H.

ASSESSMENT LECTURE
YEAR 1 : SEM 2 : FINAL

CHAPTER 15: NEUROLOGIC SYSTEM

CHAPTER OUTLINE functions such as memory, perception,
I. STRUCTURE AND FUNCTION communication, and initiation of voluntary movements.
A. Central Nervous System • Consisting of aggregations of neuronal cell bodies,
a. Brain gray matter rims the surfaces of the cerebral
b. Spinal Cord hemispheres, forming the cerebral cortex.
B. Peripheral Nervous System
II. COLLECTING SUBJECTIVE DATA Lobes of the Cerebral Hemispheres and their Function
III. COLLECTING OBJECTIVE DATA LOBE FUNCTION
Directs voluntary, skeletal
actions (left side of lobe
STRUCTURE AND FUNCTION controls right side of body and
• The very complex neurologic system is responsible for right side of lobe controls left
coordinating and regulating all body functions. It side of the body). Also
consists of two structural components: the central Frontal influences communication
nervous system (CNS) and the peripheral nervous (talking and writing), emotions,
intellect, reasoning ability,
system.
judgment, and behavior.
CENTRAL NERVOUS SYSTEM Contains Broca’s area, which
BRAIN is responsible for speech.
• Located in the cranial cavity, the brain has four major Interprets tactile sensations,
divisions: Parietal
including touch, pain,
o the cerebrum, temperature, shapes, and two-
o the diencephalon point discrimination.
o the brain stem, and Influences the ability to read
o the cerebellum Occipital with understanding and is the
primary visual receptor.
Receives and interprets
impulses from the ear.
Temporal Contains Wernicke’s area,
which is responsible for
interpreting auditory stimuli.

DIENCEPHALON
• The diencephalon lies beneath the cerebral
hemispheres and consists of the thalamus and
hypothalamus.
• Most sensory impulses travel through the gray matter
of the THALAMUS, which is responsible for screening
and directing the impulses to specific areas in the
cerebral cortex.
• The HYPOTHALAMUS (part of the autonomic
nervous system, which is a part of the peripheral
nervous system) is responsible for regulating many
body functions including water balance, appetite, vital
signs (temperature, blood pressure, pulse, and
respiratory rate), sleep cycles, pain perception, and
emotional status.
CEREBELLUM
CEREBRUM • The cerebellum, located behind the brain stem and
• The cerebrum is divided into the right and left cerebral under the cerebrum, also has two hemispheres.
hemispheres, which are joined by the CORPUS • Although the cerebellum does not initiate movement,
CALLOSUM—a bundle of nerve fibers responsible for its primary functions include coordination and
communication between the hemispheres. smoothing of voluntary movements, maintenance of
• Each hemisphere sends and receives impulses from equilibrium, and maintenance of muscle tone.
the opposite sides of the body and consists of four SPINAL CORD
lobes (frontal, parietal, temporal, and occipital). • The spinal cord is located in the vertebral canal and
• The lobes are composed of a substance known as extends from the medulla oblongata to the first lumbar
GRAY MATTER, which mediates higher-level vertebra.

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 CHAPTER 15: NEUROLOGIC SYSTEM
• The inner part of the cord has an H-shaped Cranial Nerves: Type and Function
appearance and is made up of two pairs of columns CRANIAL NERVE TYPE OF
FUNCTION
(dorsal and ventral) consisting of gray matter. (NAME) IMPULSE
• The outer part is made up of white matter and Carries smell impulses
I (Olfactory) Sensory from nasal mucous
surrounds the gray matter. membranes to brain.
• The spinal cord conducts sensory impulses up Carries visual impulses
ascending tracts to the brain, conducts motor II (Optic) Sensory
from eye to brain.
impulses down descending tracts to neurons that Contracts eye muscles
stimulate glands and muscles throughout the body, to control eye
and is responsible for simple reflex activity. movements (interior
• Reflex activity involves various neural structures. For III (Oculomotor) Motor lateral, medial, and
example, the stretch reflex—the simplest type of reflex superior), constricts
pupils, and elevates
arc—involves one sensory neuron (afferent), one
eyelids.
motor neuron (efferent), and one synapse. An Contracts one eye
example of this is the knee jerk, which is elicited by muscle to control
tapping the patellar tendon. More complex reflexes IV (Trochlear) Motor
inferomedial eye
involve three or more neurons. movement.
PERIPHERAL NERVOUS SYSTEM Carries sensory
• Carrying information to and from the CNS, the impulses of pain, touch,
peripheral nervous system consists of 12 pairs of and temperature from
cranial nerves and 31 pairs of spinal nerves. These Sensory the face to the brain.
V (Trigeminal)
motor Influences clenching
nerves are categorized as two types of fibers: somatic and lateral jaw
and autonomic. movements (biting,
• SOMATIC fibers carry CNS impulses to voluntary chewing).
skeletal muscles; autonomic fibers carry CNS Controls lateral eye
VI (Abducens) Motor
impulses to smooth, involuntary muscles (in the heart movements.
and glands). The somatic nervous system mediates Contains sensory fibers
conscious, or voluntary, activities; for taste on anterior
• The AUTONOMIC nervous system mediates two-thirds of tongue,
and stimulates
unconscious, or involuntary, activities.
Sensory secretions from salivary
CRANIAL NERVES glands (submaxillary
• Twelve pairs of cranial nerves evolve from the brain or and sublingual) and
brain stem and transmit motor or sensory messages. VII (Facial) tears from lacrimal
SPINAL NERVES glands.
• Comprising 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,
Supplies the facial
and 1 coccygeal nerves, the 31 pairs of spinal nerves muscles and affects
are named after the vertebrae below each one’s exit Motor facial expressions
point along the spinal cord. (smiling, frowning,
• Each nerve is attached to the spinal cord by two nerve closing eyes).
roots. VIII (Acoustic,
Contains sensory fibers
• The SENSORY (AFFERENT) fiber enters through the Vestibulocochlear)
Sensory for hearing and
dorsal (posterior) roots of the cord; the MOTOR balance.
(EFFERENT) fiber exits through the ventral (anterior) Contains sensory fibers
for taste on posterior
roots of the cord.
third of tongue and
• The sensory root of each spinal nerve innervates an Sensory sensory fibers of the
area of the skin called a dermatome. pharynx that result in
the gag reflex when
IX
stimulated.
(Glossopharyngeal)
Provides secretory
fibers to the parotid
Motor salivary glands;
promotes swallowing
movements.
Carries sensations from
the throat, larynx, heart,
lungs, bronchi,
gastrointestinal tract,
Sensory
X (Vagus) and abdominal viscera.
motor
Promotes swallowing,
talking, and production
of digestive juices.

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 CHAPTER 15: NEUROLOGIC SYSTEM
Innervates neck important information with the examiner if these fears
muscles and concerns are not addressed.
(sternocleidomastoid
and trapezius) that
XI (Spinal
Motor promote movement of
Accessory)
the shoulders and head
rotation. Also promotes
some movement of the
larynx.
Innervates tongue
muscles that promote
XII (Hypoglossal) Motor
the movement of food
and talking.

AUTONOMIC NERVOUS SYSTEM

• Some peripheral nerves have a special function
associated with automatic activities; they are referred
to as the autonomic nervous system.
• Autonomic nervous system impulses are carried by
both cranial and spinal nerves. These impulses are
carried from the CNS to the involuntary, smooth
muscles that make up the walls of the heart and
glands.
• The autonomic nervous system, which maintains the
internal homeostasis of the body, incorporates the
sympathetic and parasympathetic nervous systems.
• The SYMPATHETIC NERVOUS SYSTEM (“FIGHT-
OR-FLIGHT” SYSTEM) is activated during stress and
elicits responses such as decreased gastric
secretions, bronchiole dilatation, increased pulse rate,
and pupil dilatation.
• These sympathetic fibers arise from the
thoracolumbar level (T1 to L2) of the spinal cord. The
PARASYMPATHETIC NERVOUS SYSTEM functions
to restore and maintain normal body functions, for
example, by decreasing heart rate.
• The parasympathetic fibers arise from the craniosacral
regions (S1 to S4 and cranial nerves III, VI, IX, and X).

COLLECTING SUBJECTIVE DATA

• Problems with other body systems may affect the
neurologic system, and neurologic system disorders
can affect all other body systems.
• Regardless of the source of the neurologic problem,
the client’s total lifestyle and level of functioning are
often affected.
• Because of their subjective nature, neurologic
problems related to activities of daily living (ADLs) are
typically detected through an in-depth nursing history.
For example, problems with loss of concentration, loss
of sensation, or dizziness are usually identified only
through precise questioning during the interview with
the client.
• Clients who are experiencing symptoms associated
with the neurologic system (such as headaches or
memory loss) may be very fearful that they have a
serious condition such as a metastatic brain tumor or
a difficult-to-treat disease such as Alzheimer’s.
• Fear of losing control and independence, along with
threatened self-esteem or role performance, are
common.
• The examiner needs to be sensitive to these fears and
concerns because the client may decline to share

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 CHAPTER 15: NEUROLOGIC SYSTEM
impaired, another means of obtaining necessary
subjective data must be identified.
• The cranial nerve evaluation provides information
regarding the transmission of motor and sensory
messages, primarily to the head and neck.
o Many of the cranial nerves are evaluated during
the head, neck, eye, and ear examinations.
• The motor and cerebellar systems are assessed to
determine functioning of the pyramidal and
extrapyramidal tracts.
o The cerebellar system is assessed to determine
the client’s level of balance and coordination. The
motor system examination is usually performed
during the musculoskeletal examination.
• Examining the sensory system provides information
regarding the integrity of the spinothalamic tract,
posterior columns of the spinal cord, and parietal
lobes of the brain.
• Testing reflexes provides clues to the integrity of
deep and superficial reflexes.
o Deep reflexes depend on an intact sensory
nerve, a functional synapse in the spinal cord, an
intact motor nerve, a neuromuscular junction, and
competent muscles.
o Superficial reflexes depend on skin receptors
rather than muscles.
o If meningitis is suspected, the examiner may try
to elicit Brudzinski’s and Kernig’s signs, which
are characteristic of meningeal irritation.
Sometimes, a complete neurologic examination is
unnecessary.
o In such cases, the nurse performs a “neuro
check”—a brief screening of the client’s
neurologic status.

COLLECTING OBJECTIVE DATA

• A complete neurologic examination consists of
evaluating the following five areas:
o mental status
o cranial nerves
o motor and cerebellar systems • A neuro check includes the following assessment
o reflexes points:
• Mental status examinations provide information o Level of consciousness
about cerebral cortex function. o Pupillary checks
o Cerebral abnormalities disturb the client’s o Movement and strength of extremities
intellectual ability, communication ability, or o Sensation in extremities
emotional behaviors. o Vital signs
o A mental status examination is often performed at • A neuro check is useful in an emergency situation and
the beginning of the head-to-toe examination when frequent assessments are needed during an
because it provides clues regarding the validity of acute phase of illness to detect rapid changes in
the subjective information provided by the client. neurologic status.
o For example, if the nurse finds that the client’s • It is also useful for a client who has already had a
thought processes are distorted and memory is complete neurologic examination but needs to be

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 CHAPTER 15: NEUROLOGIC SYSTEM
rechecked for changes related to therapy or other
conditions.
Preparing the Client:
• Prepare for the neurologic examination by asking the
client to remove all clothing and jewelry and to put on
an examination gown.
• Initially have the client sit comfortably on the
examination table or bed, but explain to him or her
that several different position changes are necessary
throughout the different parts of the examination.
• Assure the client that each position will be explained
before the start of the particular examination.
• Explain also that the examination will take a
considerable amount of time to perform and that you
will provide rest periods as needed.
• If the client is older or physically weak, divide the
examination into parts and perform over two different
time periods.
• Explain that actions the client will be asked to perform,
such as counting backward or hopping on one foot,
may seem unusual but that these activities are parts
of a comprehensive neurologic evaluation.
Equipment:
• General
o Examination gloves
• Cranial Nerve Examination
o Cotton-tipped applicators
o Newsprint to read
o Ophthalmoscope
o Paper clip
o Penlight
o Snellen chart
o Sterile cotton ball
o Substances to smell
o Tongue depressor
o Tuning fork
• Sensory Examination
o Cotton ball
o Objects to feel such as a quarter or key
o Paper clip
o Test tubes containing hot and cold water
o Tuning fork
• Reflex Examination
o Cotton-tipped applicator
o Reflex (percussion) hammer
Physical Assessment:
Prior to the physical examination, review these key points:
• Understand what is meant by mental status and level
of consciousness
• Know how to correctly apply and interpret mental
status examinations and how to use the Glasgow
Coma Scale (GCS)
• Identify the 12 Cranial Nerves and their sensory and
motor functions
• Know how to thoroughly assess movement, balance,
coordination, sensation, and reflexes
• Know how to use a reflex hammer
• Coordinate patient education – particularly in regard to
risks related to stroke – with the health interview and
physical examination

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