The neurologic assessment is one of the most important assessments you will ever perform as a Registered Nurse.
Unlike many other body systems, neurological changes can occur within seconds.
A patient may be talking normally one minute and become unresponsive the next.
Your assessment may literally determine whether a patient receives life-saving treatment in time.
Because of this, nurses are expected to recognize neurological emergencies immediately.
This chapter is one of the highest-yield topics for:
Nursing School
Clinical Rotations
Emergency Nursing
Intensive Care Unit (ICU)
Stroke Unit
Medical-Surgical Nursing
Pediatrics
Geriatrics
NCLEX
By the end of this lecture, you should be able to:
Explain the anatomy and physiology of the nervous system.
Differentiate the Central Nervous System (CNS) from the Peripheral Nervous System (PNS).
Explain the function of neurons and neurotransmitters.
Describe the major lobes of the brain.
Understand the autonomic nervous system.
Obtain a comprehensive neurologic health history.
Recognize neurological emergencies.
Begin thinking like a neurological nurse.
You are caring for a 62-year-old patient admitted for pneumonia.
At 8:00 AM you assess him.
He is:
Alert.
Speaking normally.
Moving all four extremities.
At 8:30 AM you return.
Now you notice:
His speech is slurred.
The right arm is weak.
His smile is uneven.
A new nursing student says,
"Maybe he's just tired."
The experienced RN immediately activates the stroke protocol.
Why?
Because neurological symptoms are emergencies until proven otherwise.
Every minute during an ischemic stroke, approximately 1.9 million neurons may be lost if blood flow is not restored.
This is why nurses never ignore sudden neurological changes.
The nervous system performs three major functions.
The body gathers information.
Examples:
Touch
Pain
Temperature
Vision
Hearing
Smell
Taste
Pressure
Balance
The brain interprets information.
It decides:
What does this mean?
What should the body do?
The nervous system sends commands.
Examples:
Move your arm.
Walk.
Speak.
Blink.
Swallow.
Increase heart rate.
Slow breathing.
Everything begins with these three steps:
Sense
↓
Think
↓
Respond
There are two major divisions.
Includes:
Brain
Spinal cord
Think:
The command center.
Includes:
All nerves outside the brain and spinal cord.
Think:
Communication lines.
The PNS carries messages:
To the CNS.
Away from the CNS.
The CNS is responsible for:
Thinking
Memory
Movement
Language
Balance
Vision
Hearing
Emotion
Learning
Personality
Consciousness
Respiration (through the brainstem)
Cardiovascular regulation
Without the CNS:
No body system can function normally.
The PNS connects:
Brain
↓
Body
It contains:
Cranial nerves
Spinal nerves
Peripheral nerves
The neuron is the functional unit of the nervous system.
Think of it as:
The body's electrical wire.
Each neuron communicates through electrical and chemical signals.
The human nervous system contains billions of neurons.
Every neuron has three major parts.
Receive information.
Think:
Dendrites Detect.
Processes information.
Contains:
Nucleus
Organelles
Carries signals away.
Think:
Axon = Away.
Many axons are covered with:
Myelin.
Purpose:
Insulates the nerve.
Allows rapid conduction.
Think:
Electrical wire insulation.
Diseases like Multiple Sclerosis (MS) damage myelin, slowing nerve transmission and causing neurological deficits.
Neurons communicate using chemicals called neurotransmitters.
Common neurotransmitters include:
Acetylcholine
Dopamine
Serotonin
Norepinephrine
Gamma-aminobutyric acid (GABA)
Glutamate
These chemicals influence movement, mood, memory, sleep, and many other body functions.
The adult brain weighs approximately:
1.3–1.4 kg (about 3 pounds).
Despite its size, it controls the entire body.
The brain has three major parts.
Cerebrum
Cerebellum
Brainstem
Largest portion.
Responsible for:
Thinking
Language
Reasoning
Memory
Voluntary movement
Vision
Hearing
Personality
Judgment
Emotion
There are:
Right hemisphere
Left hemisphere
Generally:
The left hemisphere controls the right side of the body.
The right hemisphere controls the left side of the body.
This is called contralateral control.
Each lobe has specialized functions.
Responsible for:
Personality
Decision making
Planning
Judgment
Speech production (Broca's area)
Voluntary movement
Problem solving
Emotion
Damage may cause:
Poor judgment
Personality changes
Weakness
Difficulty speaking
Responsible for:
Touch
Pain
Temperature
Pressure
Position sense
Spatial awareness
Damage may result in difficulty interpreting sensory information or recognizing the position of body parts.
Responsible for:
Hearing
Memory
Language comprehension (Wernicke's area)
Emotion
Damage may affect understanding of spoken language or memory.
Responsible for:
Vision.
Damage may cause visual disturbances or loss of visual fields.
F P T O
Front = Thinking and movement
Parietal = Pressure and touch
Temporal = Talking and hearing
Occipital = Optical (vision)
The cerebellum controls:
Balance
Coordination
Fine motor movement
Posture
Smooth movement
Damage produces:
Unsteady gait
Poor coordination
Difficulty with rapid movements
The patient is not weak.
They simply cannot coordinate movement properly.
The brainstem includes:
Midbrain
Pons
Medulla
Controls:
Breathing
Heart rate
Blood pressure
Swallowing
Level of consciousness
Many cranial nerve functions
Brainstem injury is often life-threatening.
The spinal cord connects:
Brain
↓
Peripheral nerves
Functions:
Carries motor signals.
Carries sensory signals.
Coordinates reflexes.
Damage may cause:
Paralysis
Loss of sensation
Loss of bowel or bladder control
Respiratory failure (high cervical injuries)
Controls:
Voluntary skeletal muscle movement.
Example:
Walking.
Writing.
Talking.
Controls:
Involuntary functions.
Examples:
Heart rate
Blood pressure
Digestion
Sweating
Pupil size
Respiration
Think:
Fight or Flight
Effects include:
Heart rate increases.
Blood pressure increases.
Pupils dilate.
Bronchi dilate.
Digestion slows.
Blood glucose rises.
The body prepares for action.
Think:
Rest and Digest
Effects include:
Heart rate decreases.
Pupils constrict.
Digestion increases.
Salivation increases.
Energy is conserved.
Sympathetic = Stress
Parasympathetic = Peace
Begin with:
"What brought you in today?"
Then ask focused questions.
Ask:
When did it begin?
Where is it located?
How severe is it?
Sudden or gradual?
Associated nausea?
Vision changes?
Weakness?
A sudden "worst headache of my life" is a medical emergency and may indicate a subarachnoid hemorrhage.
Ask:
Which side?
Sudden or gradual?
Constant or intermittent?
Associated numbness?
Difficulty speaking?
Difficulty walking?
Sudden weakness should raise concern for stroke.
Determine:
Location.
Pattern.
Duration.
Associated weakness.
Clarify what the patient means.
Do they mean:
The room is spinning (vertigo)?
Feeling faint (presyncope)?
Loss of balance (disequilibrium)?
General lightheadedness?
These symptoms have different causes.
Ask:
First seizure?
Duration?
Loss of consciousness?
Tongue biting?
Loss of bladder control?
Confusion afterward?
Witnesses?
Determine:
Resting tremor?
Occurs with movement?
One side or both?
A resting tremor is classically associated with Parkinson disease.
Ask:
Recent memory?
Long-term memory?
Difficulty finding words?
Difficulty performing familiar tasks?
Family concerns?
Memory complaints deserve careful assessment, especially in older adults.
Neurologic causes include:
Stroke
Parkinson disease
Peripheral neuropathy
Cerebellar disorders
Medication effects
Every fall deserves investigation.
Immediately recognize:
Sudden unilateral weakness
Slurred speech
Facial droop
New seizure
Sudden vision loss
Sudden confusion
Loss of consciousness
Worst headache of life
Neck stiffness with fever
Acute paralysis
These findings require urgent evaluation.
A patient suddenly develops:
Right facial droop
Right arm weakness
Slurred speech
Think:
Acute stroke.
Time-sensitive emergency.
A patient reports:
Gradually worsening hand tremor
Slow movements
Shuffling gait
Think:
Parkinson disease.
A patient reports:
Sudden severe headache
Neck stiffness
Vomiting
Think:
Possible subarachnoid hemorrhage.
A patient reports:
Progressive numbness in both feet
Burning pain
Difficulty walking
Think:
Peripheral neuropathy.
Patient is alert and oriented. Reports intermittent headaches over the past three days rated 4/10 without visual changes, weakness, or loss of consciousness. Denies numbness, seizures, dizziness, or recent falls.
Assuming dizziness always means vertigo.
Ignoring sudden neurological changes.
Confusing weakness with fatigue.
Failing to assess symptom onset.
Not recognizing stroke warning signs.
Ignoring family observations about memory changes.
Which structure is part of the central nervous system?
A. Sciatic nerve
B. Median nerve
C. Brain
D. Femoral nerve
Answer: C
The sympathetic nervous system primarily prepares the body for:
A. Digestion
B. Sleep
C. Fight-or-flight responses
D. Tissue repair
Answer: C
A patient develops sudden facial droop, slurred speech, and right arm weakness. What is the nurse's priority action?
A. Reassess in one hour.
B. Encourage the patient to rest.
C. Activate the stroke protocol and notify the provider immediately.
D. Give oral fluids.
Answer: C
Which lobe of the brain is primarily responsible for vision?
A. Frontal
B. Parietal
C. Temporal
D. Occipital
Answer: D
The myelin sheath primarily functions to:
A. Produce cerebrospinal fluid.
B. Slow nerve conduction.
C. Insulate axons and speed nerve impulse transmission.
D. Store neurotransmitters.
Answer: C
Central = Command Center
Brain + Spinal Cord.
Peripheral = Pathways
Carries messages to and from the CNS.
Dendrites Detect
Receive information.
Axon = Away
Carries impulses away from the cell body.
F P T O
Frontal = Thinking, personality, movement
Parietal = Pressure, touch, sensation
Temporal = Talking, hearing, memory
Occipital = Optical (vision)
Without looking at your notes:
What are the three major functions of the nervous system?
What is the difference between the CNS and PNS?
What are the parts of a neuron and their functions?
What is the purpose of myelin?
What are the functions of each cerebral lobe?
What does the cerebellum control?
What functions does the brainstem regulate?
What is the difference between the sympathetic and parasympathetic nervous systems?
Which neurological symptoms require immediate evaluation?
Why is determining the exact onset of neurological symptoms so important?
Practice obtaining a focused neurologic health history from a classmate or family member.
Include:
Chief complaint.
Headache assessment.
Weakness or numbness.
Dizziness (clarify the type).
Vision or hearing changes.
Seizure history.
Tremors.
Memory changes.
Falls.
Current medications that may affect neurologic function.
Today you built the foundation for neurologic assessment. You learned the organization of the nervous system, neuron structure, neurotransmission, brain anatomy, spinal cord function, the autonomic nervous system, and how to obtain a comprehensive neurologic health history. You also learned to recognize time-sensitive neurologic emergencies such as stroke and subarachnoid hemorrhage.