L6 (Part 2) Nursing assessment of physical systems: Neurologic system

1. Learning outcomes
After you have read the textbook chapter 6 & 25 you should be able to:
1.1 Select pertinent the sensory-neurologic history questions
1.2 Obtain a history specifically for the sensory-neurologic system
1.3 Complete a sensory-neurologic physical assessment
1.4 Document assessment findings
2. Contents
Review of anatomy and physiology
Signs and symptoms
Health assessment
Nursing health history
General survey
Physical examination
Investigation
Documentation

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3. Key functions of nervous systems
The nervous system is divided into two regions:

The central The peripheral

nervous system nervous system

cranial
brain
nerves

spinal cord spinal nerves

autonomic
nervous
system

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The Central Nervous System Functions Signs and symptoms
The brain divides into three areas
The cerebrum Lobes Cognition Sense Motor Seizures
Frontal √+ √ Vertigo
emotion voluntary Visual disturbances (e.g. diplopia)
Parietal - √ - Memory loss
Sensation Muscle weakness
Temporal - √ auditory -
Occipital - √ visual -
The brain stem  Connects the pons and the cerebellum with the Brain stem death
Cranial nerves III to XII situate in the midbrain, cerebral hemispheres; will not regain consciousness or be able to breathe
pons and medulla;  Contains sensory and motor pathways and without support
Respiratory centre situate in the medulla serves as the centre for auditory and visual
oblongata reflexes;

The cerebellum  Control balance, position sense (proprioception) Ataxia

The structures protect the brain
Meninges: Cerebrospinal fluid
Cerebral circulation: Blood brain barrier
and coordinate movement
 Provide nutrient to brain
 Eliminate waste
 The arteries of the circle of Willis provide
collateral circulation if one or more of four
Fever, Headache
Headache
Congenital or degenerative aneurysms form at the
arterial anastomoses along the circle of Willis.

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 vessels supplying it become occluded or are  The blood-brain barrier might be altered by
ligated trauma, cerebral edema and cerebral
 Tight junctions between adjacent endothelial hypoxemia.
cells in the cerebral vasculature form the blood–
brain barrier
 The CNS is inaccessible to many substances that
circulate in the blood plasma (e.g. medication
and antibiotics) due to the blood-brain barrier

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 Name of Cranial nerves Essential senses Motions Signs and symptoms
CN I 臭 Olfactory Control smell Loss of sensation
CN II 視 Optic Control visual acuity Visual disturbances
CN III 動眼 Oculomotor Pupillary constriction and Nystagmus
extraocular movement
CN IV 滑車 Trochlear Pupillary constriction and Nystagmus
extraocular movement
CN VI 外展 Abducens Pupillary constriction and Nystagmus
extraocular movement
CN V 三义 Trigeminal Control somatic sensations Temporomandibular joint Trigeminal neuralgia
ROM Malocclusion
CN VII 面 Facial Control taste Muscles of facial expression Bell’s palsy
Corneal reflex
CN VIII 聽 Acoustic Control hearing Hearing loss
CN IX 舌咽 Glossopharyngeal Control taste Palate, pharynx, larynx Dysarthria (difficulty in
(speaking & swallowing) & Gag forming words)
reflex Dysphagia (difficulty in
swallowing)
CN X 迷走 Vagus Control senses in pharynx an Palate, pharynx, larynx Dysarthria (difficulty in
larynx (speaking & swallowing) & Gag forming words)
Sensorimotor for reflex Dysphagia (difficulty in
Cardiovascular, respiratory, swallowing)
and digestive systems
CN XI 副 Spinal accessory Control muscles of neck Weakness or twitching
(sternocleidomastoid) and
shoulders (Trapezius)
CN XII 舌下 Hypoglossal Control tongue movement Weakness or twitching

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The spinal cord
Spinal nerve  The ascending tracts (sensory) are responsible Abnormal sensation
Sensory and motor pathways: The spinal tracts for conduction of tactile sensation, pain, Muscle twitching or cramps
temperature, vibration, proprioception, and Muscle weakness or paralysis
integration of sensation. Atrophy
 The descending tracts (motor) involve in the Foot drop
control voluntary muscle activity, in some Constipation or diarrhea
autonomic functions and involuntary muscle Bowel incontinence
movement. Erectile dysfunction
Excessive sweating or a lack of sweating
Retention of urine

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Spinal cord with spinal nerve
Ascending tracts are sensory
Descending tracts are motor
Aims
Deliver information to the brain
Deliver information to the periphery
Name of tracts Functions
Posterior columns tract (Fasciculus gracilis proprioception, discriminative touch,
and Fasciculus cuneatus) two-point discrimination, pressure and
vibration
Spinothalamic tract pain, temperature, deep pressure & crude
touch
Spinocerebellar tract Proprioception (sense of body position)
Corticospinal tract Conscious control of skeletal muscles
Subconscious motor tracts
• Vestibulospinal tracts programming automatic movements,
• Tectospinal tracts posture & muscle tone, equilibrium &
• Reticulospinal tracts coordination of visual and limb reflexes
• Rubrospinal tracts
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 Known functions Signs and symptoms
Autonomic nervous system transmits motor The autonomic nervous system controls internal ??dangerous??
body processes such as the following:
commands in response to sensory information;
directs the activity of glands, smooth muscles,  Blood pressure
and cardiac muscle
 Heart and breathing rates

 Body temperature

 Digestion

 Metabolism (thus affecting body weight)

 The balance of water and electrolytes (such

as sodium and calcium)
 The production of body fluids (saliva, sweat,
and tears)

 Urination

 Defecation

 Sexual response

Sympathetic nervous system Fight-or-flight response

Parasympathetic nervous system Create controlled opposition, with a delicate
balance maintained between the two (sympathetic
and parasympathetic systems) at all times

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Anterior cerebral artery Cerebral blood circulation supply by
 Internal carotid arteries (anteriorly) and the vertebral arteries (posteriorly)
 The cerebral hemispheres receive blood supply from the anterior and
middle internal cerebral arteries
 The brainstem and cerebellum receive blood supply from the basilar artery
Posterior cerebral artery  The posterior cerebrum receives blood from the posterior cerebral arteries
 The normal cerebral blood flow accounts for 20% of the cardiac output
each minute and 20% of the body’s oxygen consumption for metabolism
of glucose
 Cerebral blood flow is self-regulated by the brain to meet metabolic needs
despite changes in systemic blood pressure (within the range of mean
blood pressure from 50 to 160 mmHg)
 Cerebral blood flow will increase in response to increased carbon dioxide
concentrations, increased hydrogen ion concentrations, and decreased
oxygen concentration

The circle of Willis

These major cerebral arteries are connected by small anterior and posterior
communicating arteries which form a circle of connected blood vessels
 Function: serve as a protecting device by providing alternatives routes of
circulation for brain tissues

The veins in the cerebral system

Two sets of veins drain cerebral blood into venous plexuses and dural sinuses
and then into the internal jugular veins at the base of the skull
 Veins in cerebral systems do not have valves
 The direction of venous blood back flow depends on gravity or pressure
difference between the venous sinuses and the extracranial veins
 Implication: intracranial pressure can increase because the increased
intrathoracic pressure is transmitted through the internal jugular veins and
Vertebral artery the dural sinuses
 Activities that increase intrathoracic pressure (such as sneezing, coughing,
straining to have a bowel movement, or vomiting) could briefly increase
intracranial pressure

The blood-brain barrier (BBB) 9

The capillaries in the brain have low permeability due to the specific cell
structure of capillary walls as the blood-brain barrier
 Allows lipids, glucose, some amino acids, water, carbon dioxide and oxygen
to pass through it
 Maintain a controlled environment that protect the brain from many
 SRS
Match the right column of description to the correct items that are listed in the left column.
Items Description
Spinal cord 1. Evolve clusters of neurons which act to accept, interconnect, interpret and
generate a response to nerve impulses originating throughout the body.
Spinal nerves 2. Extends from the medulla to the level of the first lumbar vertebra as a
centre for conducting messages to and from the brain and as a reflex centre.
Brain 3. Twelve pairs of nerves originate in the forebrain and brainstem which only
one pair extends into the ventral body cavity, but the 11 others pairs innervate
only head and neck regions.
Cranial nerves 4. The roots of 31 pairs of nerves arise from the cord that each separates in
posterior roots for sensory and anterior roots for motor.
Autonomic nervous system 5. The peripheral nervous system regulates the internal environment of the
body such as regulate cardiac rate, blood vessel diameter, and gastrointestinal
function.

6. The cerebral circulation mainly receives blood from body system via two main vessels including:

(i) Basilar artery

(ii) Internal carotid arteries
(iii) Vertebral arteries
(iv) Internal jugular vein
(v) Circle of Willis

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7. Which substances could pass through the blood-brain barrier to the brain?
(i) Proteins
(ii) Alcohol
(iii) Cocaine
(iv) Heroin
(v) Glucose
(vi) Water
(vii) Antibiotics
(viii) Bacteria
(ix) Oxygen
(x) Carbon dioxide

8. The function of the circle of Willis is to

(i) Release intrathoracic pressure
(ii) Provide alternatives routes of cerebral circulation
(iii) Provide extra blood supply to tissues

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4. Frame of assessment
Nursing health history→ general survey→Mental status assessment (client should be stable) →if client is semiconscious, use GCS→ I (pupil size, responses
include eye opening, verbal and motor) P (test for sensation) P (strike tendon reflex by a hammer) →specific test →+investigation→Documentation

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 5. Nursing health history of neurological problems
5.1. Present health concern: Types of discomfort (Textbook, p.550-553)
NS Aetiology Characteristic Onset Location Duration Severity Pattern Associated
factors
Generalized seizures *The entire brain It includes four Pre tonic- Clonic phase Clonic phase Clonic phase: keep closed The post seizure
affected by phases: clonic phase Generalized persistent for 30 desaturation, observation period: Confused
infection or mass 1.Pre tonic-clonic includes aura seizures signaled to 60 seconds head injury, until full acuity and fatigue;
injuries of brain 2. Tonic and LOC Tonic by contraction bladder Sleep deeply for
Or other reasons 3. Clonic phase and relaxation of incontinence; 30 minutes to
cause ischemia of 4. post seizure Sudden all muscles in a aspiration several hours,
brain tissues Rigidity and jerky pattern Clients may
(referred to below fall on the realize the
remarks) ground. Pupils seizure but not
fixed and remember the
dilated, the event itself
hands and associated with
jaws clenched, headache.
breathing
stopped

Paresthesia Diabetes and a sensation of Progressive initial on the Intermittent in Affect one’s NA Associated with
is an abnormal neurologic, numbness, And recurrent distal chronic problems daily life other accidental
sensation caused metabolic, tingling, tickling, or of extremities Persistent in events i.e.
chiefly by pressure cardiovascular, burning of a acute problems temporary
on or damage to renal and person's skin over restriction of the
peripheral nerves. inflammatory hands and feet blood supply to
diseases an area of nerves
Difficult in speaking Injury to the Difficulty forming Sudden or NA Persistent Affect one’s NA drool and have
cerebral cortex words (dysarthria) progressive daily life problems
Difficulty chewing or
comprehending swallowing
and expressing
thoughts (aphasia)

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NS Aetiology Characteristic Onset Location Duration Severity Pattern Associated
factors
Difficult in Injury to CN IX, X Choking Progressive NA Persistent Affect one’s NA drool and be
swallowing or XII; or related daily life difficult to
to stroke or move the lips,
Parkinson’s tongue, or jaw.
disease
Memory loss Impaired in Recent memory Progressive/ NA Persistent Affect one’s NA Various
dementia or (24-hour Intermittent/ daily life physical,
cerebral cortex memory) Recur psychological
disorders Remote memory problems
(past dates and
historical
accounts)

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5.2 Other nursing health history (Textbook, p.553)
Category Questions Significance
Past health history Did you have any injuries or trauma on your head or surgeries? Provide baseline data for physical assessment. Past
Did you have any injuries or trauma on the spinal cord? injuries may affect the client’s current mental
status, sensation, cognitive function.

Have you ever been diagnosed with meningitis, encephalitis, injury to the spinal These disease places the client at risk for
cord, or stroke? development of musculoskeletal problems such as
Are you receiving any type of treatment? osteoporosis.

Family health Does anyone in your family have the mentioned problems such as meningitis, These disorders tend to run in families.
history encephalitis, injury to the spinal cord, stroke, epilepsy, Alzheimer's disease, chronic
headaches, psychiatric disorders, or alcoholism?
Review of body Have you experienced mood, headaches, concussions, loss of strength or sensation, Reconfirm any neurological symptoms
systems dysarthria (slurring), coordination, difficulty reading or learning, syncope?
Have you experienced chest discomfort, breathlessness, fainted, difficulty in Autonomic nervous system control and regulate
elimination? internal environment of the body
Lifestyle and Tell me what you ate yesterday for the entire day. Folic acid and vitamin B12 deficiency can cause
health practice peripheral neuropathy.
Do you smoke? Can blood vessels constrictions which decrease
blood flow to brain.
Do you use any over-the-counter drugs or herbal remedies? Drugs cause various neurologic symptoms such as
As always, ask about medications-specifically, aspirin, anticoagulants, dizziness, alter level of consciousness, mood and
anticonvulsants, antihypertensive, central nervous system depressants and temperament
stimulants, narcotics, and tranquilizers. Risk factors of generalized seizures
➢ Fluid and electrolyte imbalance
➢ Hypoxia
➢ Low cerebral tissue perfusion
➢ Nutritional deficiencies
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 ➢ Infections
➢ Renal and liver disease
➢ Hyper- or hypothermia
➢ Trauma (brain or spinal cord)
➢ Medication adverse effects
➢ Drug or alcohol abuse

Can you take care of yourself? Neurologic symptoms affect the ability of self-care.
Do you frequently life heavy objects or perform repetitive motions? Repetitive motions can cause peripheral nerve
injuries.
Improper lifting heavy objects can cause
intervertebral disc injuries.
How did you view yourself before you had problems, how do you view yourself Body image disturbances and chronic low self-
now? esteem may lead to depression and changes in role
functions.
lifestyle alterations can cause increased stress and
difficulties in coping

Glossary
Head injury: Any injury that results in trauma to the scalp, skull, or brain. The terms traumatic brain injury and head injury are often used interchangeably.
Cerebrovascular accident (CVA): The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture
of an artery to the brain. CVA is also referred to as a stroke.
Epilepsy : a group of long-term neurological disorders characterized by epileptic seizures. These seizures are episodes that can vary from brief and nearly
undetectable to long periods of vigorous shaking.
Meningitis : is an acute inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges. The inflammation
may be caused by infection with viruses, bacteria, or other microorganisms.
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Encephalitis : an acute inflammation of the brain. This definition means encephalitis is different from meningitis, which is defined as inflammation of the layers of
tissue, or membranes, covering the brain.
Parkinson disease : a degenerative disorder of the central nervous system. The motor symptoms of Parkinson's disease result from the death of dopamine-
generating cells in the substantia nigra, a region of the midbrain. Early in the course of the disease, the most obvious symptoms are movement-related; these
include shaking, rigidity, slowness of movement and difficulty with walking and gait.
Alzheimer disease : the most common form of dementia causes memory loss and other intellectual abilities serious enough to interfere with daily life.
Multiple sclerosis : an inflammatory disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This damage disrupts the ability
of parts of the nervous system to communicate, resulting in a wide range of signs and symptoms, including physical, mental and sometimes psychiatric problems.
Spinal cord injury : damage to any part of the spinal cord or nerves at the end of the spinal canal — often causes permanent changes in strength, sensation and
other body functions below the site of the injury.
Herniated intervertebral disc : occurs when the disc degenerates and the inner core leaks out. This puts pressure directly on the spinal nerve root, which in turn
can prompt back pain.
Alert: orientated to time, place, person
Confusion: disorientated to time, place and person sequentially
Lethargy: Response to verbal command and back to sleep
Drowsiness: refers to feeling abnormally sleepy during the day and may fall asleep in inappropriate situations or at inappropriate times.
Delirium: is a transient loss of intellectual function, and rapidly changing of mental states. Behaviours change simultaneously that include
1. Attention and awareness
2. Thinking and memory
3. Emotion
4. Muscle control
5. Sleeping and waking
Stupor: unresponsiveness from which a person can be aroused only by vigorous, physical stimulation.
Coma: unresponsiveness from which a person cannot be aroused.
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6. Physical assessment
A complete neurologic examination consists of evaluating the following areas:
➢ General survey and vital signs
➢ Mental status (level of consciousness, communication and cognitive function) via interviewing and inspection
➢ Cranial nerves via inspection, palpation, percussion and specific test
➢ Motor and cerebella system via inspection
➢ Sensory system via inspection and palpation
➢ Reflexes via infection and percussion with a reflex hammer

Tools
Mental status assessment via interviewing (Textbook, P.83- 89) is a more comprehensive assessment that performs to one’s condition is stable.
Category Questions asked to test client’s neurological status Rationale/significance
Orientation What’s your name? Disorientation is often an initial sign of a neurological
What is the month? Year? disorder.
Where are you now?
Do you know my occupation? (test the client knowing that you
are the health care professional in the health care setting)

Language ability
(communication)
Concentration
Ask client to read a paragraph of a newspaper
Read the following sentence, …
Repeat the sentence I just said.
Subtract 7 from 100, then 7 from that answer, and so on.
Different types of aphasia can result from injury to different
parts of the brain.
Aphasia is an impairment of language, affecting the
production or comprehension of speech and the ability to
read or write.
Most people with intact neurological function can complete
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and calculative ability serial 7s in about 1.5 minutes.
Memory Recent memory Impaired memory can be affected by both delirium and
Repeat these four or five words such as Key, Watch, door, Cat, dementia.
and apple, Delirium can cause impaired immediate and short-term
Repeat them again in 5, 10, 15, 20 minutes. memory, whereas dementia not only affects immediate
and short-term memory but also the ability to learn new
information.
It can also be related to stroke.
Remote memory
What’s the maiden name of your mother?
Judgment What will you do if you smell something burning? Assessment of the patient’s ability to interpret information
What would you do if you smelled smoke? and act appropriately is an important safety issue and
Where would you put milk? activity of daily living.

Abstract reasoning Tell me the meaning of “Kill two birds with one stone.” Deterioration of abstract reasoning ability in mild cognitive
impairment and Alzheimer’s disease.

Construction Copy the design below Agnosia (inability to interpret or recognize familiar objects)
Write a circle of a clock, point the long hand by 12 and point the can occur in cerebral vascular accidents and brain lesions.
short hand by 2.
Show pen and pencil and ask what each is.
Or show client toothbrush and comb and ask what each is.

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Category: To test client who does not respond appropriately.
Glasgow Coma Scale It is useful for rating one’s response to stimuli.
(Text book p.94)
Score
Eye opening response Spontaneous opening 4
To verbal command 3
To pain 2
No response 1
Most appropriate Oriented 5
verbal response Confused 4
Inappropriate words 3
Incoherent 2
No response 1
Most integral motor Obey verbal commands 6
response Localizes pain 5
Withdraws from pain 4
Flexion (decorticate rigidity) 3
Extension (decerebrate rigidity) 2
No response 1
Total score 3-15, On this scale, patients receiving 3-8 points are said to be in
a coma. 9-12 points show a moderate amount of reduced
consciousness. 13-14 show minor impairment.

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Mr. Kong:

• Opened his eyes once in response to speech, and once in response to pain. In cases when more than one answer is possible, use the higher value. (3 points)
• Is not able to converse. Gives inappropriate responses (calling for his deceased wife), but his words, though slurred, are discernable. (3 points)
• Not only withdraws from pain (moves hand), but uses purposeful movement (putting hand under covers). (5 points)

His cumulative score is 11/15. On this scale, patients receiving 3-8 points are said to be in a coma. 9-12 points show a moderate amount of reduced consciousness. 13-14 show minor
impairment.

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Mini-Mental Exam
https://www.youtube.com/watch?v=_93i2xZQsd4
Planning For Life With Dementia - Louis Theroux: Extreme Love - Dementia - BBC
https://www.youtube.com/watch?v=ROQxM9-6w0g
12 Cranial nerve assessment (Textbook, p.558 -562) https://www.youtube.com/watch?v=-J9QEddbJAU

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Name Type Function Assessment
CNI Olfactory Sensory Smell With eyes closed, the patient identifies familiar odors (coffee,
tobacco). Each nostril is tested separately.
CNII Optic Sensory Vision 1. Use a Snellen chart to assess vision acuity in each eye
https://www.youtube.com/watch?v=LMl8Sy6wsZQ i. Position the partner 20 feet from the chart and ask him or
https://www.youtube.com/watch?v=j8MRREOP4Q8 her to read each line ,Normally 20/20 vision OD (right
eye) and OS (left eye)
2. Ask the partner to read a newspaper to assess near vision,
client reads print at 14 inches without difficulty.
3. Assess visual fields of each eye by confrontation with Full
visual fields
4. Use an ophthalmoscope to view the retina and optic disc of
each eye
CNIII Oculomotor Motor Opening eyelid 1. Assess ocular rotations, conjugate movements, nystagmus
Moving eye superiorly medially, diagonally, 2. Assess pupillary reflexes to light and inspect eyelids for ptosis
constricting pupils 3. Normal result: Pupils Equal, Round, React to Light and
CNIV Trochlear Motor Moving eye down and laterally Accommodation (PERRLA)
CNVI Abducens Motor Moving eye laterally https://www.youtube.com/watch?v=PAor9WG7XF4

CNV Trigeminal Motor Control the facial motor-Chewing and jaw 1. Begin testing its motor integrity by asking your patient to clench
opening and clenching her jaw while you palpate the temporalis muscle contraction.
i. Then move your hands down to the jaw angle and ask her
https://www.youtube.com/watch?v=HKlcjOCw3_8 to clench again, palpating the masseter muscle
contraction.
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Sensory Conveying sensory data from eyes (cornea), nose,
mouth, teeth, jaw, forehead, scalp, and facial skin
CNVII Facial Motor Closing eyes & mouth, moving lips and other
muscles of facial expression, salivation and
lacrimation (secreting saliva & tears)
ii. Her side-to-side jaw movement, while you resist, will help
allow you to check the strength and symmetry of the
temporalis and masseter muscles.
iii. The jaw should move easily, even against resistance.
Bilateral weakness might represent nervous system
dysfunction; unilateral weakness may be the mark of a CN
V lesion.
1. test facial sensation and corneal reflex
i. With your patient's eyes closed, touch her forehead,
cheeks, and chin with the rounded and then the pointed
end of an open paper clip.
ii. Ask her to identify each touch as "sharp" or "dull".
iii. Partial or total loss of sensation could signify either CN V
damage or lesions in the spinothalamic tract or posterior
spinal column.
2. A patient should remove contact lenses for the corneal reflex
test.
i. Ask her to look up and away from you. With a wisp of
cotton, lightly touch the cornea.
ii. Observe for bilateral blink; repeat on the other eye.
Abnormal findings may indicate CN V or VII dysfunction.
1. Assess motor function by asking your patient to smile, frown,
bare her teeth, puff her cheeks, purse her lips, raise her
eyebrows, and close her eyes against resistance.
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https://www.youtube.com/watch?v=BPDbWP2FhLA
https://www.youtube.com/watch?v=sbIQx6bEFhY
Sensory Tasting on anterior tongue
i. Assess each movement for symmetry, mobility, and tics,
tremors, or immobility.
ii. Unilateral facial paralysis may be caused by CN VII
damage (Bell's palsy) or by an upper motor neuron lesion.
The sensory component of CN VII involves taste; it's generally tested
only when the patient reports a problem with taste.

CNVIII Acoustic Sensory Hearing, equilibrium 1. Whisper test

https://www.youtube.com/watch?v=_ZKPrYLKY-Y 2. Test for lateralization by Weber test
https://www.youtube.com/watch?v=iIbaq15t1L0 3. Test for air and bone conduction by Rinne tests
4. Assess the partner’s equilibrium (Romberg test)
5. Use the otoscope to inspect the external auditory canal and
the tympanic membrane
CNIX Motor Swallowing, gag sensation, secretion of saliva The glossopharyngeal and vagus nerves control swallowing and
Glossopharyngeal https://www.youtube.com/watch?v=qyP05hnl7OM phonation, and have both motor and sensory components.
1. With your patient open mouthed and saying "ahh," the uvula
Sensory Tasting on posterior tongue and soft palate should rise symmetrically and smoothly, and the
CNX Vagus Motor Palate, pharynx, larynx (speaking & swallowing) "ahh" shouldn't sound hoarse.
i. Uneven movement or uvular deviation may indicate a CN
Sensory Sensations in pharynx and larynx X lesion.
Sensorimotor Cardiovascular, respiratory, and digestive systems 2. Next, warn the patient that you'll be testing the gag reflex;
gently touch the posterior pharynx with a tongue depressor and
observe the gag.
i. Offer her some water, and note ability to swallow.
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 ii. Absent or diminished gag reflex and hoarseness may
signal dysfunction in CNs IX and X.
iii. Taste in the posterior third of the tongue-the sensory
component of CN IX-is rarely tested.
CNXI Spinal accessory Motor Contracting muscles of neck (sternocleidomastoid) 1. Face your patient and observe the SCM's contour and size.
and shoulders (Trapezius) i. With your right palm on the left side of your patient's
face, ask her to turn toward your resistance; repeat for
https://www.youtube.com/watch?v=1klaVBL5HU4 the right SCM.
ii. A person without CN XI impairment will be able to turn
the head smoothly, despite resistance.
2. Standing behind your patient, observe shoulders and scapula for
symmetry and contour.
i. Test the trapezius muscles by placing one of your hands
on each shoulder and asking her to shrug while you resist.
ii. Atrophy, tremors, or unilateral paralysis in the SCM or
trapezius muscles may be a sign of nerve damage,
trauma, or tumor.
CNXII Hypoglossal Motor Tongue movement, articulating with tongue, 1. Ask your patient to stick out her tongue and move it from side
swallowing to side.
https://www.youtube.com/watch?v=7TEOHbo49po i. Ask her to say the words "tight" and "light," noticing
articulation.
ii. Note any atrophy, lateral deviations, or tremors.

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Assessment for Motor and cerebellar systems (Textbook, p. 563 -566)
1. Test condition and movement of muscles
2. Test balance https://www.youtube.com/watch?v=U5a4lbmwmOw
3. Test coordination
https://www.youtube.com/watch?v=QjllDK6xGuA
Spinal nerves (Textbook, p. 566 - 569)
1. Test light touch, pain, and temperature sensations. (On four limbs)
2. Test position sensations (proprioception)
https://www.youtube.com/watch?v=kIdPvg80QP8
They control muscles movement, balance and
coordination
Observe the gait, evenly weight disturbed. Stand on
heel and toes.
Romberg test by asking the client to stand erect. Note
any unsteadiness or swaying. Then ask client close the
eye for 20 seconds. Again note any imbalance or
swaying.
Walk a straight heel-to-toe
Stand on one foot and do a shallow knee bend or hop
Rapid alternating movements of the hands
Finger-to-nose
Heel slide test
Spinal nerves control the sensations.
Light touch, then pain, last for temperature
Begin distally and move proximally along each limb
Begin a light touch with a wisp of cotton ball and
repeat the same procedure using a sharp object
Grasp client’s index finger and move the index finger
up or down
Ask the client to describe the direction when the eyes
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 closed.
Grasp the client’s toes and perform the same
procedure repeatedly.
Any abnormal description noted, move to the next
proximal joint (the wrist or ankle) and repeat the same
procedure.
3. Test vibratory sensations Using a tuning fork with the similar procedure as above
https://www.youtube.com/watch?v=X3kW26L_7dA

4. Test tactile discrimination (fine touch) Stereognosis: recognize objects by touching

https://www.youtube.com/watch?v=yuRLPSh6hnA&list=PLSUy74GVC4Tsy4id_VRhjmW- Graphesthesia: identify shapes, numbers traced on the
51gkPWX_7 skin
Two-point discrimination: Ask the client to identify the
number of points felt when touched with the ends of
two applicators at the same time
Extinction: ask the client to identify the area touched,
nurse should touch the client in the same area on both
sides
Spinal nerves (Textbook, p. 569 -573) A reflex is built into Spinal nerves and does not need
the intervention of conscious thought to take effect.
1. Test superficial reflexes (plantar (S1-S2), abdominal (T7-T12), cremasteric (T12-L1)) Light stroke on the sole to elicit the plantar reflex
https://www.youtube.com/watch?v=svs4Mv0TtUg Light touch on the abdomen on each side above and
https://www.youtube.com/watch?v=4oo1oDQSfPs below the umbilicus
https://www.youtube.com/watch?v=Nn94Efmrg7I Test cremasteric reflex in male clients by touching the
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 inner aspect of the upper thigh.

2. Test deep tendon reflexes (biceps (C5-C6), brachioradialis(C5-C6), triceps (C7), patellar (L2-L4),
Achilles (S1))
https://www.youtube.com/watch?v=yX0L93E9EPQ

3. Test for meningeal irritation/inflammation (Specific tests; Textbook, p. 573) ➢ Brudzinski’s sign
(Brudzinski’s and Kernig’s signs if indicated) ◆ Lie flat with your patient’s head flexed to his
https://www.youtube.com/watch?v=Ntusx07WYfQ or her chest
◆ Normally no flexion of the hips
subsequently
◆ If knees and hips flex during the test, you've
elicited a positive Brudzinski's sign,
indicative of meningeal irritation.
➢ Kernig’s sign
◆ Lie flat your patient, with your patient’s hip
and knee flexed at 90 degree angles
◆ Try to extend the leg while you apply
pressure to the knee
◆ Normally no resistance to extension
◆ A positive Kernig's sign of leg contraction or
resistance, marks meningeal irritation.

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*Reflexes
➢ Deep tendon reflexes (DTRs)
◆ Test the five DTRs- Biceps, brachioradialis, triceps, patellar & Achilles - requires practice and a relaxed patient.
◆ Have your patient sit with feet dangling. It's generally easier to elicit a DTR if you distract her-asking her to contract an unrelated muscle group, for
example, by grimacing or making a fist.
◆ Hold the reflex hammer handle loosely so that it swings freely.
◆ Palpate each tendon location first, and then strike with a quick, sharp tap, using the pointed hammer end to tap small tendons and the flat end to
tap larger ones.
◆ Compare bilateral responses.
◆ Documenting reflex findings (refer to page. 576)
DTRs grades interpretation
0 Absent
+ Present but diminished
++ Normal
+++ Increased but not necessarily pathologic
++++ Hyperactive
Superficial reflex grades
0 absent
++ present
◆ Scores can be recorded on a stick-figure drawing beside the corresponding areas on the patient.
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7. Investigation
Items Significance
Computed tomography Focus on a particular brain soft tissue, help for diagnosing problems of brain tumor and blood
scanning vessels problems
Myelogram Visualize the spine and spinal cord with contrast medium for diagnosing problems of peripheral
nervous systems
Cerebral angiography An X-ray study of the cerebral circulation with a contrast agent injected into a selected artery
to investigate vascular disease, aneurysms and arteriovenous malformations.
Noninvasive carotid flow Use ultrasound imagery and doppler measurements of arterial blood flow to evaluate carotid
studies and deep orbital circulation regarding blood velocity.
Transcranial doppler Use ultrasound imagery to record the blood flow velocities of the intracranial vessels through
thin areas of the temporal and occipital bones of the skull.
Electroencephalography Represents a record of the electrical activity generated in the brain through electrodes applied
on the scalp to provide a physiologic assessment of cerebral activity.
Electromyography Represents a record of the electrical potential of the muscles and the nerves leading to them
through needle electrodes into the skeletal muscles. It helps to distinguish weakness due to
neuropathy or other causes.
Lumbar puncture Aseptic technique carried out by inserting a needle into the lumbar subarachnoid space to
withdraw cerebrospinal fluid analysis.

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8. Documentation

Mr. Kong’s past health was good except diagnosed with influenza A 3 weeks ago. Glasgow coma scale was E3V3M5, Blood pressure increased 160/90 mmHg,
High Fever 39 Celsius Degree. RR 22/min with SpO2 95%. Brudzinski’s sign and Kernig’s sign were positive. Due to the serious condition, keep observation Q1H
for GCS, vital signs until alert. Pending to have the investigation of computed tomography scanning and lumbar puncture to confirm the diagnosis of meningitis.

Mr. Kong, 55-year-old, was admitted to the medical ward due to generalized seizures and witnessed by his wife. Mrs. Kong claimed that she found him
developing tonic-clonic convulsion at 8 a.m. for about 40 sec and called the ambulance to AED. Mr. Kong had a laceration on his cheek due to a fall before the
convulsion and urine incontinence. After the convulsion, Mr. Kong was fatigued and sleepy.

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Suggested answers for documentation
Mr. Kong, 55-year-old, was admitted to the medical ward due to generalized seizures and witnessed by his wife. Mrs. Kong claimed that she found him developing
tonic-clonic convulsion at 8 a.m. for about 40 sec and called the ambulance to AED. Mr. Kong had a laceration on his cheek due to a fall before the convulsion and
urine incontinence. After the convulsion, Mr. Kong was fatigued and sleepy. Mr. Kong’s past health was good except diagnosed with influenza A 3 weeks ago.
Glasgow coma scale was E3V3M5, Blood pressure increased 160/90 mmHg, High Fever 39 Celsius Degree. RR 22/min with SpO2 95%. Brudzinski’s sign and Kernig’s
sign were positive. Due to the serious condition, keep observation Q1H for GCS, vital signs until alert. Pending to have the investigation of computed tomography
scanning and lumbar puncture to confirm the diagnosis of meningitis.

9. Reference
Assessing the cranial nerves following these steps will help you evaluate your patient’s nervous system. Nursing, 36 (11), 49.
Huntley, A. (2008). Documenting level of consciousness. Nursing, 38 (8), 63.
Lower, J (2003). Using pain to assess neurologic response. Nursing, 33 (6), 56-57.
Lower, J. (2002). Facing neuro assessment fearlessly. Nursing, 32 (2), 58-64.

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