I.

NEUROANATOMY

Anatomy and Physiology

Gross anatomy
The nervous system is divided into the central and peripheral nervous system The Central nervous system consists of the BRAIN and the Spinal Cord The peripheral nervous system consists of the Spinal nerves and the cranial nerves

BRAIN
The Brain is divided into 3 major areas: 1. Cerebrum 2. Brain Stem 3. Cerebellum

BRAIN- 1. Cerebrum
The largest part of the brain.
Composed of: 2 hemispheres- the right and left, and the basal ganglia. The hemisphere is connected by corpus callosum, a band of fibers. Each hemisphere is divided into 4 lobes.

The 4 Lobes of the CEREBRUM

1. Frontal Lobe
Largest lobe

location: front of the skull.

contains the primary motor cortex and responsible for functions related to motor activity.

The left frontal lobe contains Brocas area (control

the ability to produce spoken words)

The frontal lobe controls higher intellectual function, awareness of self, and autonomic responses related to emotions.

2. Parietal
Sensory lobe location: near the crown of the head.
Contains the primary sensory cortex. One of its major function is to process sensory input such as position sense, touch, shape, and consistency of objects.

3. Temporal
Location: around the temples. Contains the primary auditory cortex. Wernickes area is located on left temporal lobe.
Contains the interpretative area where auditory, visual and somatic input are integrated into thought and memory

Lobes-cont.
4. Occipital
Location: lower back of the head Contains the primary visual cortex Function: responsible for visual interpretation.

THE 4 LOBES
Frontal- motor /controls higher intellectual function, awareness of self, and autonomic responses related to emotions. Parietal- sensory Temporal-auditory (Wernickes); Contains the interpretative area where auditory, visual and somatic input are integrated into thought and memory Occipital-visual

Structure of the Brain

BRAIN-2. Brain Stem

Consist of the midbrain, pons, and medulla oblongata. Midbrain -connects the pons and the cerebellum with the cerebral hemisphere, it contains sensory and motor pathways -center for auditory and visual reflexes Pons -connects the two halves of the cerebrum - involved in the integration of movements in the right and left sides of the body, and the transmission of motor information from the higher brain areas and the spinal cord to the cerebellum. medulla oblongata - involved in the respiration, circulation, gastrointestinal functioning, coughing, sneezing, and swallowing.

BRAIN-3. Cerebellum
Location: base of the brain. Responsible for coordination, balance and posture. Damage to the cerebellum can result in ataxia, a condition characterized by drunken-like movements, severe tremors, and loss of balance.

Structures Protecting the Brain

The brain is contained in the rigid skull, which protects it from injury. The meninges (fibrous connective tissues that cover the brain and the spinal cord) provide protection, support and nourishment to the brain and the spinal cord. Layers of the meninges: 1.dura mater 2.arachnoid 3.pia mater.

CSF
CSF - provide a cushion, provide nutrition,
maintain normal ICP, remove metabolic waste.
Composition colorless, odorless fluid containing glucose, electrolytes, oxygen, water, small amount of carbon monoxide and few leukocytes. Produced in the choroid plexus of the ventricles.

BLOOD SUPPLY TO THE CNS

1/3 of the cardiac output From 2 vertebral artery and one internal carotid arteries Circle of willis

Spinal Cord
Approximately 45 cm long (18 inches) long.

Acts as a passageway for condition of

sensory information from the periphery of the body to the brain (via afferent nerve fibers).
Serve as the connection between the brain and the periphery. Mediates the reflexes.

Spinal Nerves
Spinal nerves 31 pairs 8 cervical, 12 thoracic, 5 lumbar 5 sacral, 1 coccygeal Two roots

Ventral root (motor) Carry impulses from the spinal cord to the muscles Dorsal root (sensory) Carry impulses from sensory receptors to the body of the spinal cord Then to brain for interpretation Initiate a reflex response
Dermatome distribution

Cranial Nerves
12 pairs emerge from the undersurface of the brain. Cranial nerve conducts impulses (motor and sensory information) between the brain and various structures of the head, neck, thoracic cavity and abdominal cavity.
IOlfactory nerve IIOptic nerve IIIOculomotor nerve IVTrochlear nerve VTrigeminal nerve VIAbducens nerve VIIFacial nerve VIIIAcoustic/Vestibulococ hlear IXGlossopharyngeal nerve XVagus nerve XIAccessory nerve XIIHypoglossal nerve

Autonomic Nervous System

Contains motor neurons that regulate visceral organs & innervate ( supply nerves to ) smooth & cardiac muscles & the glands

TWO PARTS OF ANS

1. sympathetic nervous system Controls the fight or flight response 2. parasympathetic nervous systrem Maintains the baseline of the body functions Resposible for the rest & digest response

 the NEURON or NERVE CELL is the nervous systems fundamental unit this highly specialized conductor cell receives and transmits electrochemical nerve impulses delicate, threadlike nerve fibers called AXONS & DENDRITES extend from the cell body & transmit signals Axons carry impulses away from the cell body;dendrites carry impulses to the cell body

Each neuron communicates with each other to a specific target tissue through neurotransmitters These neurotransmitters are produced & stored in the synaptic vesicles;they enable conduction of impulses across the synaptic cleft The action of neurotransmitters is to potentiate, terminate or modulate a specific action & can either excite or inhibit the target cells activity. MAJOR NEUROTRANSMITTERS: 1. Acetycholine 2. Serotonin 3. Dopamine 4. Norepinephrine 5. Gamma-aminobutyric acid (GABA) 6. Enkephalin,endorphin

II. NEUROLOGICAL ASSESSMENTS

NEUROLOGICAL ASSESSMENT
I. Mental Status: Reveals cerebral function (intellectual and affective) Major areas of assessment: a. Language b. Orientation c. Memory d. Attention span e. Calculation Level of consciousness

NEUROLOGICAL ASSESSMENT
A. Language Aphasia inability to express oneself by speech, writing or comprehend spoken or written language due to disease of cerebral cortex Two Categories: 1. Sensory or receptive aphasia 2. Motor or expressive aphasia

NEUROLOGICAL ASSESSMENT
1. Sensory/receptive aphasia - loss of ability to comprehend written or spoken words Two types: a. Auditory aphasia unable to understand symbolic content associated with sounds b. Visual aphasia unable to understand printed or written figures

NEUROLOGICAL ASSESSMENT
2. Motor/ expressive aphasia - loss of power to express oneself by writing, making signs or speaking How to assess language deficits: Point to common objects and name them Read some words and match printed and written words with pictures Respond to verbal/written commands

NEUROLOGICAL ASSESSMENT
Speech Patterns: - pace, clarity, spontaneity Abnormalities: a. Perseveration - repeating the same response as different questions are asked b. Paraphasia - speech appropriately expressed but contains incorrect words

NEUROLOGICAL ASSESSMENT
B. Orientation 3 spheres C. Memory - Listen for lapses of memory - If problems are present: Three categories of memory: 1. Immediate recall N: can repeat series of 5 8 digits in sequence and 4 6 digits in reverse order

NEUROLOGICAL ASSESSMENT
C. Memory 2. Recent memory - Ask to recall the events of the day - Recall information given early in the interview - Provide 3 facts to recall (color, object, address), then ask later

NEUROLOGICAL ASSESSMENT
C. Memory 3. Remote memory - Previous illness or surgery (years ago), birthday, anniversary D. Attention Span - Tests the ability to concentrate (alphabet, count backward from 100)

NEUROLOGICAL ASSESSMENT
E. Calculation - Serial seven or serial three test N: can complete serial seven in 90 seconds with 3 or less errors

Mental status
Utilize the Glasgow Coma Scale An easy method of describing mental status and abnormality detection Tests 3 areas- eye opening, verbal response and motor response Scores are evaluated- range from 3-15 No ZERO score

Glascow Coma Scale

Score BEST response in each category Highest score = 15 (normal) Lowest score = 3 (deep coma)

Eye Opening
Spontaneous To Voice To Pain None
4 3 2 1

Best Verbal
Oriented Confused Inappropriate Words Incomprehensible Sounds None

5
4 3 2 1

Best Motor
Obeys Commands Localizes Pain Withdraws to Pain Flexion to Pain (decorticate) Extension to Pain (decerebrate) None

6 5 4 3 2 1

Altered Level of Consciousness (LOC)

can result from destruction of the brain stem or its reticular formation of ascending nerves, or from other structural, metabolic, or psychogenic disturbances.

Confusion

Impaired ability to think clearly Disturbed ability to perceive, respond to, and remember current stimuli Disorientation Functional in activities of daily living (ADLs)
Motor restlessness Increased disorientation Transient hallucinations Delusions possible Requires some assistance with ADLs

Delirium

Altered Arousal/Level of Consciousness (LOC) cont.

Obtundation Decreased alertness Psychomotor retardation Requires complete assistance with ADLs Arousable but not alert Severe disorientation Little or no spontaneous activity Unarousable Unresponsive to external stimuli or internal needs Determination commonly documented using Glasgow Coma Scale score

Stupor

Coma

Altered Movement
Involves certain neurotransmitters (ex. dopamine) Hyperkinesia- excessive movement Hypokinesia- decreased movement Marked by paresis- partial loss of motor function and muscle power; commonly described as weakness; can result from destruction of upper & lower motor neurons

Cranial Nerve Function

Assess cranial nerve function.

CRANIAL NERVES
Cranial Nerves I II olfactory optic smell vision

III
IV V VI VII VIII IX X XI XII

oculomotor
trochlear trigeminal abducent facial acoustic glossopharynge al vagus accessosy hypoglossal

Most eye movt, pupillary constriction, upper eyelid elevation

Down & in down movt Chewing, corneal reflex, face & scalp sensations Lateral eye movement Expressions in forehead Hearing & balance Swallowing, salivating, taste Swallowing, gag reflex, talking, sensations of the throat, larynx & abdl viscera, activities of thoracic & abdl viscera, e.g. HR, & peristalsis Shoulder movt, head rotation Tongue movt

Cranial Nerve Function: Cranial Nerve 1- Olfactory

Check first for the patency of the nose Instruct to close the eyes Occlude one nostrils at a time Hold familiar substance and asks for the identification Repeat with the other nostrils PROBLEM- ANOSMIA- loss of smell

Cranial Nerve Function: Cranial Nerve 2- Optic

Check the visual acuity with the use of the Snellen chart Check for visual field by confrontation test Check for pupillary reflex- direct and consensual

Snellen chart

Cranial Nerve Function: Cranial Nerve 3, 4 and 6

Assess simultaneously the movement of the extra-ocular muscles Deviations: Opthalmoplegia- inability to move the eye in a direction Diplopia- complaint of double vision

Cranial Nerve Function: Cranial Nerve 5 -trigeminal

Sensory portion- assess for sensation of the facial skin Motor portion- assess the muscles of mastication Assess corneal reflex

Cranial Nerve Function: Cranial Nerve 7 -facial

Sensory portion- prepare salt, sugar, and vinegar. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids

Cranial Nerve Function: Cranial Nerve 8- vestibuloauditory

Test patients hearing acuity Observe for nystagmus and disturbed balance

Cranial Nerve Function: Cranial Nerve 9glossopharyngeal

Together with Cranial nerve 10 vagus Assess for gag reflex Watch the soft palate rising after instructing the client to say AH The posterior one-third of the tongue is supplied by the glossopharyngeal nerve

Cranial Nerve Function: Cranial Nerve 11- accessory

Press down the patients shoulder while he attempts to shrug against resistance

Cranial Nerve Function: Cranial Nerve 12- hypoglossal

Ask patient to protrude the tongue and note for symmetry

3. Motor System Function

Assess muscle size (inspect and palpate) tone, and strength; assess symmetry differences between right and left side; balance and coordination.

Altered Muscle Tone Hypotonia- severely reduced degree of tension or resistance to movement in a muscle Hypertonia- marked increase in a muscle tension and decreased ability of a muscle to stretch

 MUSCLE GRADING
5- Normal -Complete range of motion against gravity with full resistance 4- Good -Complete range of motion against gravity with some resistance 3- Fair -Complete range of motion against gravity 2- Poor -Complete range of motion against gravity eliminated 1- Trace -Evidence of slight contractility. No joint motion. 0- Zero No evidence of contractility

4.Sensory Function
Test for: superficial tactile sensation superficial and deep pressure pain thermal sensitivity sensitivity to vibration point localization.

Reflexes
Evaluate deep and superficial reflexes (biceps, triceps, patellar, ankle reflexes) and abnormal reflexes (Babinskis reflex).

4.Sensory Function
Primary Sensory Functions
Always with the persons eyes closed Vision, hearing, smell, taste and facial sensations

Part to be Assess
Hands Lower arms Abdomen Feet Lower legs

4.Sensory Function
Primary Sensory Functions
Superficial touch
Use a cotton wisp Have the person point to the area touched

Superficial pain
Sharp and dull sensations Allow 2 seconds between each stimulus

Temperature and deep pressure

ONLY TESTED when superficial pain sensation is not intact

4.Sensory Function
Primary Sensory Functions
Vibration
Place stem of tuning fork against bony prominences Begin distally Sites
Sternum Finger wrist elbow - shoulder Toes ankle shin

Position of joints (great toes, one finger on each hand)

Up Down

4.Sensory Function
Cortical Sensory Functions
Always with the persons eyes closed Stereognosis
Ability to identify a familiar object by touch and manipulation
Tactile agnosia: inability to recognize objects

Graphesthesia
With a blunt pen, draw a letter or number on the palm Should be readily recognized

4.Sensory Function
Cortical Sensory Functions
Point location
Touch an area of the body and ask the person to point to where you have touched
This is being tested the same time as superficial touch

Extinction phenomenon
Simultaneously touch one or both sides of the body Ask the person to point to where you have touched

4.Sensory Function
Cortical Sensory Functions
Two-point discrimination
Use two pointed objects, alternate touching skin with one or two points Find the distance at which the person can no longer discriminate 2 points
Fingertips Toes Palms Forearms Upper arms and thighs 2 - 8 mm 3 - 8 mm 8-12 mm 40 mm 75 mm

Proprioception/Cerebellar Function
Proprioception
The sensation of position and muscular activity originating from within the body which provides awareness of posture, movement, and changes in equilibrium

Test
Coordination and Fine Motor Skills Balance

Proprioception/Cerebellar Function
Coordination and Fine Motor Skills
Rapid rhythmic alternating movements
Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed person should be able to do these movements smoothly, maintaining rhythm, with increasing speed Observe for slow, stiff, non-rhythmic, or jerky movements

Proprioception/Cerebellar Function
Coordination and Fine Motor Skills
Accuracy of movement
Finger-to-finger test with persons eyes open
Movements should be rapid, smooth, and accurate Consistent past pointing may indicate cerebellar impairment

Finger to nose test with persons eyes closed

Movement should be smooth, accurate, and rapid

Heel-to-shin with person supine, sitting, or standing

Should move heel from knee up and down the shin in a straight line, without irregular deviations to the side

Proprioception/Cerebellar Function
Coordination and Fine Motor Skills
Balance: Equilibrium
Romberg test
Have person stand with arms at side and feet together Have person perform initially with eyes open and then with eyes closed Stand close to prevent falls person should maintain position with eyes open or closed for 20 seconds with only minimal swaying If the Romberg is positive (i.e. there is significant swaying or the person has to take a step to maintain/regain balance) DO NOT DO OTHER TESTS OF BALANCE

III.DIAGNOSTIC TEST

DIAGNOSTIC TESTS
EEG - Graphic record of the electrical activity generated in the brain.

EEG is a useful test for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome.

Nursing implication:
Withhold medications that may interfere with the resultsanticonvulsants, sedatives and stimulants Wash hair thoroughly before procedure Explain the procedure, assure the client he/she will not receive electrical shock. The nurse needs to check doctors order regarding the administration of antiseizure medication prior to testing. Withhold tranquillizer and stimulants for 24 to 48 hours. Inform the client that the standard EEG takes 45 to 60 minutes and 12 hours for sleep EEG.

DIAGNOSTIC TESTS
CT scan
Visualize

sections of the spinal cord as well as intracranial contents The injection of a water-soluble iodinated contrast into the subarachnoid space through lumbar puncture helps noninvasive and painless has a high degree of sensitivity for detecting lesions. Use of xray beams cross section Use : to identify intracranial tumor, hemorrhage, cerebral atrophy, calcification, edema, infarction, congenital abnormality.

With radiation risk If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected

DIAGNOSTIC TESTS
MRI Uses magnetic waves Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure

DIAGNOSTIC TESTS
Cerebral arteriography
Is

an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery (femoral) Visualize aneurysm

Nursing consideration
Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site

DIAGNOSTIC TESTS
Lumbar Puncture
is a procedure to collect cerebrospinal fluid to check for the presence of disease or injury. A spinal needle is inserted, usually between the 3rd and 4th lumbar vertebrae in the lower spine. Once the needle is properly positioned in the subarachnoid space (the space between the spinal cord and its covering, the meninges), pressures can be measured and fluid can be collected for testing.

DIAGNOSTIC TESTS

Lumbar puncture
Nursing considerations
Ensure consent, determine ability to lie still Contraindicated in patients with increased ICP Keep flat on bed after procedure Increase fluid intake after procedure

Tapos na PO