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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