GROUP 5

NEUROLOGIC ASSESSMENT

Members:
Tumulak, Anne Corraine
Ubas, Ma. Marithel
Ueno, Liza
Yray, Aireen Mae
Ycong, Dixie
Objectives: After 5 hours of varied classroom activities, the Level 1 students will be able to:

1. define the following terms:

1.1 Spinal Accessory 1.9 Abducens
1.2 Glossopharyngeal 1.10 Oculomotor
1.3 Olfactory 1.11 Trigeminal
1.4 Facial 1.12 Trochlear
1.5 Hypoglossal 1.13 Cerebrospinal fluid
1.6 Acoustic 1.14 Hypothalamus
1.7 Optic 1.15 Gag Reflex
1.8 Vagus

2. briefly discuss the anatomy and physiology of the Nervous System with emphasis on
the following concepts:
2.1 classification of the Nervous System
● Central Nervous System
● Peripheral Nervous System
2.2 major Structures of the Brain
2.3 Major types and functions of the 12 Cranial Nerves
2.4 Cross-Section of the Spinal Cord
3. state the purpose of neurologic assessment.
4. enumerate the indications of neurologic assessment.
5. discuss the following:
5.1 Mental Status Assessment
5.2 Glasgow Coma Score
5.3 Cranial Nerve Assessment
5.4 Sensory Nerve Assessment
● Test for light touch sensation, pain sensation, temperature sensation
● Test for vibratory sensation, sensitivity to position
● Assessing tactile discrimination (stereognosis, graphesthesia)
● Two point discrimination, extinction and etc.

5.5 Motor Assessment and Cerebellar Assessment

● To evaluate balance (heel to toe, Romberg’s Test)
 ● To assess coordination (finger to nose test, test for rapid alternating
movements, heel to shin test)
5.6 Reflex Assessment
- Deep Tendon Reflex - Patellar Reflex
- Biceps Reflex - Achilles Reflex
- Brachioradialis Reflex - Plantar Reflex
- Triceps Reflex
5.7 Test for meningeal irritation or inflammation
● Test for brudzinski’s sign
● Test for kernig’s sign
6. present the steps, normal and abnormal assessment findings in neurologic assessment
7. enumerate the assessment findings in the following conditions:
7.1 Cerebrovascular Accident (include its risk factor)
7.2 Cerebral Cortex Disorder
7.3 Oculomotor Nerve Paralysis
7.4 Peripheral Neuropathy
8. identify the different materials needed and its uses in neurologic assessment
9. state the nursing responsibilities before, during and after neurologic assessment
10. demonstrate beginning skills in neurologic assessment
1. Define the following terms:
1.1 Spinal Accessory
- The spinal accessory nerve, is the Cranial Nerve #11. It has a motor impulse
that innervates neck muscles (sternocleidomastoid and trapezius) that promote
movement of the shoulders and head rotation. It also promotes some movement
of the larynx.

1.2 Glossopharyngeal
- It is also known as the Cranial Nerve #9. For its sensory impulse, it contains
sensory fibers for taste on the posterior third of the tongue and sensory fibers of
the pharynx that result in the gag reflex when stimulated. For its motor impulse, it
provides secretory fibers to the parotid salivary glands and promotes swallowing
movements.

1.3 Olfactory
- It is also known as the Cranial Nerve #1. It has a sensory impulse; it is the
nerve that carries smell impulses from the nasal mucous membrane to the brain.
1.4 Facial
- It is also known as the Cranial Nerve #7. For its sensory impulse, it contains
sensory fibers for taste on anterior two thirds of tongue, and stimulates secretions
from salivary glands (submaxillary and sublingual) and tears from lacrimal
glands. For its motor impulse, it supplies the facial muscles and affects facial
expressions (smiling, frowning, closing eyes).

1.5 Hypoglossal
- It is the Cranial Nerve #12. It has a motor impulse; it innervates tongue
muscles that promote the movement of food and talking.

1.6 Acoustic/Vestibulocochlear
- It is the Cranial Nerve #8 which contains sensory fibers that are concerned
with hearing, balance, and head position. It branches into two parts, acoustic
nerve is for transmitting sound reception for hearing and vestibulocochlear is for
hearing, balance, and head position.
1.7 Optic
- It is also known as the Cranial Nerve #2. It has a sensory impulse; it is the
nerve that carries visual impulses from the eye to the brain.

1.8 Vagus
- It is also known as the Cranial Nerve #10. It has a sensory motor impulse that
carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal
tract, and abdominal viscera. It also promotes swallowing, talking, and production
of digestive juices. It is the longest nerve of the autonomic nervous system in the
human body.

1.9 Abducens
- It is also known as the Cranial Nerve #6. It has a motor impulse that controls
the lateral eye movements, responsible for outward gaze. It is a somatic efferent
nerve.
1.10 Oculomotor
- It is the Cranial Nerve #3. It has a motor impulse that contracts eye muscles to
control eye movements (interior lateral, medial, and superior), constricts pupils,
and elevates eyelids. Paralysis of the oculomotor nerve results in a drooping
eyelid (ptosis), deviation of the eyeball outward (and therefore double vision),
and a dilated (wide-open) pupil.

1.11 Trigeminal
- It is the Cranial Nerve #5. It has a sensory motor impulse that is responsible
for carrying sensory impulses of pain, touch, and temperature from the face to the
brain. It influences clenching and lateral jaw movements (biting, chewing).

1.12 Trochlear
- It is the Cranial Nerve #4. It has a motor impulse that contracts one eye muscle
 (extraocular muscles) to control the superior oblique muscle of the eye. Paralysis
of the trochlear nerve results in rotation of the eyeball upward and outward (and,
therefore, in double vision). The trochlear nerve is the only cranial nerve that
arises from the back of the brain stem. It follows the longest course within the
skull of any of the cranial nerves.

1.13 Cerebrospinal fluid

- Cerebrospinal fluid (CSF) is a clear, colorless liquid that surrounds and
protects the CNS. It bathes the brain and spine in nutrients and eliminates waste
products. It also cushions them to help prevent injury in the event of trauma.
- A CSF culture is used to detect infectious organisms in the CSF. The CNS is
vulnerable to infection by bacteria, viruses, and fungi.

1.14 Hypothalamus
- The hypothalamus is a small region of the brain. It is located at the base of the
brain, near the pituitary gland.
- While it’s very small, the hypothalamus is responsible for regulation many
 body functions, including water balance, appetite, vital signs (temperature, blood
pressure, pulse, and respiratory rate), sleep cycles, pain perception, and emotional
status.

1.15 Gag Reflex

- The gag reflex, also known as the pharyngeal reflex or laryngeal spasm, is a
contraction of the back of the throat triggered by an object touching the roof of
your mouth, the back of your tongue, the area around your tonsils, or the back of
your throat.

2. Briefly discuss the anatomy and physiology of the Nervous System with emphasis on the
following aspects:

2.1 Classification of the Nervous System

2.1.1 Central Nervous System
The CNS encompasses the brain and spinal cord, which are covered by
meninges, three layers of connective tissue that protect and nourish the CNS. The
subarachnoid space surrounds the brain and spinal cord. The subarachnoid space is
filled with cerebrospinal fluid (CSF), which formed in the ventricles of the brain and
flows through the ventricles into the space. The CNS contains upper motor neurons
that influence lower motor neurons, located mostly in the peripheral nervous system.

2.1.2 Peripheral Nervous System

Carrying information to and from the CNS, the peripheral nervous system
consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves. The nerves are
categorized as two types of fibers: somatic and autonomic. Somatic fibers carry CNS
impulses to voluntary skeletal muscles. Autonomic fibers carry CNS impulses to
smooth, involuntary muscles (in the heart and glands). The somatic nervous system
mediates conscious, or voluntary, activities; the autonomic nervous system mediates
unconscious, or involuntary, activities.
2.2 Major Structures of the Brain
Located in the cranial activity, the brain has four major divisions; the cerebrum, the
diencephalon, the brain stem, and the cerebellum.
 1. Cerebrum - it is the largest part of the brain and is composed of right and left
hemispheres. It performs higher functions like interpreting touch, vision and hearing,
as well as speech, reasoning, emotions, learning, and fine control of movement.
2. Diencephalon - it lies beneath the cerebral hemisphere and consists of the thalamus
and hypothalamus. Most sensory impulses travel through the gray matter of the
thalamus, which is responsible for screening and directing the impulses to specific
areas in the cerebral cortex. The hypothalamus is responsible for regulating many
body functions, including water balance, appetite, vital signs, sleep cycles, pain
perception and emotional status.
3. Brain Stem - it is located between the cerebral cortex and spinal cord, the brain stem
consists of mostly nerve fibers and has three part: the midbrain, pons, and medulla
oblongata.
a. Midbrain - it serves as a relay center for ear and eye reflexes
b. Pons - it is responsible for various reflex actions.
c. Medulla Oblongata - contains the nuclei for cranial nerves, and has centers
that control and regulate respiratory function, heart rate and force, and blood
pressure.
4. Cerebellum - it is located under the cerebrum. Its function is to coordinate muscle
movements, maintain posture, and balance.

2.3 Major types and functions of the 12 Cranial Nerves

Cranial Nerve (Name) Type of Impulses Function

I (olfactory) Sensory Carries smell impulses from nasal mucous

membrane to brain.

II (optic) Sensory Carries visual images from eye to brain.

Motor Contracts eye muscles to control eye

III (oculomotor) movements, constricts pupils, and elevates
eyelids.

IV (trochlear) Motor Contracts one eye muscle to control

inferomedial eye movement.

Sensory motor Carries sensory impulses of pain, touch, and

V (trigeminal) temperature from the face to the brain.
Influences clenching and lateral jaw
movements (biting, chewing).

VI (abducens) Motor Control lateral eye movements.

Sensory Contains sensory fibers for taste on anterior

two thirds of tongue and stimulates secretions
from salivary glands and tears from lacrimal
VII (facial) glands.

Motor Supplies the facial muscles and affects facial

expressions (smiling, frowning, closing eyes)

VIII (acoustic, Sensory Contains sensory fibers for hearing and

vestibulocochlear) balance.

Sensory Contains sensory fibers for taste on posterior

third of the pharynx that result in the gag
IX (glossopharyngeal) reflex when stimulated.
Motor Provides secretory fibers to the parotid
salivary glands , provides swallowing
 movements.

Sensory motor Carries sensations from the throat, larynx,

X (vagus) heart, lungs, bronchi, gastrointestinal tract,
and abdominal viscera. Promotes swallowing,
talking, and production of digestive juices.

Motor Innervates neck muscles (sternocleidomastoid

XI (spinal accessory) and trapezius) that promote movement of the
shoulders and head rotation. Also promotes
some movement of the larynx.

XII (hypoglossal) Motor Innervates tongue muscles that promote the

movement of food and talking.

2.4 Cross-section of the spinal cord

Spinal nerves comprising 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal

nerves, the 31 pairs of spinal nerves are named after the vertebrae below each one’s exit point
along the spinal cord. The nerve is attached to the spinal cord by two nerve roots. The
sensory (afferent) fiber enters through the dorsal (posterior) root of the cord; the motor
(efferent) fiber exits through the ventral (anterior) roots of the cord.

● 8 cervical (C1-C8) nerves emerge from the cervical spine; cervical means of the neck
(there are 8 cervical nerves, but only 7 cervical vertebra).
● 12 thoracic (T1-T12) nerves emerge from the thoracic spine; thoracic means of the
chest.
● 5 lumbar (L1-L5) nerves emerge from the lumbar spine; lumbar means from the lower
back region.
● 5 sacral (S1-S5) nerves emerge from the sacral bone; sacral means of the sacrum, the
bony plate at the base of the vertebral column.
● 1 coccygeal nerve emerge from the coccygeal bone; coccygeal means of the coccyx,
the tailbone.

3. Purpose of Neurologic Assessment

● Determine, through an organized and thorough examination or screening, whether a
neurological dysfunction/disorder exists.
● Learn how alterations in the neurological assessment findings would indicate potential
nervous system abnormalities.
● Identify which component(s) of the neurological system are affected (mental and
emotional status, intellectual function, cranial nerve function, sensory function, motor
function, and reflexes).
● Serves as a cursory screening or documentation of baseline function for those who are
otherwise healthy.

4. Indications of Neurologic Assessment

A complete neurological exam may be done:
● during a routine physical
● following any type of trauma
● to follow the progression of a disease/neurological disorder (meningitis, brain tumor)
● if the patient has any of the following complaints:
- Headaches
- Blurry vision
- Change in behavior
- Fatigue
- Change in balance or coordination
- Numbness or tingling in the arms or legs
 - Decrease in movement of the arms or legs
- Injury to the head, neck, or back
- Fever
- Seizures
- Slurred speech
- Weakness
- Tremor

5. Discuss the following:

5.1 Mental Status Assessment
Mental status assessment is an assessment of current mental capacity through
evaluation of general appearance, behavior, any unusual or bizarre beliefs and perceptions
(eg, delusions, hallucinations), mood, and all aspects of cognition (eg, attention, orientation,
memory).
The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and
hinders testing. Any hint of cognitive decline requires examination of mental status which
involves testing multiple aspects of cognitive function, such as the following:

● Orientation to time, place, and person

● Attention and concentration
● Memory
● Verbal and mathematical abilities
● Judgment
● Reasoning

Loss of orientation to person (ie, not knowing one’s own name) occurs only when
obtundation, delirium, or dementia is severe; when it occurs as an isolated symptom, it
suggests malingering.
Insight into illness and fund of knowledge in relation to educational level are assessed, as are
affect and mood. Vocabulary usually correlates with educational level.

The patient is asked to do the following:

● Follow a complex command that involves 3 body parts and discriminates between
right and left (eg, “Put your right thumb in your left ear, and stick out your tongue”)
● Name simple objects and parts of those objects (eg, glasses and lens, belt and belt
buckle)
 ● Name body parts and read, write, and repeat simple phrases (if deficits are noted,
other tests of aphasia are needed)

Spatial perception can be assessed by asking the patient to imitate simple and complex finger
constructions and to draw a clock, cube, house, or interlocking pentagons; the effort expended
is often as informative as the final product. This test may identify impersistence,
perseveration, micrographia, and hemispatial neglect.
Praxis (cognitive ability to do complex motor movements) can be assessed by asking the
patient to use a toothbrush or comb, light a match, or snap the fingers.

5.2 Glasgow Coma Score

The GCS allows the nurse to evaluate a client’s neurological status over time. It is
also the most common scoring system used to describe the level of consciousness in a person
following a traumatic brain injury. Basically, it is used to help gauge the severity of an acute
brain injury. A patient's Glasgow Coma Score (GCS) should be documented on a coma scale
chart. This allows for improvement or deterioration in a patient's condition to be quickly and
clearly communicated. Individual elements, as well as the sum of the score, are important.
The individual elements of a patient's GCS can be documented numerically.

Every brain injury is different, but generally, brain injury is classified as:
● Severe: GCS 8 or less
● Moderate: GCS 9-12
● Mild: GCS 13-15
Mild brain injuries can result in temporary or permanent neurological symptoms and
neuroimaging tests such as CT scan or MRI may or may not show evidence of any damage.
Moderate and severe brain injuries often result in long-term impairments in cognition
(thinking skills), physical skills, and/or emotional/behavioral functioning.

Glasgow Coma Scale

Action Response Score

Eyes Open Spontaneously +4

 To speech +3

To pain +2

None +1

Best verbal response Oriented +5

Confused +4

Inappropriate words +3

Incomprehensible sounds +2

None +1

Best motor response Obeys commands +6

Localized pain +5

Flexion withdrawal +4

Abnormal Flexion +3
(decorticate)

Abnormal extension +2
(decerebrate)

Flaccid or No response +1

Total score: =15

An example of this is when a patient scored 2(to pain) in the action of eyes opening, a score
of 4(confused) in the verbal response and a score of 6(obeys commands) in the motor
response, this can be documented as E2 V4 M6 that when added together equals to 12 (e.g.
E2V4M6 = 12). It can also be documented as GCS 12 = E2 V4 M6. As for the patient, he
scored 12 which means that the patient has a moderate brain injury.
 5.3 Cranial Nerve Assessment
The nurse may assess all 12 cranial nerves or test a single nerve or related group of
nerves. A test of the oculomotor nerve measures pupillary response. Assessment of the
glossopharyngeal and Vagus nerves reveals integrity of the gag reflex. Measurements used to
assess the integrity of organs within the head and neck also assess cranial nerve function. The
function of the ninth and tenth nerves can be assessed during examination of the pharynx. A
dysfunction in any nerve reflects an alteration at some point along the cranial nerve’s
distribution.

Cranial Nerves (CN) Normal findings Abnormal findings

Test CN I (olfactory)
Ask the client to clear the nose to Client correctly identifies Inability to smell (neurologic
remove any mucus, then close scent presented to each anosmia) or identify the correct
eyes, occlude one nostril, and nostril. scent may indicate olfactory tract
identify a scented object that you Some older clients sense of lesion or tumor or lesion of the
are holding such as soap, coffee smell may be decreased. frontal lobe.
or vanilla.

Test CN II (optic)
Use a snellen chart to assess the Client has 20/20 vision OD Abnormal findings include
vision in each eye. (right eye) and OS (left eye). difficulty reading snellen chart,
missing letters, and squinting.
Test CN III (oculomotor), IV
(trochlear), and VI (abducens).
Inspect margins of the eyelids of Eyelids cover about 2 mm of Ptosis (drooping of the eyelid) is
each eye. the iris. seen with weak eye muscles such
as in myasthenia gravis.

Test CN V (trigeminal)
Test motor function. Ask the Temporal and masseter Decreased contraction in one of the
client to clench the teeth while muscles contract bilaterally. both sides. Asymmetric strength in
you palpate the temporal and moving the jaw may be seen with
masseter muscles. lesion or injury of the 5th cranial
nerve.

Test CN VII (facial)

Test motor function. Ask the Client smiles, frowns, Inability to close eyes, wrinkle
client to: wrinkles forehead, shows forehead, or raise forehead along
- Smile teeth, puffs out cheek, purses with paralysis of the lower part of
- Frown and wrinkle lips, raises eyebrows, and the face on the affected side is seen
forehead close eyes against resistance. with Bell palsy (a peripheral injury
- Show teeth Movements are symmetric. to cranial nerve VII facial).
- Puff out cheeks Paralysis of the lower part of the
- Purse lips face on the opposite side affected
- Raise eyebrows may be seen with a central lesion
 - Close eyes tightly against that affects the upper motor
resistance neurons, such as from stroke.

Test CN VIII
(acoustic/vestibulocochlear)
Test the client’s hearing ability in Client hears whispered words Vibratory sound lateralizes to good
each ear and perform the Weber from 1 to 2 ft. Weber test: ear in sensorineural loss. Air
and Rinne tests to assess the vibration heard equally well conduction is longer than bone
cochlear (auditory) component of in both ears. Rinne test: AC > conduction, but not as twice as
cranial nerve VIII. BC (air conduction is twice as long, in a sensorineural loss.
long as bone conduction).

Test CN IX (glossopharyngeal)
and X (vagus)
Test motor function. Ask the
client to open mouth wide and
say “ah” while you use a tongue
Uvula and palate rise Soft palate does not rise with
bilaterally and symmetrically bilateral lesions of cranial nerve X
on phonation. (vagus). Unilateral rising of the soft
depressor on the client’s tongue.
Test CN XI (spinal accessory)
Ask the client to turn the head
against resistance, first to the
right then to the left, to assess the muscle on the side opposite
sternocleidomastoid muscles.
Test CN XII (hypoglossal)
To assess strength and mobility
of the tongue, ask the client to
protrude tongue, move it to each
side against the resistance of a
tongue depressor, and then put
back in the mouth.
There is a strong contraction
of the sternocleidomastoid
the turned face.
Tongue movement is
symmetric and smooth, and
bilateral strength is apparent
palate and deviation of the uvula to
the normal side are seen with a
unilateral lesion of the cranial
nerve X (vagus).
Atrophy with fasciculations may be
seen with peripheral nerve disease.
Fasciculations and atrophy of the
tongue may be seen with the
peripheral nerve disease. Deviation
to the affected side is seen with a
unilateral lesion.
 5.4 Sensory Nerve Assessment
● Test for light touch sensation, pain sensation, temperature sensation
● Test for vibratory sensation, sensitivity to position
● Assessing tactile discrimination (stereognosis, graphesthesia)
● Two point discrimination, extinction and etc.

Assessment procedure Normal findings Abnormal findings

Assess light touch, pain and Many disorders can alter a

temperature sensations person’s ability to perceive
For each test, ask clients to close sensations correctly. These include
both eyes and tell you what they feel peripheral neuropathies (due to
and where they feel it. diabetes mellitus, folic acid
deficiencies, and alcoholism) and
lesions of the ascending spinal
cord, brain stem, cranial nerves
and cerebral cortex.

To test light touch sensation, use a
wisp of cotton to touch the client.
To test pain sensation, use the blunt
and sharp ends of a safety pin or
paper clip.
Client correctly identifies light
touch. In some older clients,
light touch may be decreased.
Client correctly differentiates
between dull and sharp
sensations.
Client reports:
● Anesthesia (absence of touch
sensation)
● Hypesthesia (decreased
sensitivity to touch)
● Hyperesthesia (increased
sensitivity to touch)
● Analgesia (absence of pain
sensation)
● Hypalgesia (decreased
sensitivity to pain)
● Hyperalgesia (increased
sensitivity to pain)

To test temperature sensation, use
test tubes filled with hot and cold
water.
Test vibratory sensation.
Strike a low pitched tuning fork on
the heel of your hand and hold the
base on the distal radius, medial
malleolus and last, the tip of the
great toe. Ask client what he or she
feels, repeat on the other side.
Test sensitivity to position.
Ask the client to close both eyes.
Then hold the client’s toe or a finger
on the lateral sides and move it up or
down. Ask the client to tell you the
Client correctly differentiates
hot and cold temperatures over
various body parts.
Client correctly identifies
sensation.
Client correctly identifies the
direction of movements.
Inability to sense vibrations may
be seen in posterior column
disease or peripheral neuropathy
(e.g., as seen with diabetes or
chronic alcohol abuse.
Inability to identify the directions
of the movements may be seen in
posterior column disease or
peripheral neuropathy (e.g., as
direction it is moved. Repeat on the
other side.
Assessing tactile discrimination
(fine touch)
Remember that the client should
have eyes closed. To test
stereognosis, place a familiar object
such as a quarter, paper clip, or key
in the client’s hand and ask the
client to identify it.
To test point localization, briefly
touch the client and ask the client to
identify the points touched.
To test graphesthesia, use a blunt
instrument to write a number such as number written
2,3, or 5 on the palm of the client.
Ask client to identify the number.
Client correctly identifies
object.
Client correctly identifies area
touched.
Client correctly identifies
seen with diabetes or chronic
alcohol abuse).
Inability to correctly identify
objects (astereognosis), area
touched, number written in hand;
to discriminate between two
points; or identify areas
simultaneously touched may be
seen in lesions of the sensory
cortex.
Same as above
Same as above
Test two point discrimination.
Two point discrimination can be
determined on the fingertips,
forearm, dorsal hands, back or
thighs. Ask the client to identify the
number of points (one or two) felt
when touched with the EKG
calibers. Measure the distance
between the two points when the
client can no longer distinguish the
two points as separate (client states
only one point is felt).
To test extinction.
Simultaneously touch the client in
the same area on both sides of the
body at the same point. Ask the
client to identify the area touched.
Client identifies two points on:
● Fingertips at 2-5mm apart
● Forearm at 40 mm apart
● Dorsal hands at 20-30 mm
apart
● Back at 40 mm apart
● Thighs at 70 mm apart
Client correctly identifies points objects (astereognosis), area
touched.
Inability to correctly identify
objects (astereognosis), area
touched, number written in hand;
to discriminate between two
points; or identify areas
simultaneously touched may be
seen in lesions of the sensory
cortex.
Inability to correctly identify
touched, number written in hand;
to discriminate between two
points; or identify areas
simultaneously touched may be
seen in lesions of the sensory
cortex.
 5.5 Motor Assessment and Cerebellar Assessment
● To evaluate balance (heel to toe, Romberg’s Test)
● To assess coordination (finger to nose test, test for rapid alternating movements,
heel to shin test)

Assessment procedure Normal findings Abnormal findings

Evaluate balance and gait. Gait and balance can be affected

To assess gait and balance, ask the
client to walk naturally across the
room. Note posture, freedom of
movement, symmetry, rhythm and
balance.
Gait is steady; opposite arms
swings.
by disorders of the motor,
sensory, vestibular, and
cerebellar systems. Therefore, a
thorough examination of all
systems is necessary when an
uneven or unsteady gait is noted.

Perform Romberg test.

Ask the client to stand erect with
arms at the side and feet together.
Note any unsteadiness or swaying.
Then with the client in the same
body position, ask the client to close
the eyes for 20 seconds.
Client stands erect with minimal Positive Romberg test: swaying
swaying, with eyes both open and moving feet apart to prevent
and closed. fall is seen with disease of the
posterior columns, vestibular
dysfunction, or cerebellar
disorders.

Assess coordination.
Demonstrate the finger-to-nose test Client touches finger to nose Uncoordinated, jerky movements
to assess accuracy of movements, with smooth, accurate and inability to touch the nose
then ask the client to extend and hold movements, with little may be seen with cerebellar
arms out to the side with eyes open. hesitation. disease.
Next, say “touch the tip of your nose
first with your right index finger,
then with your left index finger.
Repeat this three times”
Assess rapid alternating
movements.
Have the client sit down. First, ask
the client to touch each finger to the
thumb and to increase the speed as
the client progresses. Repeat with
the other side.
Perform the heel-to-shin test.
Ask the client to lie down (supine
position) and to slide the heel of the
right foot down the left shin. Repeat
with the other heel and shin.
Client touches each finger to the
thumb rapidly
Client is able to run each heel
smoothly down each shin.
Inability to perform rapid
alternating movements may be
seen with cerebellar disease,
upper motor neuron weakness, or
extrapyramidal disease.
Deviation of heel to one side or
the other may be seen in
cerebellar disease.
 5.6 Reflex Assessment
● Deep Tendon Reflex
● Biceps Reflex
● Brachioradialis Reflex
● Triceps Reflex
● Patellar Reflex
● Achilles Reflex
● Plantar Reflex

Assessment procedure Normal findings Abnormal findings

Test deep tendon reflexes. Absent or markedly decreased

Position client in a comfortable
sitting position. Use the reflex
hammer to elicit reflexes
Older adult considerations:
Reinforcement techniques may
also help the older client who has
difficulty relaxing.
Normal reflex scores range from
1+ (present but decreased) to 2+
(normal) to 3+ (increased or
brisk, but not pathologic)
Older adult considerations:
Older clients usually have deep
tendon reflexes intact, although a
decrease in reaction time may
slow the response (Lim et al.,
2009; Sirven & Malamut, 2008)
(hyporeflexia) deep tendon
reflexes (rated 0) occur when a
component of the lower motor
neurons or reflex arc is impaired;
this may be seen with spinal cord
injuries. Markedly hyperactive
(hyperreflexia) deep tendon
reflexes (rated 4+) may be seen
with lesions of the upper motor
neurons and when the higher
cortical levels are impaired
Older adult considerations:
Some older client may have
decreased deep tendon reflexes
and unstable balance due to
peripheral neuropathy, which also
causes disturbed propriOCEPtion,
loss of vibratory and temperature
sense, and possible pain, tingling,
and distal weakness (Yeager,
2016).
 a. Test biceps reflex.
Ask the client to partially bend the
arm at the elbow with palm up.
Place your thumb over the biceps
tendon and strike your thumb with
the pointed side of the reflex
hammer. Repeat on the other side.
Elbow flexes and contraction of No response or an exaggerated
the biceps muscles is seen or felt. response is abnormal.
Ranges from 1+ to 3+
Forearm flexes and supinates.
Ranges from 1+ to 3+

b. Assess brachiocephalic reflex.

Ask the client to flex elbow with Flexion and supination of No response or an exaggerated
palm down and hand resting down forearm response is abnormal
the abdomen or lap. Use the flat
side of the reflex hammer to tap
the tendon at the radius about 2 in
above the wrist. Repeat on the
other side (this evaluates the
function of spinal levels C5 and
C6)

c. Test triceps reflex.

Ask the client to hang the arm Elbow extends, triceps contracts. No response or exaggerated
freely (“limp, like it is hanging Ranges from 1+ to 3+ response.
from a clothesline to dry”) while
you support it with your non
dominant hand. With the elbow
flexed, use the flat side of the
hammer to tap the tendon above
the olecranon process. Repeat on
the other side. This evaluates the
function of spinal level C6, C7 and
C8.

d. Assess patellar reflex.

Ask the client to let both legs hang Knee extends, quadriceps muscle No response or an exaggerated
freely off the side of the contracts. Ranges from 1+ to 3+ response is abnormal.
examination table. Using the flat
side of the reflex hammer, tap the
patellar tendon, which is just
located just below the patella.
Repeat on the other side. For the
client who cannot sit up, gently
flex the knee and strike the patella.
This evaluates the function of
spinal levels L2, L3, and L4.
e. Test achilles reflex
With the client’s leg still hanging
freely, dorsiflex the foot. Tap the
achilles tendon with the flat side
of the reflex hammer. Repeat on
the other side.
f. Test ankle clonus
When the other reflexes tested
have been hyperactive, place one
hand under the knee to support the
leg, then briskly dorsiflex the foot
toward the client’s head. Repeat
on the other side.
Normal response is plantar No response or an exaggerated
flexion of the foot ranges from response is abnormal.
1+ to 3+.
Older adult considerations:
In some older clients, the achilles
reflex may be absent or difficult
to elicit.
No rapid contractions or Repeated rapid contractions or
oscillations (clonus) of the ankle oscillations of the ankle and calf
are elicited. muscle are seen with lesions of
the upper motor neurons.
Test superficial reflexes
a. Assess plantar reflex
With the end of the reflex hammer
or tongue blade, stroke the lateral
aspect of the side from the heel to
the ball of the foot, curving
medially across the ball. Repeat on absent.
the other side. This evaluates the
spinal levels L4, L5, S1, and S2.
b. Test abdominal reflex
Lightly stroke the abdomen on
each side, above and below the
umbilicus. This evaluates the
function of spinal levels T8, T9,
and T10 with the upper abdominal
reflex, and spinal levels T10, T11,
and T12 with the lower abdominal
reflex.
Test cremasteric reflex in male
clients
Lightly stroke the inner aspect of
the upper thigh. This evaluates the
function of spinal levels T12, L1
and L2.
Flexion of the toes occurs
Older adult considerations:
In some older adult clients,
flexion of the toes may be
difficult to elicit and may be
Abdominal muscles contract; the
umbilicus deviates toward the
side being stimulated .
Scrotum elevates on stimulated
side .
The toes will fan out for abnormal
response (positive babinski
response).
Except in infancy, extension
(dorsiflexion) of the big toe and
fanning of all toes (positive
babinski response) are seen with
lesions of upper motor neurons.
Unconscious states resulting from
drug and alcohol intoxication,
brain injury, or subsequent to an
epileptic seizure may also cause
it.
Superficial reflexes may be
absent with lower or upper motor
neuron lesions.
Absence of reflex may indicate
motor neuron disorder.
 5.7 Tests for meningeal irritation or inflammation
● Test for Brudzinski sign
● Test for Kernig sign

Assessment procedure Normal findings Abnormal findings

a. Test for Brudzinski sign

As you flex the neck, watch the Hips and knees remain relaxed Pain and flexion of the hips and
hips and knees in reaction to your and motionless. knees are positive Brudzinski
maneuver. signs, suggesting meningeal
inflammation.

b. Test for Kernig sign

Flex the client’s leg at both the hip
and knee, then straighten the knee.
No pain is felt. Discomfort
behind the knee during full
extension occurs in many normal
people.
Pain and increased resistance to
extending the knee are positive
Kernig signs. When Kernig sign
is bilateral, the examiner suspects
meningeal irritation.

6. Present the steps, normal and abnormal assessment findings in neurologic assessment
Physical Assessment
Prior to the examination, review these key points:
1. Understand what is meant by mental status and the level of consciousness.
2. Know how to correctly apply and interpret mental status examinations and the Glasgow
Coma Scale (GCS).
3. Identify the 12 cranial nerves and their sensory and motor functions.
4. Thoroughly assess movement, balance, coordination, sensation, and reflexes during
physical examination.
5. Know how to use a reflex hammer.
Coordinate patient education- particularly in regard to risks related to stroke- with the health
 CRANIAL NERVES

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Test CN 1 (Olfactory)
1. For all assessments of the Client correctly identifies Inability to smell (neurogenic
cranial nerves, have client sit scent presented to each anosmia) or identify the correct scent
in a comfortable position at nostril. may indicate olfactory tract lesion or
your eye level., occlude one tumor or lesion of the frontal lobe.
nostril, and identify a
scented object that you are
holding such as soap, coffee,
or vanilla.

Test CN II (Optic)
1. Use a Snellen chart to assess Client has 20/20 vision OD Abnormal findings include difficulty
vision in each eye. (right eye) and OS (left reading Snellen chart; missing letters,
eye). squinting.

2. Ask the client to read a Client reads print at 14 Client reads print by holding closer
newspaper or magazine paragraph inches without difficulty. than 14 inches or holds print farther
to assess near vision. away as in presbyopia, which occurs
with aging.
3. Assess visual fields of each eye Full visual fields. Loss of visual fields may be seen in
by confrontation. retinal damage or detachment with
lesions of the optic nerve or parietal
cortex.

4. Use an ophthalmoscope to view Round red reflex is present, Papilledema (swelling of the optic
the retina and optic disc of each optic disc is 1.5 mm, round nerve) results in blurred optic disc
eye. or slightly oval, well- margins and dilated, pulsating veins.
defined margins, creamy
pink with paler physiologic
cup. Retina is pink.

Assess CN III (Oculomotor), IV

(Trochlear), and VI (Abducens).
1. Inspect margins of the eyelids of Eyelid covers about 2 mm Ptosis (drooping of the eyelid) is sees
each eye. of the iris with a weak eye muscles such as in
myasthenia gravis.

2. Assess extr aocular movements. Eyes move in a smooth, Some abnormal eye movements and
If nystagmus is noted, determine coordinated motion in all possible causes follow:
the direction of the fast and slow direction ( the six cardinal  Nystagmus: rhythmic,
phases of movement. fields). oscillation of the eyes,
cerebellar disorders.
 Limited eye movement
through the six cardinal fields
of gaze
 Bilateral illuminated pupils Some abnormalities and their
3. Assess pupillary response to
constrict simultaneously. implications follow:
light (direct and indirect) and
Pupil opposite the one  Dilated pupil (6-7 mm):
accomodation in both eyes.
illuminated constricts oculomotor nerve paralysis.
simultaneously.  Argyll Robertson pupils:
CNS syphilis, meningitis,
brain tumor, alcoholism..

Assess CN V (Trigeminal)
1. Test motor function. Ask the Temporal and masseter Decreased contraction in one of both
client to clench the teeth while you muscles contract sides. Asymmetric strength in moving
palpate the temporal and masseter bilaterally. the jaw may be seen with lesion or
muscles for contraction. injury of the fifth cranial nerve.
Clinical Tip:
Test may be difficult to
perform and evaluate in
the client without teeth.

2. Test on sensory function. Tell The client correctly Inability to feel and correctly identify
the client: “I am going to touch identifies sharp and dull facial stimuli occurs with lesions of
your forehead, cheeks, and chill stimuli and light touch to the trigeminal nerve or lesions in the
with the sharp or dull side of this the forehead, cheeks, and spinothalamic tract or posterior
safety pin or paper clip (a paper chin. columns.
clip is less hazardous). Please close
your eyes and tell me if you feel a
sharp or dull sensation. Vary the
sharp and dull stimulus in the facial
areas and compare sides. Repeat
test for light touch with a wisp of
cotton.
Safety tip:
To avoid transmitting infection,
use a new object with each client.
Avoid “stabbing” the client with
the object’s sharp side.

3. Test corneal reflex. Ask client to Eyelids blink bilaterally Absent corneal reflex may be noted
look away and up while you lightly with lesions of the trigeminal nerve or
touch the cornea with a fine wisp of lesions of the motor part of cranial
cotton. Repeat on the other side. nerve VII (facial).
Clinical tip:
This reflex may be absent or
reduced in clients who wear
contact lenses.
Test CN VII (facial)
1. Test motor function. Ask the Client smiles, wrinkles Inability to close eyes, wrinkle
client to: forehead, shows teeth, forehead, or raise forehead along with
● Smile puffs out cheeks, purses paralysis of the lower part of the face
● Frown and wrinkle forehead lips, raises eyebrows, and on the affected side is seen with
● Show teeth closes eyes against Bell’s palsy lower part of the face on
● Puff out cheeks resistance. Movements are the opposite side affected may be
● Purse lips symmetrical. seen with a central lesion that affects
● Raise eyebrows ● Client identifies the upper motor neurons such as from
● Close eyes tightly against correct flavor. stroke.
resistance
Sensory function is not routinely OLDER ADULT
tested. If it is, however, touch the CLIENT
anterior two-thirds of the tongue CONSIDERATIONS
with a moistened applicator dipped In some older clients, the
in salt, sugar, or lemon juice and sense of taste may be
ask the client to identify the flavor. decreased.
If the client is unsuccessful, repeat
the test using one of the other
solutions. If needed, repeat the test
using the remaining solution.
Clinical tip:
Make sure the client leaves the
tongue protruded to identify the
flavor. Otherwise the substance
may move to the posterior third
of the tongue (vagus nerve
innervation). The posterior
portion is tested similarly to
evaluate functioning of cranial
nerves IX and X. The client
should rinse the mouth with
water between each taste test.
Test CN VIII (acoustic/
vestibulocochlear).
1. Test the client’s hearing ability in Client hears whispered Vibratory sound lateralizes to good
each ear and perform the Weber words from 1 to 2 feet. ear in sensorineural loss. Air
and Rinne tests to assess the Weber test: Vibration heard conduction is longer than bone
cochlear (auditory) component of equally well in both ears. conduction but not twice as long, in a
cranial nerve VIII. Rinne test: AC>BC (air sensorineural loss.
conduction is twice as long
Clinical tip:
as bone conduction).
The vestibular component,
responsible for equilibrium, is not
routinely tested. In comatose
clients, the test is used to
determine integrity of the
vestibular system.
Test CN IX (glossopharyngeal)
and X (vagus).
1. Test motor function. Ask the Uvula and soft palate rise
client to open mouth wide and say bilaterally and
“ah” while you use a tongue symmetrically on
depressor on the client’s tongue. phonation.
Soft palate does not rise with bilateral
lesions of cranial nerve X (vagus).
Unilateral rising of the soft palate and
deviation of the uvula to the normal
side are seen with a unilateral lesion
of cranial nerve X.

2. Test the gag reflex by touching Gag reflex intact. Some An absent gag reflex may be seen
the posterior pharynx with the normal clients may have a with lesions of cranial nerve IX
tongue depressor. reduced or absent gag (glossopharyngeal) or X (vagus)
Clinical tip: reflex.
Warn the client that you are
going to do this and that the test
may feel a little uncomfortable.
3. Check the client’s ability to Client swallows without Dysphagia or hoarseness may
swallow by giving the client a drink difficulty. No hoarseness indicate a lesion of cranial nerve IX
of water. Also note the client’s noted. (glossopharyngeal) or X (vagus) or
voice quality. other neurologic disorder.

Test CN XI (spinal accessory).

1. Ask the client to shrug the There is a symmetric, Asymmetric muscle contraction or
shoulders against resistance to strong contraction of the drooping of the shoulder may be seen
assess the trapezius muscle. trapezius muscles. with paralysis or muscle weakness
due to neck injury or torticollis.

2. Ask the client to turn the head There is strong contraction Atrophy with fasciculations may be
against resistance, first to the right of sternocleidomastoid seen with peripheral nerve disease.
then to the left, to assess the muscle on side opposite the
sternocleidomastoid muscle. turned face.
Test CN XII (hypoglossal).
1. To assess strength and mobility Tongue movement is Fasciculations and atrophy of the
of the tongue, ask the client to symmetric and smooth and tongue may be seen with peripheral
protrude tongue, move it to each bilateral strength is nerve disease. Deviation to the
side against the resistance of a apparent. affected side is seen with a unilateral
tongue depressor, then put it back in lesion.
the mouth.

MOTOR AND CEREBELLAR SYSTEMS

ASSESSMENT
NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE

Assess condition and

movement of muscles.
1. Assess the size and Muscles are fully developed Muscle atrophy may be seen in diseases of
symmetry of all muscle and symmetric in size the lower motor neurons or muscle
groups. (bilateral side may vary 1 cm disorders.
from each other).
OLDER ADULT
CONSIDERATIONS
Some older clients may have
 reduced muscle mass from
degeneration of muscle
fibers.

2. Assess the strength and Relaxed muscles contract Soft, limp, flaccid muscles are seen with
tone of all muscle voluntarily and show mild, lower motor neuron involvement. Spastic
groups smooth resistance to passive muscle tone is noted with involvement of
movement. All muscle the corticospinal motor tract. Rigid muscles
groups equally strong that resist passive movement are seen with
against resistance, without abnormalities of the extrapyramidal tract.
flaccidity, spasticity, or
rigidity.

3. Note any unusual No fasciculations, tics, or Abnormal findings include:

involuntary movements tremors are noted.  Tic (twitch of the face, head, or
such as fasciculations, shoulder) from stress or neurologic
tics, or tremors. OLDER ADULT disorder.
CONSIDERATIONS  Unusual, bizarre face, tongue, jaw, or
Some older clients may lip movements from chronic
normally have hand or head psychosis or long-term use of
tremors or dyskinesia psychotropic drugs.
(repetitive movements of the  Tremors (rhythmic, oscillating
lips, jaw, or tongue). movements) from Parkinson’s
 disease, cerebellar disease, multiple
sclerosis, hyperthyroidism, or anxiety
 Slow, twisting movements in the
extremities and face from cerebral
palsy.
 Brief, rapid, irregular, jerky
movements from Huntington’s
chorea.

Evaluate gait and balance.

1. To assess gait, ask the Gait is steady; opposite arm Gait and balance can be affected by
client to walk naturally swings. disorders of the motor, sensory, vestibular,
across the room. Note and cerebellar systems. Therefore, a
posture, freedom of OLDER ADULT thorough examination of all systems is
movement, symmetry, CONSIDERATIONS necessary when an uneven or unsteady gait
rhythm, and balance. Some older clients may have is noted.
Clinical tip: It is best to a slow and uncertain gait.
assess gait when the client The base may become wider
is not aware that you are and shorter and the hips and
directly observing her gait. knees may be flexed for a
bent-forward appearance.
2. Ask the client to walk in Client maintains balance An uncoordinated or unsteady gait that did
heel-to-toe fashion with tandem walking. Walks not appear with the client’s normal walking
(tandem walking), next on heels and toes with little may become apparent with tandem walking
on the heels, then on the difficulty. or when walking on heels and toes.
toes. Demonstrate the
walk first; then stand OLDER ADULT
close by in the case the CONSIDERATIONS
client loses balance. For some older clients, this
examination may be very
OLDER ADULT
difficult.
CONSIDERATIONS
For some older clients, this
examination may be very
difficult.

Perform the Romberg test.

1. Ask the client to stand Client stands erect with Positive Romberg test: Swaying and
erect with arms at side minimal swaying with eyes moving feet apart to prevent fall is seen
and feet together. Note both open and closed. with disease of the posterior columns,
any unsteadiness or vestibular dysfunction, or cerebellar
swaying. Then with the disorders.
client in the same body
position, ask the client to
close the eyes for 20
seconds. Again note any
imbalance or swaying.
Safety tip: Stand near the
client to prevent a fall
should she lose balance.

2. Now ask the client to

Bends knee while standing Inability to stand or hop on one foot is seen
stand on one foot and to
on one foot; hops on each with muscles weakness or disease of the
bend the knee of the leg
foot without losing balance. cerebellum.
he or she is standing on.
Then ask the client to
hop on that foot. Repeat
on the other foot.

OLDER ADULT
CONSIDERATIONS
This test is often impossible
for the older adult to perform
because of decreased
flexibility and strength.
Moreover, it is not usual to
perform this test with the
older adult because it puts
the client at risk.
Assess coordination.
1. Demonstrate the finger- Client touches finger to nose Loss of positional sense and inability to
to-nose test to assess with smooth, accurate touch tip of nose are seen with cerebellar
accuracy of movements movements with little disease.
the ask the client to hesitation.
extend and hold arms out
to the side with eyes Clinical tip:
open. Next say “Touch When assessing
the tip of your nose first coordination of
with your right index movements, bear in mind
finger, then with your that normally the client’s
left index finger. Repeat dominant side may be
this three times”. Next more coordinated than the
ask the client to repeat nondominant side.
these movements with
eyes closed.

Assess rapid alternating

movements.
1. Have the client sit down. Client touches each finger to Inability to perform rapid alternating
First ask the client to thumb rapidly. movements may be seen with cerebellar
 touch each finger to the OLDER ADULT disease, upper motor neuron weakness, or
thumb and to increase CONSIDERATIONS extrapyramidal disease.
the speed as the client For some older clients, rapid
progresses. Repeat with alternating movements are
the other side. difficult because of
decreased reaction time and
flexibility.

2. Next ask the client to put Client rapidly turns palm up Uncoordinated movements or tremors are
the palms of both hand and down. abnormal findings. They are seen with
down on both legs, then cerebellar disease (dysdiadochokinesia).
turn the palms down
again. Ask the client to
increase the speed.
3. Perform the heel-to-shin Client is able to run each Deviation of heel to one side or the other
test. Ask the client to lie heel smoothly down each may be seen in cerebellar disease.
down (supine position) shin.
and to slide the heel of
the right foot down the
left shin. Repeat with the
other heel and shin.

SENSORY SYSTEMS

ASSESSMENT
NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE

Asses light touch, pain, and

temperature sensations.
1. For each test, ask clients Client correctly identifies
Many disorders can alter a person’s ability
to close both eyes and light touch.
correctly to perceive sensations. These
tell you what they feel
include peripheral neuropathies and lesions
and where they feel it.
of the ascending spinal cord, the brain
Scatter stimuli over the
stem, cranial nerves, and cerebral cortex.
 distal and proximal parts OLDER ADULT
of all extremities and the CONSIDERATIONS
trunk to cover most of In some older clients, light
the dermatomes. It is not touch and pain sensations
necessary to cover the may be decreased.
entire body surface
unless you identify
abnormal symptoms such
as pain, numbness, or
tingling.

2. To test light touch Clients correctly Client reports

sensation, use a wisp of differentiate between dull  Anesthesia (absence of touch
cotton to touch the client. and sharp sensations and hot sensation)
and cold temperatures over  Hypesthesia (decreased sensitivity
various body parts. to touch)
 Hyperesthesia (increased sensitivity
to touch)
 Analgesia (absence of pain
sensation)
3. To test pain sensation,
 Hypalgesia (decreased sensitivity to
use the blunt and sharp
pain)
ends of a safety pin or
 Hyperalgesia (increased sensitivity
paper clip.
to pain)

4. To test temp. sensation,

use test tubes filled w/
hot & cold water.
Clinical tip:
Test temperature sensation
only if abnormalities are
found in the client’s ability
to perceive light touch and
pain sensations.
Temperature and pain
sensations travel in the
lateral spinothalamic tract,
thus temperature need not
be tested if pain sensation
is intact.

Test vibratory sensation.

1. Strike alow-pitched Client correctly identifies Inability to sense vibrations may be seen
tuning fork on the heel of sensation. posterior column disease or peripheral
your hand and hold the neuropathy.
base on a bony surface of OLDER ADULT
the fingers or big toe. CONSIDERATIONS
Vibratory sensation at the
ankles usually decreases
after age 70.
2. Ask the client to indicate
what he feels. Repeat on
the other side.

Clinical tip:
If vibratory sensation is
intact distally, then it is
intact proximally.

Test sensitivity to position.

1. Ask client to close both Client correctly identifies Inability to identify the directions of
eyes. The move the directions of movements. movements may be seen in posterior
client’s toes or a finger column disease or peripheral neuropathy.
OLDER ADULT
up or down. Ask the
CONSIDERATIONS
client to tell you the
In some older clients, the
direction it is moved.
sense of position of great toe
Repeat on the other side.
may be reduced.
Clinical tip:
If position sense is intact
distally, then it is intact
proximally.

Assess tactile
discrimination (fine touch).
1. Remember that the
Client correctly identifies Inability to correctly identify objects, area
client should have her
object. touched, number written in hand,
eyes closed. To rest
discriminate between two points, or
stereognosis, place a
identify areas simultaneously touched may
familiar object such as a
be seen in lesions of the sensory cortex.
quarter, paper clip, or
key in the client’s hand
and ask the client to
 identify it. Repeat with
another object in the
other hand.

2. To test point Client correctly identifies Same as above.

localization, briefly area touched.
touch the client and ask
the client to identify the
points touched.

3. To test graphesthesia, Client correctly identifies Same as above.

use a blunt instrument to number written.
write a number, such as
2,3 or 5, on the palm of
the client’s hand. Ask the
client to identify the
number. Repeat with
another number on the
other hand.

4. To test two-point Client identifies two points Same as above.

discrimination can be on:
determined on the
 Fingertips at 2 to 5
 fingertips, forearm, mm apart
dorsal hands, back, or  Forearm at 40 mm
thighs. Ask the client to apart
identify the number of  Dorsal hands at 20 to
points felt when touched 30 mm apart
with the EKG calibers.  Back at 40 mm apart
Measure the distance  Thighs at 70 mm
between the two points apart
when the client can no
longer distinguish the
two points as separate.

5. To test extinction, Correctly identifies points Same as above

simultaneously touch the touched.
client in the same area on
both sides of the body at
the same point. Ask the
client to identify the area
touched.
 REFLEXES

ASSESSMENT
NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE

Test deep tendon reflexes.

1. Position client in a Normal reflex scores range Absent or markedly decreased deep tendon
comfortable sitting from 1+ (present but reflexes occur when a component of the
position. Use the reflex decreased) to 2+ (normal) to lower motor neurons or reflex arc is
hammer to elicit reflexes. 3+ (increased or brisk, but impaired; may be seen with spinal cord
Clinical tip: not pathologic). injuries. Markedly hyperactive deep tendon
If deep tendon reflexes are reflex may be seen with lesions of the
diminished or absent, two OLDER ADULT upper motor neurons and when the higher
reinforcement techniques CONSIDERATIONS cortical levels are impaired.
may be used to enhance Older clients usually have
their response. When deep tendon reflexes intact, OLDER ADULT CONSIDERATIONS
testing the arm reflexes although a decrease in Some older clients may have decreased
have the client clench the reaction time may slow the deep tendon reflexes and unstable balance
teeth. When testing the leg response. due to peripheral neuropathy, which also
reflexes, have the client causes disturbed proprioception, loss of
interlock the hands. vibration and temperature sense, and
possible pain, tingling, and distal weakness.
OLDER ADULT
CONSIDERATIONS
Reinforcement techniques
may also help the older
client who has difficulty
relaxing.
Test biceps reflex.
1. Ask the client to partially Elbow flexes and contraction No response or an exaggerated response is
bend arm at elbow with of the biceps muscle is seen abnormal.
palm up. Place your or felt. Ranges from 1+ to 3
thumb over the biceps +.
tendon and strike your
thumb with the reflex Forearm flexes and
hammer. Repeat on the supinates. Ranges from 1+ to
other side. (This 3+.
evaluates the function of
spinal levels C5 and C6.)

Assess brachioradialis
reflex.
1. Ask the client to flex
Flexion and supination of No response or an exaggerated response is
elbow with palm down
forearm. abnormal.
and hand resting on the
abdomen or lap. Tap the
tendon at the radius
about 2 inches above the
wrist. Repeat on the
 other side. (This
evaluates the function of
spinal levels C5 and C6.)

Test triceps reflex.

1. Ask the client to hang his Elbow extends, triceps No response or an exaggerated response.
or her arm freely (“limp contracts. Ranges from 1+ to
like it is hanging from a 3+.
clothesline to dry”) while
you support it with your
nondominant hand. With
the elbow flexed, tap the
tendon above the
olecranon process.
Repeat on the other side.
(This evaluates the
function of spinal levels
C6,C7, and C8.)

Assess patellar reflex.

1. Ask the client to let both Knee extends quadriceps No response or an exaggerated response is
legs hang freely off the muscle contracts. Ranges abnormal.
side of the examination
 table. Tap the patellar from 1+ to 3+.
tendon, which is located
just below the patella.
Repeat on the other side.
(This evaluates the
function of spinal levels
L2, L3, and L4.)

Assess Achilles reflex.

1. With the client’s leg still Normal response is plantar No response or an exaggerated response is
hanging freely, dorsiflex flexion of the foot. Ranges abnormal.
the foot. Tap the Achilles from 1+ to 3+.
tendon with the reflex
hammer. Repeat on the OLDER ADULT
other side. (This CONSIDERATIONS
evaluates the function of In some older clients, the
spinal levels S1 and S2.) Achilles reflex may be

absent or difficult to elicit.

Test ankle clonus when the

other reflexes tested have
been hyperactive.
1. Place one hand under the No rapid contractions or Repeated rapid contractions or oscillations
knee to support the leg oscillations (clonus) of the of the ankle and calf muscle are seen with
then briskly dorsiflex the ankle are elicited. lesions of the upper motor neurons.
foot toward the client’s
head. Repeat on the other
side.

Test superficial reflexes

Assess plantar reflex.

Clinical tip:
Use the handle end of the
reflex hammer to elicit
superficial reflexes, whose
receptors are in the skin
rather than the muscles.

1. With the end of the Flexion of the toes occurs.

The toes will fan out for abnormal response
reflex hammer, stroke
(positive Babinski response).
the lateral aspect of the OLDER ADULT
sole from the heel to the CONSIDERATIONS
ball of the foot, curving In some older clients, flexion
Except in infancy, extension (dorsiflexion)
medially across the ball. of the toes may be difficult
of the big toe and fanning of all toes
Repeat on the other side. to elicit and may be absent.
(positive Babinski response) are seen with
(Evaluates the function
lesions of upper motor neurons.
of spinal levels L4, L5,
Unconscious states resulting from drug and
S1, and S2.)
alcohol intoxication, brain injury, or
subsequent to an epileptic seizure may also
 cause it.

Test abdominal reflex.

1. Lightly stroke the Abdominal muscles Superficial reflexes may be absent with
abdomen on each side, contract; umbilicus deviates lower or upper motor neuron lesions.
above and below the toward the side being
umbilicus. (Evaluates the stimulated. Caution: The abdominal reflex may be
function of spinal levels concealed because of obesity or muscular
T8, T9, and T10 with the Clinical tip: stretching from pregnancies. This is not an
upper abdominal reflex The abdominal reflex may abnormality.
and spinal levels T10, be concealed because of
T11, and T12 with the obesity or muscular
lower abdominal reflex). stretching from pregnancies.

This is not an abnormality.

Test cremasteric reflex in
male clients.
1. Lightly stroke the inner
Scrotum elevates on Absence of reflex may indicate motor
aspect of the upper thigh.
stimulated side. neuron disorder.
(Evaluates the function
of spinal levels T12, L1,
and L2).

TESTS FOR MENINGEAL IRRITATION OR INFLAMMATION

ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS

PROCEDURE

If you suspect that the client

has meningeal irritation or
inflammation from infection
or subarachnoid
hemorrhage, assess the
client’s neck mobility.
1. First, make sure that there Neck is supple; client can Pain in the neck and resistance to flexion

is no injury to the cervical easily bend head and neck can arise from meningeal inflammation,

vertebrae or cervical cord. forward. arthritis or neck injury.

2. Then, with the client

supine, place your hands
behind the patient’s head
 and flex the neck forward
until the chin touches the
chest if possible.

Test for Brudzinski’s sign.

1. As you flex the neck, Hips and knees remain Pain and flexion of the hips and knees
watch the hips and knees relaxed and motionless. are positive Brudzinski’s sign and
in reaction to your suggest meningeal inflammation.
maneuver.

Test for Kernig’s sign.

1. Flex the client’s leg at both No pain is felt. Discomfort Pain increased resistance to extending
the hip and the knee then behind the knee during full the knee are a positive Kernig’s sign.
straighten the knee. extension occurs in many When Kernig’s sign is bilateral, the
normal people. examiner suspects meningeal irritation.
7. Enumerate the assessment findings in the following conditions:

7.1 Cerebrovascular Accident

Cerebrovascular accident (CVA) is the medical term for a stroke. A stroke is when blood
flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel.
There are important signs and symptoms of a stroke that you should be aware of and watch
out for these are the following:

● Sudden numbness or weakness in the face, arm, or leg, especially on one side of the
body
● Sudden confusion, trouble speaking, or difficulty understanding speech
● Sudden trouble seeing in one or both eyes
● Sudden trouble walking, dizziness, loss of balance, or lack of coordination
● Sudden severe headache with no known cause

Seek medical attention immediately if you think that you or someone around you might be
having a stroke. The more quickly you receive treatment, the better the prognosis, as a stroke
left untreated for too long can result in permanent brain damage.
Risk Factors

● Hypertension
● Smoking
● Chronic alcohol intake (more than three drinks per day)
● History of cardiovascular disease such as coronary artery disease, heart failure,
rhythm abnormalities (especially atrial fibrillation), mitral valve prolapsed
● Overweight

7.2 Cerebral Cortex Disorder

A number of disorders result from damage or death to brain cells of the cerebral cortex.
Apraxia is a group of disorders that are characterized by the inability to perform certain
motor tasks, although there is no damage to motor or sensory nerve function.

Signs and symptoms of apraxia:

● Impaired volitional oral movements (oral apraxia) Difficulty with volitional “smiling”
“kissing” “puckering”
● Delays with fine/gross motor skills.
● Feeding difficulties that include choking and/or poor manipulation of food.
● General awkwardness or clumsiness.
Damage to the cerebral cortex parietal lobe can cause a condition known as agraphia. These
individuals have difficulty writing or are unable to write.

Signs and symptoms of agraphia:

● reluctance towards writing activities
● problems with transposing, omitting, or adding letters to words, and their spelling
suffers as a result.
● experience pain in their arm or hand while writing.
● have muscle spasms while writing, hold a writing implement strangely or in an
awkward position, and write very quickly or (more rarely) very slowly
Damage to the cerebral cortex may also result in ataxia. These types of disorders are
characterized by a lack of coordination and balance. Individuals are unable to perform
voluntary muscle movements smoothly.

Signs and symptoms of ataxia:

● Impaired coordination in the torso or arms and legs.
● Frequent stumbling.
● An unsteady gait.
● Uncontrolled or repetitive eye movements.
● Trouble eating and performing other fine motor tasks.
 7.3 Oculomotor Nerve Paralysis

Oculomotor nerve palsy or third nerve palsy is an eye condition resulting from damage to the
third cranial nerve or a branch thereof. As the name suggests, the oculomotor nerve supplies
the majority of the muscles controlling eye movements. Thus, damage to this nerve will result
in the affected individual being unable to move his or her eye normally.

Risk Factors

● diabetes mellitus
● hypertension
● hyperlipidemia
● heart disease
● smoking

7.4 Peripheral Neuropathy

Peripheral neuropathy refers to the conditions that result when nerves that carry messages to
and from the brain and spinal cord from and to the rest of the body are damaged or diseased.
Damage to these nerves interrupts communication between the brain and other parts of the
body and can impair muscle movement, prevent normal sensation in the arms and legs, and
cause pain.

Signs and symptoms of peripheral neuropathy might include:

● Gradual onset of numbness, prickling or tingling in your feet or hands, which
can spread upward into your legs and arms
● Sharp, jabbing, throbbing, freezing or burning pain
 ● Extreme sensitivity to touch
● Lack of coordination and falling
● Muscle weakness or paralysis if motor nerves are affected

If autonomic nerves are affected, signs and symptoms might include:

● Heat intolerance and altered sweating
● Bowel, bladder or digestive problems
● Changes in blood pressure, causing dizziness or lightheadedness

Risk factors
● Diabetes mellitus, especially if your sugar levels are poorly controlled
● Alcohol abuse
● Vitamin deficiencies, particularly B vitamins
● Infections, such as Lyme disease, shingles, Epstein-Barr virus, hepatitis C and
HIV
● Autoimmune diseases, such as rheumatoid arthritis and lupus, in which your
immune system attacks your own tissues
8. Identify the different materials needed and its uses in neurologic assessment
For complete examination, the following special equipment will be needed:
● Snellen eye chart- used to assess visual acuity and tests functionality of optic nerve.

● Tongue depressor- to assess the gag reflex.

● Newsprint to read- to test the reading comprehension of the client.

● Examination gloves - prevent cross-contamination between patients and caregivers.

● Stethoscope- used for ocular auscultation or to detect other abnormal sounds.

● Ophthalmoscope- used to detect and evaluate symptoms of various retinal vascular
diseases or eye diseases such as glaucoma.

● Penlight- used to diagnose and discern the severity of a concussion and is often used
with patients that are passed out to check reflex and brain function.

● Two test tubes, one filled with hot water and the other with cold water- to evaluate
thermal sensitivity on the injured skin of leprosy patients.

● Sterile cotton balls or cotton-tipped applicators- to examine ability to feel fine touch
with a monofilament. These are called small fiber sensations.
● Tuning fork- used to test a patient’s hearing. The physician strikes the prongs causing
them to vibrate and produce a humming sound.

● Percussion or reflex hammer- used to test neurologic reflexes. The head of the
instrument is used to test reflexes by striking the tendons of the ankle, knee, wrist and
elbow.

● Paper clip- Testing between areas for diminished/altered sensation. May be usual in
patients with central sensation.

● Substances to smell, such as coffee, vanilla, and perfume- to assess cranial nerve
number 2
● Objects to touch/feel, such as quarter or key- to assess nerves for sensations.
● Substances to taste, such as salt, lemon, and sugar- to assess cranial nerve number 7.
9. State the nursing responsibilities before, during and after neurologic assessment
Before:
● Check physician’s order.
● Gather the necessary equipment.
● Wash hands and observe appropriate infection control procedures.
● Make a brief survey to determine the client’s ability to participate.
● Ensure that the room is warm and free of drafts, with full lighting.
● Explain all procedures to the client. Identify client.
During:
● Ensure client privacy and safety.
● Vary your approach according to the physical condition of the client.
● When possible, perform the nonthreatening, easily performed tasks first.
● Use standard precautions throughout the neurologic assessment.
● Work in an organized manner, taking a head-to-toe and distal-to-proximal approach.
● Assess mental status, cranial nerves, motor function, sensory function, and reflexes.

After:
● Record or document findings from physical assessment.
● Review and validate all findings before assisting the client with dressing, if necessary,
to recheck any information or gather additional data.
● Do after care.
 BIBLIOGRAPHY

How to Assess Mental Status - Neurologic Disorders. (n.d.). Retrieved from

https://www.msdmanuals.com/professional/neurologic-disorders/neurologic-
examination/how-to-assess-mental-status

What Is the Glasgow Coma Scale? (2018, July 25). Retrieved from
https://www.brainline.org/article/what-glasgow-coma-scale

Potter, P. A., & Perry, A. (2005). Virtual clinical excursions--medical-surgical for Potter &
Perry: Fundamentals of nursing, 6th edition (6th ed.). St. Louis, MO: Elsevier Mosby.

Sims, L., D’Amico, D., Stiesmeyer, J., & Webster, J. (1995). Health Assessment in Nursing.
Redwood City, California: Addison-Wesley Publishing Company.

John Hopkins Medicine: Neurological Assessment. (n.d.). Retrieved from

https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/neurol
ogical_examination_85,p00780