NEUROLOGICAL ASSESSMENT

PREPARATION
1. Gather all materials needed for neurologic assessment.
a. Penlight
b. Tuning fork
c. Reflex hammer
d. Cotton wisp
e. Paper clip
f. Salt
g. Sugar
h. Cotton tip applicators
i. Glass of water
j. Tongue blade
k. ophthalmoscope
2. Explain procedure to the client.
3. Ask the client to wear gown.
Ang red po mention nalang no need to perform :>

STEPS NORMAL FINDINGS ABNORMAL FINDINGS

Assessment
I. Mental Status (Refer to
Mental Status
checklist)
II. Cranial Nerves
4. Ask the patient to close Client correctly identifies Inability to smell or identify
eyes and occlude one scent presented to each the correct smell.
nostril. nostril.
a. a. Test CNI by
placing object with
scent/aroma near
the nose and ask the
client to identify the
object. (Coffee,
orange or any object
with scent/aroma
can be used)
5. Test CNII and III by
assessing vision and visual
fields.
a. Vision
b. Visual Fields
6. Test CN IV and VI by
assessing extraocular
movements. Assess
PERRLA.
a. Ask client to look
straight ahead
approach each eye
from the client’s side
with a penlight.
b. Assess for equality of
pupils and reactivity
to light.
C. Assess Accommodation by
asking a client to stare at an
object 3-4 feet away, and
move in object towards the
client’s nose.

7. Test CN V by: a. Eyelids blink bilaterally. a. An absent of corneal

a. Assessing sensory reflex with lesion of the
function by touching trigeminal nerve.
cornea lightly with b. Inability to feel and
wisp of cotton.
correct identify facial
b. Assessing facial
stimuli.
sensation to feel light
 touch, dull and sharp B. correctly identifies sharp c. Pain occurs with
sensations on the and dull stimuli and light clenching teeth.
forehead, cheek touch.
and chin areas while
eyes are closed.
c. Assessing motor function
by palpating masseter
and temporal muscles
as client clench teeth. c. temporal and masseter
muscles contract bilaterally.

8. Test CN VII by assessing -Movements are symmetric.

motor function of the -Client smiles, frown, wrinkles Inability to close eyes,
face. forehead, shows teeth, puffs wrinkles forehead or raise
Upper Part of Face out cheeks, purses lips, raises forehead.
a. Asking patient to raise
eyebrows and close eyes
eyebrow and observe
against resistance.
even wrinkling of the
forehead.
b. Ask client to close eyes
while you try to force it
open.
Lower Part of Face
a. Ask the patient to show
the teeth, smile and puff Inability to identify correct
out the cheeks while you flavor suggests impairment
palpate for even muscle of CN VII.
strength. yiee
b. Assess sensory function by cuteon ate HAHAHAHHA
asking client to identify
sugar, lemon, salt on the Client identifies correct
anterior two thirds of the flavors.
tongue, with eyes
closed and tongue
protruded.

9. Test CN VIII:
a. Whisper Test
b. Rinne’s Test
c. Weber Test
10. Test CN IX Client swallows without Dysphagia may indicate
a. Ask the client to difficulty. lesions of CN IX.
identify lemon juice
and salt to posterior
one-third of the
tongue with eyes
closed.
b. Ask the client to drink
water and observe
for difficulty
swallowing.
c. Ask the patient if he/she
experience any difficulty
in swallowing water.
11. Test CN X. Uvula and soft palate rise Soft palate does not rise with
a. Ask the client to open bilaterally and symmetrically bilateral lesions of CN X.
mouth and say “ah”. on phonation
b. Check if the uvula elevates
and inspect the palate for
symmetry.
c. Talk with the client to assess
voice for hoarseness.
d. Ask the client to cough to
examine for vagus nerve
impairment.
e. Assess the gag reflex by
asking the client to open
Gag reflex intact. An absent gag reflex may
mouth.
be seen with lesion of CN X
d. Touch back of tongue with
tongue depressor at both sides
12. Assess CN XI
Trapezius Assessment
a. Ask the client to sit down, There is symmetric, strong Asymmetric muscle
stand at the back of the contraction of the trapezius contraction or drooping of
client. muscles. shoulder.
b. Ask the client to shrug the
shoulder against your
hands.

Sternocleidomastoid Assessment
a. Ask the client to turn There is strong contraction of Atrophy with fasciculations
head against the Sternocleidomastoid muscle. may be seen with peripheral
resistance of your hand. nerve disease.

13. Assess CN XII Tongue movement is symmetric Fasciculations and atrophy

a. Ask the client to open and smooth, and bilateral of the tongue may be seen
mouth and protrude strength is apparent. with peripheral nerve
tongue and assess disease.
for any deviation.
b. Test tongue strength by
asking patient to protrude
tongue to side of the
cheek while you press it at
the side of the cheek.
III. MOTOR AND CEREBELLAR SYSTEM
14. Test condition and All muscle groups are Rigid muscles that resist
movement of muscles equally strong against passive movement are seen.
a. Assess for strength and tone resistance, without flaccidity,
of all muscles spasticity, or rigidity.
a.1 Assess muscle tone
a.2 Check for muscle atrophy
Biceps, Triceps
a.3 Assess finger muscle

15. Evaluate gait and Gait is steady. Uneven or unsteady gait is

balance noted.
a. Testing balance tandem
walking

16. Test Coordination Client touches fingers to nose Uncoordinated, jerky

a. Testing Coordination – with smooth, accurate movements and inability to
the finger to nose movements touch the nose
test
b. Testing rapid alternating
movement palm

alternating palm
 IV. SENSORY SYSTEM
17. Test light touch, pain Client correctly identifies Altered perceive sensation.
and temperature light touch, temperature.
sensation
a. Light touch
b. Pain
c. Temperature

18. Test vibratory sensation Inability to sense vibrations

a. strike a low-pitched Correctly identifies sensation
tuning fork on the heel
of your hand and hold
the base on the
a.1 Distal radius
a.2 Forefinger
a.3 Medial Malleolus
a.4 Tip of the great
toe

19. Test for position Correctly identifies directions Inability to identify the
sensation. of movements. directions of the movements.
a. Ask the client to close
both eyes.
b. Hold the client’s finger
on the lateral side
and move it up and
down.
c. Ask the client to tell you
the direction it is moved.
20. Assess tactile Correctly identifies object Inability to identify objects
discrimination(Fine
touch)
a. Ask the client to close
his eyes to test
stereognosis
b. Place a familiar object
such as paper clip or
key in the client’s
hand and ask the
client to identify
V. REFLEXES
21. Assess deep tendon
reflexes
22. Place client in a
comfortable position.
23. Assess biceps reflex Elbow flexes and contraction No response or an
a. Ask the client to of the muscle is seen exaggerated response is
partially bend the arm at the seen
elbow with palm up.
b. Place your thumb over the
biceps tendon and strike your
thumb with the pointed side of
the reflex hammer
c. Repeat on the other side
24. Assess triceps reflex Elbow extends, triceps No response or an
a. Ask the client to contracts. exaggerated response is
hang the arm freely seen
while you support it
with your non
dominant hand
b. With the elbow flexed, use
the flat side of the reflex
hammer to tap the tendon
above the olecranon process.
c. Repeat on the other side
25. Assess patellar reflex Knee extends, quadriceps No response or an
a. Ask the client to let both muscle contracts. exaggerated response is
legs hang freely off the seen
 side of the examination Naka sitting position or supine..
table. sa may knee pupukpukon..
b. Using the flat side of the refer sa book.
reflex hammer, tap the
patellar tendon, which is
located just below the
patella.
c. Repeat on the other side
26. Test Superficial Reflexes Abdominal muscle Superficial reflexes may be
a. Test abdominal reflex contracts, the umbilicus absent.
a.1 Lightly stroke the deviates toward the side.
abdomen on
each side, above and
below the
umbilicus.

27. Test for meningeal

Irritation or
inflammation.
a. Test for Brudzinski sign Hips and knees remain relaxed pain and flexion of the hips
a.1 Flex the neck. and motionless
and knees are seen
a.2 Watch the
hips and knees in
reaction to your
maneuver.
b. Test for Kernig sign
b.1 Flex the client’s leg at
both the hip and the Pain and increased
knee , then No pain is felt or any discomfort
behind the knee. resistance to extending knee
b.2 Straighten the knee are positive kernig signs.

ANALYSIS OF DATA
28. Analyse and formulate appropriate Nursing Diagnosis
DOCUMENTATION OF DATA
29. Document the collected data following the health care or agency policy

Performs after care of materials.

GOOOODDDDLUCKKK HAHAHHAHA