Assessing Clients with

Neurologic Disorders
Anatomy and Physiology
Nervous system divided into 2 regions:
1. Central nervous system (CNS):
brain and spinal cord
2. Peripheral nervous system
(PNS): cranial nerves, spinal
nerves and autonomic nervous
system
Function of the nervous system are
sensory input, integration, motor
output, homeostasis, mental activity.

Central Nervous System : BRAIN

Major regions are:
 Diencephalon
 Brainstem
 Cerebrum
 Cerebellum

BRAIN: Diencephalon
 Thalamus – largest part,
influences mood and registers an
unlocalized, uncomfortable
perception of pain.
 Epithalamus – small area superior
and posterior to the thalamus,
involved in the emotional and
visceral response to odors, pineal
body (onset of puberty)
 Hypothalamus – most inferior
part, important in maintaining
homeostasis, plays a central role in
the control of body temperature,
hunger and thirst, plays a major
role in controlling the secretion of
hormones from the pituitary gland.
 - Superior to the pons
- Smallest region of the brainstem
- CN 3 and 4
- Found superior and inferior
colliculus
- Superior colliculi – involved in
visual reflexes, turning the head, a
sudden loud noise, bright flash of
light
- Inferior colliculi – major relay
centers for the auditory nerve
pathways in the CNS
- General functions : coordination of
eye movements and in the control
BRAIN : Brainstem of pupil diameter and lens shape
- Connects the spinal cord to the - Contains a nuclear black mass
remainder of the brain called Substantia Nigra
- Consists of the medulla
oblongata, pons, and midbrain

NERVOUS SYSTEM
- Involved in vital body functions
such as the control of HR, BP, and
breathing

Brainstem : Medulla Oblongata

- Most inferior portion of the
brainstem
- Continuous with the spinal cord
- Extends from the level of the
foramen magnum to the pons
- CN 9, 10, 11, 12 BRAIN : Cerebrum
- Specific functions: regulation of
HR and BV diameter,
breathing, swallowing,
vomiting, coughing, sneezing,
balance and coordination

Brainstem : Pons
- Immediately superior to the
medulla oblongata
- Means “bridge”
- CN 5, 6, 7, 8
- Lower part of the pons: breathing,
swallowing and balance - Largest part of the brain
- Other nuclei in the pons control - Divided into left and right
functions such as chewing and hemisphere by a longitudinal
salivation fissures
- The surface of each hemisphere is
Brainstem : Midbrain wrinkled by presence of eminences
 known as Gyri and furrows called
Sulci or Fissures
- Each cerebral hemispheres is
divided into lobes:
1. Frontal lobes
- Principal motor area (4)
- Important in the control of
voluntary motor functions,
motivation, aggression, mood, and
olfactory (smell) reception
- Brocas area (44,45) – Brocas
aphasia (executive, motor,
nonfluent, anterior)
2. Parietal lobe
- Principal center for the reception
and conscious perception of most
sensory information, such as touch, BRAIN : Cerebellum
pain, temperature, balance and - Composed of gray matters
taste - Posterior and inferior to the
- Principal sensory area (3,1,2) cerebrum
3. Occipital lobe - Involved in balance, maintenance
- Functions in the reception and of muscle tone and coordination of
perception of visual input fine motor movements
- Principal visual cortex (17) - Major function of the cerebellum is
4. Temporal lobe that of comparator
- Involved in olfactory (smell) and - Also involves learning motor skills
auditory (hearing) sensations and (riding a bicycle/playing a piano)
plays an important role in memory
- They associated in abstract
thought and judgement
- Primary auditory cortex (41,42)
- Wernicke’s area (22) – wernickes
aphasia (receptive, sensory, fluent,
posterior)

Central Nervous System: Spinal Cord

- Spinal cord extends from the
foramen magnum to the 2nd
lumbar vertebra below which is the
cauda equina
- It has a central gray part organized
into horns and a peripheral white
part forming nerve tracts
- Roots of spinal nerves extend out 12 pairs of CN
of the cord 31 pairs of SN

PNS: Cranial Nerves

- 12 cranial nerves
- Designated by numerals from I to
XII
- General categories:
Sensory
Motor

Cranial nerves
- sensory – I,II,VIII
- motor – III, IV, VI, XI, XII
- mixed – V, VII, IX, X

Central Nervous System: Spinal Cord

- VERTEBRAL COLUMN
- surrounds and protects the spinal
cord
- 7 cervical, 12 thoracic, 5 lumbar, 5
sacral, coccyx (4 fused vertebra)

PNS: Spinal Nerves

Peripheral Nervous System

- Consists of the nerves and ganglia
located outside the brain and
spinal cord
- Divided into two groups:
- Arise along the spinal cord from the - Organized into 3 plexuses
union of the dorsal and ventral

Autonomic Nervous System:

Sympathetic Nervous System
- Originates from the T1-L2/L3
segments of the spinal cord
roots
PNS: Spinal Nerves
- They contain axons of both sensory
and somatic motor neurons
- Also contain parasympathetic and
sympathetic axons

(thoracolumbar)
- Utilized by the body for FLIGHT and
FIGHT response
- Neurotransmitter agents are
Epinephrine and Norepinephrine
(coming from the adrenal gland)
- ADRENERGIC system
PNS: Spinal Nerves
-
Sympathetic Responses:
Categorized
Increased:
by the
- HR
region of
- RR
vertebral
- BP
column
- Visual Acuity (Pupillary Dilation)
- 31 pairs
- Smooth Muscle tone sphincters are
(c8, t12,
contracted
l5, s5, c1)
- Vasoconstriction – peripheral
- Metabolism ↑ glucose, ↑ fatty
acids
Decreased
- Peristalsis
- Salivary secretions
- Ejaculation
ANS: Parasympathetic Nervous - Flaccid muscle paralysis
System - Muscle atrophy
- CHOLINERGIC system - Absent or decreased reflexes
- The vegetative system
- Feed and Breed responses Structures supporting the brain
- Cranio-sacral location Skull
- Cranial nerves- 3, 7, 9, 10 and S2- - Frontal bone
S4 - Parietal bone
- Neurotransmitter is Acetylcholine - Temporal bone
- Occipital bone

Parasympathetic Responses Meninges

Decreased: - Surround and protect the spinal
- HR cord
- RR - 3 layers
- BP
- Visual Acuity (Pupillary Meninges
constriction)  Dura mater
- Smooth Muscle tone􏰀 sphincters - Dural venous sinuses
are relaxed - Epidural space (SC)
- Vasodilation = peripheral
- Metabolism􏰀 dec glucose, fatty
acids
Increased:
- Peristalsis
- Salivary secretions
- Erection

 Arachnoid
- Subdural space (space between
dura mater and arachnoid, contains
Comparison of UMN and LMN small amount of serous fluid)
Upper motor neuron lesions
- Loss of voluntary control
- Increased muscle tone
- Muscle spasticity
- No muscle atrophy
- Hyperactive and abnormal reflex

Lower motor neuron lesions

- Loss of voluntary control
- Decreased muscle tone
  Pia mater Cerebral Circulation
- Tightly bound to the surface of brain - Receives approximately 15% of the
and SC cardiac output or 750 ml per minute
- Subarachnoid space (bet. Arachnoid - Does not store nutrients and has a
and pia mater, filled with CSF and high metabololic demand that
BV) requires high blood flow
- Unique BF bec. It flows against
gravity
- Poor collateral BF
- Two internal carotid arteries and two
vertebral arteries
- Empty into the dural sinuses

Cerebrospinal Fluid
- Bathes the brain and spinal cord
- Protective cushion aound the CNS
- Produced by the Choroid plexus of
the lateral, third, and fourth
ventricles
- Clear, colorless, SG of 1.007
- In normal adult, approximately 500
ml of CSF produced each day, all but
125 to 150 ml is absorbed by the
villi

BLOOD-BRAIN BARRIER
- CNS is inaccessible to many
substances
- Many substances cannot reach the
neurons of the CNS
- Formed by the endothelial cells of
the brains capillaries, which form
continuous tight junctions, creating
BBB to macromolecules
- Must filter through the capillary
endothelial cells and astrocytes
- Can be altered by trauma, cerebral - Serotonin (↓ depression, ↑ manic)
edema and hypoxia - Glutamine (excitatory
NEURONS ASSESSMENT OF THE
- Basic functional NEUROLOGIC SYSTEM PHYSICAL
unit of the brain EXAMINATION
- Composed of a cell 5 categories:
body, dendrite and 1. Cerebral function- LOC, mental
an axon status
2. Cranial nerves
3. Motor function
4. Sensory function
5. Reflexes

ASSESSMENT OF THE
NEUROLOGIC SYSTEM
Neuro Check
- Level of consciousness
- Pupillary size and response
- Verbal responsiveness
- Motor responsiveness
- Vital signs

- Dendrite- branch type structure HISTORY

with synapses for receiving - A confused client becomes an
electrochemical messages unreliable source of history
- Axon – long projection that carries
impulses away from the cell body A. Health assessment interview to
collect subjective data
Neurotransmitters 1. If client’s ability to
communicate is challenged by
- Acetycholine altered level of consciousness,
- Dopamine interviewer may discuss with family
- Epinephrine and Norepinephrine member or close friend
2. If client has a health problem
involving neurologic function,
determine
a. Onset
b. Characteristics and course
c. Severity
d. Precipitating and relieving
factors
e. Associated symptoms noting
timing and circumstances
3. Questions about present health
status include
a. Numbness or tingling
- GABA (inhibitory) sensations
 b. Tremors, problems with cerebral artery, paralysis of vocal
coordination or balance cords, cranial nerve X
c. Loss of movement of any part of h. Dysarthria (difficulty in speaking):
the body strokes involving anterior inferior
d. Difficulty with speaking or and superior cerebral arteries,
sense lesions involving UMN, LMN,
e. Information about memory cerebellum, extrapyramidal tract
f. Feeling state, e.g. anxious, i. Decreased level of consciousness:
depressed brain trauma, infections, TIAs,
g. Changes in sleep patterns stroke, brain tumors
h. Ability to perform self-care and j. Confusion, coma: strokes affecting
ADL vertebralbasilar arteries
i. Sexual activity
j. Weight changes 2. Cognitive function
k. Prescribed and over the counter assessment with abnormal
medications, frequency of use findings
and duration a. Disorientation to time and place:
stroke of right cerebral hemisphere
4. Determine history of b. Memory deficits: anterior cerebral
a. Seizures, fainting, dizziness, artery and vertebralbasilar artery
headaches c. Perceptual deficits: strokes of
b. Trauma, tumors, surgery involving middle cerebral artery, brain
brain, spinal cord, nerves trauma, dementing conditions
c. Diseases that might affect d. Impaired cognition: strokes of
neurologic function middle cerebral artery, cerebral
1. Cardiac disease trauma, brain tumors
2. Strokes
3. Pernicious anemia CEREBRAL FUNCTION
4. Sinus infections - Assess the degree of wakefulness/
5. Liver dysfunctions alertness
6. Diabetes mellitus - Note the intensity of stimulus to
7. HPT cause a response
8. Mental health problems
- Apply a painful stimulus over the
nailbeds with a blunt instrument
B. Physical assessment to collect
objective data - Ask questions to assess
a. Unilateral neglect orientation to person, place and
b. Poor hygiene and grooming time
c. Abnormal gait and posture - Utilize the Glasgow Coma Scale
d. Emotional swings, personality - An easy method of describing
changes e. Masklike appearance on mental status and abnormality
face detection
e. Apathy - Tests 3 areas- eye opening, verbal
f. Aphasia (defective or absent response and motor response
language function): TIAs, strokes; - Scores are evaluated- range from 3-
strokes involving posterior or
15
anterior artery involve receptive
aphasia - No ZERO score
g. Dysphonia (change in tone of
voice): strokes of posterior inferior Glasgow Coma Scale
Glasgow Coma Score - Fundoscopy to check for
- Eye Opening (E) papilledema
- Verbal Response (V)
- Motor Response (M) CN 3, 4 and 6
- 8 and Below= COMA! - Assess simultaneously the
movement of the extra-ocular
Glasgow Coma Scale muscles
Glasgow Coma Score Deviations:
Eye Opening (E) - Opthalmoplegia- inability to move
4=Spontaneous the eye in a direction
3=To voice (when told to) - Diplopia- complaint of double
2=To pain vision
1=None (No response)

Verbal Response (V)

5=Normal/oriented
4=Disoriented/CONFUSED
3=Words, but incoherent/
inappropriate
2=Incomprehensible/mumbled words
1=None

Motor Response (M)

6=Normal- obeys command
5=Localizes pain CN 5 -trigeminal
4=Withdraws to pain (Flexion)
- Sensory portion- assess for
3=Decorticate posture
sensation of the facial skin
2=Decerebrate posture
1=None (flaccid) - Motor portion- assess the muscles of
mastication
Cranial Nerve Function: - Assess corneal reflex
Cranial Nerve 1- Olfactory
- Check first for the patency of the CN 7 -facial
nose - Sensory portion- prepare salt, sugar,
- Instruct to close the eyes vinegar. Place each substance in the
anterior two thirds of the tongue,
- Occlude one nostrils at a time
rinsing the mouth with water
- Hold familiar substance and asks for - Motor portion- ask the client to
the identification
make facial expressions, ask to
- Repeat with the other nostrils forcefully close the eyelids
- PROBLEM- ANOSMIA- “loss of smell”
CN 8- vestibulo-auditory
CN 2- Optic - Test patient’s hearing acuity
- Check the visual acuity with the use - Observe for nystagmus and
of the Snellen chart disturbed balance
- Check for visual field by
confrontation test CN 9- glossopharyngeal
- Check for pupillary reflex- direct and - Together with Cranial nerve 10 –
consensual vagus
- Assess for gag reflex Brainstem
- Watch the soft palate rising after Test for the Oculocephalic reflex-
instructing the client to say “AH” doll’s eye
- The posterior one-third of the - Normal response- eyes appear to
tongue is supplied by the move opposite to the movement of
glossopharyngeal nerve the head
- Abnormal- eyes move in the same
CN 11- accessory direction
- Press down the patient’s shoulder
while he attempts to shrug against Test for the Oculovestibular reflex
resistance - Slowly irrigate the ear with cold
water and warm water
CN 12- hypoglossal - Normal response- cOld- OppOsite,
- Ask patient to protrude the tongue wArM- sAMe
and note for symmetry
Assessing the sensory function
ASSESS Motor function - Evaluate symmetric areas of the
- Assess muscle tone and strength by body
asking patient to flex or extend the - Ask the patient to close the eyes
extremities while the examiner while testing
places resistance - Use of test tubes with cold and
- Grading of muscle strength warm water
- Use blunt and sharp objects
Muscle Motor Grading: - Use wisp of cotton
5/5 – normal active movement, full
range of motion against full resistance
- Ask to identify objects placed on the
hands
4/5 – active movement, full ROM
against moderate resistance - Test for sense of position
3/5 – active movement, full ROM
against gravity Assessing the reflexes
2/5 – active movement, full ROM w/ Deep tendon reflexes
gravity eliminated(horizotal/side to - Biceps (C5-C6)
side) - Triceps (C6-C8)
1/5 – palpable or visible contraction - Brachioradialis (C5-C6)
0/5 – no movement, total paralysis
- Patellar
Assessing the motor function of - Assessing the sensory function
the Achilles
Cerebellum Superficial reflexes
- Test for balance- heel to toe - Abdominal (T9-T10)
- Test for coordination- rapid - Cremasteric (L1-L2)
alternating movements and finger to - Anal (S3-S5)
nose test Pathologic reflex
- ROMBERG’s is actually a test for the - Babinski- stroke the lateral aspect of
posterior spinothalamic tract the soles doing an inverted “J”
(+)- DORSIFLEXION of the Big toe
Assessing the motor function of with fanning out of the little toes
the
 Grading of reflexes - Decorticate posturing (upper arms
Deep tendon reflex close to sides, elbows, wrists and
0- absent fingers flexes, legs extended with
+ present but diminished internal rotation, feet are flexed:
++ normal average body parts pulled into core of body):
+++ increased but not necessary lesions of corticospinal tracts
abnormal - Decerebrate posturing (neck
++++ hyperactive or clonic extended with jaw clenched, arms
pronated, extended, close to sides,
Superficial reflex legs are extended straight out and
0 absent feet plantar flexed): lesions of
+present midbrain, pons, diencephalon
Reflex assessment with abnormal Diagnostic Test
findings A. Skull and spinal x-ray
A. Hyperactive reflexes: lesions
affecting UMN
- identify fractures dislocation.
Compression, spinal cord problem
B. Decreased reflexes: LMN
Nursing Care
involvement
C. Clonus of foot (hyperactive, - provide nursing support for the
rhythmic dorsiflexion and plantar confused or combative patient
flexion of foot): UMN disease - maintain immobilization
D. Superficial reflexes (such as - remove metal items
abdominal) and cremasteric reflex B. CT Scan
may be absent with LMN and UMN - detect intracranial bleeding, space
diseases occupying lesion, cerebral edema.
E. Positive Babinski reflex Hydrocephalus, infarction
(dorsiflexion of big toe with fanning Nursing Care
of other toes): UMN diseases of - Assess for allergies
pyramidal tract
- Instruct to lie still and flat
Special neurologic assessment - Inform pt that there may be hot,
with abnormal findings flushed sensation and metallic taste
- Positive Brudzinski’s sign (pain, in the mouth
resistance, flexion of hips and knees - Treat allergic reaction
when head flexed to chest with C. Magnetic Resonance
client supine) indicates meningeal Imaging
irritation - provides more detailed pictures
- Positive Kernig’s sign (excessive - Patients with pacemakers,
pain and/or resistance when orthopedic metal prosthesis and
examiner attempts to straighten implanted metal devices cannot
knees with client supine and knees undergo this procedure
and hips flexed) indicates meningeal D. EEG (Electroencephalogram)
irritation - Withhold medications that may
- Positive Babinski reflex (dorsiflexion interfere with the results-
of big toe with fanning of other anticonvulsants, sedatives and
toes): UMN diseases of pyramidal stimulants
tract - Wash hair thoroughly before
procedure
Lumbar tap Contraindications:
- Unstable vital signs or
cardiopulmonary compromise
- space occupying lesions
- infections on the site
- hematologic problems

CSF obtained from LUMBAR

Space bet. L4 & L5
1. skin/superficial fascia
2. Ligaments
3. Epidural Space
4. Dura mater
5. Subdural space
6. Archnoid space
7. Subarachnoid space