Transcript Neurologic System - Denver School of Nursing

Chapter 15
DSN
Neurologic System
Kevin Dobi, MS, APRN
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Concept Overview
 Intracranial regulation:
 Mechanisms that facilitate or impair neurologic function.
 Interrelationships:
 Brain requires oxygenation.
 Respiratory and cardiovascular systems impacted by
neurologic control.
 Extensions of neurologic function:
 Sensory perception.
 Tactile perception.
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Anatomy and Physiology
 Nervous system controls body functions
through voluntary and autonomic
responses to external and internal stimuli.
 Structural divisions of nervous system are:
Central nervous system (CNS), which
consists of brain and spinal cord
Peripheral nervous system (PNS)
Autonomic nervous system (ANS)
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Anatomy and Physiology:
CNS: Protective Structures
 Skull protects brain.
 Foramen magnum is large oval opening at base of skull in
occipital bone.
Spinal cord extends through from
medulla oblongata.
 Other foramina at base for entrance and exit of paired
cranial nerves and cerebral blood vessels.
 Meninges, three layers between skull and brain:
Dura mater, outer double layer.
Arachnoid, middle meningeal
layer.
Pia mater, inner meningeal layer.
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Anatomy and Physiology:
CNS: Protective Structures
(contd.)
 Between arachnoid and pia mater is
subarachnoid space where
cerebrospinal fluid (CSF) circulates.
 Falx cerebri, a fold of dura mater,
separates two cerebral hemispheres.
 Tentorium cerebelli, another fold of dura
mater, supports temporal and occipital
lobes and separates cerebral
hemispheres from cerebellum.
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Anatomy and Physiology: CNS:
Cerebrospinal Fluid
 CSF is colorless, odorless fluid containing:
 Glucose, electrolytes, oxygen, water, carbon dioxide,
and leukocytes.
 Circulates around brain and spinal cord.
 Provides cushion, maintains normal intracranial pressure,
nutrition, and removes metabolic wastes.
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Anatomy and Physiology: CNS:
Cerebral Ventricular System
 Cerebral ventricular system consists of
four interconnecting ventricles
producing and circulating CSF:
 Two lateral ventricles, one in each hemisphere.
 One ventricle adjacent to thalamus.
 One ventricle adjacent to brainstem.
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Anatomy and Physiology: CNS:
CSF and Cerebral Ventricular System
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 CSF circulates from lateral ventricles
through the interventricular foramen to
third ventricle.
 Through aqueduct of Sylvius to fourth ventricle.
 Into cisterna magna, a small reservoir for CSF.
 To subarachnoid space up around brain and down
around spinal cord.
 Absorbed through arachnoid villi that extend into
subarachnoid space and returned to venous system.
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Anatomy and Physiology:
Brain
 Brain consists of cerebrum, diencephalon,
cerebellum, and brainstem; is composed of:
 Gray matter (cell bodies).
 White matter (myelinated nerve fibers).
 Carotid arteries supply most of blood to
brain, and branch off into posterior cerebral,
middle cerebral, and anterior cerebral
arteries.
 Remaining blood flows through two vertebral arteries and
into posterior and anterior communicating arteries that
supply blood through circle of Willis.
 Blood leaves brain through venous sinuses that empty into
jugular veins.
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Anatomy and Physiology:
Brain – Cerebrum
 Cerebrum is largest part of brain
consisting of two hemispheres, each
divided into four lobes: Frontal lobe,
parietal lobe, temporal lobe, and
occipital lobe.
 Frontal lobe contains primary motor cortex and functions
related to voluntary motor activity.
 Broca’s area is located in left frontal lobe involved in
formulation of words.
 Frontal lobe also controls intellectual function, awareness
of self, personality, and autonomic responses related to
emotion.
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Anatomy and Physiology:
Brain – Cerebrum (contd.)
 Cerebrum:
 Parietal lobe contains primary somesthetic (sensory) cortex that receives
sensory input such as position, touch, shape, and texture of objects.
 Temporal lobe contains primary auditory cortex:
Wernicke’s area located in left temporal lobe,
responsible for comprehension of spoken and
written language.
Also interprets auditory, visual, and somatic
sensory inputs that are stored in thought and
memory.
 Occipital lobe contains primary visual cortex, which receives and interprets
visual information.
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Anatomy and Physiology:
Brain – Diencephalon
 Diencephalon is made up of thalamus,
hypothalamus, epithalamus, and subthalamus.
 Thalamus is relay and integration station from spinal cord to cerebral
cortex and other parts of brain.
 Hypothalamus important in maintaining homeostasis.
Functions include regulation of body
temperature, hunger, and thirst; formation of
autonomic nervous system responses; and
storage and secretion of hormones from
pituitary gland.
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Anatomy and Physiology:
Brain – Diencephalon (contd.)
 Epithalamus contains pineal gland, which causes
sleepiness and helps regulate some endocrine
functions
 Subthalamus is part of extrapyramidal system of
autonomic nervous system and basal ganglia.
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Anatomy and Physiology:
Brain – Basal Ganglia
 Basal ganglia lies between cerebral cortex and
midbrain, adjacent to diencephalon.
 Basal ganglia comprised of six ganglia: Putamen, caudate nucleus,
globus pallidus, thalamus, red nucleus, and substantia nigra.
 Function is balancing production of two neurotransmitters—acetylcholine
and dopamine—that create smooth, coordinated voluntary movement.
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Anatomy and Physiology:
Brain – Brainstem
 Brainstem is made up of midbrain, pons, and
medulla oblongata.
Ten of twelve cranial nerves (CNs)
originate from brainstem.
 Midbrain functions to relay stimuli concerning muscle
movement to other brain structures.
Contains part of motor tract pathways
that control reflex motor movements in
response to visual and auditory stimuli.
Oculomotor nerve (CN III) and
trochlear nerve (CN IV) originate in
midbrain.
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Anatomy and Physiology:
Brain – Brainstem (contd.)
 Brainstem:
 Pons relays impulses to brain centers and lower spinal
nerves.
 CNs that originate in the pons are trigeminal (CN V),
abducens (CN VI), facial (CN VII), and acoustic (CN VIII).
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Anatomy and Physiology:
Brain – Brainstem (contd.)
 Brainstem:
 Medulla oblongata contains reflex centers for controlling
involuntary functions such as breathing, sneezing,
swallowing, coughing, vomiting, and vasoconstriction.
 Motor and sensory tracts from frontal and parietal lobes
cross from one side to other in medulla; lesions on right
side create abnormal movement and sensation on left
side, and vice versa.
 Cranial nerves originating in medulla are
glossopharyngeal (CN IX), vagus (CN X), spinal accessory
(CN XI), and hypoglossal (CN XII).
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Anatomy and Physiology:
Brain – Cerebellum
 Cerebellum separated from cerebral
cortex by tentorium cerebelli.
 Functions of cerebellum include
coordinating movement, equilibrium,
muscle tone, and proprioception.
 Each cerebellar hemisphere controls movement for same
(ipsilateral) side of body.
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Anatomy and Physiology:
Brain – Spinal Cord
 Spinal cord is continuation of medulla
oblongata that begins at foramen
magnum and ends at first and second
lumbar (L1 and L2) vertebrae.
 At L1 and L2, spinal cord branches into lumbar and sacral
nerve roots termed cauda equina.
 Spinal cord consists of 31 segments, each giving rise to a
pair of spinal nerves.
 Nerve fibers, grouped into tracts, run through the spinal
cord transmitting sensory, motor, and autonomic
impulses between brain and body.
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Anatomy and Physiology:
Brain – Spinal Cord (contd.)
 Spinal cord:
 Myelinated nerves form white matter of spinal cord and contain
ascending and descending tracts of nerve fibers.
 Descending or motor tracts carry impulses from frontal lobe to muscles for
voluntary movement and play a role in muscle tone and posture.
 Ascending or sensory tracts carry sensory information from body through
thalamus to parietal lobe.
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Anatomy and Physiology:
Brain – Spinal Cord (contd.)
 Spinal cord:
 Fasciculus gracilis travels within medial lemniscus in posterior (dorsal)
column carrying sensations of touch, deep pressure, vibration, position of
joints, stereognosis, and two-point discrimination.
 Lateral spinothalamic tract carries fibers for sensations of light touch,
pressure, temperature, and pain.
 Gray matter, which contains nerve cell bodies, arranged in a butterfly
shape with anterior and posterior horns.
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Anatomy and Physiology:
Peripheral Nervous System
 12 pairs of cranial nerves:
Five pairs have only motor fibers.
Three pairs have only sensory
fibers.
Four pairs have both motor and
sensory fibers.
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Anatomy and Physiology:
Peripheral Nervous System –
Spinal Nerves
 Spinal nerves, 31 pairs, emerge from spinal cord:
 Cervical nerves: 8 pairs
First 7 exit above their corresponding
vertebrae; remaining pair exit below
corresponding vertebrae.




Thoracic nerves: 12 pairs
Lumbar nerves: 5 pairs
Sacral nerves: 5 pairs
Coccygeal nerves: 1 pair
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Anatomy and Physiology:
Peripheral Nervous System –
Spinal Nerves (contd.)
 Spinal nerve pairs formed by union of efferent or
motor (ventral) root and afferent or sensory
(dorsal) root.
 Motor fibers carry impulses from frontal lobe through spinal cord to
muscles and glands; sensory fibers carry impulses from sensory receptors
of body through spinal cord to parietal lobe.
 Each pair of spinal nerves and its corresponding part of the spinal cord
make up a spinal segment and innervate specific body segments.
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Anatomy and Physiology:
Peripheral Nervous System –
Spinal Nerves (contd.)
 Spinal nerve pairs:
 Dorsal root of each spinal nerve supplies sensory innervation to a specific
area of skin known as a dermatome.
For example, if patient complains of pain with
numbness and tingling across right knee, the
nurse knows that fourth lumbar spinal segment
is involved and perhaps compressed.
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Anatomy and Physiology:
Peripheral Nervous System –
Reflex Arc
 Reflex arcs tested by observing muscle movement
in response to sensory stimuli.
 Deep tendon reflexes are responses to stimulation of tendon that stretches
neuromuscular spindles of muscle group.
Striking a deep tendon stimulates a sensory
neuron that travels to spinal cord where it
stimulates an interneuron, which stimulates a
motor neuron to create movement.
 Superficial reflexes tested similarly.
 Each reflex corresponds to a specific spinal segment.
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Anatomy and Physiology:
Autonomic Nervous System
 Autonomic nervous system (ANS)
regulates body’s internal environment in
conjunction with endocrine system.
ANS has two components:
Sympathetic nervous system
Parasympathetic nervous system
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Anatomy and Physiology:
Autonomic Nervous System –
SNS
 Sympathetic nervous system (SNS) arises
from thoracolumbar segments of spinal
cord and is activated during stress (the
“fight-or-flight” response).
 SNS actions include:




Increasing blood pressure and heart rate.
Vasoconstricting peripheral blood vessels.
Inhibiting gastrointestinal peristalsis.
Dilating bronchi.
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Anatomy and Physiology:
Autonomic Nervous System –
PNS
 Parasympathetic nervous system (PNS)
arises from craniosacral segments of
spinal cord and controls vegetative
function. “Helps out the SNS”
 PNS actions associated with conserving
energy such as:
 Decreasing heart rate and force of myocardial
contraction.
 Decreasing blood pressure and respiration.
 Stimulating gastrointestinal peristalsis.
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General Health History:
Present Health Status
 Have you noticed any changes in ability
to move around or participate in usual
activities?
 Do you have any chronic diseases?
 High blood pressure?
 Myasthenia gravis?
 Multiple sclerosis?
 What medications do you take?
 Are you taking medications as prescribed?
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General Health History:
Past Medical History
 Have you ever had injury to head or
spinal cord?
 What changes have you experienced since injury?
 Have you had surgery on brain, spinal
cord, or nerves?
 Have you ever had a stroke?
 What changes have you had as result of stroke?
 Do you have a seizure disorder?
 How often?
 What do you do to prevent seizures?
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General Health History:
Family History
 In your family, has anyone ever had:
 A stroke?
 Seizures?
 Tumor in brain or spinal cord?
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General Health History:
Personal and
Psychosocial History
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 Have you had changes in your ability to perform
personal care?
 Do you drink alcohol?
 Have you ever used recreational drugs?
 Do you use seat belts?
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Problem-Based History:
Headache
 Describe your headaches.
 What do they feel like?
 Where?
 Last how long?
 How often?
 Have you had any recent surgeries or
medical procedures such as spinal
anesthesia or lumbar puncture?
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Problem-Based History:
Dizziness
 What does it feel like when you are dizzy
or lightheaded?
 Do you feel faint?
 How often do you experience this dizziness?
 What makes dizziness worse?
 Have you ever had a sensation that
room is spinning (objective vertigo), or
that you are spinning (subjective
vertigo)?
 Does this happen suddenly or gradually?
 What makes vertigo worse?
 What relieves vertigo?
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Problem-Based History:
Seizures
 Have you ever had a seizure?




How often are you having seizures?
When was your last seizure?
What are they like?
Do you become unconscious?
 Do you have any warning signs before
the seizure starts?
 How do you feel after the seizure?
 Are you confused?
 Have a headache or aching muscles?
 Do you spend too much time sleeping?
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Problem-Based History:
Seizures (contd.)
 When patient loses consciousness during
seizures, refer these questions to person
who observed patient’s seizure:
 Describe the seizure movements that you observed.
 Did you notice any other signs such as a change in color
of the face or lips?
 Loss of consciousness (if so, how long)?
 Did the patient urinate or have a bowel movement
during the seizure?
 After the seizure, how long did it take the patient to get
back to normal?
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Problem-Based History:
Seizures (contd.)
 Are there any factors that start these
seizures?




Stress?
Fatigue?
Activity?
Do you take actions to prevent hurting yourself during
seizures?
 How have seizures affected your life?
 Your occupation?
 Do you wear any identification that indicates you have
seizures?
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Problem-Based History:
Loss of Consciousness
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 When did you lose consciousness or feel you were
not aware of surroundings?




Did it occur suddenly?
What happened just before?
Other symptoms?
Have diabetes mellitus, liver failure, or kidney failure?
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Problem-Based History:
Changes in Movement
 How long have you had a change in
your mobility?
 Continuous or intermittent?
 Noticed tremors or shaking of hands or
face?
 When did they start?
 Do they seem worse when you are anxious or at rest?
 Are they worse when you focus on doing something
(intention)?
 What relieves tremors—rest, activity, or alcohol?
 Do they affect your performance of daily activities?
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Problem-Based History:
Changes in Movement (contd.)
 Have you felt sense of weakness in or
difficulty moving parts of your body?
 Confined to one area or generalized?
 Associated with anything in particular (e.g., activity)?
 Does anything help to relieve weakness?
 Do you have problems with
coordination?
 Do you have difficulty keeping your balance when you
walk?
 Do you lean to one side or fall?
 Which direction?
 Do your legs suddenly give way?
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Problem-Based History:
Changes in Sensation
 Where are you experiencing numbness
or tingling?
 How does it feel?
 Is it associated with any activity?
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Problem-Based History:
Difficulty Swallowing
(Dysphagia)
 How long have you had problems
swallowing?




Do these problems involve liquids or solids?
Both?
Do you have excessive saliva or drooling?
Do you cough or choke when trying to swallow?
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Problem-Based History: Difficulty
Communicating
(Aphasia/Dysphasia)
 How long have you had problems speaking?
 Difficulty forming words or finding right words? Difficulty understanding
things said to you?
 Has handwriting changed?
 When did that begin?
 How long did it last?
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Physical Examination
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Examination: Routine
Techniques
with Normal Findings
 Assess mental status and level of
consciousness.
 Evaluate speech for articulation and
voice quality and conversation for
comprehension.
 Note cranial nerve functions (data
about expected cranial nerve functions
collected during interview).
 Assessing cranial nerves is not ordinarily performed during
routine examination, but when you suspect an abnormal
finding of one or more of cranial nerves.
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Examination: Routine
Techniques with Normal Findings
(contd.)
 Observe gait for balance and symmetry.
 Evaluate extremities for muscle strength.
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Examination: Special Circumstances and
Advanced Practice
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 Assess individual cranial nerves:
 Test nose for smell (olfactory nerve CN1).
 Test eyes (visual acuity optic nerve CN II) for visual acuity
using Snellen’s chart and an ophthalmoscopic
examination of eyes.
 Test eyes for peripheral vision.
 Observe eyes for extraocular muscle movement;
oculomotor (CN III), trochlear (CN IV), and abducens (CN
VI) nerves are tested together because they control eye
movement.
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Examination: Special Circumstances
and Advanced Practice (contd.)
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 Assess individual cranial nerves:
 Observe eyes for pupillary size, shape, equality, construction,
and accommodation.
 Evaluate face for movement and sensation; evaluate the
trigeminal nerve (CN V) for facial movement and sensation.
Test motor function by having patient
clench his or her teeth, then palpate
temporal and masseter muscles for
muscle mass and strength; there
should be bilaterally strong muscle
contractions.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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
Assess individual cranial nerves:
 Test ears for hearing and balance (CN VIII).
• Whisper test, Weber/Rinne. P.166-8
 Test tongue for taste (CNs VII, IX).
• Sweet, salty (VII); sour, bitter (IX).
• Not done unless problem reported.
 Inspect oropharynx for gag reflex and soft palate
movement (CNs IX, X).
• Touch posterior pharynx with
tongue blade.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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
Assess individual cranial nerves:
 Inspect tongue for movement, symmetry, strength,
absence of tumors (CN XII).
• Have patient protrude tongue,
move toward nose, chin, side to
side.
• Have patient press tongue against
gloved finger.
 Test shoulder and neck muscles for strength and
movement (CN XI).
• Have patient shrug shoulders and
turn head to side against hands.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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 Test cerebellar function for balance and
coordination.
 Tests for balance:
Romberg test (patient standing)—feet
together, arms at side, eyes
open/closed.
Eyes closed, stand on one foot.
Tandem walking.
Hopping on one foot, then other.
Knee bending.
Walking on toes and heels.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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 Test cerebellar function for balance and
coordination:
 Tests for coordination of upper extremity:
Rapid pronation/supination on thighs.
Alternately touching nose with index
fingers (eyes closed).
Touching each finger to thumb in
rapid sequence.
Moving index finger between nose
and examiner finger.
 Tests for coordination of lower extremity:
Heel to shin of opposite leg.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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 Assess peripheral nerves.
 Assess for sensation:
Areas routinely assessed are the hands,
lower arms, abdomen, lower legs, and
feet.
Flex muscles, then resist against opposite
force.
Dermatome map to identify spinal nerve
providing sensation.
Monofilament for peripheral sensation for
peripheral neuropathy.
Light touch with cotton tipped swab.
Vibration using tuning fork on bony
prominence; feel vibration and when it
stops.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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 Assess peripheral nerves
 Assess for sensation:
Kinesthetic sensation by moving finger
and toe up and down.
Stereognosis by identification of
familiar object in hand.
Two-point discrimination by touching
parts of body simultaneously with two
points—how many points felt?
Graphesthesia by identification of
number and letter drawn on hand,
back, other area.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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 Assess peripheral nerves
 Evaluate extremities for deep tendon reflexes:
Muscle contraction response to direct
and indirect percussion of tendon.
Patient relaxed and lying or sitting
down; 4+ scoring system.
Triceps reflex: Contraction of triceps
muscle, extension of elbow.
Biceps reflex: Contraction of biceps
muscle, flexion of elbow.
Brachioradial reflex: Pronation of
forearm, flexion of elbow.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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 Assess peripheral nerves.
 Evaluate for deep tendon reflexes:
 Patellar reflex: Contraction of quadriceps muscles,
extension of lower leg.
 Achilles tendon: Contraction of gastrocnemius
muscle, plantar flexion of toes.
 Plantar: Plantar flexion of toes using end of handle
on reflex hammer, stroke lateral aspect of sole of
foot from heel to ball, curving medially across the
ball of the foot; expected findings should be
plantar flexion of all toes.
 Ankle clonus reflexes if reflexes are hyperactive:
Sharply dorsiflex foot, maintain in flexion; should
be no movement.
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Examination: Special Circumstances and
Advanced Practice (contd.)
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 Evaluate superficial reflexes (little clinical
significance for presence or absence):
 Abdominal reflexes by stroking abdomen away from
umbilicus.
 Cremasteric reflexes (men) by stroking upper, inner thigh;
testicle should rise slightly.
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Additional Assessment for
Special Cases
 Altered level of consciousness (LOC):
 Nurse can determine if the patient is alert and
oriented by the way questions are answered
during interview.
 Change in LOC is earliest and most sensitive
indicator of alterations in cerebral function.
Awareness is higher level function
controlled by reticular activating
system.
Wakefulness is controlled by
brainstem.
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Additional Assessment for
Special Cases (contd.)
 Altered LOC
 Assessing awareness:
Determined by orientation,
memory, attention, calculation,
recall, and language, as well as
judgment, insight, and abstraction.
 Awareness—mental status (orientation, memory,
attention, calculation, recall, language, insight,
abstraction).
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Additional Assessment for
Special Cases (contd.)
 Altered LOC:
 If orientation is a concern during history, determine if oriented
to time, place, and person.
Date and time is first orientation to
disappear.
Only a problem if remains
disoriented after being reoriented.
Place is second orientation to
disappear.
Person is last orientation to disappear.
 Orientation returns in opposite order in which is lost.
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Additional Assessment for
Special Cases (contd.)
 Altered LOC:
 Assessing arousal—modified assessment for unconscious
individual who cannot participate.
When interacting: Assume ability to
hear.
Pupillary reaction: Hold eyelid open when
shining light.
Inspect to observe respiratory pattern.
Cheyne-Stokes is alternating periods of
apnea with hyperventilation
(brainstem compression).
Central neurogenic hyperventilation is
sustained hyperventilation (lesions of
midbrain/pons).
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Additional Assessment for
Special Cases (contd.)
 Altered LOC:
 Assessing arousal—modified assessment for unconscious individual who
cannot participate.
 Smell breath for alcohol.
Pupillary response: CN III oculomotor, which
originates in midbrain.
Small, reactive pupils: Bilateral cerebral
dysfunction.
Bilaterally dilated pupils: Overdose of
hallucinogens or CNS stimulants; pressure in
brainstem compressing CN III bilaterally.
Unilateral fixed and dilated pupil: Pressure on
ipsilateral CN III.
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Additional Assessment for
Special Cases (contd.)
 When patient’s awareness cannot be
assessed because unconscious,
awakening is assessed.
 Glasgow Coma Scale: Assess LOC using 15-point scale.
 Assess for best response to eye opening, motor response,
and verbal response.
 Determine stimulation or pain required to elicit response.
Only time acceptable to inflict
pain on patient.
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Additional Assessment for
Special Cases (contd.)
 Assessing awakening:
 First stimulation is touch, normal voice tone.
 Shake patient on shoulder or leg; shout.
 Painful stimuli begin peripherally, move centrally.
Applied until patient responds in
some way or for at least 15
seconds, but no more than 30
seconds.
 Begin by depressing nail bed at cuticle with your
fingernail or length of pen or pencil.
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Additional Assessment for
Special Cases (contd.)
 Assessing awakening:
 Squeeze trapezius muscle very hard.
 Push upward on supraorbital notch above eye.
 Best motor response describes and
assigns arbitrary number to level of
movement.





5: Localization of pain: Moves to remove stimulus.
4: Attempt to withdraw from stimulus.
3: Abnormal flexion (decorticate).
2: Abnormal extension.
1: No response.
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Additional Assessment for
Special Cases (contd.)
 Meningeal irritation: Assessed when meningitis
suspected
 Kernig’s sign: Flexing one leg at hip and knee,
then extending knee:
No pain indicates negative Kernig’s sign.
If inflammation of meninges, patient
reports pain along vertebral column when
leg is extended.
 Brudzinski’s sign tested with patient supine.
Patient’s neck flexed: Reports no pain or
resistance to neck flexion.
Positive Brudzinski’s sign patient passively
flexes hip and knee in response to head
flexion; reports pain along vertebral
column.
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Age-Related Variations:
Infants, Children, and
Adolescents
 There are several differences in
assessment of system for infants and
young children.
 Infants’ sensation and cranial nerves are assessed by
observation.
 Unique reflexes are assessed in infants.
 Children’s motor development is compared with
standardized tables of normal age and sequences of
motor development.
 Assessment of older children and adolescents follows
same procedures and reveals similar expected findings.
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Age-Related Variations:
Older Adults
 Assessing neurologic system of an older
adult usually follows same procedures as
for younger adults.
 Tests for balance and gait are often
assessed for older adults to identify those
at risk for falls.
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Disorders of the CNS:
Multiple Sclerosis
 Multiple sclerosis:
 Progressive demyelination of nerve fibers of brain and
spinal cord
 Autoimmune disorder initiated by virus attacks on myelin
at various sites of CNS
 Symptoms vary depending on areas of
central nervous system demyelinated:
 Symptoms: Fatigue, depression, paresthesias
 Signs: Clinical findings
 Signs and focal muscle weakness, ocular changes,
bowel, bladder, sexual dysfunction, gait instability,
spasticity
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Disorders of the CNS:
Meningitis
 Meningitis:
 Inflammation of meninges that surround brain and spinal
cord.
 Invasion of bacteria, viruses, fungi, parasites, or other
toxins.
 Bacterial meningitis most common; death results if not
treated promptly.
 Viral meningitis: Self-limiting infection with full recovery.
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Disorders of the CNS:
Meningitis (contd.)
 Clinical findings: Meningitis:
 Symptoms: Severe headache, fever, and generalized
malaise.
 Signs: Stiff neck, and positive Brudzinski’s and Kernig’s
signs.
 LOC may decrease (drowsiness and reduced attention
span), may progress to stupor and coma.
 Confusion, agitation, and irritability may occur.
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Disorders of the CNS:
Encephalitis
 Encephalitis is inflammation of brain tissue and
meninges.
 Caused by bacteria, viruses, fungi, and parasites; viral encephalitis most
common.
 Clinical findings:
 Symptoms depend on invading organism and part of brain involved.
 Onset may be gradual or sudden with symptoms of headache, lethargy,
irritability, nausea, signs of fever, nuchal rigidity, and vomiting.
 May develop decreased consciousness, motor weakness, tremors, seizures,
aphasia, and positive Babinski’s sign over several days.
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Disorders of the CNS:
Spinal Cord Injury
 Spinal cord injury (SCI):
 Any traumatic disruption of spinal cord.
 Vertebral fractures or dislocations—car accidents, sports
injuries, and other violent impacts.
Injury to cervical spinal cord:
Quadriplegia—injury to the thoracic
or lumbar spinal cord—or paraplegia.
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Disorders of the CNS:
SCI (contd.)
 Clinical findings: SCI:
 Symptoms of complete spinal cord transection:
paresthesia or anesthesia.
 Signs: Paralysis below level of injury; loss of bowel and
bladder control.
 SCIs damage upper motor neurons causing spastic
paralysis.
 When injury incomplete, manifestations are variable and
correlates to location and extent of injury.
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Disorders of the CNS:
Head Injury
 Craniocerebral injury (head injury):
 Injury to scalp, skull, brain sufficient to alter normal
function.
 Open-head injuries result from fractures or penetrating
wounds.
 Closed-head injuries result from blunt head injury:
Cerebral concussion, contusion, laceration.
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Disorders of the CNS:
Head Injury (contd.)
 Clinical findings: Craniocerebral injury:
 Depend on severity of trauma and areas of brain
involved (LOC for a few minutes to several weeks)
 May have residual deficits in memory, cognition, and
motor or sensory abilities.
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Disorders of the CNS:
Parkinson’s Disease
 Parkinson’s disease:
 Develops slowly as brain’s dopamine-producing neurons
in substantia nigra of basal ganglia degenerate; second
most common neurodegenerative disease after
Alzheimer’s disease.
 Clinical findings:
 Resting tremor, bradykinesia, and rigidity.
 Other manifestations: Masklike facies, trunk-forward
flexion, muscle weakness, shuffling gait, and finger pillrolling tremor.
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Disorders of the CNS:
Cerebrovascular Accident
 Cerebrovascular accident (CVA, stroke):
When cerebral blood vessels become
occluded by thrombus or embolus, or
when intracranial hemorrhage occurs,
brain tissues become ischemic,
resulting in CVA or stroke.
Hemorrhage can be caused by
hypertension or a cerebral aneurysm
(a weakened area in an artery that
balloons out due to high pressure of
blood).
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CVA
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CVA Warning Signs
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Disorders of the CNS: CVA
(contd.)
 Clinical findings:
 Signs and symptoms directly related to areas
of brain involved and extent of ischemia.
 Sudden unilateral numbness or weakness of
face, arm, or leg.
 Trouble walking, dizziness, or loss of balance.
 Sudden, severe headache with no known
cause.
 May be sudden confusion, difficulty
swallowing (dysphagia), difficulty speaking or
understanding speech (aphasia), or partial
loss of vision.
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Disorders of the CNS:
Alzheimer’s Disease
 Alzheimer’s disease:
 Incurable, degenerative neurologic disorder; begins with
decline in memory.
Most common cause of dementia
in Western countries.
 Cause unknown; theories suggest genetic tendency,
environmental toxins, altered neurotransmitter function,
autoimmune reaction, or slow virus.
 Patients with history of small strokes have tendency to
develop Alzheimer disease; stroke-prevention measures
may reduce risk of developing disease.
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Disorders of the CNS:
Alzheimer’s Disease (contd.)
 Clinical findings: Alzheimer’s disease:
 Three stages of Alzheimer’s disease have been described:
Early stage lasts 2 to 4 years when patient’s
memory begins to fail, such as forgetting
names and misplacing items.
Second stage lasts from 2 to 12 years when
patient experiences progressive memory loss
and has difficulty with activities of daily living;
language skills deteriorate and patient
becomes disoriented and confused.
During final stage, patient requires total care
and is unable to communicate.
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Disorders of Cranial Nerves:
Trigeminal Neuralgia
 Trigeminal neuralgia:
 Trigeminal neuralgia (tic douloureux)—intense
paroxysmal pain (1 or all 3 branches of CN V).
 Etiology is unknown but trauma to face or head or
infection of teeth or jaw are contributing factors.
 Many can identify trigger points: Small areas on cheek,
lip, gum, forehead that initiate pain.
 Clinical findings:
 Abrupt, intense unilateral pain along tissue innervated by
trigeminal nerve; lasts few seconds.
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Disorders of Cranial Nerves:
Bell’s Palsy
 Bell’s palsy:
 Acute unilateral paralysis of facial nerve.
 80% of patients recover fully after few weeks or months.
 Clinical findings:
 History of pain behind ear or face few hours or days
before paralysis.
 Affected side: Eye does not close, forehead does not
wrinkle; patient is unable to whistle or smile.
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Disorders of Peripheral Nerves:
Myasthenia Gravis
 Myasthenia gravis:
 Neuromuscular disease with abnormal weakness of
voluntary muscles; improves with rest and
anticholinesterase drugs.
 Acetylcholine (Ach) receptor sites destroyed, so fewer
receptor sites available to initiate muscle contraction,
muscle weakness.
 Some cases associated with tumors of thymus gland.
 Three types: Ocular (eyes); bulbar (swallowing),
generalized (skeletal muscles).
 Most common in younger women and older men.
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Disorders of Peripheral Nerves:
Myasthenia Gravis (contd.)
 Clinical findings:
 Ocular myasthenia: Weakness of muscles of eye (ptosis
and diplopia).
 Bulbar myasthenia: Aspiration of saliva and fluids
(impaired swallowing).
 Generalized myasthenia: Weakness of face, limbs, trunk,
including muscles of breathing.
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Disorders of Peripheral Nerves:
Guillain-Barré Syndrome
 Guillain-Barré syndrome:
 Widespread demyelinization of nerves of peripheral
nervous system (PNS).
 Motor component of peripheral nerves; believed to be
caused by cell-mediated autoimmune response to viral
infection.
 Respiratory or gastrointestinal viral infection weeks before
onset.
 80% to 90% recover with few or no residual deficits;
however, patients may die if respiratory depression
develops rapidly.
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Disorders of Peripheral Nerves:
Guillain-Barré Syndrome
(contd.)
 Clinical findings:
 Ascending paralysis begins with weakness and
paresthesia in lower extremities, and ascends to upper
extremities and face.
 Descending variation: Facial, glossopharyngeal, vagus,
hypoglossal CNs downward to hand; can reach feet.
 Deep tendon reflexes absent.
 If paralysis of thorax, respiratory depression may result.
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Question 1
A patient suffered a head injury, and the
neurologist notes a deficit in cerebellar function. As
the nurse performs the neurologic assessment,
which finding indicates a deficit in cerebellar
function?
A.
B.
C.
D.
The patient is unable to count by serial sevens in
reverse order.
When doing the heel-shin exercise (patient
supine), the patient’s heel overshoots shin and
oscillates.
The patient is unable to identify a paper clip
(altered stereognosis).
The right patellar deep tendon reflex is
diminished.
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Question 2
Three days after a camping trip, a patient is in the hospital
with a severe headache and photophobia. The nurse
performed a test for Kernig’s sign and documented the
results as negative. What best explains this action?
The Kernig’s sign assesses for level of consciousness. A
negative finding indicates that the patient is alert and
oriented to person, place, and time.
B. The symptoms reported could be a sign of peripheral
nervous system damage.
C. The symptoms reported could be a sign of meningeal
irritation.
D. The Kernig’s sign is a good test of a patient’s ability to
withstand
deep
reflex
assessments.
Copyright
© 2013 by tendon
Mosby, an imprint of Elsevier
Inc.
A.
10
2
The End
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