Neurological

Anatomy and Physiology of Nerves

Types and Functions
Neurons Neuroglial cells
-Impulse conducting cells that facilitate communications -Specialized cells that support and protect neurons
-Receive and transmit/conduct information in response to stimuli -“Glue” that holds neurons together, provide support, nutrition and
-3 types protection
Afferent (sensory): detect sensory stimuli from receptors (sensory -Astrocytes: stars  provide structure and support, attach to blood
nerve endings) and transmit to CNS vessels, neurons and pia matter  restrict substances from entering
Efferent (motor): transmits message from brain back to muscles or neurons (BBB), assist in conduction of impulses, known to clear cellular
glands that respond debris
Interneurons: transmit messages integrate incoming and outgoing -Ependymal cells: line ventricles of brain and central canal of spinal cord
messages, process and store information, make decisions about body’s  assist in production of CS and protect brain from foreign materials
response to stimuli entering through bloodstream
-Cell body: contains nucleus, nucleolus, ER, Golgi apparatus, -Microglia: small cells that are phagocytic when encountered
mitochondria inflammation or debris, means of defense
-Dendrites: short, treelike structure that receive stimuli and transmit -Oligodendrocytes: small cells that form myelin sheaths, aid in
them to cell body conduction of impulses
-Axon: extends away from cell body carrying impulses to another neuron, -Schwann cells: form myelin sheath that cover axons in PNS
muscle cell or NT, chemical messengers
-Grey matter: contain cell bodies, dendrites, axon terminals
-White matter: contains neuronal axons covered w/myelin sheath
(insulates axon and speeds impulse transmission  myelin is NOT
continuous, segmented in evenly space intervals (spaces = nodes of
Ranvier)

Conduction of Nerve Impulses

The action potential of a nerve cell facilitates the transmission of information from a presynaptic neuron to a receptor through the action of a sodium-
potassium pump. At rest, the cell has a negative charge inside and a positive charge on the outside. When the cell receives a stimulus, sodium
channels are opened, allowing positively charged sodium to enter the cell, which makes the inside of the cell positive. This is the depolarization
phase of the action potential. Repolarization occurs when sodium channels close and potassium channels open fully, allowing potassium to exit
the cell. This repolarization results in a return to the negative charge inside the cell or a return to the resting cell membrane potential.
 Hyperpolarization: makes cell refractory to another impulse. During hyperpolarization, sodium potassium pump gradually reestablishes the
resting intracellular and extracellular sodium and potassium concentrations
Central Nervous System
 Brain is divided into 3 parts
o Cerebrum
 Largest portion of brain, covered by thin layer of grey matter, cerebral cortex
 Divided into R and L hemispheres by longitudinal fissure  connected by corpus callosum (thick fibers that facilitates
communication between 2 hemispheres)
 Folds  gyri
 Grooves  sulci
 Deep sulci  fissures
 Divided into 4 lobes
 Frontal
 Parietal
 Temporal
 Occipital
 Thalamus: relay center for sensory impulses to cerebral cortex
 Information for pain, temperature, taste, smell, hearing, equilibrium, vision and touch
 Helps monitor control
 Basal ganglia: regulators movement by sending information back and forth through thalamus to cerebral cortex
 Signals from basal ganglia are inhibitory, cerebellum signals are excitatory
 Coordinated movement achieved through balance of both systems operating properly
 Results in movement disorders (Parkinson’s)
 Hypothalamus: main regulator for ANS by sending signals to brainstem, regulating HR and BP
 Regulates metabolism reproduction, growth and stress response by secreting hormones that control anterior
pituitary gland
 Thermoregulation, regulating food and water intake, sleep, memory and emotional behavior
 Limbic system: consist of cingulate gyrus, hippocampus and amygdala
 Primary role: memory and emotions, center for gratification and aversion
 Stimulated  gratification center produces sensations of pleasure or reward and aversion center produces
objectionable feelings of grief or dread
o Cerebellum
 Located at base of brain or posterior fossa, behind medulla and pons
 Attached to brainstem by nerve fibers  peduncles (carry signals to and from cerebellum)
 Divided into R and L lobes, connected by narrow structure (vermis)
 Responsible for coordination of muscle activates, fine muscle movement, balance
 Problems  present with balance and gait issues
 Nonmotor functions  speech, sensing, emotion
o Brainstem
 Injury to area can be life-threatening
 Reticular formation: runs throughout brainstem
 Motor control and coordination and maintaining balance and posture during movement
 Respiratory and cardiac control
 Pain modulation by providing a route of passage for pain signals from the lower body
 Alertness and sleep by controlling some of the sensory stimuli that reach the cerebral cortex
 Consist of 3 areas
 Medulla: located at level and below foramen magnum (opening in skull that allows spinal cord to connect
w/brainstem)
• Contains respiratory and cardiac centers
• HR, RR, BP regulation, rate, depth of breathing located here
• Vomiting, coughing, sneezing and swallowing controlled in medulla
• 4 cranial nerves: glossopharyngeal (IX), vagus (X), spinal accessory (XI), hypoglossal (XII)
 Pons: rest above the medulla, below and anterior to midbrain
• relays all impulses between brain and spinal cord
• 4 cranial nerves: trigeminal (V), abducens (V), facial (VII), acoustic (VIII)
 Midbrain: contains nerve pathway between cerebrum and medulla
• Contains aqueduct of sylvius of ventricular system (contain 3 rd and 4th ventricles)
• Cranial nerves: oculomotor (III), trochlear (IV)
Blood flow in Brain
 Arterial circulation of brain supplied by R and L internal carotid arteries and R and L vertebral arteries
 Internal carotids  supply blood to cerebrum
o Divided into middle cerebral artery (MCA) and connected to each other by small interior communicating artery
o Strokes  MCA
o Vertebral arteries join to form basilar artery  divides into posterior cerebral arteries  supply blood into posterior portion of brain,
cerebellum and brainstem
 Circle of Willis: formed by the joining of internal carotid arteries and vertebrobasilar arteries  provide blood flow throughout brain
o If blocked/ruptured  arterial circulation in brain impacted leading to damage secondary to hypoperfusion and ischemia
 Venous blood flow: occurs through Dural sinuses  venous channels between dura matter and brain
o Blood from deep internal and external veins, as well as CSF from subarachnoid space empty into channels to be transported back to
heart via internal jugular vein (NO VALVES)
Spinal cord
 Pathway that carries information to and from brain and rest of body via spinal nerves of PNS
 Begins at brainstem and extends to levels of L1-2
 Composed of both grey and white matter
 White matter  contains ascending and descending tracts (transmits information to and from brain and target organs/cells)
o Ascending  contain sensory neurons and carry impulses UP spinal column TO the brain
o Descending  contain motor neurons, carry impulses DOWN spinal column to target MUSCLES
 Decussation  “crossover” in spinal column  R side of brain control L side of body (contralateral)
 Ipsilateral  origin and track are on same side of body
Protective Mechanisms for Brain and Spinal Cord
 Skull
o Encases and protects brain from injury
o Fontanelles  “soft” spots during infancy that provides flexibility during delivery and passage through birth canal  closes at
approximate age of 2 y/o
 Vertebrae
o Skeletal structures that cover and protect spinal cord
o Provides head w/support, allows flexibility and movement, maintain body in upright body position
 Cervical: 7
 Thoracic: 12
 Lumbar: 5
 Sacral (fused): 5
 Coccygeal (fused): 4
  Meninges
o Fibrous membrane layer that protect brain and spinal cord
o Falx cerebri: separates R and L cerebral hemispheres
o Supratentorial structures: cerebrum and diencephalon (thalamus and hypothalamus)
o Infratentorial structure: cerebellum and brainstem
o Meningeal spaces
 Spaces between membrane
 Epidural space: between skull and dura matter  middle meningeal artery located here  if torn/damaged, epidural bleed
 If bleed occurs  venous hemorrhage (3rd subarachnoid space)

FIGURE 35.12 Vertebral body and curvatures. The vertebrae consist of a body and a vertebral arch composed of a pedicle and a lamina. Vertebrae are
connected by facet joints that allow movement of the vertebral column. Each vertebra has a central canal, the vertebral foramen, through which the
spinal cord passes.

FIGURE 35.13 Meningeal layers and spaces. The meninges protect the brain and spinal. The outermost layer is called the dura mater, that is a tough,
fibrous membrane that rests against the interior part of the skull. The second layer of the meninges is the arachnoid, which is a very thin layer with a
spider-web appearance. The inner membrane is the pia mater, which is a highly vascular membrane that lies in direct contact with the brain. The
epidural space is a potential space that exists between the skull and the dura mater. The subdural space sits between the inner dura matter layer and
the arachnoid layer. The third space is the subarachnoid space. This is between the arachnoid membrane and the pia matter.

FIGURE 35.15 Flow of cerebrospinal fluid. Starting in the lateral ventricles, the choroid plexus secretes CSF. From there, CSF flows into the third
ventricle, then into the fourth ventricle. CSF then flows into the central canal that houses the spinal cord or into the subarachnoid space to circulate
around the brain, brainstem, and spinal cord, providing cushioning, protection, and nutrition.
 CSF
o Circulates through ventricles in brain and into subarachnoid space
o Produced in choroid plexus of ventricles
o Hydrocephalus  CSF not able to drain adequately into venous system, causing ventricles to enlarge with fluid
 BBB
o Protective structure of brain
o Separates circulating blood volume from ECF in brain and prevents passage of abx, toxins or macrophages
o Formed by tight junctions  more selective
Peripheral Nervous System
 Spinal nerves
o Transmit information to and from spinal cord and receptors throughout body
o Dorsal root carries sensory information to spinal cord (afferent)
o Nerve plexuses: cervical, brachial, lumbar and sacral plexuses
 Cervical: innervate head and shoulders (phrenic nerve  diaphragm to stimulate breathing)
 Brachial: innervate neck, shoulder and arm
 Lumbar: innervate thigh and leg
 Sacral: innerve posterior thigh, lower leg and foot
 Sciatic nerve: arises from sacral plexus and travels down posterior thigh
o Dermatome: area on skin supplied by specific spinal nerve and maps where nerve fiber provides sensation/feeling
 Cranial nerves
o 3 sensory
o 5 motor
o 4 mixed
ANS SNS PNS
-Consist of sympathetic and parasympathetic -Thoracolumbar system, stress/physical activity -Craniosacral system, receives information from
-Regulated by type of NT released at synapse -Fight or flight brainstem or sacral region of spinal cord
site and type of receptor on target cells -NT released is NE -NT released is ACH
-Receptors: adrenergic receptors -Nerve fibers that secrete ACH are cholinergic
-Alpha: excitatory effect, vasoconstriction, fibers
increase BP -Muscarinic receptors: located on cardiac and
-Beta: inhibitors, dilate bronchioles, enhances smooth muscles, gland cells are excitatory or
airflow inhibitory response depending on target organ
system
**ACH has excitatory effect on intestinal
smooth muscle and inhibitory effect on cardiac
muscle
-Nicotine receptors: located on skeletal muscle
and cells of adrenal medulla, excitatory effect

FIGURE 35.16 Spinal nerves. Spinal nerves transmit information to and from the spinal cord and receptors
throughout the body. There are 31 pairs of spinal nerves: eight cervical, twelve thoracic, five lumbar, five sacral, and one coccygeal. The phrenic nerve
innervates the diaphragm.
Neuro Assessment
Mini-mental status examination: used to assess cognitive function, asses persons orientation, attention, calculation ability, memory and language
abilities
Score <20  cognitive impairment
VS and Increased ICP
 Increased ICP  disturbance in balance of volumes within brain: brain tissue, CSF and blood
o Occurs  mass/lesion, increased blood volume due to hemorrhagic event
o Increase CSF r/t blockage/shock
o Monro-Kellie hypothesis  sum of volumes of the brain (brain tissue, CSF, intracranial blood) is constant
o Normal: 7-15 mmHg, >15-20 mmHg requires interventions.
o Classic sign of ICP: Cushing’s triad, elevated BP w/widening pulse pressure, bradycardia, irregular respirations

Diagnostic studies
Radiographic procedures
 Done to assess skull and spinal column for fx, compression, stenosis and malformation
 Close monitoring for pt w/suspected c-spine injury b/c potential injury and paralysis if damage to spinal cord occurs
 Immobilized w/hard collar until spinal cord injury ruled out
CT scan
  Used to assess bleeding, edema, tumors
 Required for pt w/suspected hemorrhagic or ischemic stroke to rule out bleeding prior to receiving thrombolytic therapy
 1st step prior to MRI or if MRI is contraindicated
 Nursing implications
o Explain procedure
o Assessing potential need to medicate for anxiety
o IV access
o Check allergies to iodine (shellfish or dye)
o Monitory BUN and Creatinine (kidney function)  contrast is toxic to kidney and can impair renal function
o Assess for DM2 and use of metformin
o Post procedure care
 Administer IV fluids/increase PO fluids to clear contrast medium from system
 Monitor for allergic reactions

PET scan
 Administration of radioactive glucose tracer fluorodeoxyglucose (FDG)  detect areas of increased metabolic activity in body
 Sensitive for detecting cancer b/c rapidly dividing cancer cells absorbed the tracer
 Nursing implications
o NPO 6-12 hrs prior procedure to limit metabolic activities r/t digestion
o NO caffeine, EtOH or tobacco for 24 hrs prior to procedure  interfere/scan results
o Lie still during exam to minimize metabolic activity
o Tracer administered pt to remain quietly in dark room to allow tracer to be distributed throughout body
o Post procedure
 Adequate fluid intake to clear tracer from circulation
MRI
 NONINVASIVE and painless imaging study that uses magnetic fields to obtain images
 If contrast used  noniodine (limits issues w/allergies and nephrotoxicity)
 Used to assess injuries of brain and spinal column (tumor dx, infections, bleeding, CVA/stroke
 Nursing implication
o Pt education
o Screening pt for metal objects  metal interfere w/magnetic field, safety hazard
o Implanted device that contain metal (ie: pacemaker) may be contraindicated to MRI b/c field may disable device
o Assess for anxiety, process for procedure  up to 50 mins in tunnel like chamber
 Claustrophobic pt  may need sedation
o Post procedure
 Hydration, clearance through kidneys
MRA
 Type of MRI that uses radio wave signal characteristics of flowing blood to get images of body’s blood vessels
 Used to determine presence of aneurysms, clots, dissections, vessel stenosis
Cerebral Angiography
 Invasive, intra-arterial, radiologic procedure that involves administration of radiopaque dye through catheter inserted in artery (femoral)
 Fluoroscopy  done to visualize cerebral circulation
 Angiography done  evaluate cerebral and ocular vessel occlusion, carotid disease, aneurysm, arteriovenous malformation, other vascular
disorders
 Nursing implications
o Providing preprocedure education to include:
o • Instructing the patient not take anything by mouth after midnight before the procedure
• Explaining that the procedure takes approximately 60 to 120 minutes
• Describing that an IV catheter will be inserted prior to the procedure to provide hydration during and after the procedure to
help clear the contrast
• Teaching that the administration of IV contrast may cause a warm, flushed feeling
• Providing preprocedure care to include:
• Ensuring informed consent has been obtained
• Completing a neurological, peripheral pulse, and vital signs assessment before the procedure to establish a baseline
from which to evaluate any changes. Ensuring that the patient and family understand that there are risk factors including
the risk for a stroke because of the potential for thrombus dislodgement, and the risk for impaired peripheral circulation
distal to the arterial catheter placement
• Assessing for allergies to contrast dye, iodine, and seafood because contrast dye contains iodine. Seafood typically
contains iodine.
• Evaluating renal function parameters (BUN and creatinine levels) prior to IV contrast administration because contrast is
nephrotoxic
• Assessing for use of anticoagulants as they place the patient at risk for bleeding during and after the angiogram.
• Administer IV sedation as ordered
• Providing postprocedure care to include:
• Monitoring vital signs, neurological status, and pulses distal to the catheter insertion site every 15 minutes for the first
hour, then every hour as ordered. (It is important to follow agency specific policies).
• Maintaining pressure on arterial catheter (puncture) site for 15 to 20 minutes after removal to avoid bleeding or
hematoma formation at the site
• Ensuring that the patient keeps the leg straight and maintains bedrest for 6 to 12 hours as ordered post procedure and
after catheter removal to avoid bleeding or hematoma formation at the catheter insertion site
• Maintaining IV fluid hydration post procedure to help clear contrast dye from the circulation
• Monitoring for bleeding, hematoma formation, or infection at catheter insertion site
• Monitoring renal function (BUN and creatinine levels) post procedure
CTA
 Used to evaluate cerebral vasculature
 Less invasive b/c contrast is injected into vein rather than artery
 Used if MRA is contraindicated
  Same pt info as CT scan
EEG
 Inexpensive, noninvasive procedure that uses 8-24 scalp electrodes to trace spontaneous electrical activity of brain
 Dx test for epilepsy and other electrical activity abnormalities
 Used also part of sleep studies/way to evaluate unconscious pt or determine brain death
 Nursing implications
o No caffeine consumption 8-12 hrs prior to procedure (caffeine may alter results)
o Wash hair night before and morning of test and avoid use of hair products prior to test to aid in scalp electrode attachment
Evoked Potentials
 Painless, noninvasive test that measures the speed and size of nerve conduction generated by nervous system in response to stimuli
 Visual evoked potentials use visual test patterns as stimulus, indicated for optic neuritis or tumors
 Auditory brainstem stimulated by sounds, used to test for VIII damage
 Somatosensory evoked potentials focus on nerve conduction in arms and legs, done w/mild electrical stimulation
o Placed on wrist (medial nerve) or knee (perineal nerve)
 Nursing implications
o Pt education include  wash hair night before and morning of test (same as EEG)
LP
 Most common procedure to obtain sample of CSF for analysis and measure pressure
 Glucose or protein/cloudy appearance  infection
 Blood  bleeding into subarachnoid space or traumatic spinal puncture/tap
 Used to administration of spinal anesthesia and intrathecal medication or to remove CSF to reduce pressure
 Positioned on side, with legs drawn up toward chest (invasive procedure L3-L4)
 Nursing Implication
o Providing preprocedure education explaining the lumbar puncture
o Providing preprocedure care to include:
 Ensuring that antiplatelet or anticoagulation medications have been held prior to the test to reduce the risk of bleeding
 Checking coagulation studies prior to the test
 Ensuring that informed consent has been obtained
o Providing supportive care as necessary during the test
o Providing postprocedure care to include:
 Ensuring flat bedrest for 4 to 6 hours after the test to help prevent CSF leakage, which can cause severe headache (see
Safety Alert)
 Encouraging fluids post procedure to decrease headache intensity if present

Myelography
 Invasive radiographic procedure that involves LP and injection of contrast medium into subarachnoid space around spina cord
 Evaluate for lesions, cyst, injury, herniated discs, tumors
 Not performed since MRI developed
 Nursing implication
o Checking for allergies to contrast dyes, iodine, or seafood because of the administration of contrast during the test
o Ensuring that informed consent has been obtained
o Educating the patient to take nothing by mouth for 4 hours prior to the test
o Ensuring hydration after the test to promote excretion of contrast dye
Biopsy
 Invasive procedures done to obtain tissue samples for examination (ie: CJD)
 Types
o Needle
 Involves drilling small hole into skull, inserting needle and withdrawing sample
o Stereotactic
 Use of specialized computer imaging that utilizes 3D coordinate system to locate area to be bx
o Open
 Removing bone from skull in operative procedure, exposing tumor or tissue to be bx (done in OR under general
anesthesia)
Psychosocial considerations

Age related changes

 Decline in availability of NT and postsynaptic receptors  voluntary motor movements decreased functioning
 Vascular changes (loss of elasticity and stenosis after delivery of O2 to brain)
 Balance and coordination impaired  lead to increase falls
 Polypharmacy, orthostatic hypotension, osteoporosis, arthritis is complication (increased falls)
 Decreased awareness of sense of touch, smell, temperature and pain sensations
 Cognitive impairment ranges from confusion, disorientation, impulsive behavior and poor judgement
 UTI  untreated in elderly = altered mental status
Coordinating care for Patients with Brain Disorders
Headache
-Cephalalgia
-Results of reaction of nociceptors (pain sensitive nerve endings) to triggers, sending messages to thalamus vs CN V (trigeminal)
-2 Types of HA: Primary and Secondary
Primary Secondary
-NOT associated w/underlying causes -Caused by underlying pathology, such as infections, neoplasms
-Major types: migraine, tension HA, cluster (tumors), vascular (blood vessels), medication induced disorders,
idiopathic, typically present w/sudden onset of pain (severe)

Clinical manifestations
Tension Cluster Migraine
Episodic or chronic nature -Nervous HA -Premonitory phase: occurs 24 hrs before HA
-Episodic: typically occur 10-15 days per -Presents: severe, unrelenting, unilateral pain develops (manifestations mood changes, fluid
month, lasting 30 mins to several days in and around eye retention, increased urine output, excessive
-Chronic: occur more than 15 days per month -Peak pain  5-19 minutes after onset, lasting and uncontrolled yawning, food cravings)
over 3-month period, generally more severe 1-3 hours -Aura (flashing lights and muscle weakness),
than episodic -Generally, occur around same time for several followed by HA phase, pain starts gradually,
-Manifestations: mild to moderate pain (B/L in weeks, more often at night, reoccur daily to building in intensity
occipital area), constant pressure to face, head near daily for weeks to months followed by -Postdromal phase: experience confusion and
and neck, often w/sensitivity to light periods of remission exhaustion, can last for 24 hrs before pt feel
they are back to baseline health
Management
 Sudden onset of HA: evaluated for s/s of meningitis, CSF leak, cerebral aneurysm (rupture), brain tumor
 Atypical HA: sudden and severe onset, accompanied by neurological deficits, unusual precipitating factors, pain in neck or jaw, age >50 y/o,
other dx testing
 Diagnostic: CT, blood test, MRI, EEG, sleep studies for OSA
Treatment
Medication Lifestyle Modification/Complementary and Alternative Therapies (CAM)
-NSAIDs, Analgesics, Muscle relaxants, Sedatives, Antidepressants -ID food triggers and eliminating them from diet
-Serotonin (NT)  vasoconstriction, lowers pain threshold -Regular meals and adequate hydration
-Triptans  increase serotonin, moderate to severe migraine pain -Establish consistent sleep habits
-Antiseizure medication (lamotrigine and gabapentin)  increase level of Riboflavin (vit B12), magnesium and Coenzyme 10
NT and diminish pain impulses Alternative therapies: biofeedback, massage, gentle exercise of neck,
-Anti-HTN  b blockers (propranolol) and CCB (amlodipine)  prevention cognitive behavior therapy (stress reduction techniques), meditation,
of migraines by increasing serotonin, dopamine and NE relaxation training, yoga, acupuncture/acupressure
-SSRI
-TCA
Age related considerations
 Children: shorter duration and more B/L in nature
 GI disturbances more common in children as well
 Dental care: caries, ill0fiting denture (source of HA)
 Age >50 y/o  assessed for vascular cause of HA such as cerebral blood vessel abnormality and stroke
Complications
Medication Overuse Status Migrainosus and Hemicrania Continua
-Chronic daily HA r/t excessive use of OTC (acetaminophen and -tx: IV hydration and medication tx w/dihydroergotamine and antiemetics
ibuprofen)
-Sudden withdrawal of medication while provider places pt on medication
to prevent HA or gradual withdrawal of OTC
Nursing Management
 Assessment and Analysis
o Acute HA, photophobia, N, vertigo, aura
o VS, pain, triggers, Abortive and preventive measure, aura for HA
o Administer medication prescribed
o Maintain calm, dark, quiet environment
o Importance of adequate sleep
o Pain medication as prescribed
o Food triggers
Primary Brain Tumors

Seizures
Meningitis
Encephalitis
Parkinson’s
Alzheimer’s