TWO MAIN BRANCHES of NEUROLOGICAL SYSTEM

CNS (CENTRAL NERVOUS SYSTEM)

PNS (PERIPHERAL NERVOUS     SYSTEM)

CNS (CENTRAL NERVOUS SYSTEM)

CNS (CENTRAL NERVOUS SYSTEM)

function

RECEIVES, INTERPRETS & RESPONDS TO DATA

REASONING, ABSTRACT THOUGHT, EMOTION

DOES NOT REGENERATE   

PNS (PERIPHERAL NERVOUS     SYSTEM)

CONSISTS OF

CRANIAL NERVES – 12 PAIRS

                                 SPINAL NERVES – 31 PAIRS

AUTONOMIC NERVOUS SYSTEM

PNS 

FUNCTIONS

–ENABLES CNS TO INTERACT WITH BODY

nMAY REGENERATE IF DAMAGE NOT TOO CLOSE TO SPINAL CORD OR TOO SEVERE    

THE NEUROLOGICAL SYSTEM

BASIC FUNCTIONAL UNIT

CONDUCT IMPULSES AWAY FROM THE CNS

THE NEUROLOGICAL SYSTEM

nSITE OF METABOLIC ACTIVITIES

nFORMS GRAY MATTER IN THE CNS

nFORMS GANGLIA OUTSIDE THE CNS

nCONDUCT IMPULSES AWAY FROM CELL BODY

NERVE IMPULSE  TRANSMISSION

IMPULSE TRAVELS FROM ONE NEURON TO ANOTHER VIA THE SYNAPSE

NEUROTRANSMITTERS

CHEMICALS WHICH ENABLE IMPULSES TO CROSS SYNAPSE

EXCITATORY – ENABLE TRANSMISSION (DOPAMINE, SEROTONIN ACETYLCHOLINE)

INHIBITORY – INHIBIT TRANSMISSION (GAMMA-AMINOBUTYRIC ACID = GABA)

WHERE THE IMPULSE MOVES FROM THE NERVE TO THE MUSCLE

a neurotransmitter released at the nerve endings of parasympathetic nerve fibers, at some nerve endings in the sympathetic nervous system, and at nerve endings of skeletal muscles.

IMBALANCE = NEUROMUSCULAR DISORDER

NOT ENOUGH = NO ACTION POTENTIAL

TOO MUCH = MUSCLE FATIGUE

nFOUND IN NMJ -- INACTIVATES ACETYLCHOLINE TO RETURN THE MUSCLE TO ITS RESTING STATE

IMBALANCE = NEUROMUSCULAR DISORDER

–NOT ENOUGH = MUSCLE FATIGUE

–TOO MUCH = NO ACTION POTENTIAL

THE NEUROLOGICAL SYSTEM

PROTECTIVE STRUCTURES

BONE, SKULL, VERTEBRAE (33)

VERTEBRAE (33)

–CERVICAL – 7–THORACIC – 12–LUMBAR – 5–SACRAL – 5 [FUSED], COCCYX 4 – [FUSED]

MENINGES

DURA MATER -- “TOUGH MOTHER Fucker!!!!”

nOUTERMOST COVERING (NEXT TO THE BONE)

nHAS RICH BLOOD SUPPLY

nFOLDS OVER ON ITSELF CREATING FISSURES WHERE THE VENOUS SINUSES ARE LOCATED

MIDDLE LAYER

DELICATE (SPIDER WEB-LIKE), VASCULAR

‘GENTLE MOTHER’

MOST DELICATE LAYER, 

ADHERES CLOSELY TO THE SURFACE OF THE BRAIN & SPINAL CORD

CEREBROSPINAL FLUID (CSF)

PROVIDES CUSHIONING FROM SUDDEN OR ABRUPT MOVEMENT TO CNS

 CONSTANTLY FORMED IN CHOROID PLEXIS OF LATERAL VENTRICLES

 CIRCULATES THROUGH THE SUBARACHNOID SPACE

 CONSTANTLY REABSORBED INTO VENOUS SINUSES VIA ARACHNOID VILLI

DIRECT PATHWAY TO ELIMINATE WASTE PRODUCTS

NEUROLOGICAL  ASSESSMENT

 I    

  OLFACTORY

ASSESSMENT TECHNIQUE-Ask client to occlude each nostril separately and close the eyes. Present familiar odors, such as vinegar, lemon, coffee, and ammonia.

norm-Client identifies odors correctly.

NEUROLOGICAL  ASSESSMENT

II

OPTIC

ASSESSMENT TECHNIQUE- Help client cover each eye separately; test visual acuity using a Snellen. 

Client and examiner cover an eye, and examiner moves an object from the periphery toward client's nose from superior, inferior, medial, and lat¬ eral positions while both fix their gaze straight ahead. Examiner then tests opposite eye. Inspect optic nerve with an ophthalmoscope.

norm-Client names letters or reads words accurately. 

Client and examiner see object at the same time in the visual field. Optic nerve appears round and lighter than surrounding retina.

NEUROLOGICAL  ASSESSMENT

III

OCCULOMOTOR

ASSESSMENT TECHNIQUE-In a darkened room, shine a bright light in each pupil; ask client to look at a near and far object Ask client to follow an object you move in horizontal, vertical, and oblique directions

norm- Pupil constricts briskly in response to light and dilates when looking far away. Eye movement is coordinated in all directions. 

NEUROLOGICAL  ASSESSMENT

IV

TROCHLEAR      

ASSESSMENT TECHNIQUE-See assessment for motor function of oculomotor nerve.

norm-Eyes move interiorly and medially.                                

NEUROLOGICAL  ASSESSMENT

V

TRIGEMINAL

ASSESSMENT TECHNIQUE-Observe for jaw symmetry while client opens mouth. 

Instruct client to clamp jaws tightly together. Stroke forehead, cheeks, and jaw with a wisp of cotton, sharp object (e.g., pin), cold and warm objects, and a vibrating tuning fork. 

Touch each cornea with a wisp of cotton. 

Tap center of chin with a reflex hammer while client slightly opens the mouth.

norm-Appearance is symmetric. 

The muscles contract bilaterally. Client shows bilateral sensitivity and correctly identifies sensory experience. 

Client blinks. 

Jaw closes suddenly and slightly.

NEUROLOGICAL  ASSESSMENT

VI

ABDUCENS

ASSESSMENT-See assessment for motor function of oculomotor

norm-Client moves eyes in lateral directions.

NEUROLOGICAL  ASSESSMENT

VII

FACIAL

ASSESSMENT TECHNIQUE-Ask client to wrinkle the forehead, smile, frown, raise eyebrows, look at ceiling, and whistle. 

Instruct client to close eyelids and resist examiner's efforts to open them. 

Apply sweet, sour, salty, and bitter flavors to both sides ofthe anterior tongue.

norm-Facial movements are symmetrical. 

Both eyes equally resist efforts to open them. 

Client accurately identifies tastes.

NEUROLOGICAL  ASSESSMENT

VIII

ACOUSTIC (AUDITORY, VESTIBULOCOCHLEAR)

ASSESSMENT TECHNIQUE-Test hearing acuity and perform the Rinne and Weber tests with a tuning fork. Have client stand with both feet close together; note for swaying with eyes open and

then shut.

norm-Client repeats whispered words correctly; sound is lateralized equally and heard longer by air than by bone conduction. Client maintains balance or sways slightly.

NEUROLOGICAL  ASSESSMENT

IX

GLOSSOPHARYNGEAL

ASSESSMENT TECHNIQUE-Touch palate with a tongue blade. 

Ask client to say "ah."

norm-Blade elicits a gag response. 

Uvula remains in midline.

NEUROLOGICAL  ASSESSMENT

X

VAGUS

ASSESSMENT TECHNIQUE-Have client say "la, la, la."

norm-Client speaks clearly and distinctly, with no hoarseness.

NEUROLOGICAL  ASSESSMENT

XI

ACCESSORY (SPINAL)

ASSESSMENT TECHNIQUE-Instruct client to shrug the shoulders as you apply resistance.

norm-Client raises shoulders.

NEUROLOGICAL  ASSESSMENT

XII

HYPOGLOSSA

ASSESSMENT TECHNIQUE-Tell client to stick out the tongue.

norm-Tongue remains in midline with no lateral deviation.

NEURO ASSESSMENT

n   OBJECTIVE DATA

 GENERAL APPEARANCE, POSITION & POSTURE

MOVEMENT OR NONMOVEMENT OF ALL EXTREMITIES & FACE

SENSATION – SHARP & DULL – FACE, ARMS, LEGS

SWALLOW INTACT?, GAG WHEN SUCTIONED? -- (#9-GLOSSOPHARYNGEAL)

SPEECH PATTERN–      APHASIA -- EXPRESSIVE, RECEPTIVE, GLOBAL (BOTH)

BEHAVIOR/MENTAL STATUS

  INTELLECT – SERIAL 7'S; SPELL “WORLD” BACKWARD

assess

MEMORY

n   TELL THEM 3 OBJECTS TO REMEMBER

n   SHORT TERM

n   LONG TERM (SEVERAL MIN. LATER)

NEURO ASSESSMENT

n   GLASCOW COMA SCALE

   EYE OPENING- SPONTANEOUSLY (4), n  TO SPEECH (3)n  TO PAIN (2)n  NO OPENING (1)

n   BEST VERBAL RESPONSEn  ORIENTED (5)n  CONFUSED (4)n  INAPPROPRIATE WORDS (3)n  INCOMPREHENSIBLE (2)n  NO RESPONSE (1)

n   BEST MOTOR RESPONSEn  OBEYS COMMANDS (6)n  LOCALIZES PAIN (5)n  FLEXION WITHDRAWL TO PAIN (4)n  ABNORMAL FLEXION (3)n  EXTENSION TO PAIN (2)n  NONE (1)

n   SCORES 3-15n   < 10 = EMERGENT SITUATION

n   SCORE < 7 = COMA

DECORTICATE (FLEXOR)

INDICATES CEREBRAL DYSFUNCTION–      SPINE RIGID–      ARMS ADDUCTED & FLEXED, LEGS EXTENDED & PLANTAR FLEXED

n   DECEREBRATE (EXTENSOR POSTURING)

n  INDICATES BRAINSTEM DYSFUNCTION

–      SPINE RIGID , POSSIBLY OPOSTOTONUS

–      ARMS EXTENDED & INTERNALLY ROTATED

n   BABINSKI (PLANTAR) 

if present in adult = brain dysfunction

adult refelxes should protect the foot not flare

n   PAINFUL STIMULATION

TRAPEZIOUS PINCH, INNER ARM PINCH, FINGERNAIL PINCH

NEURO ASSESSMENT

n   MAINTAIN HEAD & NECK IMMOBILIZATION UNTIL CERVICAL SPINE X-RAY READ BY MD & “NECK CLEARED”

n   CHECK SCALP FOR WOUNDS & BLEEDING & SWELLING

n   CHECK EARS & NOSE FOR BLEEDING OR CSF LEAK

n   HOW TO CHECK FOR  CSF LEAK

n   CHECK DRAINAGE FOR GLUCOSE 

n  NEG = NOT CSF

n  POS = CSF OR BLOOD PRESENT

n   IF POS. FOR GLUCOSE CHECK FOR HALO SIGN

n  ALLOW DRAINAGE TO DRIP ONTO 4X4

–      RED CENTER = BLOOD

–      YELLOW RING = CSF

NEURO ASSESSMENT

REPORT 

NEURO ASSESSMENT

PUPIL CHANGES 

NEURO ASSESSMENT

LOC

n   PAY ATTENTION TO LOC

n   LOC WILL CHANGE FIRST

NEURO ASSESSMENT

  VITAL SIGNS

n   AFFECTED BY NEURO DISORDERS

n  SBP INCREASES WITH ­ICP

n  PULSE DECREASES WITH ­ICP

n  TEMP–      CAN BE HIGH & REFRACTORY TO TYLENOL

–      VERY LOW USU. MEANS DEATH SOON

n   CT (CAT) [COMPUTERIZED AXIAL TOMOGRAPHY

 ID, EVALUATE, DIFFERENTIATE & F/U  ABNORMALITIES OF    CRANIAL STRUCTURES  GOOD  FOR VASCULAR LESIONS, SMALL LESIONS, TO SHARPLY DEFINE LESION BORDERS.  MAY BE UNENHANCED, ENHENCED (USE IV DYE), OR BOTH–      UNENHANCED DONE 1^ST

CAT sacn

 NURSING roll

–      TELL PT. HE MUST LIE STILL

–      ASSESS SHELLFISH/ IODINE ALLERGY

–      MAY NEED WRITTEN CONSENT IF ENHANCED    

n   MRI (MAGNETIC RESONANCE IMAGING)

n   USES A MAGNET & RADIOFREQUENCY SIGNALS & COMPUTER MAKES A PICTURE

CAN REVEAL SUBTLE CHANGES IN SOFT TISSUES IE BRAIN, SPINAL CORD, BLOOD VESSELS

n  PT. MUST LIE STILL–      EARPLUGS & MAY NEED SEDATION

  NO METAL IN ROOM

n  FACILITY CHECK LIST FOR PACER, VALVES, NEW STENTS, AICD, HARDWARE, ETC.   

PET SCAN (POSITRON EMISSION TOMOGRAPHY)

n   SHOWS METABOLIC FUNCTION

n   CAN COMBINE WITH MRI & HAVE COMPUTER GENERATED 3D PICTURE 

   LP (LUMBAR PUNCTURE)

n   USES

n  MEASURE CSF PRESSURE (80-180 MM H2O)

–      OPENING – AT BEGINNING; CLOSING – AT END

   DX. MENINGITIS, SUBARACHNOID HEMMORHAGE, GUILLIAN BARRE’

n  CHECK FOR GLUCOSE, PROTEIN, CELLS, C&S

–      SPINAL ANESTHESIA (NOT EPIDURAL)

–      ANTIBX (NEED TO GIVE DIRECTLY INTO CSF R/T BLOOD BRAIN BARRIER WON’T LET MANY MEDS ACROSS)

n   CONTRAINDICATED IN ­ICP

n   MD INSERTS NEEDLE BETWEEN L3-L4 OR L4-L5  

n   OBTAIN SUPPLIES (USU.DISPOSABLE TRAY ON SUPPLY CART OR FROM MATERIAL SUPPLY)

n   OBTAIN INFORMED CONSENT

n   MAINTAIN PT. POSITIONn  MUST BE STILL

n  PREFERRED – SIDELYING WITH KNEES DRAWN UP & CHIN ON CHEST

n  SUPPORT PT. THROUGHOUT PROCEDURE 

 NOTE ORDER THEY WERE COLLECTED IN &

LABEL IF CONTAINERS NOT ALREADYLABELED (#1, #2, #3)

n  KEEP STERILE FOR C&S

LP- 

n   POST CARE

n   LIE FLAT X 6-8 HRS AFTER

n   CHECK VITAL SIGNS & NEURO’s & COMPARE TO BASELINE (Q2H THEN Q4H X 24 HRS.)

n   PUSH PO FLUIDS TO PREVENT HA

n   MONITOR FOR COMPLICATIONS- INFECTION-  NERVE DAMAGE- HEADACHE (MOST COMMON

n   10% PT. GET IT R/T CSF LEAKAGE AT SITE & TRACTION ON MENINGES

n   LASTS HOURS TO DAYS, MILD TO SEVERE, HARMLESS BUT REALLY MISERABLE, THROBBING FRONTAL OR OCCIPITAL, AGGRAVATED BY SITTING OR STANDING

n   TREATMENT: BEDREST IN DARK, QUIET ROOM, NARCOTIC ANALGESICS IE CODIENE, BLOOD PATCH

n   EMG (ELECTROMYOGRAPHY)

n   STUDIES ELECTRICAL POTENTIAL OF MUSCLES & THE NERVES SUPPLYING THEM

n   USES NEEDLE ELECTRODES PLACED INTO SKELETAL MUSCLES & GRAPH IS MADE (LIKE AN EKG FOR SKELETAL MUSCLE)

n   USED TO DX. NEUROMUSCULAR DISEASES IE MYASTHENIA GRAVIS 

n   CEREBRAL ANGIOGRAM

n   NURSING CARE-PRE-PROCEDURE

–      OBTAIN INFORMED CONSENT & ASSESS  FOR IODINE/SHELLFISH ALLERGY

–      NPO X 8 HRS.

–      GET BASELINE VITAL & NEURO SIGNS

–      HAVE PT. VOID BEFORE & REMOVE JEWELRY  

CEREBRAL ANGIOGRAM

n   NURSING CARE- POST PROCEDURE

n   SITE CARE SAME AS CORONARY ANGIOS BUT FOCUS ON NEURO

n   PUSH PO FLUIDS TO CLEAR DYE

n   OBSERVE FOR COMPLICATIONS (MAY BE MANIFESTED AS BEHAVIOR, MOTOR, SENSORY, OR LANGUAGE DYSFUNCTION)

n  DYE ALLERGY

–      DYSPNEA, ITCHING, RASH

n  VASOSPASM, THROMBOSIS, HEMORRHAGE, HEMATOMA, EMBOLISM, CVA, RENAL FAILURE 

 EEG (ELECTROENCEPHALOGRAM)

n   MEASURES ELECTRICAL IMPULSES OF THE BRAIN

n  PT. CAN HAVE SEIZURES WITHIN THE BRAIN THAT WE CAN’T SEE

n   NEEDLES OR STICKY ELECTORODES PLACED ON UNSHAVEN SCALP

n   USED IN DX.

n  SEIZURES, BRAIN TUMORS, HA, SLEEP DISORDERS, HEAD INJURY, CONFIRM BRAIN DEATH

n   REST (BASELINE)

n   HYPERVENTILATE

n   PHOTIC (MAY CAUSE SZ.)

n   SLEEP (MAY SEDATE)

n  MAY ALSO DO SLEEP DEPRIVED

n   INSTRUCT PT.

n  PAINLESS, NONINVASIVE, DOESN’T PUT ELECTRICITY IN BRAIN, CAN’T READ THOUGHTS

n  ASK MD WHETHER TO HOLD ANTICONVULSANTS R/T THEY MASK SEIZURE ACTIVITY

–      IF HELD GIVE MEDS IMMEDIATELY AFTER

n  HOLD STIMULANTS IE COFFEE, TEA R/T THEY INFLUENCE IMPULSES 

n   ULTRASOUND OF CAROTID ARTERIES

n   SHOWS BLOOD FLOW & VISUALIZES VESSELS

n   STENOSIS, OCCLUSIONS WHICH WILL LEAD TO CVA

n   NONINVASIVE, PAINLESS, NO PRE OR POST CARE