Luisito P. Yolangco, RN.DVM.MAN.

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 CONTROL CENTER & COMMUNICATION NETWORK of the body Works hand in hand with ENDOCRINE system to regulate and maintain homeostasis

HOW IT WORKS? Directs the functions of the bodys organs and systems Uses rapid & specific electrical impulses as signaling devices Allows us to interpret and respond to the changes in the external environment Thoughts, actions & emotions reflect its activity

INPUT

Sensory Reception (Receptors)

INTEGRATION
OUTPUT

Motor Response (Effector)

NERVOUS SYSTEM

CNS
Brain
Spinal Cord

PNS
12 CNs 31 SNs

ORGANIZATION OF THE NERVOUS SYSTEM

Somatic

Autonomic

SNS

PSNS

One of the largest organs of the body Weights about 3 lbs Protected by cranial bones and the meninges DM, AM, PM Contains CSF

CEREBRUM

BRAINSTEM DIENCEPHALON
HYPOTHALAMUS THALAMUS PONS

MIDBRAIN

CEREBELLUM
MEDULLA OBLONGATA

MIDBRAIN

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Neurotransmitter
-communicate messages from one neuron to another or from a neuron to a specific target tissue.

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Neurotransmitters
Acetylcholine major transmitter of the PNS usually excitatory in CNS and NMJ Inhibitory or excitatory in ANS

Gamma-aminobutyric acid (GABA) - inhibitory

Enkephalin, endorphin excitatory, pleasurable sensation, inhibits pain transmission

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CSF Characteristics
Clear & colorless Sp. Gr. = 1.007 Approx. 150 ml ( 15-25 ml in each ventricle) Contains:

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Albumin Glucose Glutamine IgG WBC

15-30 mg.dl 50-75 mg.dl 6-15mg/dl 0-6.6 mg/dl 0-5 per mm3

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THE PERIPHERAL NERVOUS

SYSTEM

1. Sensory-Somatic
a. Cranial Nerves b. Spinal Nerves

2. Autonomic a. Parasympathetic
b. Sympathetic

CN

PSNS

SNS

PNS

SN

Consists of NERVES, CELL BODIES & PROCESSES outside the CNS 1. sensory-somatic

2. autonomic nervous system

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Cranial Nerves
12 pairs of CNs Primarily innervate the HEAD & NECK except for CN X which extends to the thorax & abdomen Functions: 1. Sensory 2. Motor (Somatic) 3. Parasympathetic
Sensory-Somatic Nervous System

I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal* VI. Abducens VII. Facial VIII. Acoustic/ Vestibulocochlear IX. Glossopharyngeal X. Vagus XI. Accessory/Spinal XII. Hypoglossal
Note: * S,M only

Olfactory

Optic

Oculomotor Trochlear On Old Obando Tower Top A Filipino Army Guards Villages And Houses.
Some Say Marry Money But My Brother Says Big Business Makes Money.

Abducens

Trigeminal
Facial

Acoustic/Vestibulocochlear
Glossopharyngeal

Still can't remember the names of the cranial nerves?

Vagus

Hypoglossal

Accessory/Spinal

# I Olfactory

Name

Type S smell

Function

II
III IV V VI VII

Optic
Oculomotor Trochlear Trigeminal Abducens Facial

S
M M B M B

vision
extraocular eye movement;pupillary reaction upward & downward eye movement sensation from the face & mouth; mastication lateral eye movement taste;saliva & tears production; facial expression

VIII IX X

Acoustic Glossopharyngeal Vagus

S B B

hearing & balance taste; swallowing; tongue movement; salivation swallowing; digestive,respiratory, cardiovascular activities

XI
XII

Accessory
Hypoglossal

M
M

Head & shoulder movement

Tongue movement

Spinal Nerves
31 pairs of SNs Formed by dorsal & ventral roots of the spinal cord Divided into dorsal & ventral rami which contain both motor & sensory fibers Named according to segment of spinal cord they are attached.
Sensory-Somatic Nervous System

Nerve Plexuses
Complex networks of nerves

Serve the motor and sensory needs of the extremities

Classified into (4): Cervical Brachial

Lumbar
Sacral
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Regions supplied/Major nerves

neck, shoulder & diaphragm phrenic nerve upper extremity- shoulder, forearm, wrist & hand axillary, radial, median, musculocutaneous, & ulnar lower abdomen, buttocks, anterior/ medial thigh, medial leg & hip femoral & obturator nerve lower trunk, posterior thigh & lateral and posterior leg, foot, buttocks & external genitalia sciatic (peroneal & tibial), pudendal nerve

PLEXUSES
Cervical Plexus C1 C5 Brachial Plexus C6 C8; T1

Lumbar Plexus L1 L4

Sacral Plexus L4 L5; S1-S4

PSNS

SNS

A U T O N O M I C
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utomatically & continuously functions nder involuntary control

wo neurons between CNS & effector organs

ne stimulates and the other inhibits eurotransmitters cholinergic & adrenergic pposite effects on the same organs otor impulses

nnervates smooth & cardiac muscles and glands

oncerned with vital signs & other visceral activities

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NEUROLOGIC ASSESSMENT
NVS
Neurovital Signs

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NEUROLOGIC ASSESSMENT
Neurologic Examination
Mental Status Sensation Cranial Nerves Motor Function Reflexes

COMPOSURE
quick neurological assessment..

Consciousness
FORMS OF STIMULI

LOC

VERBAL VOICE SHOUT TACTILE TOUCH TAP/ SHAKE PAIN SUPERFICIAL DEEP

Verbal Conscious (+) Lethargic (+) Stuporous (-) Comatose (-)

Tactile (+) (+) (-) (-)

Pain (+) (+) * (+) (-)

* delayed reaction

Pain Stimulus
NAIL BED COMPRESSION

fine pressure with thumb over pencil on the base of the cuticle Test bilaterally N=(+)Crushing pain
STERNAL RUB

DSP use knuckle over sternum as if grinding a pill for 5 sec. N=20-30 sec. Posturing (initial reaction) Wait for at least 30 seconds

TRAPEZIUS SQUEEZE using thumb & 2 fingers, grasp 2 inches of the muscle & then twist SUPRAORBITAL PRESSURE use thumb C/I: Cranial fracture

IMPLICATION:

Consciousness
1st & MOST sensitive indicator of neurologic change

Awareness / Content (cognition & affect); orientation (3 spheres: TPP) Arousal (appearance of wakefulness)
Time Disorientation
Place Disorientation

cerebral cortex Brainstem

anxiety, depression, or OBS

severe OBS & psychiatric illness

Person Disorientation

trauma, amnesia, or seizures

Sundowning - wild, impossible to keep in bed, confused, combative

GLASGOW COMA SCALE

Subscale Description Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 Spontaneously To Speech To Pain Do not Open Oriented Confused Inappropriate Speech Unintelligible speech No verbalization Obeys Command Localizes Pain Withdraws from pain Abnormal Flexion Abnormal Extension No Motor Response

* Clients who are unable to cooperate can be evaluated using this scale Best Score = 15 Worse = 3 Scoring E4 V5 M6 ES - Eyes swollen Untestable = (+) dressing ET TR Paresis Plegia Traction Cast

EYE OPENING (E)

VERBAL RESPONSE (V)

MOTOR RESPONSE (M)

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Oxygenation
Assess respiratory status.
Resp rate, rhythm

Auscultate breath sounds/ air entry. Maintain patent airway & adequate ventilation.
O2 therapy, Mechanical Ventilation

Monitor for S/S of cardiorespiratory distress Note for S/S of Hypoxia/ hypoxemia

S/O

Hypoxia/ Hypoxemia
(-) Spontaneous respiration Restlessness/ irritability Peripheral/ central cyanosis Use of accessory muscles of respiration Nasal flaring Angina Tachycardia Tachypnea GIT/ Renal Dysfunction (Late sx) Dx/ Lab results: Pulse Oximetry Capnography ABG Hematology (hct; hgb)

Motor Function
Assess integration of consciousness & voluntary movement. Look for purposeful or nonpurposeful response. Assess muscle tone, size, strength. Observe for symmetric, spontaneous movement of arms & legs

IMPLICATION:
tics, tremors

Motor Function

stress, long term use of psychotropic drugs, neurologic disorders (Parkinsons, MS, or HC)

atrophy, paresis, motor neuron or muscle plegia, flaccidity, disease spasticity, rigidity hemiplegia decorticate corticospinal tract damage upper corticospinal tract damage brainstem damage

decerebrate

ABNORMAL POSTURING

decerebrate brainstem damage

decorticate - upper corticospinal damage

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Assessment tool

Motor Function

MUSCLE STRENGTH GRADING Grade 0 1 2 3 4 Description 2 No contraction Slight contraction Full passive ROM Full ROM Full ROM against some resistance Full ROM against full resistance 2 5 1 4

5
1 5

Pupils
Assess for size, shape & reaction to light. Observe for ptosis.

GENERAL IMPLICATION: Controlled by: CN-III Brainstem Midbrain

Ocular Movement
Assess for deviation to one side. Also assess voluntary & spontaneous movement GENERAL IMPLICATION: Controlled by:

III, IV, VI
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Signs
Assess V/S. Observe for significant trends. Look for Cushings reflex: PR, RR, Widened Pulse Pressure

Urinary Output
Assess for increased output, possible S/S of impaired water regulation. Also assess for electrolyte imbalance

GENERAL IMPLICATION:

Oliguria = ( below 30 cc)

Reflexes
Assess for pathologic reflexes, especially babinski & loss of corneal or gag reflex

Babinski reflex

controlled by L4 & L5, S1 & S2

N=toe flexion (except in infant) Abn=Dorsiflexion of big Toe, Fanning of Little Toes (except in infant) Pyramidal Tract / Upper Motor Neuron Damage
Corneal Reflex Pons Medulla Medulla CN IX CN X

Gag/ cough Reflex

Biceps, Triceps, Patellar, Achilles, Brachioradialis

Requires practice & a relaxed client. Sitting with feet dangling. Easier if used with distractions. Pointed hammer small tendons Flat end larger tendons Compare bilateral responses If any of the DTRs are hyperactive = test for ankle clonus(rhythmic contraction). Lift 1 of the clients legs & support the flexed knee with non-dominant hand. Grasp the foot & quickly dorsiflex the toes. N=(-)Pain & involuntary movement Abn= Clonus=motor neuron mgsp'09 dysfunction

DTR GRADING DTR GRADE Response

0 1+ 2+ 3+ 4+

Absent reflex Diminished Normal Slightly increased Hyperactive

Emergency
Evaluate assessment findings to determine whether emergency exists. If so report findings to doctor STAT

CN I : OLFACTORY
Ask client to SNIFF & identify aromatic substances.

CN II : OPTIC
Use of Snellen Chart Ask client to read printed materials

CN III : OCULOMOTOR

Assess directions of gaze by asking client to follow moving objects. Measure pupillary reaction to light reflex & accommodation

CN IV & VI: TROCHLEAR and ABDUCENS

Assess directions of gaze by asking client to follow moving objects.

CN V : TRIGEMINAL
Corneal reflex Assess light touch & pain sensation across the face Opening the mouth against resistance & moving the jaw from the side to side

CN VII : FACIAL
Ask client to smile, whistle, frown, puff out cheeks, & move eyebrows Have client identify salty & sweet tastes on front of the tongue

CN VIII : ACOUSTIC
Air & bone conduction Ability to hear spoken word

CN IX : GLOSSOPHARYNGEAL

Ask client to identify sour, salty or sweet tastes on back of the tongue Elicit gag reflex and assess swallowing reflex. Ask to speak or cough.

CN X : VAGUS
Ask client to say ah and assess for movement of the palate and pharynx Elicit gag reflex Ask client to speak.

CN XI : ACCESSORY
Ask client to SHRUG shoulders & turn head against resistance

CN XII : HYPOGLOSSAL

Ask client to stick out tongue and move it from side to side

DIAGNOSTIC

EVALUATION

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1. Computed Tomography Scanning (CTScan) 2. Positron Emission Tomography (PET) 3. Single Photon Emission Computed Tomography (SPECT) 4. Magnetic Resonance Imaging (MRI) 5. Cerebral Angiography 6. Myelography 7. Noninvasive Carotid Flow Studies 8. Transcranial Doppler 9. Electroencephalography (EEG) 10.Electromyography (EMG) 11.Evoked Potential Studies 12.Lumbar Puncture and Examination mgsp'09 of CSF

Computed Tomography Scanning

-Makes use of a narrow x-ray beam to scan the body part in successive layers. -Can be performed first without contract followed with contrast.
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Positron Emission Tomography

-A computer-based nuclear imaging technique that produces images of actual organ functioning. -Permits the measurement of blood flow, tissue composition and brain metabolism
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Single Photon Emission Computed Tomography

-A three-dimensional imaging technique that uses radio-nuclides and instruments to detect single photons. -A perfusion study that captures a moment of mgsp'09 cerebral blood flow.

Magnetic Resonance Imaging

-Uses a powerful magnetic field to obtain images of different areas of the body. -Can be performed with or without contrast -Provides information about the chemical changes within the cells
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Cerebral Angiography

-An X-ray study of the cerebral circulation with a contrast agent injected into a selected artery. -Performed by threading a catheter through the femoral artery in the groin and up to the desired vessel.
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Myelography

-An xray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. -Outlines the subarachnoid space and shows any distortion of the spinal cord or spinal dural mgsp'09 sac

Noninvasive Carotid Flow Studies

-Use ultrasound imagery and doppler measurements of arterial blood flow to evaluate carotid and deep orbital circulation.

Transcranial Doppler
-Uses the same noninvasive techniques as carotid flow studies except that it records the blood flow velocities of the intracranial vessels.
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Electroencephalography

-Represents a record of the electrical activity generated in the brain.

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Electromyography

-Is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles and the nerves leading to them.
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Evoked Potential Studies

-These studies are based on the concept that any insult or dysfunction that can alter neuronal metabolism or disturb membrane function may change evoked responses in brain waves.
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Lumbar Puncture and Examination of CSF

-Queckenstedts test: lumbar manometric test -Check for post-lumbar headache and other complications of lumbar puncture.
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lpy

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