function use the following tests:
1. Finger to finger test: have the patient touch their index finger to your index finger (repeat several times). 2. Finger to nose test: perform with eyes open and then eyes closed.

3. Tandem walking: heel to toe on a straight line

 4. Romberg test: stand with feet together and arms at their sides. Have patient close his/her eyes and maintain this position for 10 seconds. If the patient begins to sway, have them open their eyes. If swaying continues, the test is positive or suggestive of cerebellum problems

 Physical Examination
Mental status Cranial nerves Sensory system Motor system Cerebellar function Reflexes Vital signs

 Rapid Neurologic Assessment

GCS scoring

Level of consciousness
Response to painful stimuli

Pupil assessment

 Diagnostic examination Radiologic examination Cerebral angiography

Computed tomography scan

Position emission tomography Single photon emission computed tomography Magnetic resonance imaging

Electroencephalography
Lumbar puncture and examination of cerebrospinal fluid

Cerebral Angiography Angiography is a minimally invasive medical test that uses x-rays and a contrast material to produce pictures of blood vessels in the brain. In cerebral angiography, a thin plastic tube called a catheter is inserted into an artery in the arm or leg through a small incision in the skin. Once the catheter is guided to the area being examined, contrast material is injected through the tube and images are captured using a small dose of ionizing radiation (x-rays). Cerebral angiography is also called intraarterial digital subtraction angiography (IADSA).

procedure to detect or confirm abnormalities within the blood vessels in the brain, including: an aneurysm

atherosclerosis, a narrowing of the arteries.

arteriovenous malformation vasculitis a tumor a blood clot a tear in the lining of the artery

Cerebral angiography

Computed tomography scan

Position emission tomography

Magnetic resonance imaging

 Electroencephalography

Lumbar puncture and examination of cerebrospinal fluid

 Neuro-Pharmacology (Assignment)

Thrombolytics, anti-coagulants and anti-platelets Anti-seizure and anti-hypertensive

Anti-inflammatory

Anti-cholinergics
Muscle relaxants

 Neurologic disorders Conditions related to increased intra-cranial Pressure

Stroke
Traumatic brain injury

Tumor
Seizure