Prepared by: Robert Adrian L. Peñaranda

The Neurologic System responsible for many functions including

initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought process, control of speech, and storage of memory

assessment of neurological function can be time consuming

a client’s LOC influences the ability to follow directions

The neurologic exam

A thorough neurologic exam takes about 2-3 hours; however, routine tests are done first. If the tests raised questions, more extensive neurologic exam is performed.

Three major considerations The client’s chief complains Client’s physical condition Client’s willingness to participate

Examination of the neurologic system includes assessment of: Mental status including the level of

consciousness The cranial nerves Reflexes Motor function Sensory function

Mental Status

Reveals the general Cerebral functions These functions include intellectual

(cognitive) as well as emotional (affective) functions

Major areas of mental status assessment includes language, orientation, memory, and attention span and calculation.

Language

AphasiaLoss of power to express oneself by speech,

writing or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex

Could be categorized as sensory or receptive and motor or expressive aphasia

Orientation

Determines the person’s ability to recognize familiar persons, awareness to where and when they presently are (time and place), and who they, themselves, are (self).

Memory

Assessment of recall of information presented seconds previously (immediate recall), events or information earlier in the day or examination (recent memory) and knowledge recalled from months or years ago (remote or long term memory)

Attention Span and Calculation Determines the client’s ability to focus

on a mental task that is expected to be performed by person of normal intelligence

Level of Consciousness

Anywhere along a continuum from a state of alertness to coma.

Level Description

Conscious Normal

ConfusedDisoriented; impaired thinking and responses

DeliriousDisoriented; restlessness, hallucinations, sometimes delusions

ObtundedDecreased alertness; slowed psychomotor responses

StuporousSleep-like state (not unconscious); little/no spontaneous activity

ComatoseCannot be aroused; no response to stimuli

The Glasgow Coma Scale

1 2 3 4 5 6

EyesDoes not open eyes

Opens eyes in response to painful stimuli

Opens eyes in response to voice

Opens eyes spontaneously

N/A N/A

VerbalMakes no sounds

Incomprehensible sounds

Utters inappropriate words

Confused, disoriented

Oriented, converses normally

N/A

MotorMakes no movements

Extension to painful stimuli(decerebrate)

Abnormal flexion to painful stimuli(decorticate)

Flexion / Withdrawal to painful stimuli

Localizes painful stimuli

Obeys Commands

Cranial Nerves

The nurse needs to know the specific functions and assessment methods of cranial nerves to detect abnormalities. In some cases, each nerve is assessed; in other cases only selected nerve functions are evaluated

Cranial nervesName Type Function Method

I Olfactory Sensory Sense of smell Ask client to identify different nonirritating aromas such as coffee & vanilla

II Optic Sensory Visual acuity Use Snellen Chart or ask client to read printed material while wearing glasses

III Oculomotor Motor Extraocular eye movement; Pupil constriction and dilation

Assess directions of gazeMeasure papillary reaction to light reflex and accommodation

IV Trochlear Motor Upward & downward movement of eyeball

Assess directions of gaze

V Trigeminal Sensory & Motor

Sensory nerve to skin of faceMotor nerve to muscles of jaw

Lightly touch cornea with wisp of cotton. Assess corneal reflex. Measure sensation of light pain & touch across skin of facePalpate temples as client clenches teeth

VI Abducens Motor Lateral movement of eyeballs Assess directions of gazeVII Facial Sensory

& MotorFacial expressionTaste

As client smiles, frowns, puffs out cheeks, & raises & lowers eyebrows, look for asymmetryHave client identify salty or sweet taste in front of tongue

VIII Auditory Sensory Hearing Assess ability to hear spoken wordIX Glossopharyngeal Sensory

& MotorTasteAbility to swallow

Ask client to identify sour or sweet taste on back of tongueUse tongue blade to elicit gag reflex

X Vagus Sensory & Motor

Sensation of pharynxMovement of vocal cords

Ask client to say “ah”. Observe movement of palate and pharynxAssess speech for hoarseness

XI Spinal Accessory Motor Movement of head & shoulders Ask client to shrug shoulders and turn head against passive resistance

XII Hypoglossal Motor Position of tongue Ask client to stick out tongue to midline and move it from side to side

Reflexes An automatic response of the body to a

stimulus. The deep tendon reflex (DTR) can be

activated by tapping the tendon and its associated muscles contract

Reflexes are tested using a percussion hammer.

Motor Function Evaluates proprioception and cerebellar

functions Proprioceptors are sensory nerve terminals

occurring chiefly on muscles, tendons, joints and the internal ear, that give information about movements and the position of the body

Cerebellar functions include posture control, coordination and smoothness of movements (work together with the cerebral cortex) and maintenance of the skeletal muscle equilibrium

Sensory Function

Includes touch, pain, temperature, position and tactile discrimination

Tests for sensory function include one- and two-point discrimination, stereognosis and extinction

Assessment Proper

LanguageIf the client displays difficulty speaking

○ Point to a common objects and ask the client to name them

○ Ask the client to read some words and match written words to pictures

○ Ask the client to respond to simple verbal commands like asking the client to point to his toes or raise an arm

Orientation Determine if the client is oriented to

person, place and time by asking tactful questions.

Ask the client his state or city of residence, time of the day, day of the week, duration of illness, and names of family members

If the client cannot answer the questions correctly, include questions about himself like his name for example

Memory

Listen for lapses in memory. Ask client about difficulty with memory. If problems are apparent, three categories of memory are tested: Immediate recall, recent memory and remote memory

To assess immediate recall: Ask the client to repeat series of three

digits. E.g. 7-4-3 spoken slowly Gradually increase the number of digits.

E.g. 7-4-3-4, 7-4-3-4-5, 7-4-3-4-5-6-7 Start again with a series of three digits,

but this time ask the client to repeat it backwards. An average person is able to repeat series of five to eight digits in sequence and four to six digits in reverse order

To assess recent memory Ask the client what happened earlier

such as how he got to the clinic. Ask the client to recall information given

earlier like the doctors name. Ask the client to remember three facts (a

color, an object or an address; or a three digit number) and ask the client to repeat all three facts later at the interview.

Remote memory

Ask the client to describe a previous illness or surgery. E.g. 5 years ago, or anniversary or birthday

Attention span and calculation Test the clients ability to concentrate or

maintain attention span by asking the client to recite the alphabet or to count backwards from 100.

Test the client’s ability to calculate by asking the client to subtract 7 or 3 progressively from 100.

Level of Consciousness

Apply the Glasgow Coma Scale A score of 15 indicates that the client is

alert and completely oriented. A comatose patient scores 7 or lower

Cranial NervesName Type Function Method

I Olfactory Sensory Sense of smell Ask client to identify different nonirritating aromas such as coffee & vanilla

II Optic Sensory Visual acuity Use Snellen Chart or ask client to read printed material while wearing glasses

III Oculomotor Motor Extraocular eye movement; Pupil constriction and dilation

Assess directions of gazeMeasure papillary reaction to light reflex and accommodation

IV Trochlear Motor Upward & downward movement of eyeball

Assess directions of gaze

V Trigeminal Sensory & Motor

Sensory nerve to skin of faceMotor nerve to muscles of jaw

Lightly touch cornea with wisp of cotton. Assess corneal reflex. Measure sensation of light pain & touch across skin of facePalpate temples as client clenches teeth

VI Abducens Motor Lateral movement of eyeballs Assess directions of gazeVII Facial Sensory

& MotorFacial expressionTaste

As client smiles, frowns, puffs out cheeks, & raises & lowers eyebrows, look for asymmetryHave client identify salty or sweet taste in front of tongue

VIII Auditory Sensory Hearing Assess ability to hear spoken wordIX Glossopharyngeal Sensory

& MotorTasteAbility to swallow

Ask client to identify sour or sweet taste on back of tongueUse tongue blade to elicit gag reflex

X Vagus Sensory & Motor

Sensation of pharynxMovement of vocal cords

Ask client to say “ah”. Observe movement of palate and pharynxAssess speech for hoarseness

XI Spinal Accessory Motor Movement of head & shoulders Ask client to shrug shoulders and turn head against passive resistance

XII Hypoglossal Motor Position of tongue Ask client to stick out tongue to midline and move it from side to side

Reflexes

Assess the reflexes using a percussion hammer

The grading for reflex are as follows:0 - no response1+ - Low normal with slight muscle contraction2+ - Normal with visible muscle twitch and

movement of the arm or leg3+ - Brisker than normal; may not indicate

disease4+ - Hyperactive and very brisk; often associated with spinal cord disorders

Biceps Reflex Tests the spinal cord level c5 and c6 Slightly flex the arm with the forearm

resting over the thumb with the palm of the hand down

Place your nondominant hand horizontally over the biceps tendon

Deliver a blow with the percussion hammer over your thumb

Observe for the slight flexion of the elbow and fell the biceps contract with your thumb

Triceps Reflex

Tests the spinal cord c7 and c8Flex the clients arm at the elbow, and

support it in the arm of your nondominant arm

Palpate the triceps tendon about 2-5cm (1 to 2in.) above the elbow

Deliver a blow with the percussion hammer directly to the tendon

Observe the slight extension of the elbow

Brachioradialis Reflex

Tests the spinal cord c5-c6Rest the client’s forearm in a relaxed

position externally rotated on a firm surfaceDeliver a blow directly on the radius 2 to

5cm (1 to 2 in.) above the wrist or the stylus process

Observe the normal flexion or supination of the forearm. The fingers of the hand may also extend slightly

Patellar Reflex Tests the spinal cord L2, L3 and L4

Ask the client to sit on the edge of the examining table so the legs would hang freely

Locate the patellar tendon directly below the patella

Deliver a blow with the percussion hammer directly to the tendon

Observe the normal extension or kicking out of the leg as the quadriceps muscle contracts

If no response occurs and you suspect that your client is not relaxed, ask the client to interlock the fingers and pull (Jendrassik’s maneuver)

Achilles Reflex

Tests the spinal cord S1 and S2With the client in the same position as in the

patellar reflex, slightly dorsiflex the client’s ankle by supporting the ball of the foot lightly in the hand

Deliver a blow with the percussion hammer directly to the Achilles tendon just above the heel

Observe the normal plantar flexion (downward jerk) of the foot

Plantar or Babinski Reflex The plantar or babinski reflex is

superficial and may be absent to adults without pathology or is overridden by voluntary control

Motor Function

Walking GaitAsk the client to walk across the room and

back. Observe for the client’s gait.Normally, the client stands in an upright

position with the arms swinging in opposite direction, walks unaided and maintains balance

Romberg Test Ask the client to stand with feet together

first with eyes open and then closed Negative Romberg: may sway a bit but

maintains upright posture and foot stance Positive Romberg: cannot maintain foot

stance, presence of ataxia or lack in the coordination of the voluntary muscles, and cerebellar ataxia or the inability to maintain stance with the eyes open or shut.

Standing on one foot with eyes shut Ask the client to close eyes and stand

with only one foot. Normally, the client should be able to

maintain stance at least for 5 seconds

Heel-Toe Walking

Ask the client to walk a straight line with the advancing foot’s heel touching the toes of the other foot.

A client assumes a larger foot gait to stay upright if she cannot perform this procedure

Toe or Heel Walking

Ask the client to walk several steps on the toes and then on the heels

Fine motor tests for the upper extremeties Finger-To-Nose test

Ask the client to abduct and extend the arms at shoulder height and then rapidly touch the nose alternatively with one index finger and then the outer. The client repeats the test with the eyes closed if the test is performed easily

Normally, the movements are coordinated and the finger do not miss the nose

Alternating Supination and Pronation of Hands on Knees Ask the client to pat both knees with the

palm of the hands and then with the backs of the hands alternatively at an ever-increasing rate

Assessment of the Nose and to the Nurse’s Finger Ask the client to touch the nose and

then your index finger, held at a distance about 45cm (18in.) at a rapid and increasing rate

Fingers to Fingers

Ask the client to spread the arms broadly at shoulder height and then bring the fingers together at the midline, first with the eyes open and then closed, first slowly, then rapidly

Fingers to Thumb (Same Hand) Ask the client to touch each finger of

one hand to the thumb of the same hand as rapidly as possible

Fine motor tests for the Lower extremities Heel Down Opposite Shin

Ask the client to place the heel of one foot just below the opposite knee and run the heel down the shin to the foot. Repeat with the other foot. The client may also sit for this test

Toe or Ball of Foot to the Nurse’s Finger Ask the client to touch your finger with

the large toe of each foot

Light-Touch Sensation

Compare the light-touch sensation of symmetric areas of the body

Ask the client to say “yes” or “now” whenever the client feels the cotton wisp touching the skin

Test areas in the forehead, cheek, hand, lower arm, abdomen, foot and lower leg.

Ask the client to point to the area where he felt the cotton wisp

Light-Touch Sensation

If areas of sensory dysfunction are found, determine the boundaries of sensation by testing responses about every 2.5cm (1 in.) in the area

Make a sketch of the sensory loss area for recording purposes

Pain Sensation Assess pain sensation by asking the client

to say “sharp”, “dull” or “don’t know” when the sharp or dull end of the tongue depressor is felt.

Alternately, use the sharp and dull end to slightly prick the designated anatomic areas at random, e.g. hand, forearm, lower leg, abdomen. The face is not tested in this manner

Give at least two seconds at each prick to prevent summation of stimuli

Temperature Sensation

If pain sensation is intact, temperature sensation tests are no longer performed. If there are pain sensation abnormalities, then the temperature sensation test is performed.

Touch skin with test tubes containing hot or cold water and ask the client to respond with “hot”, “cold” or “don’t know”

Position or Kinesthetic Sensation Commonly, the middle fingers and the

large toes are tested for kinesthetic sensation (sense of position)Support client’s arm and hand, or place the

client’s heel on the examining tableAsk client to close eyesGrasp the finger with your thumb and index

finger, and exert the same pressure on both sides of finger or toe while moving it

Move finger or toe until it is up, straight or down and ask the client to identify the position

Tactile Discrimination

For all tests, the clients eyes must be closed

Kinds of Tactile Discrimination TestsOne- and two- point discriminationStereognosisExtinction Phenomenon

One- and Two- Point Discrimination Alternatively stimulate the skin with two

pins simultaneously and then with one pin. Ask whether the client feels one or two pinsPerception varies widely in adults over different

parts of the body. The common sites for this test are:○ Fingertips, 2.8 mm○ Palms of the hands, 8-12 mm○ Chest, forearm, 40mm○ Back, 50-70 mm○ Upper arm, Thigh, 75 mm○ Toes, 3-8 mm

Stereognosis

Ability to recognize objects by touching themPlace familiar objects such as a key, paper

clip, or coin, in the client’s hand and ask the client to identify them

If the client cannot move the hands, write a number on the client’s palm using a blunt object and ask the client to identify it (graphesthesia)

Extinction Phenomenon

Simultaneously stimulate two symmetric areas of the body, such as the thighs, the cheeks or the hands

The client should be able to feel both stimulus