ASSESSMENT OF:

Central Nervous System (CNS)

• Brain
• Spinal cord

Peripheral Nervous System (PNS)

• Cranial nerves
• Spinal nerves
• Autonomic nervous system

ANATOMIC AND
PHYSIOLOGIC OVERVIEW
Cells of the Nervous System
§ Nerve cell, cell body, nuclei
§ Dendrites – branch-type
structure for receiving
electrochemical messages.
§ Axon – a long projection
that carries electrical
impulses away from the cell
body.
§ Myelin sheath – it increases
the speed of conduction.
ü Neurons are supported, protected and nourished by glial cells,
which are 50 times greater in number than neurons.
Neurons
Ø They conduct impulses that enable the
body to interact with its internal and
external environments. There are various
types of neurons. The tissues that support
the nerve cells are called neuroglia.

Types
§ Motor Neurons
§ Sensory Neurons
§ Interneuron
 SENSORY NEURONS
§ Sensory neurons do not have true dendrites. They are attached
to sensory receptors and transmit impulses to the central
nervous system, which then stimulates the interneurons, and
then motor neurons.
NERVE RECEPTORS

SENSORY NEURONS

INTERNEURONS

MOTOR NEURONS
§ Interneurons are located entirely within the central nervous
system. They intercept the impulses from the sensory neurons
and transmit the signals to the motor neurons.
§ The motor neurons usually have one
axon and several dendrites.
§ The axon is covered with an
insulating fatty layer called a myelin
sheath, and transmits signals a long
distance from the neuron to the area
to be activated.
§ Dendrites are short and unsheathed.
§ Motor neurons cause muscle
contractions and control secretions
from glands and organs…
controlling body functions.

MOTOR NEURONS
NERVE FIBERS
Schwann cells, only found
on peripheral nerves can
regenerate

Myelin sheath, a fatty

The axon that transmits
layer of insulation on
the message
some nerve fibers

There are no Schwann cells on nerve fibers in the central nervous

system, therefore damage to those nerve fibers is not reversible. A
bundle of nerve fibers is simply called ‘a nerve’. AFFERENT nerves
conduct impulses to the central nervous system; EFFERENT nerves
conduct impulses to the muscles, organs, and glands.
 SYNAPSES
§ Nerve impulses are transmitted via branches called synapses.
The synapses are connectors… hooking dendrites and axons
from one neuron to another.
§ The number of synapses
influences transmission.
That number can decrease
with disease, lack of
stimulation, drug use, etc.
 § The brain and spinal cord of
the central nervous system
receive impulses, process
information, and respond with
the appropriate action.
§ The gray matter of the brain
and spinal cord consists of
unsheathed nerve fibers
(cannot be regenerated if

GRAY & WHITE

damaged) in the cortex or
surface layer. The white matter
makes up the internal

MATTER structure and consists of

myelinated nerve fibers.
 MENINGES
The brain and spinal
cord are enclosed by 3
membranes, collectively
known as the meninges:
1. DURA MATER - the outside
membrane
2. ARACHNOID - the middle
membrane
3. PIA MATER - the inside
membrane
 § Taking up 7/8ths of the brain’s
weight, the cerebrum governs
all sensory and motor activity.
This includes sensory
perception, emotions,
consciousness, memory, and
voluntary movements.
§ It is divided into the left and
right hemispheres. The surface
or cortex is arranged in bulging
folds, each one called a gyrus

CEREBRUM and furrows, each one called a

sulcus.
The cortex is also divided into 4
lobes that correspond to the
overlying bones of the skull:
1. the frontal lobe specializes in
motor activity, personality, and
speech;
2. the parietal lobe is where
language, temperature,
pressure, and touch are
interpreted
3. the temporal lobe contains
centers for hearing, smell, and
language input;
4. the occipital lobe specializes in
vision.
 The cerebellum is the
second largest part of the
brain. It contains nerve
fibers that connect it to
every part of the central
nervous system. It
coordinates voluntary and
involuntary patterns of
movements. It also adjusts
muscles to automatically
maintain posture.
CEREBELLUM
DIENCEPHALON
The diencephalon refers to the
thalamus and hypothalamus.

Ø The thalamus is the relay

center for all sensory impulses
except olfactory (sense of
smell) and motor areas of the
cortex.
Ø The hypothalamus regulates behavior and emotional
expression, body temperature, and many metabolic activities.
Attached to the pituitary gland, it also controls the hormonal
secretions of this gland.
The brainstem consists of 3
structures:
1. the gray matter of the
midbrain controls visual
reflexes and sense of hearing.
2. The white matter of the pons
plays a role in regulating
visceral (internal organ)
control.
3. The medulla oblongata
connects the rest of the brain

BRAINSTEM
to the spinal cord. It regulates
breathing, swallowing,
coughing, sneezing, vomiting,
heartbeat, and blood
pressure
 The spinal cord has 31 segments:
§ 8 cervical segments that

SPINAL CORD correspond to the C1-C8 vertebrae;

§ 12 thoracic
corresponding to
segments
the T1-T12
vertebrae;
§ 5 lumbar segments corresponding
to L1-L5 vertebrae,
§ 5 sacral segments corresponding
to S1-S5 vertebrae
§ 1 coccygeal segment.
The 44 cm long spinal cord is shorter
than the spinal column, so segments
do not perfectly correspond to the
vertebrae.
 A colorless fluid is
produced in the ventricles
of the brain; it surrounds
the brain and spinal cord. It
is called cerebrospinal fluid,
and it cushions the brain
and cord from shocks that
could cause injury. It is
maintained at a level
around 1/2 - 2/3 cup.

CEREBROSPINAL FLUID
PERIPHERAL NERVOUS SYSTEM
The network of nerves
branching out throughout the
body from the brain and spinal
cord is called the peripheral
nervous system. In addition to the
31 pairs of spinal nerves
mentioned in the slides on the
spinal cord, 12 pairs of cranial
nerves attach to the brain:
No CRANIAL NERVE MAJOR FUNCTIONS
I OLFACTORY Smell
II OPTIC Vision
III OCULOMOTOR Eyelid & Eyeball movement
IV TROCHLEAR Innervates superior oblique; Turns eye downward & laterally
V TRIGEMINAL Chewing; Face & Mouth touch & pain
VI ABDUCENS Turns eye laterally
Controls most facial expressions
VII FACIAL
Secretion of tears & saliva, tears
VIII VESTIBULOCOCHLEAR Hearing, equilibrium sensation
IX GLOSSOPHARYNGEAL Taste, Senses carotid blood pressure
Senses aortic blood pressure, slows heart rate
X VAGUS
Stimulates digestive organs, Taste
Controls trapezius & sternocleidomastoid
XI SPINAL ACCESSORY
Controls Swallowing movements
XII HYPOGLOSSAL Controls tongue movement
 The autonomic nervous
system is a part of the
peripheral nervous system. It
controls involuntary bodily
functions such as sweating,
gland secretions, blood
pressure, and the heart. It is
divided into the “sympathetic”
and “parasympathetic”
divisions.

AUTONOMIC NERVOUS SYSTEM

§ The sympathetic nervous system
is responsible for the ‘flight or
fight’ responses…
Ø increased alertness
Ø metabolic rate
Ø Respiration
Ø blood pressure
Ø heart rate
Ø Sweating
Ø decrease in digestive and
urinary function.
§ The parasympathetic nervous
system counteracts the
responses of the sympathetic Ø digestion of food
system restoring homeostasis. Ø expulsion of waste
Controls mostly visceral functions Ø general maintenance
Nervous System
ASSESSMENT
§ An evaluation of a person's nervous system includes the brain,
spinal cord, and the nerves that connect these areas to other
parts of the body.
§ It focuses on the nervous system to assess and identify any
abnormalities affecting function and daily living activities.
§ It helps to:
Ø Identify which components of the
neurological system are affected.
Ø If possible, determine the precise location
of the problem.
Ø Screening for the presence of discrete
abnormalities in patients at risk for the
development of neurological disorders.

NEUROLOGICAL ASSESSMENT
§ An important aspect of the
neurologic assessment is the
history of the present illness.
§ An initial interview provides an
excellent opportunity to
systematically explore the
patient’s current condition
§ Includes the details about the
onset, characteristics, severity, Common Symptoms
location, duration and frequency § Pain
of signs and symptoms. § Seizures

HEALTH HISTORY
§ Dizziness and Vertigo
§ Visual Disturbances
§ Muscle Weakness
§ Abnormal Sensation
 § The neurologic assessment is a
systematic process that includes a
variety of clinical tests, observations
and assessments designed to evaluate
the neurologic status of a complex
system.
§ Cannot be examined as directly as
other systems of the body. A neurologic
assessment is divided into five
components:
• consciousness and cognition
• cranial nerves • sensory system
• motor system • reflexes

PHYSICAL ASSESSMENT
 § Mental Status
§ Intellectual Function
§ Thought Content
§ Emotional Status
§ Language Ability
§ Impact on Lifestyle
§ Level of Consciousness

1. CONSCIOUSNESS & COGNITION

2. CRANIAL NERVE EXAM
 3. MOTOR SYSTEMS
• Motor Ability - includes an assessment of muscle size and
tone as well as strength, coordination and balance.
• Muscle Strength - Patient’s ability to flex or extend the
extremities against resistance test muscle strength.
• Gait Testing – ability to stand and walk
• Balance and Coordination - Coordination in hands and upper
extremities is tested by having the patient perform rapid,
alternating movements and point-to-point testing.
- Romberg test screening for balance
 4. SENSORY SYSTEM
- The sensory examination is largely subjective and requires the
cooperation of the patient.
- The examiner should be familiar with the dermatomes that
represent the distribution of the peripheral nerves that arise
from the spinal cord.
- Involves test for tactile
sensation, superficial pain,
temperature, vibration and
position sense
(proprioception)
1. Deep Tendon Reflexes
- A reflex hammer is used to elicit a deep tendon reflex, the handle of
the hammer is held loosely between the thumb and index finger,
allowing a full swing motion.
- deep tendon reflexes are graded on a scale of 0 – 4
• Biceps Reflex 2. Superficial Reflexes
• Triceps Reflex - The major superficial reflexes include
• Brachioradialis reflex corneal, palpebral, gag, upper/lower
• Patellar Reflex abdominal, cremasteric & perianal.
• Achilles Reflex - These reflexes are graded differently than
the motor reflexes and are noted to be
present or absent.
3. Pathologic Reflexes
- Are seen in the presence of neurologic
disease; they often represent the

5. REFLEXES
emergence of earlier reflexes that
disappear with the maturity of the nervous
system.
NEURODIAGNOSTIC TESTING
 SKULL FILMS
§X–ray visualization of the skull
§Remove metallic items from hair

SPINE FILMS
• X-ray visualization of the spine
• Remove metallic items from around the
neck or body
• Avoid flexion/rotation of the spine
 CAT SCAN (Computed Axial Tomography)
• Computerized reconstruction of
body parts by passage of
multiple X-ray beams.
• Remove metallic objects from
hair
• Must remain still
• The time is approximately 20
minutes. If without contrast; 60
mins. if with contrast.
• Sedation if unable to remain still
• NPO 4-6 hrs. if contrast medium
is used
• Observe for allergic reaction
 Nursing consideration
ü Obtain history of metal
implants (+) metal
implants are not eligible
for MRI scan
ü The procedure lasts from
30-90 mins.
ü Reassure the client that
the procedure is painless
ü Assess for clautrophobia
ü Inform the client that the
machine makes a drum-
MRI (Magnetic Resonance Imaging) like sound
§ Uses a very strong magnet ü Request the client to
combined with radio frequency remove any metal items
that may be
waves and a computer to produce demagnetized 36
X-ray-like images of body chemistry.
§ Graphical recording of
spontaneous electrical impulses
of the brain from scalp electrode.
§ Explain the procedure to the client
§ Hair shampoo to remove
oil/sprays
§ No caffeine and other stimulants,
anticonvulsant for at least 24
hours
§ Wash hair after the procedure to
remove the EEG paste

EEG (Electroencephalography)
37
 CEREBRAL ANGIOGRAPHY (ARTERIOGRAM)
Before procedure
ü Explain the procedure to
the client
ü Check for BUN & crea
ü May experience a hot,
flushing sensation as the
dye is injected
ü Check for allergy to
iodine/seafoods
ü NPO 4 – 6 hrs
ü IVF to ensure adequate Intra–arterial injection of
hydration contrast medium with
ü Pre-medicate as simultaneous radiographs of head
ordered and neck to visualize intracranial
and extracranial vessels.
CEREBRAL ANGIOGRAPHY (ARTERIOGRAM) After Procedure

§ Observe arterial
puncture site for
bleeding or
hematoma
§ Observe pulse distal
to the punctured site
§ Observe the affected
limb for color and
temperature
§ Observe for
bradycardia
39 and
hypotension which
may occur due to
§ Observe for any changes in neurologic status
vagal irritation in the
§ Bed rest
carotid artery.
 Before and During the Procedure
• Assist client in assuming “fetal Position”
• Local anesthesia is used to numb the
lumbar area
• Label the specimen collected
• Queckenstedt’s test may be performed
to test for subarachnoid obstruction.

After Procedure
• Lie flat on bed for 6- 8 hours (may turn
side to side)
Introduction of needle into spinal • Encourage fluids if not restricted
subarachnoid space usually at L3 – 4, • Headache may develop due to CSF
L4 – 5, L5 – S1, intervertebral space, to leakage
assess cerebrospinal fluid (CSF). • Observe for changes in neurologic
status

LUMBAR PUNCTURE (lumbar tap/spinal tap)

 Myelography is the
Myelography
introduction of radiopaque Before Procedure
solution, oil or water-based, into § Consent must be sign
the spinal subarachnoid space § Requires lumbar puncture
between fluoroscopic and § Pre-medicate client as order
radiographic observation. § Inform the client that time is approximately 2
Detects vertebral disk hours
disease, spinal cord tumors
After Procedure
§ For a pantopaque myelogram (oil–based), the
patient lies flat for 6 to 24 hours to prevent
spinal headache
§ For metrizamide myelogram (water-based),
HOB is elevated at 30 degrees for at least 8
hours to prevent meningeal irritation
§ Encourage fluids to enhance the excretion of
dye
§ Observe for any change in neurologic status
§ Observe for generalized seizure
§ EMG records electrical activity in
muscles at rest, during voluntary
contraction and in response to
electrical stimulation.
§ NCV studies, record speed of
conduction in motor and sensory
fibers of peripheral nerves.
§ Detects neuromuscular disorders.
§ Explain the procedure to the client;
small electrode needles will be
inserted into the muscle
§ May be with mild discomfort
§ Time is approximately 45 minutes for
one muscle.
Electromyography (EMG) and Nerve Conduction Velocity (NVC)
§ Involves the use of radioactive substances that emit positive
electrons (positron) while a CT scan is performed.
§ The patient either inhales a radioactive gas or is injected with a
radioactive substance that emits positively charged particles.
§ Provides metabolic profile by revealing the rate at which tissues
metabolize glucose
§ PET permits the
measurement of blood
flow, tissue composition,
and brain metabolism
and thus indirectly
evaluates brain functions

Positron Emission Tomography (PET Scan)

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