Medical-Surgical Nursing: An
Integrated Approach, 2E
Chapter 25
NURSING CARE OF
THE CLIENT:
NEUROLOGICAL
SYSTEM
The Human Nervous System
Its purpose is to control motor, sensory,
and autonomic functions of the body.
 This is accomplished by coordination and
initiation of cellular activity through the
transmission of electrical impulses and
various hormones.

The Nervous System: Structure

The nervous system is divided into:
The central nervous system, consisting of the
brain and spinal cord.
 The peripheral nervous system, which
consists of the cranial nerves and spinal
nerves.
 The autonomic nervous system, which is part
of the peripheral nervous system and
consists of sympathetic and parasympathetic systems.

The Brain

Composed of gray matter and white
matter, the brain controls, initiates, and
integrates body functions through the use
of electrical impulses and complex
molecules.
Physiology of the Brain
The brain is contained within the skull, or
cranium.
 Three coverings of the brain, called the
meninges. They are the dura mater,
arachnoid mater, and pia mater.

The Brain Hemispheres
The right side receives information from
and controls the left side of the body.
Specializes in perception of physical
environment, art, music, nonverbal
communication, spiritual aspects.
 The left receives information from and
controls the right side of the body.
Specializes in analysis, calculation,
problem solving, verbal communication,
interpretation, language, reading, and
writing.

The Spinal Cord
A continuation of the brain stem.
 Exits the skull through the foramen
magnum, an opening in the base of the
skull.

Cerebrospinal Fluid

Provides for shock absorption and bathes
the brain and spinal cord.
Peripheral Nervous System:
Cranial Nerves

Twelve pairs of cranial nerves have
sensory, motor, or mixed functions.
Peripheral Nervous System:
Cranial Nerves

Twelve pairs of cranial nerves have
sensory, motor, or mixed functions.
Cranial Nerves
Olfactory
Optic
Oculomotor Trochlear
Sensory;smell
Sensory;Vision
Motor; Pupil
Constriction
Motor;upper
eyelid elevation
Trigeminal
Abducens
Facial
Acoustic
cornea, nose,
oral mucosa;
mastication
Motor;
Extraocular eye
movement
Motor (facial
muscles);
Sensory (taste)
Sensory;
Hearing;
Equilibrium
GlossoPharyngeal
Vagus
Spinal
Accessory
Hypoglossal
Taste;
Swallowing
Motor and
Sensory
Motor
Tongue
Movement
Peripheral Nervous System:
Spinal Nerves
NERVES
Cervical
 Thoracic
 Lumbar
 Sacral
 Coccyx

NUMBER OF PAIRS
8
12
5
5
1
Peripheral Nervous System:
Autonomic Nervous System


Main function is to maintain internal
homeostasis.
Two subdivisions of ANS:
 The sympathetic system (activated by stress,
prepares body for “fight or flight” response).
 The parasympathetic system (conserves,
restores, and maintains vital body functions,
slowing heart rate, increasing gastrointestinal
activity, and activating bowel and bladder
evacuation).
Cerebral Function: Assessment
Level of Consciousness
Responsiveness; Glasgow Coma Scale (objective tool)
Orientation
Awareness of self in
relation to person, place, and time
Mental Status
Observation of client's
appearance, behavior, posture,
mood, gestures, facial expressions
Emotional Status
Pupil Reaction
Obsevation of client's affect
(emotional repsonse or mood)
Size, equality, and roundness of pupils
Intellectual Function
ability of brain to perform thought processes
Communication
Both written and oral communications
are assessed
Cranial Nerve Function Assessment:
Motor Function
Muscle Size and Symmetry
Type Title Here
Muscle Tone
Type Title Here
Muscle Strength
Coordination
Balance
Posturing
Cranial Nerve Function Assessment:
Sensory Function
Tactile Sensation
Pain and Temperature
Vibration
Proprioception
Sense of joint position in space
Stereognosis
Ability to recognize an object by feel
Graphesthesia
Ability to identify letters, numbers, or shapes drawn on the skin
Integration of Sensation
Cranial Nerve Function Assessment:
Reflexes
Examination
Use of reflex hammer
Description or Grading of Response
Abnormal Reflexes
Common Diagnostic Tests for
Nervous System Disorders
Lumbar puncture (LP).
 Electroencephalogram (EEG).
 Electromyogram (EMG).
 Imaging Procedures.
 Cerebral Angiography.
 Brain scan.
 Myelogram.

Head Injuries
Head injuries involve trauma to the:
Scalp.
 Skull.
 Brain.

Scalp Injuries
They bleed profusely because of the
abundance of blood vessels in the scalp.
 Infection is of major concern.

Skull Injuries
May occur with or without brain injury,
 Fracture usually caused by extreme force,
 Skull fractures considered closed if dura
mater is intact; open if dura mater is torn.

Types of Skull Fractures
Linear (nondisplaced cracks in the bone).
 Comminuted (bone broken into
fragments).
 Depressed (bone fragments pressing into
intracranial cavity).
 Basiliar (fractures of the bones in the
base of the skull).

Brain Injuries: Causes



Acceleration-deceleration force (acceleration
injuries caused by moving objects striking the
head; e.g. baseball bat. Deceleration injuries
result when head is moving and strikes object,
e.g. dashboard).
Rotational (twisting of the cerebrum on the
brain stem, e.g. whiplash).
Penetrating missile (direct penetration of an
object, e.g. bullet, into brain tissue).
Brain Injuries: Open
Brain injuries resulting from skull fractures
and penetrating injuries are referred to as
open head injuries.
 Hemorrhaging from the nose, pharynx, or
ears; ecchymosis over the mastoid area
(Battle’s sign) or blood in the conjunctiva
may occur in conjunction with open head
injuries.

Brain Injuries: Closed
Caused by blunt force to the head.
 Types of closed head injuries include
concussion, contusion, and laceration.

Concussion
Transient neurological deficits caused by
the shaking of the brain.
 Clinical manifestations may include
immediate loss of consciousness lasting
from minutes to hours, momentary loss of
reflexes, respiratory arrest for several
seconds, an amnesia afterwards.

Contusions
Surface bruises of the brain.
 Skin is cool and pale.
 Pulse, blood pressure, and respirations
are below normal.
 Cerebral edema may occur in conjunction
with widespread injury.

Cerebral Lacerations
Tearing of cortical tissue.
 Symptoms include deep coma from time
of impact, decerebate posturing,
autonomic dysfunction, nonreactive
pupils, respiratory difficulty.

Hemorrhage
Intracranial hemorrhage is common
complication of any head injury.
 Treatment is surgery to evacuate the
hematoma, stop the bleeding, and relieve
pressure on the brain.

Brain Tumor
Space-occupying intracranial lesions,
either benign or malignant.
 Clinical manifestations differ according to
area of lesion and rate of growth, but
commonly include alterations in
consciousness, decreased mental
functioning, headaches, seizures, or
vomiting (sometimes sudden and
projectile),

Cerebrovascular Accident
(CVA)
Also known as stroke, CVA is a sudden
loss of brain function accompanied by
neurological deficit.
 Third highest cause of death in U.S.
 Strokes are caused by ischemia (oxygen
deprivation) resulting from a thrombus,
embolus, severe vasospasm, or cerebral
hemorrhage.

Transient Ischemic Attacks
(TIAs)
Frequently preceding CVAs, TIAs are
temporary or transient episodes of
neurological dysfunction caused by
temporary impairment of blood flow to the
brain.
 Classic symptom is fleeting blindness in
one eye.

Epilepsy/Seizure Disorder
Epilepsy is a disorder of cerebral function
in which the client experiences sudden
attacks of altered consciousness, motor
activity, or sensory phenomenon.
 Most clinicians use the term seizure
disorder for epilepsy or seizures
 Seizures are classified as generalized or
partial.

Herniated Intervertebral Disk
A major cause of chronic back pain.
 Majority of herniated disks occur in
lumbar or cervical spine. This can occur
either suddenly from trauma, lifting, or
twisting, or gradually from aging,
osteoporosis, or degenerative changes.

Spinal Cord Injury (SCI)
Occurs from trauma to the spinal cord or
from compression of the spinal cord due
to injury to the supporting structures.
 Each year, almost 10,000 new spinal cord
injuries occur.
 Leading causes are motor vehicle
accidents, acts of violence, falls, and
sporting accidents.

Parkinson’s Disease
A chronic, progressive, degenerative
disease affecting the area of the brain
controlling movement.
 Typical symptoms include muscular
rigidity, bradykinesia (slowness of
voluntary movement and speech), resting
tremors, muscular weakness, and loss of
postural reflexes.

Multiple Sclerosis (MS)
A chronic, progressive, degenerative
disease wherein scattered nerve cells of
the brain and spinal cord are
demyelinated.
 Symptoms include visual disturbance,
numbness, paresthesia, pain, decreased
sense of temperature, decreased muscle
strength, spasticity, paralysis, bowel and
bladder incontinence or retention.

Amyotrophic Lateral Sclerosis
(ASL) (Lou Gehrig’s Disease)

A progressive, fatal disease characterized
by the degeneration of motor neurons in
the cortex, medulla, and spinal cord.
Alzheimer’s Disease (AD)
A progressive, degenerative neurological
disease wherein brain cells are destroyed
and the cerebral cortex atrophies.
 Risk factors include advanced age,
female gender, head injury, history of
thyroid disorders, and chromosomal
abnormalities.

Stages of Alzheimer’s Disease
Stage 1: Early
Forgetfulness, often subtle and masked by client;slowed reaction time;Increasing self-centeredness;
difficulty in learning new information;beginning of compromised performance at home and work
Stage 2: Middle
Progressing forgetfulness; confusion; tendency to lose things; fearfulness; easily induced frustration;
inability to follow simple directions; paranoia; changes in eating and sleep patterns; pacing; wandering
Stage 3: Late
Inability to communicate; Inability to eat; Incontinence; Confinement to bed;
Inability to recognize family and friends
;Total dependence relative to care
Guillain-Barré Syndrome
An acute inflammatory process primarily
involving the motor neurons of the
peripheral nervous system.
 Clinical manifestations include motor
weakness and absence of reflexes
(areflexia).

Headache

Also known as cephalagia, headache is
the condition of pain in the head, caused
by stimulation of pain-sensitive structures
in the cranium, head, or neck.
Types of Headache: Primary
Tension-Type
 Migraine.
 Cluster Headaches.

Types of Headache: Secondary
Secondary headaches are the result of
pathological conditions such as
aneurysm, brain tumor, or inflamed cranial
nerves.
 The headache is caused by compression,
inflammation, or hypoxia of pain-sensitive
structures.

Client Teaching: Headaches

Advise clients to:
 Keep a diary of headache history to
ascertain pattern.
 Avoid foods that trigger headaches.
 Reduce salt intake.
 Practice relaxation techniques.
Trigeminal Neuralgia
(Tic Douloureux)

A condition of cranial nerve V that is
characterized by abrupt paroxysms of
pain and facial muscle contractions.
Encephalitis/Meningitis
Encephalitis is inflammation of the brain.
 Meningitis is inflammation of the
meninges.
 Most common cause of both is a virus.
 Cerebral edema, hemorrhage, and
necrosis of brain tissue can occur.
 Fever, headache, nuchal rigidity,
photophobia, irritability, lethargy, nausea,
and vomiting are typical symptoms.

Huntington’s Disease or Chorea

A chronic, progressive hereditary disease
of the nervous system characterized by
chorea, abnormal involuntary,
purposeless movements of all
musculature of the body.
Gilles de la Tourette’s
Syndrome

A neurological movement disorder that
also has prominent behavioral
manifestations.