University of Santo Tomas College of Nursing

Assessment of Neurologic System

Anatomy and Physiology

Nervous System

Central Nervous System (Brain and Spinal Cord)

Peripheral Nervous System (Cranial and Spinal Nerves)

Somatic (Voluntary)

Autonomic (Involuntary)

Sympathetic Nervous System

Parasympathetic Nervous System

Neurons

Neuroglia

Neurotransmitters
Acetylcholine Serotonin Dopamine Major areas of the brain; autonomic nervous system Brain stem, hypothalamus, dorsal horn of spinal cord Substantia nigra and basal ganglia Brain stem, hypothalamus Spinal cord, cerebellum, basal ganglia Nerve terminals in the spine, brain stem, thalamus, pituitary gland Usually excitatory Inhibitory; helps control mood and sleep Usually inhibitory; affects behavior and fine motor Usually excitatory Inhibitory; muscle and nerve transmission Excitatory; pleasurable sensation; inhibits pain transmission

Norepinephrine Gammaaminobutyric acid (GABA) Enkephalin, Endorphin

CENTRAL NERVOUS SYSTEM

Brain

Brain

It is approx. 2% of the total body weight It weighs approx. 1400 g in an average young adult In weighs an average of 1200 g in the elderly It is divided into three major areas: cerebrum, brain stem and the cerebellum

Cerebrum

Cerebrum

It consists of two hemispheres that are incompletely separated by the great longitudinal fissure It is separated into right and left hemispheres by sulcus It is joined at the lower portion by corpus callosum It has wrinkled appearance due to presence of folded layers or convolutions called gyri It has an external of outer portion made up of gray matter approx. 2 to 5 mm in depth and is made up of billions of neurons and cell bodies It has an innermost layer made up of white

Four Lobes of the Cerebrum

Frontal Lobe Largest lobe Controls concentration, abstract thought, information storage or memory, and motor function Contains Brocas area, a speech association area that participates in word formation Responsible for large part of individuals affect, judgment, personality and inhibitions

Parietal Lobe Predominantly a sensory lobe Contains primary sensory cortex, which analyzes sensory information and relays the interpretation of this information to the thalamus and other cortical areas Controls awareness of the body in space, orientation in space and spatial relations

Temporal Lobe Contains auditory receptive areas Contains a vital area called interpretative area, which provides integration of somatization, visual and auditory areas

Occipital Lobe Contains visual areas, which important role in visual interpretation

play

Other Areas of Cerebrum

Corpus Callosum Thick collection of nerve fibers that connects the two hemispheres of the brain and is responsible for the transmission of information from one side of the brain to the other Information transferred is sensory, memory and learned discrimination

Basal Ganglia Masses of nuclie located deep in the cerebral hemispheres Responsible for motor control of fine body movements

Thalamus Lies on either side of the third ventricle Acts primarily as a relay station for all sensation except smell All memory, sensation and pain impulses pass through this section

Hypothalamus Located anterior and inferior to the thalamus It includes the optic chiasm and mamillary bodies Plays a role in the regulation of pituitary secretion of hormones that influence metabolism, reproduction, stress response and urine production Called as hunger and satiety centers Regulates sleep-wake cycle, blood pressure, aggressive and sexual behaviors, and emotional responses

Pituitary Gland Located at the sella turcica at the base of the brain Divided into anterior and posterior sections which secrete hormones necessary in maintaining life

Brain Stem

Brain Stem

Contains the midbrain, pons and medulla oblongata The midbrain contains sensory and motor pathways and serves as the center for auditory and visual reflexes The pons contains motor and sensory pathways, and controls the heart, respiration and blood pressure The medulla oblongata transmits both sensory and motor fibers, and is the bodys respiratory center

Cerebellum

Cerebellum

Separated from the cerebral hemispheres by a fold of dura matter, the tentorium cerebelli Has both excitatory and inhibitory actions and is largely responsible for coordination of movement Controls fine movement, balance, position sense and integration of sensory input

Structures Protecting the Brain

Meninges Fibrous connective tissues that cover the brain and spinal cord Provides protection, support and nourishment to the brain and spinal cord Composed of dura mater, arachnoid and pia mater

Dura mater Outermost layer Tough, thick, inelastic, fibrous and gray in color Has four extensions: falx cerebri, tentorium, falx cerebelli and diaphragma sellae

Arachnoid Middle membrane Extremely thin, delicate membrane which resembles a spider web Appears white because of absence of blood supply Contains the choroid plexus, which produces the cerebrospinal fluid (CSF) Contains arachnoid villi, which absorb CSF

Pia mater Innermost membrane Thin, transparent layer that hugs the brain closely and extends into every fold of the brains surface

Cerebrospinal Fluid (CSF)

Clear and colorless fluid with a specific gravity of 1.007 Cushions and nourishes the brain Produced in the ventricles and is circulated around the brain and the spinal cord by the ventricular system The organic and inorganic contents of CSF are similar to those of plasma but differs in concentration Analyzed for presence of protein, glucose, chloride and immunoglobulins Normally contains minimal number of WBCs and no RBCs

Cerebral Circulation

The brain requires 20% of the oxygen of the body The brain requires 65-70% of the glucose in the body The brain requires 1/3 of the cardiac output The brain does not store nutrients and has a high metabolic demand that requires high blood flow The brain lacks additional collateral blood flow, which may result in irreversible damage when blood flow is occluded

Arterial Supply

The arterial blood supply to the brain is provided by two internal carotid arteries and two vertebral arteries At the base of the brain, a ring is formed between the vertebral and internal carotid arterial chains called circle of Willis The arterial anastomosis along the circle of Willis is a frequent site of aneurysms

Clipping of Aneurysm

Craniotomy

Venous Drainage

The veins of the brain reach the brains surface and join larger veins which empty into the dural sinuses Dural sinuses are vascular channels lying within the tough dura mater The network of the sinuses carries venous outflow for the brain and empties into the internal jugular veins, which return the blood into the heart Cerebral veins and sinuses are unique because they dont have valves

Blood-Brain Barrier

Formed by the endothelial cells of the brain capillaries, which form continuous tight junctions, creating a barrier to macro molecules and many compounds All substances entering the CSF must filter through the capillary membranes of the choroid plexus Often altered by trauma, cerebral edema and cerebral hypoxemia

Spinal Cord

Spinal Cord

Serves as a connection between the brain and the periphery Approx. 45 cm (18 in) long and about the thickness of a finger Extends from the foramen magnum at the base of the skull to the lower border of the first lumbar vertebra, where it tapers to a fibrous band conus medullaris Below the second lumbar space are nerve roots that extend beyond the conus, which are called cauda equina Contains gray matter, located at the center, and white matter on its sides

Sensory and Motor Pathways: The Spinal Tract

Fiber bundles with a common function are called tracts There are six (6) ascending tracts conducting sensation such as perception of touch, pressure, vibration, position and passive motion from the same side of the body Ex. Spinocerebellar tracts - conduct sensory impulses from muscle spindles, providing necessary input for coordinated muscle contraction

1.

2.

3.

4.

There are eight (8) ascending tracts, seven of which are engaged in motor function Examples: Corticospinal tracts (2) voluntary muscle activity Vestibulospinal tracts (3) autonomic functions such as sweating, pupil dilation and circulation Corticobulbar tract voluntary head and facial muscle movement Rubrospinal and reticulospinal tracts involuntary muscle movement

Vertebral Column

Surrounds and protects the spinal cord and consists of 7 cervical, 12 thoracic, 5 lumbar and 5 sacral Nerve roots exit from the vertebral column through the intervertebral foramina Separated by disks, except for the first and second cervical, sacral and coccygeal vertebrae Each vertebra has a ventral solid body and a dorsal segment or arch, which is posterior to the body

PERIPHERAL NERVOUS SYSTEM

Cranial Nerves There are 12 pairs of cranial nerves that emerge from the lower surface of the brain and pass through the foramina in the skull Three (3) are entirely sensory ( CN I, II, VIII), five (5) are motor (CN III, IV, VI) and four (4) are mixed (CN V, VII, IX, X) They are numbered in the order in which they arise from the brain

Cranial Nerves
Cranial Nerves I. Olfactory II. Optic Functions Smell Vision Abnormal Findings Anosmia (absence of smell) Papilledema; blurred vision; scotoma; blindness Anisucuria; pinpoint pupils; fixed, dilated pupils Nystagmus

III. Oculomotor

Pupil constriction; elevation of upper lid Eye movement; controls superior oblique

IV. Trochlear

V. Trigeminal

Controls muscles of mastication; sensations for the entire face

Trigeminal neuralgia (Tic douloureux)

VI. Abducens

Eye movements; controls the lateral rectus muscle Controls muscles for facial expression; anterior 2/3 of the tongue

Diplopia; ptosis of the eyelid

VII. Facial

Bells palsy; ageusia (loss of sense of taste) on the anterior 2/3 of the tongue

VIII. Acoustic/ Vestibulocochlear

Cochlear branch permits hearing; vestibular branch helps maintain equilibrium

Tinnitus; vertigo

IX. Glossopharyngeal

Controls muscles of the Loss of gag reflex; throat; taste of posterior drooling of saliva; 1/3 of the tongue dysphagia; dysphonia; posterior third ageusia Controls muscles of the throat; PNS stimulation of thoracic and abdominal organs Controls sternocleidomastoid and trapezius muscles Movement of the tongue Loss of gag reflex; drooling of saliva; dysphagia; dysarthria; bradycardia; increased HCl secretion Inability to rotate the head and move the shoulders Protrusion of the tongue; deviation of the tongue to one side of the mouth

X. Vagus

XI. Spinal Accessory

XII. Hypoglossal

Spinal Nerves Composed of 31 pairs of spinal nerves: 8 cervical; 12 thoracic; 5 lumbar; 5 sacral; and 1 coccygeal The dorsal roots are sensory and transmit impulses from specific areas of the body, known as dermatomes, to the dorsal ganglia The sensory fibers maybe somatic, carrying information about pain, temperature, touch, and position sense (proprioception) from the tendons, joints and body surfaces Fibers can also be visceral, carrying information from the visceral organs

The ventral roots are motor and transmit impulses from the spinal cord to the body These fibers can either be somatic or visceral The visceral fibers include autonomic fibers that control the cardiac muscles and glandular secretions

AUTONOMIC NERVOUS SYSTEM: Sympathetic Nervous System vs. Parasympathetic Nervous System
Structure or Activity
Pupil of the Eye Circulatory System: Rate and force of heart beat Blood Vessels In the heart muscle In skeletal muscle In abdominal viscera and skin Blood pressure Respiratory System: Bronchioles Rate of breathing

PNS
Constricted Decreased Constricted * * Decreased Constricted Decreased

SNS
Dilated Increased Dilated Dilated Constricted Increased Dilated Increased

Structure or Activity Digestive System: Peristalsis Muscular sphincters Secretion of salivary gland Secretions of stomach, intestine and pancreas Conversion of liver glycogen to glucose Genitourinary System: Urinary bladder Muscular walls Sphincters

PNS

SNS

Increased Relaxed Thin, watery Increased *

Decreased Contracted Thick, viscid * Increased

Contracted Relaxed

Relaxed Contracted

Structure or Activity

PNS * * *

SNS Increased Contracted Secretion of catecholamines

Integumentary System: Secretion of sweat Pilomotor muscles

Adrenal Medullae