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Neurologic System Neurologic System ✽ The neurological or nervous system is composed of c. Occipital: center for visual perception and two primary areas: the central nervous system, which integration. includes the brain and the spinal cord, and the peripheral d. Temporal: controls auditory, verbal, visual, nervous system, which includes the entire network of memory, and personality functions. nerves extending from the central nervous system. e. Some functions of the brain occur in more than one lobe. PHYSIOLOGY OF THE 2. Cerebellum: contains more neurons than the rest of the brain combined. It serves to interpret motor and NEUROLOGICAL SYSTEM mental dexterity, as well as sense of balance. Central Nervous System 3. Brain stem: conduit for all information transmission between upper and lower nervous system. Consists The brain and the spinal cord within the vertebral column of pons, midbrain, and medulla. make up the central nervous system (CNS). a. Pons: responsible for alertness; relays sensory A. The brain and the spinal cord are protected by the rigid information between cerebellum and cerebrum. bony structure of the skull and by the vertebral column, b. Midbrain: interprets auditory and visual refl exes. respectively (Figure 15-1). c. Medulla: lower portion of the brain stem. Con- B. Meninges: the protective membranes that cover the trols autonomic functions. brain and are continuous with those of the spinal cord. (1) Respiratory center for changes in rate and 1. Pia mater: covers the surfaces of the brain and the depth of breathing. spinal column. (2) Controls heart rate. 2. Arachnoid: waterproof membrane that encases the (3) Vomiting refl ex center. entire CNS; the subarachnoid space contains the (4) Swallowing refl ex center. cerebrospinal fl uid. 4. Diencephalon: contains thalamus and hypo- 3. Dura mater: a tough membrane that provides pro- thalamus. tection to the brain and spinal cord. C. Cerebrospinal fl uid (CSF) (Figure 15-2). 1. Serves to cushion and protect the brain and spinal cord; the brain literally fl oats in CSF. 2. CSF is clear, colorless, watery fl uid; approximately 100- to 200-ml total volume, with a normal fl uid pressure of 70 to 150 cm of water (average: 125 cm of water pressure). 3. Formation and circulation of CSF: CSF is formed continuously by the choroid plexus located in the ventricles of the brain. It is reabsorbed by the arachnoid villi in the ventricles at the same rate it is formed. D. Brain: The basic brain anatomy consists of the cere- brum, the cerebellum, the brain stem, and the interior structures. 1. Cerebrum: the largest portion of the brain; sepa- rated into hemispheres. Each hemisphere is divided into four lobes: frontal, parietal, occipital, and temporal. a. Frontal: memory, language, personality, and emotions are primarily controlled here; highly vulnerable to traumatic brain injury. FIGURE 15-1 Major divisions of the central nervous system. (From Lewis SL et al: Medical-surgical nursing: assessment and b. Parietal: integrates sensory information and management of clinical problems, ed 7, St. Louis, 2007, Mosby.) interprets spatial relationships. 307 308 CHAPTER 15 Neurological System FIGURE 15-2 Cerebrospinal fluid circulation. Cerebrospinal fluid is produced by choroid plexus in lateral ventricles and flows around brain and spinal cord until it reaches arachnoid villi, from which it is absorbed into venous circulation. Arrows indicate major pathway of cerebrospinal fluid flow.From From Monahan FD et al: Medical-surgical nursing: health and illness perspectives, ed 8, St. Louis, 2007, Mosby. a. Thalamus: receives and relays auditory, sensory, a. Cranial nerves: responsible for a variety of func- and visual signals. tions, from hearing and balance to regulation of b. Hypothalamus: controls body temperature regu- chemoreceptors in the aortic body. lation, sleep/wake cycles, and appetite; regulates b. Spinal nerves: each pair of nerves is numbered the pituitary gland. according to the level of the spinal cord from 5. Limbic system: regulates emotions, drives, and which it originates. appetite. 2. Autonomic nervous system: regulates involuntary E. Spinal cord: a nerve bundle transmitting messages to activity (e.g., cardiovascular, respiratory, metabolic, and from the body. body temperature) (Table 15-1). 1. Extends from medulla to first or second lumbar a. Parasympathetic division: maintains normal vertebra. body functions. 2. Nerves exit and enter the spinal cord at each b. Sympathetic division: prepares the body to meet vertebral body and communicate with specific areas a challenge or an emergency; “fight or flight.” of the body. c. Most of the organs of the body receive innerva- 3. Rings of bony vertebrae surround and protect cord tion from both the parasympathetic and the sym- and nerve roots. pathetic divisions. 4. Intervertebral disks cushion and provide flexibility to the spinal column. System Data Collection Peripheral Nervous System (PNS) A. History. The PNS consists of sensory and motor neurons. The PNS is 1. Neurological history. subdivided into the sensory/somatic nervous system and the 2. Medical history. autonomic nervous system. a. Chronic, concurrent medical problems. A. Types of nerves. b. Medications (especially tranquilizers, sedatives, 1. Sensory (afferent or ascending) nerves relay sensa- and narcotics). tions to the brain for response. c. If client is an infant or young child, a pregnancy 2. Motor components of cranial nerves (efferent or de- and delivery history of the mother is obtained. scending) send messages from the brain d. Sequence of growth and development. to muscles, glands, and specialized tissues (e.g., 3. Family history: presence of hereditary or congenital heart and lungs). problems. B. Functions of PNS: both sensory/somatic and autonomic 4. Personal history: activities of daily living; any responsibilities. change in routine. 1. Sensory/somatic nervous system consists of cranial 5. History and symptoms of current problem. nerves and spinal nerves. a. Paralysis or paresthesia. CHAPTER 15 Neurological System 309 TABLE 15-1 AUTONOMIC NERVOUS SYSTEM AREA AFFECTED SYMPATHETIC (FIGHT OR FLIGHT) PARASYMPATHETIC Pupil Dilates Constricts Bronchi Dilates Constricts Heart Increases rate Decreases rate Gastrointestinal Inhibits peristalsis Stimulates peristalsis Stimulates sphincter Inhibits sphincters Bladder Relaxes bladder Contracts bladder muscle muscle Constricts sphincter Relaxes sphincter TABLE b. 15- Syncope, dizziness.2 GLASGOW COMA SCALE 2. Mental status (must take into consideration the c. Headache. client’s age, culture, and educational background) CATE GORY d. Speech problems.APPROPRIATE RESPONSE (Box 15-1, Box 15-2). SCORE e. Visual problems. a. General appearance and behavior. OF RESPONSE STIMULUS f. Changes in personality. b. Level of consciousness. Eyes open g. Memory loss.Approach bedside Spontaneous response (1) Oriented to person, place, and time. 4 h. Nausea, vomiting. (2) Appropriate response to verbal and tactile Verbal command Opening of eyes to name or command 3 B. Physical assessment. stimuli. 1. General observation of client.Pain Lack of opening of eyes (3) to previous Memory, problem-solving abilities.stimuli but opening 2 a. Posture, gait. to pain c. Mood. b. Position of rest for the infant or young child. d. Thought content and intellectual capacity. c. Personal hygiene, grooming. Lack of opening of eyes e. Judgment and abstract thinking.to any stimulus 1 d. Evaluate speech and ability to communicate. f. Perceptual distortion. (1) Pace of speech: rapid, slow, halting. Untestable 3. Assess pupillary status and eye movements. U (2) Clarity: slurred or distinct. a. Size of pupils should be equal. Best verbal response Verbal questioning with maximum Appropriate orientation, conversant, correct identifica- 5 (3) Tone: high pitched, rough.arousal tion of self, place, year b. , and Reaction of pupils. month (4) Vocabulary: appropriate choice of words. (1) Direct light refl ex: constriction of pupil e. Facial features may suggest specifi c syndromes Confusion; conversant, but disorientated when light is shown directly into eye.in one or more 4 in children. spheres (2) Accommodation: pupillary constriction to accommodate near vision. BOX 15-1 OLDER ADULT CARE FOCUS Inappropriate or disorganized c. BOX Evaluate eye movements. 15-2use of wordsOLDER ADULT 3CARE FOCUS (e.g., curs ing), lack of sustained (1) Note nystagmus: fi ne, jerking eye move- conversation Assessing Neurologic Function Causes of Confusion in the Older Adult Client ment. in Older Adults Incomprehensible words, Decreased (2) sounds Ability of eyes to move together.(e.g., Cardiacmoaning) Output 2 • (3) Myocardial Resting position should be at mid-position infarction Signs of Cognitive Impairment Lack of sound, even with painful stimuli 1 • Dysrhythmias of the eye socket. • Significant memory loss (person, place, and time). • Congestive heart failure • Person: Does client know who he or she is, and can client Untestable d. PERRLA: Indicates that Pupils are UEqual, give you his or her full name? Hypoxia/RespiratoryRound, and Reactive to AcidosisLight, and that Accom- Best• Place:motor Canresponse client identifyVerbal hiscommand or her home(e.g., address“raise your and Obedience in response • to command modation is present. Pneumonia 6 where he or she is now?arm, hold up two fingers.” 4. Evaluate motor function.• Infection • Time: What was the most recent holiday; what month, a. • Assess face and upper extremities for equality of Hypoventilation time of day, day of thePain week(pressure
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