Neurologic Assessment

Goals of Neurologic Assessment

1) Determine the diagnosis and triage

2) To establish baseline for serial assessment and comparison
3) Coordinate management decision making
4) Develop a problem list of actual potential problems using appropriate nursing diagnosis.
5) To predict the outcomes
6) Identify functional restoration or rehabilitation potential

Preparation for Neurologic Assessment

1) Explain to the patient the purpose of assessment

2) Conduct examination in a quiet area
3) Examination area should be well illuminated but not bright
4) Maintain privacy
5) Assemble all the articles
6) Remove hazardous equipments from the examination area
7) Provide time for the patient
8) Be supportive to the patient
9) Do not leave the patient alone in the examination area
10) Use low pitched, soft voice especially with elderly
11) Obtain the patient’s attention before each test

Articles for neurologic assessment

Clean tray containing:

Thermometer
BP apparatus
Stethoscop Pentorch
Equipment to test sharp and dull sensation (cotton tipped applicator, pencil)
Cotton balls in a bowl
Odiferous but nonirritating substances ( coffee and tea powder)
Reflex hammer
Bottles containing hot and cold water
Tuning fork
Eye chart( snellen’s chart)
Coin (or any known small object)
 ophthalmoscope

Neurologic History

No examination is complete without a history. The importance of the history is emphasized

by the fact that an accurate diagnosis in majority of the cases of neurologic disease is based
primarily on historical data. Data collection is mainly focuses on:

a) Signs and Symptoms including date of onset, severity, localization, extension, duration
and frequency
b) Associated complaints especially pain, headache, seizures or changes in eating or
sleeping pattern
c) Any precipitating, aggravating or alleviating factors
d) Changes in the mental status and activities of daily living
e) Past or present medical or metabolic disorder with details of the treatment
f) Familial history, with familial or hereditary occurrence of similar problems
g) Smoking history, use of alcohol, or use of illicit and mood altering drugs
h) Sexual history
i) Coping strategies used
j) Dietary, elimination and sleep-rest pattern followed

Older Patient History

a) Focus on patterns of past injuries-slips or falls

b) Enquire about clumsiness, decreased performance in ADL, social withdrawal, sensory
problems, memory loss, confusion, loss of consciousness
c) Bowel and bladder incontinence
d) Any episodes of TIA( Transient Ischemic Attack)
e) History of weight gain or loss, poor appetite and feelings of low energy, loneliness,
hopelessness and helplessness

Neurologic Assessment

The neurologic examination consists of assessment of the following:

a) Mental Status
b) Cranial Nerves
c) Motor Function
d) Reflexes
e) Sensory Function
f) Cerebellar Function

MENTAL STATUS ASSESSMENT

 We gain much insight into the mental status of the patient during history collection. The
mental status examination consists of evaluation of the following:

1) Level of consciousness
2) Speech and language
3) Orientation
4) Abstraction and Judgement
5) Memory
6) Calculation
7) General Information
 Level of Consciousness

Consciousness is the state of awareness of self, the environment, and responses to the
environment; coma is its opposite, the total absence of awareness of self and environment even
when the patient is externally stimulated. Between these extreme stases there are a variety of
altered states of consciousness.Consciousness is a sensitive indicator of cortical function and is
easily disrupted by neurologic damage or disease.Components of consciousness-

a) Arousal- State of awakeness. It is the ability of the patient to respond to noxious

stimuli in an appropriate manner.
b) Awareness- implies interaction with and reaction to environment stimuli.

Glasgow Coma Scale

Behavior Response Score

Eye opening Spontaneously 4
To speech 3
To pain 2
No response 1
Verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible 2
sounds
No response 1
Motor response Obeys commands 6
Moves to localized pain 5
Flexion withdrawal 4
from pain
Abnormal flexion 3
Abnormal extension 2
No response 1
Total Best score 15
Unconscious 8 or less
Comatose 3

 Speech and Language

Communication is one of the highest cortical functions. It comprises of reading, listening,

speaking and writing. Disturbances of this complex process lead to inability to communicate,
known as aphasia, or difficulty in communication known as dysphasia.

Language function resides predominantly in the dominant hemisphere. In about 99% of

right-handed persons and 60-0% of left-handed persons, the left cerebral hemisphere is
dominant. These functions lie at the junction of the frontal, temporal, and parietal lobes, with
deep connections between these regions.

Types of Aphasia
a) Receptive aphasia: also known as Wernicke’s or fluent aphasia, results from damage in the
parietal or posterior temporal lobes. The ability to comprehend written language (alexia) or
verbal language is impaired. The patient converses fluently but without meaning.
b) Expressive aphasia: also known as Broca’s or nonfluent aphasia, results from damage to the
inferior and posterior portions of the dominant frontal lobe. The patient’s comprehension and
the ability to conceptualize are relatively preserved but the ability to
form language and express thoughts is impaired
It is often accompanied by a right hemiparesis that is worse in the arm than in the leg.
Writing is also usually impaired.
c) Global aphasia: results from a large lesion involving frontal, parietal, and temporal lobes. All
language functions are impaired.
d) Anomic aphasia: may be expressive or receptive and results in the inability to name objects.
e) Conduction aphasia: caused by a lesion between Broca’s or Wernicke’s area. Speech is fluent
but abnormalities appear in repetition and writing.
f) Transcortical aphasia: caused due to damage adjacent to Broca’s or Wernicke’s area. It is
similar to aphasias of the adjacent area except that repetition is normal.
 Orientation
 A patient is assessed for orientation to time, place, and person.Orientation to time is lost
first and may be impaired in even mild organic brain syndromes. Loss of orientation to place
may occur with a moderate disturbance of cerebral function. Disorientation to person is the last
orientation parameter lost and occurs with severe cerebral dysfunction.

 Abstraction and Judgement

Abstraction and Judgement describes the ability to project into the future and draw on
experience in response to a described situation. Both require intact frontal lobes. Abstract
thinking is tested by asking proverbs like-“all that glitters is not gold”. Judgement is poor in
organic brain disease. It is tested by giving a situation to the patient-“what will you do if you see
an accident on the road?” A patient with impaired brain function will have difficulty performing
on an abstract level.

 Memory

Memory is a complex integrated function involving the limbic system, the temporal lobe,
the prefrontal area and cortical association areas. It is the primary cognitive process associated
with learning. Memory is evaluated in three states:

a) Retention or immediate recall: It is assessed by asking the patient to repeat a given

number of digits both forward and reverse. It can be also tested by asking the patient to
repeat a sentence or to carry out a three-part command-“stand up, touch your forehead
and turn to the left.
This addresses issues of attention span and intellectual functioning. Retention is
impaired when a primary sensory receiving area of the cortex is affected.
b) Recent memory: It is assessed by asking the patient to describe what he ate for breakfast
or news events from the past few days. It can also be done by having the patient describe
the course of the current illness.

Impairment in recent memory usually implies bilateral temporal lobe dysfunction.

c) Remote memory: It is the one requiring the most validation by someone close to the
patient. Patient is asked the names and ages of children, siblings, or parents or few
important dates.
Impairment implies widespread and severe brain dysfunction
 Calculation

Patient’s intellectual level and educational background also should be considered. The
most common way of testing calculation is by serial subtraction of 7’s from 100. Difficulty may
be seen in diffuse brain disease and in focal lesions.

 General Information
 Assessment of the patient’s general fund of knowledge should be individualized to
intellectual level, social and cultural background and general interests. General information, once
accumulated, is not lost until there is severe loss of brain substance or severe impairment of
function.

ASSESSMENT OF CRANIAL NERVES

There are 12 pairs of cranial nerves. The examination of the cranial nerves should be carried out
in an orderly manner.

Cranial nerve Function Clinical findings with

lesion
I: Olfactory Smell Anosmia

II: Optic Vision Amaurosis

III: Occulomotor Eye movements, Diplopia, ptosis,
papillary constriction, mydriasis, loss of
accomodation accommodation
IV: Trochlear Eye movements Di plopia
V: Trigeminal General sensation of Numbness of face,
face, scalp and teeth weakness of muscles
chewing movements
VI: Abducens Eye movements(lateral Diplopia
rectus muscle)
VII: Facial Taste, general sensation Loss of taste on anterior
of palate and external two thirds of tongue, dry
ear, facial expression mouth, paralysis of facial
muscles, loss of
lacrimation
VIII: Vestibulo- Hearing, equilibrium Deafness, tinnitus,
cochlear vertigo, nystagmus
IX:Glossopharyngeal Taste, general sensation Loss of taste on posterior
of pharynx, elevation of one third of tongue,
palate anaesthesia of pharynx,
partially dry mouth
X:Vagus Taste, general sensation Dysphagia, hoarseness,
of pharynx and larynx, palatal paralysis
swallowing, phonation,
parasympathetic
innervations to heart
and abdominal viscera
XI: Spinal Accessory Head, neck and Weakness of head, neck
shoulder movements and shoulder muscles
XII:Hypoglossal Tongue movements Weakness and wasting of
tongue
Assessment

1) Olfactory: The patient is asked to close the eyes and one nostril as the examiner brings the
test substance close to the patient’s other nostril. Patient sniffs and tries to identify.
2) Optic: Visual field and visual acuity are assessed. Peripheral visual fields are assessed by
confrontation. Ask the patient to close one eye, look directly at the bridge of the examiner’s
nose and indicate when an object presented from the periphery of each of the four visual field
quadrants is seen.
Visual acuity is tested using a snellen’s chart placed 20 feet away from the patient.
3) Oculomotor, Trochlear and Abducens: The patient is asked to follow the examiner’s finger as
it moves horizontally, vertically and diagonally. Weakness or paralysis of one of the eyes
causes disconjugate gaze and nystagmus.
Oculomotor nerve is further tested for pupillary constriction, convergence and
accommodation. Examiner shines light into the pupil of one eye and looks for ipsilateral
constriction of the same pupil and contralateral constriction of the opposite pupil.

Assessment of pupil

a) Loss of parasympathetic control of Oculomotor nerve compression results in a dilated

nonreactive pupil while loss of sympathetic control results in pinpoint nonreactive pupils.
b) Pupil size is documented in millimeters. Normal size is 2-6mm.most individuals have equally
sized pupils or there may be a difference of 1mm. Inequality in size of the pupil is called
anisocoria.
Pupil shape is normally round, an irregularly shaped or oval pupil is indicative of
increased ICP an cranial nerve III compression.

Trigeminal: The three major divisions are the ophthalmic, maxillary and mandibular.
Examination includes:

a) Test corneal reflex-corneal reflex depends on the function of cranial nerves V(sensory
limb) and VII(motor limb). The patient is asked to look to the left side as the cotton
tip is brought in from the right side to touch the right cornea gently.
b) Test sensory function: Ask the patient to close the eyes and to respond when a touch
is felt. A piece of cotton is brushed against forehead, cheeks and jaw( both sides).
c) Test motor function: Have the patient bite down or clench the teeth while the
masseter and temporalis muscles are palpated bilaterally.
4) Facial: It includes-
  Test motor function: The patient is asked to bare the teeth, puff out the cheeks against
resistance and then to wrinkle the forehead. Ask the patient to close the eyes tightly while
the examiner tries to open them.
5) Vestibulocochlear: It is tested by having the patient close the eyes and indicate when a
ticking watch or the rustling of the examiner’s fingertips is heard. Rinne’s and Weber’s test
are also conducted. Bilateral assessment is done and compared.
6) Glossopharyngeal and Vagus:
Test sensory function: It involves the gag reflex. By touching the posterior one third of the
tongue or the soft palate gag reflex can be elicited.
Another way to test the nerve is to ask the patient to say “ah”. Symmetric elevation of the soft
palate demonstrates normal function of cranial nerves IX and X. The uvula should remain in
the midline.
7) Spinal Accessory: Supplies the sternocleidomastoid and trapezius muscles.
Test motor fuction: The left spinal accessory nerve is examined by asking the patient to turn
the head to the right against the resistance of the examiner’s hand.
Another method is by placing the hands on the patient’s trapezius muscle. Both muscles are
palpated And then the patient is asked to shrug the shoulders against the resistance of the
examiner’s hands.
8) Hypoglossal : Ask the patient to open the mouth and stick out the tongue.

MOTOR FUNCTION

The motor system is evaluated for the following:

a) Muscle bulk
b) Muscle strength
c) Muscle tone
The motor examination begins with inspection of each area being tested. The contours of
symmetric muscle masses in both the upper and lower extremities are compared.

Muscle strength is tested by having the patient move actively against the examiner’s resistance.
Grading of muscle strength:

 0, absent-no contraction detected

 1, trace-slight contraction detected
 2, weak-movement with gravity eliminated(sideways)
 3, fair-movement against gravity(upward)
 4, good-movement against gravity with some resistance
 5, normal-movement against gravity with full resistance

Abnormal motor responses

In the unconscious patient, noxious stimuli may elicit an abnormal motor response:
 a) Decorticate posturing / abnormal flexion: caused by interruption of the corticospinal
pathways in the cerebral hemispheres or in the internal capsule. There will be flexion
of the arms, wristsand fingers with adduction of upper extremities; extension,internal
rotation and plantar flexion in lower extremities.
b) Decerebrate posturing/ abnormal extension: all four extremities are in rigid extension
with hyperpronation of the forearms and plantar extension of the feet

Involuntary motor movements

a) Chorea : nonrepetitive muscular contractions, usually of the extremities of face

b) Athetosis: slow, sinous, irregular movements most obvious in distal extremities.
c) Tremor: rhythmic, oscillating movement affecting one or more body parts.
d) Myoclonus : series of shocklike nonpatterned contractions of potion of a muscle, entire
muscle or group of muscles that cause throwing movements of a limb.

REFLEXES

Two main types of reflexes are tested. They are the stretch or deep tendon reflexes and the
superficial reflexes.Reflexes are commonly graded on a scale as follows:

 0: no response
 1: diminished
 2: normal
 3:increased
 4: hyperactive

SUPERFICIAL RELEXES

Reflexes Normal response

1) Corneal :
Touch the cornea of the patient with a Prompt closure of both eyelids.
whisp of cotton.
2) Pharyngeal :
Stimulate the pharynx using a tongue Gag reflex is produced.
blade.
3) Abdominal :
Have the patient lie on back. An Contraction of the abdominal
applicator stick or tongue blade is muscles with the umbilicus
quickly stroked horizontally laterally to deviating towards the stimulus.
medially towards the umbilicus.
4) Cremasteric:
This reflex in men is elicited by lightly Rapid elevation of the testicle on
 stroking the inner aspect of the thigh. the same side.

DEEP TENDON REFLEXES

Reflexes Normal response Clinical

significance
1) Biceps Contraction of the Nerves at roots
Have the patient relax the arm biceps tendon, C5-C6 are
and pronate the forearm midway followed by flexion at tested
between flexion and extension. the elbow.
Place a thumb firmly on the biceps
tendon. The hammer is then struck
on the examiner’s thumb.

2) Triceps: Contraction of the Nerves at roots

Flex the patient’s forearm at the triceps tendon with C6-C7 are
elbow and pull the arm towards extension at the elbow. tested.
the chest. Tap the triceps tendon
about 2.5-5cm above the elbow.
Another maneuver is by hanging
the patient’s arms over the
examiner’s arms and tapping the
tendon.
3) Brachioradialis/ Supinator Flexion at the elbow and Tests the
Have the patient’s forearm in simultaneous supination nerves at roots
semiflexion and semipronation. of the forearm. C5-C6.
Strike the styloid process of the
radius about 2.5-5cm above the
wrist.
4)Patellar/ knee jerk Contraction of the Tests the
Have the patient sit with the quadriceps and nerves at roots
legs dangling off the side of the extension at the knee. L2-L4.
bed. Examiner’s hand is placed on
the patient’s quadriceps muscle.
Strike the patellar tendon firmly.
5)Achilles tendon/ankle jerk Plantar flexion at the Tests the
Have the patient sit with the legs ankle. nerves at roots
dangling off the side of the bed.leg S1-S2.
should be flexed at the hip and the
knee. The examiner places a hand
under the patient’s foot to
dorsiflex the ankle. Achilles
tendon is struck above its insertion
on the posterior aspect of the
calcaneous.
A patient with a depressed reflex
should be asked to kneel on the
bed with the feet hanging off the
side. Tap the tendon and observe
the response.

ABNORMAL RELEXES

1) Babinski’s reflex
This is a test of the nerve roots at L5-S2. It is a pathologic reflex normally, when the
lateral aspect of the sole is stroked from the heel to the ball of the foot and curved
medially across the heads of the metatarsal bones, there is plantar flexion of the big toe.
In the presence of pyramidal tract disease. There is dorsiflexion of the big toe, with

SENSORY FUNCTION

Neurologic disorders usually result in a sensory loss that is first seen more distally than
proximally.

The sensory examination consists of testing the following:

 Light touch
 Pain sensation
 Vibration sense
 Proprioception
 Tactile localization
 Discriminative sensations
 TEST LIGHT TOUCH: It is evaluated by lightly touching the patient with a small piece
of gauze or cotton. Ask the patient to close eyes and to tell when the touch is felt. If
sensation is abnormal, work proximally until a sensory level can be detected. A sensory
level is a spinal cord level below which there is a marked decrease in sensation.
TEST PAIN SENSATION: It is tested using an object with a blunt and sharp end eg. Safety
pin. If the patient has loss of sensation to pain,continue proximally to determine the sensory
level.

TEST VIBRATION SENSE: It is tested using a 128-Hz tuning fork.tap the tuning fork on the
heel of your hand and place it on the patient on a bony prominence distally. Instruct the patient to
inform when the vibration is no longer felt. If a loss is present, determine the level.

TEST PROPRIOCEPTION : It is tested by moving the distal phalanx. Hold the distal phalanx
at its lateral aspect. With the patient’s eyes closed, move the distal phalanx up and down and ask
“Is it up or down?” A loss of proprioception necessitates further evaluation to determine the level
of loss.

TEST TACTILE LOCALIZATION: It is also known as double simultaneous stimulation. Ask

your patient to close eyes and touch the patient on the right cheek and left arm. The patient is
then asked, “where did I touch you?”A patient with a lesion in the parietal lobe may feel the
individual touches but may “extinguish” the sensation on the side contralateral to the side of
lesion. This is the phenomenon termed extinction.

TEST TWO-POINT DESCRIMINATION: It tests the ability to differentiate one stimulus

from two. Gently hold two pins 2 to 3 mm apart, and touch the patient’s fingertip. Ask the
patient to state the number of pins felt. Different areas of body have different sensitivities.

Tongue – 1mm

Toes-3 to 8mm

Palms-8 to 12mm

Back-40 to 60mm

A lesion in the parietal lobe impairs two-point discrimination.

TEST STEREOGNOSIS: Stereognosis is the integrative function of the parietal and occipital
lobes. It is tested by having the patient to identify a familiar object placed in the hands with his
or her eyes closed.

TEST GRAPHESTHESIA: It is the ability to identify what is being ‘written’ in the palm of
one’s hand. Using the blunt end of pencil write numbers in the palm (patient’s eyes closed) and
ask to identify.The inability to identify the numbers is a sensitive sign of parietal lobe disease.

TEST POINT LOCALIZATION

 It is the ability of a person to point to an area where he or she was touched. Have the patient’s
eyes closed. Touch the patient and ask to open the eyes and point to the area
touched.Abnormalities of the sensory cortex impair the ability to localize the area touched.

CEREBELLAR FUNCTION

It is tested by the following:

a) Finger-to-Nose test
b) Heel-to-Knee test
c) Rapid alternating movement
d) Romberg test
e) Gait assessment

FINGER-TO NOSE TEST: This is performed by asking the patient to touch his or her own
nose and the examiner’s finger alternately as quickly, accurately, and smoothly as possible. This
is repeated several times, after which the patient is asked to perform the test with the eyes closed.

HEEL-TO-KNEE TEST: This is performed by having the patient lie on his/her back. The
patient is instructed to slide the heel of one lower extremity down the shin of the other, starting at
the knee.

RAPID ALTERNATING MOVEMENTS: The ability to perform rapid alternating movements

is called diadochokinesia. The patient is asked to pronate and supinate one hand over the other
hand rapidly. Another technique involves having the patient touch the thumb to each finger as
quickly as possible.

ROMBERG TEST: It is a screening test for balance. The patient stands in front of the
examiner with feet together so that the toes and heels are touching with eyes open and then with
both eyes closed for 20-30sec. Result is positive if the patient begins to sway and has to move
the feet for balance.Another common finding is for one of the arms to drift forward, with flexion
of the fingers. This is called pronator drift and is seen in mild hemiparesis.

 Be with the patient during the test because of the risk of fall.

ASSESS GAIT: The patient is asked to walk straight ahead . he is then instructed to return on
tiptoes;to walk away again on heels;and return by walking in tandem gait.Many neurologic
disorders produce characteristic gait.