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NEUROLOGICALASSESSMENT

INTRODUCTION

The human nervous system is a highly specialized system responsible for the control and
integration of the body's activities. The ability to conduct an accurate neurological assessment
depends on the nurse's knowledge of neuroanatomy and neurophysiology and skill in
recognizing and interpreting subtle deviations from normal. Although neurological assessment
usually is complete in phases and depends on the condition of the person and the urgency of
the situation, assessment of mental status, level of consciousness, language and speech,
perceptual status and sensory status. An accurate description of the patient's neurological
symptoms is an important aid in establishing the diagnosis; but this must be taken in
conjunction with information from other system, previous medical history, family and social
history, and current medication. Often the patient's history requires confirmation from a relative
or friend.
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DEFINITION

A neurological examination is the assessment of sensory neuron and motor responses,

especially reflexes, to determine whether the nervous system is impaired. This typically
includes a physical examination and a review of the patient's medical history, but not deeper
investigation such as neuroimaging.

NEUROLOGICAL PHYSICAL EXAMINATION

• The neurological physical examination is intended to detect abnormalities in

neurological functioning.
• The comprehensive neurological examination consists of vital signs, mental status,
language and communication, Cranial nerve assessment, motor response, sensory
response and reflexes.
• Generally, neurological examination assesses six categories of functions and reflex
function.
• The primary purpose of the nursing neurological examination is to determine the effects
of the neurological dysfunction on daily living, in relation to the patient's and the
family's ability to cope with the neurological deficits.

PURPOSES

The purposes of neurological examination include the following:

1. Nursing purpose of the examination is to determine whether nervous system

dysfunction is present or not?
2. It helps in collecting data that differentiates medical practice from nursing practice.
3. As a part of patients' record, it is available for the nurse and other health professionals
for review.
4. Comprehensive neurological examination helps to diagnose the disease first, and then
the treatment and nursing can be prescribed accordingly.
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INSTRUMENTS USED

The nurse has to use or keep ready the following equipments needed to perform a neurological
examination, which include:

1) Compass. Cotton applicators.

2) Dermatomes.
3) Dynamometer.
4) Flashlight.
5) Miscellaneous items of varied shape and size (coin, key, marble).
6) Ophthalmoscope
7) Otoscope
8) Colored pencil
9) Pins with sharp and blunt ends
10) Printed page
11) Reflex hammer
12) Tape measure
13) Tongue depressor
14) Tuning fork
15) Snellen chart
16) Stoppered vial containing:
• Peppermint, oil of cloves, coffee and soap (smell)
• Sugar, salt, vinegar and quinine(taste)
• Cold and hot water (temperature)
17) Watch with second hand

NEUROEXAMINATION TOOLS

• Deep tendon reflexes (DTRs) are automatic (involuntary) responses to a stimulus

[hammer strike] that stretches a muscle and tendon
• . A DTR involves the spinal nerve segment and when intact indicates normal function
of cutaneous innervation, motor supply and cortical input to the corresponding spinal
segment.
• Reflexes must be tested bilaterally as well as on both the upper and lower limbs.
• Reflexes are considered normal, even if diminished, if they are symmetric.
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• The least amount of force to elicit a reflex arc should be used

• The Neuro7 hammers are being particularly well suited for this.
• The most common spinal nerve roots tested are biceps (C5, C6), brachioradialis (C6),
triceps (C7), patellar (L4) and Achilles (S4).
• A multitude of pathological disease states result in hyporeflexia or hyperreflexia,
including clonus (sustained jerking).
• Hyperreflexia is associated with upper motor neuron lesions and is seen, e.g. in
hyperthyroidism and preeclampsia.
• Hyporeflexia is associated with abnormalities in upper and lower motor neuron lesions,
abnormalities in muscles and mechanical factors such as joint disease.

OPHTHALMOSCOPY

Ophthalmoscopy is of two major types.

Direct Ophthalmoscopy

One that produces an upright or unreversed image of approximately 15 times magnification.

Indirect Ophthalmoscopy

One that produces an inverted or reversed, direct image of two to five times magnification.

TWO-POINT DISCRIMINATOR

• The two-point discrimination test is the most commonly used test to assess sensory
outcome following peripheral nerve repair.
• Also, after surgical decompression of a peripheral nerve (as decompression of the carpal
tunnel at the wrist), two-point discrimination may be used to assess restoration and
improvement of nerve function.
• Likewise, with a potentially traumatic peripheral nerve injury, two-point discrimination
testing will help the examiner to determine the dysfunction and the need for specific
care, including referral to a specialist for nerve repair, when feasible.
• Two-point discrimination is useful in determining postoperative improvement
following surgical intervention for mandibular and midface fractures.
• It is also useful in assessing peripheral nerve damage and improvement or deterioration
for frostbite and burn injuries of the extremities.
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LIGHT SOURCE

The light source is a single focused LED light (with a momentary switch) for examining
pupillary light reflex, pharynx and external ears.

• The myriad of disease states, traumatic brain injuries, toxicologic and electrolyte
abnormalities causing changes in the pupillary response can be discussed as needed. As
an example, a patient overdosing on narcotics (except Dar von) will have pinpoint
pupils that respond poorly to a bright light.
• A significant disparity in the size of the pupils in a trauma patient is indicative of a
herniating brainstem through the foramen magnum of the skull, a condition requiring
immediate surgical decompression by a neurosurgeon.

BRUSH

As a part of the sensory exam, the brush is used for testing light touch sensation by brushing it
gently over a small area of skin.

• The brush may be used, for example, face in each of the three divisions of the cranial
nerve V (ophthalmic, maxillary and mandibular).
• One must remember that light touch, pain and temperature are parts of the cutaneous
sensory exam (spinothalamic), while position sense, vibratory sense and touch
localization are parts of the proprioceptive exam (dorsal column).
• Consistent technique is necessary, while performing any part of a sensory exam, which
requires a patient’s corporation and reliability.

SHARP/DULL TOOL

A basic sensory exam includes having the patient distinguish a sharp (pinprick or sharp point)
sensation from a dull sensation.

• Pain (sharp point), as well as light touch and vibration (128 Hz tuning fork) should be
tested proximally and distally on the extremities.
• Note again that pain (as well as light touch and temperature) is a component of a
cutaneous sensory exam.
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• The patient’s eyes should be closed during a sensory exam for the practitioner to be
able to identify any sensory loss or significant pattern, including dermatomal deficits,
including hypoesthesia, hyperesthesia or inability to sense pain at all.

EDGE FOR PLANTAR STIMULATION

The top edge of the pocket clip was specifically designed for the practitioner to perform plantar
stimulation, i.e., Babinski reflex.

• This edge is rubbed briskly on the lateral edge of the foot, a normal response being
plantar flexion of all toes, an abnormal response (positive Babinski reflex) being the
dorsal flexion of the great toe, indicative of some form of disruption or dysfunction of
the long corticospinal tract.
• Physicians will use any hard edge to perform this reflex.

OTOSCOPY UNIT

The otoscopic exam is performed by gently pulling the auricle upward and backward. In
children, the auricle should be pulled downward and backward. This process will move - the
acoustic meatus in line with the canal. Hold the otoscope like a pen/pencil and use the little
finger area as a fulcrum. This, prevents injury if the patient turns suddenly.

SNELLEN CHART

A Snellen chart is used to test for vision. It has several rows of letters. The letters on the top
line are the largest those on the bottom line are the smallest.

• The patient is asked to stand 20 ft (6 m) from the chart, cover one eye and read the
smallest row of letters.

HISTORY COLLECTION

• General History
• Psychosocial History
• Mental Status

Nurses in Assessment of Mental Status

The components of the mental status examination are detailed below.

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General appearance: This includes motor activities, body posture, dress and hygiene, facial
expression and speech.

State of consciousness: This includes orientation to place, person and situation, as well as
memory; general knowledge, insight, judgment, problem-solving and calculation.

Mood and affect: This includes noting agitation, anger, depression, euphoria and the
appropriateness of these states.

Thought content: This includes noting illusions, hallucinations, delusions or paranoia.

Intellectual capacity: This includes noting retardation, dementia and intelligence.

LANGUAGE AND SPEECH

Language ability is concentrated on a cortical field, which includes parts of the tern poral lobe,
the temporoparietal-occipital junction, the frontal lobe of the dominant (usually left)
hemisphere and occipital lobe.

• Lesion in any of these areas will produce some impairment in language ability aphasia
or dysarthria.
• Aphasia is the impairment of language functions.

There are different types of aphasias that had been identified and explained.

Motor Expressive Aphasia

Motor expressive aphasia is the impairment of ability to speak and write.

• Patient can understand written and spoken words. This may be due to lesions in the
insular and surrounding region including Broca's motor area
• Motor expressive aphasia can be classified into anomic, fluent and non-fluent aphasia.

Anomic Aphasia

Anomic refers to inability to name objects qualities and conditions, although speech is fluent
due to lesion in area of angular gyms.

Fluent Aphasia

Fluent refers to speech in well-articulated and grammatically correct, but lacking in content
and meaning.
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Non-fluent Aphasia

Non-fluent aphasia refers to problems in selecting. Organizing and initiating speech patterns,
may also affect writing. It is due to lesion and motor cortex at Broca's area.

Sensory (Receptive) aphasia:

Refers to impairment of ability to understand written or spoken language, which is due to

disease of auditory and visual word centers. Wernicke's aphasia is also the same as sensory
aphasia due to lesion lying in Wernicke's area of left hemisphere.

Mixed aphasia:

Refers to combined expressive and receptive aphasia deficits due to damage to various speech
and language areas.

Global aphasia:

Refers to total aphasia involving all functions that makeup speech and communication.

Few, if any, imbibe language skills. This is due to severe damage to speech area.

Dysarthria:

Refers to indistinctness in word articulation or enunciation resulting from interference with

the peripheral speech mechanisms (e.g. the muscles of the tongue, palate, pharynx or lips).

• Dysarthria may be manifested by a single alteration or a variety of alterations and there

are characteristic changes in particular diseases.
• For example, in cerebellar disease, speech is often thick with prolongation of speech
sounds occurring at intervals. In parkinsonism, speech is characterized by a decrease in
loudness and a change in vocal emphasis patterns that makes sound seem monotonous.

PERCEPTION

Sensation is integrated and interpreted in the sensory cortex, especially in the parietal lobe. It
is important for the nurse to recognize perceptual problems, because they can be more difficult
to deal with the changes in the patient's ability to move or sense. Disorders of perceptions
commonly involve spatial-temporal relationships or the perception of self.

• The ability to recognize objects through any of the special senses is known as 'gnosia'.
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• Lesions involving a specific association area of the cortex produce a specific type of
agnosia (absence of the ability).
• One type of ability often tested is stereognosis, the ability to perceive an object's nature
and form by touch. This is assessed by asking the person to identify familiar objects
placed in the hand at a time, while keeping his eyes closed.

APRAXIA

Apraxia is another perceptual problem, refers to the inability to perform skilled, purposeful
movements in the absence of motor, sensory or coordination losses. The different types of
apraxia are as follows:

1. Constructional apraxia is impairment in producing designs in two or three

dimensions, involves copying, drawing or constructing. This is due to lesion in
occipitoparietal lobe of either hemisphere.
2. Dressing apraxia is an inability to dress oneself accurately. The individual makes
mistakes as putting clothes on backwards, upside down, inside out or putting both legs
in the same pant leg. This is due to lesion in occipital or parietal lobe usually in non-
dominant hemisphere.
3. Kinaesthetic apraxia is a loss of kinaesthetic memory pattern, which result in patient
inability to perform a purposeful motor task although it is understood. This is due to
lesion in frontal lobe of either hemi sphere or precentral gyms.
4. Ideomotor apraxia is an inability to imitate gestures or perform a purposeful motor
task on command. The subject may be able to do spontaneous. This is due to lesions in
parietal lobe of dominant hemisphere and supramarginal gyms.
5. Ideational apraxia is an inability to carry out activities automatically or on command,
because of inability to understand the concepts of the act. This is due to lesion in parietal
lobe of dominant hemisphere or diffuse brain damage as in arteriosclerosis.

SENSORY STATUS

Accurate assessment of sensory function depends on the person's cooperation, alertness and
responsiveness. The person should be relaxed and have the eyes closed during all portions of
the sensory examination to avoid recovering visual clues. Also, sensation should be tested side
by side and distally to proximity. Both superficial and deep sensations are tested on trunk Arnd
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extremities. Areas of sensory loss or abnormality are mapped out on a body diagram according
to the distribution of the spinal dermatomes and peripheral nerves.

1. Pain

1.1. Superficial Pain

Perception is assessed by stimulating an area by pinprick and asking the person to report
discomfort. Sharp and dull objects can be alternated for increased discrimination.

1.2. Deep Pain

• Deep pain can be assessed by multiple means, some of which have the potential of
causing tissue injury.
• It is necessary to assess deep pain only when the person has a decreased LOC.
• Deep pain can be assessed by applying pressure over the nail beds or supraorbitally.
• Pressure may also be applied over bony areas, such as sternum.
• Nail bed pressure is applied by placing a pin or similar object on the nail bed and
squeezing it between the examiner's thumb and forefinger.
• Deep pain may also be elicited by squeezing the trapezius muscle.
• Pinching and pricking may damage tissues and are avoided wherever possible.
1.3. Crude Touch
• Crude touch may be assessed by touching area with cotton and requesting that the
person indicate when the touch is felt.
• Temperature is tested by touching particular areas with warm to hot and cool to cold
object and asking the person to state the sensations felt.
2. Motion and Position
• Proprioceptive fibres transmit sensory impulses from muscles, tender
ligaments and joints.
• This results in an awareness of the position of one's limbs in space (kinaesthetic
sense).
• Proprioception is tested by the examiner grasping the sides of the person's distal
phalanx and moving it up and down.
• If proprioception is intact, the person reports correctly the direction in which
the joint is being moved.
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• Proprioceptive ability can also be assessed by the Romberg's test in which the
person is asked to stand erect with the feet together and the eyes closed.
• A positive test occurs where the person loses balance, which indicates a
pathological condition.
• Vibration is tested by placing a low-frequency tuning fork on a bony
prominence of each extremity and assessing the person's ability to feel it.

ASSESSMENT OF CONSCIOUS LEVELS

AND HIGHER CEREBRAL FUNCTION

CONSCIOUS LEVEL ASSESSMENT

Eye opening

• Eye opens to speech

• Eye opens to pain
• No response

Verbal Response

1. Orientated: Knows place, e.g., Royal Free Hospital and time, e.g., day,
month and year.
2. Confused: Able to talk in sentences, but disorientated in time and place.
3. Words: Utters occasional words rather than sentences. Sounds-groans
or grunts, but no words.
4. None.

Motor Response

• Obeys commands
• Localizing to Pain
➢ Apply a painful stimulus to the supraorbital nerve, e.g., rub thumbnail in the
supraorbital groove, increasing pressure until a response is obtained.
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➢ If the patient responds by bringing the hand up beyond the chin indicates
localizing to pain' (pressure to nail beds or sternum at this stage may not
differentiate "localizing' from flexing').
• Flexing to Pain
➢ If the patient does not localize to supraorbital pressure, apply pressure with
a pen or hard object to the nail bed. Record elbow flexion as 'flexing to pain'.
Spastic wrist flexion may or may not accompany this response.
• Extending to Pain
➢ If in response to the same stimulus, elbow extension occurs, record as
'extending to pain'. This is always accompanied by spastic flexion of the
wrist.
• None
➢ Before recording a patient at this level, ensure that the painful stimulus is
adequate.
• During examination, the motor response may vary.
➢ Supraorbital pain may produce an extension response, whereas fingernail
pressure produces flexion.
➢ Alternatively, one arm may localize to pain; the other may flex.
➢ When this occurs, record the best response during the period of examination
(this correlates best with final outcome).
➢ The purpose of conscious level assessment uses only the arm response. Leg
response to pain gives less consistent results, often producing movements
arising from spinal rather than cerebral origin.
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EXAMINATION OF HIGHER CEREBRAL FUNCTION

COGNITIVE SKILL

Skill test Hemisphere disorders

Dominant hemispheres
Listen to language pattern: Hesitant - fluent Expressive dysphasia
Receptive dysphasia
Does the patient understand simple/complex spoken Receptive dysphasia
commands?
For example, hold up both arms, touch the right ear with
the left fifth finger’.

Ask the patient to name objects. Nominal dysphasia

Does the patient read correctly?
Dyslexia
Does the patient write correctly?
Dysgraphia

Ask the patient to perform a numerical calculation, e.g., Dyscalculia

serial 7 test, where 7 is subtracted serially from 100.

Can the patient recognize objects? For example, ask Agnosia

patient to select an object from a group.

Non-dominant hemisphere

Note the patient's ability to find his way around the ward Dressing apraxia
or his home.
Geographical agnosia
Can the patient dress himself?

Note the patient’s ability to copy a geometric pattern, Constructional apraxia

e.g., ask patient to form a star with matches or copy a
drawing of a cube
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Memory Test

Testing requires alertness and is not possible in a confused or dysphasic patient.

Immediate Memory

Digit spans: Ask patient to repeat a sequence of 5, 6 or 7 random numbers.

Recent Memory

Ask patient to describe present illness, duration of hospital stay or recent events in the news.

Remote Memory

Ask about events and circumstances occurring more than 5 years previously.

Verbal memory

Ask patient to remember a sentence and test after 15 minutes.

Visual memory

Ask the patient to remember objects on a tray and test after 15 minutes.

Note

Retrograde amnesia: loss of memory events leading up to a brain injury or insult.

Post- traumatic amnesia: permanent loss of memory of events for a period following a head
injury.

Reasoning and Problem Solving

Test patient with two-step calculations, e.g. "I wish to buy 12 articles at 7 pence each. How
much change will one receives from pound?" The procedure is as follows:

1. Ask patient to reverse 3-4 random numbers.

2. Ask patient to explain proverbs.
3. The examiner must compare patient's present reasoning ability with expected abilities
based on job history and/or school work.

Emotional State

Note the following features, while examining for emotional state:

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1. Anxiety or excitement.
2. Depression or apathy.
3. Emotional behaviour.
4. Uninhibited behaviour
5. Slowness of movement or responses.

CRANIAL NERVE EXAMINATION

OLFACTORY NERVE

• Special receptors located within the superior or upper- most part of each nasal chamber
transmit neural impulse over the olfactory bulbs to the olfactory nerves in the area of
central cortex concerned with olfaction.
• When testing this CN, the nurse asks the patient to close one nostril, close both eyes
and sniff from a bottle containing coffee, spice, soup or some other readily recognized
odor. If yes, the patient is asked to name the odor.
• Awareness of an odor must be differentiated from the ability to name a specific
substance.
• The same may be repeated in another nostril.
• Anosmia (absence of smell) or hyposmia (decreased sensitivity of the sense of smell)
is often associated with complaints of lack of taste, even though test may demonstrate
sense to be intact.
• Anosmia caused by varied lesion involving any part of the olfactory pathways.

CLASSIFICATION OF OLFACTORY DISORDERS

Olfactory disorders can be grouped into four main types:

1. Total anosmia or partial anosmia: Inability to detect olfactory sensations.

2. Distortions or illusion of smell (dysosmia).

3.Olfactory delusions or hallucinations associated with disorders of the temporal lobe and
psychiatric disease.

4. Olfactory agnosia: A disorder in which there is an inability to recognize an odor sensation

despite intact mechanism.
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OPTIC NERVE

• When retina is stimulated, nerve impulses are transmitted over the optic nerves
(extending from the optic disk to the chiasm) and the optic tracts with radiation
terminating in the visual cortex of the occipital lobes.
• Optic nerve function is assessed in relation to visual acuity, visual fields and the
appearance of fundus.
• Each eye is tested separately.

Visual Acuity

• Visual acuity is mediated by the cones of the retina.

• Central vision is grossly tested by reading newspaper print
• Distance visual activity is assessed through the use of the Snellen’s chart.
• Individuals with vision impairment are tested to determine light perception, hand
movement and finger count.

VISUAL FIELDS

• Visual fields are assessed grossly by confrontation techniques.

• The examiner, positioned directly opposite to the patient.
• Asks the patient to close one eye, look directly at the bridge of the examiner's nose and
indicate when an object (finger, pencil tip) presented from periphery of the four visual
quadrants.
• The same test is repeated for the other eye.
• Visual field defects may arise from lesions of the optic nerve, optic chiasm or tracts that
extend through the temporal, parietal or occipital lobe.
• Visual changes resulting from brain lesion are hemianopsia (One half of the field
affected) a quadrantanopia (one fourth of visual field affected) or monocular.
• The ocular fundus is defined as that portion of the interior of the eyeball that lies
posterior to the lens.
• It includes optic disk, blood vessels, retina and macula.
• Fundoscopy reveals the physical condition of the optic disk (head of the optic nerve) as
well as the retina and blood vessels.
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Fundoscopic Examination

• Normally it is not necessary to dilate the pupils in order to examine the central fundus,
but if the patient has small pupils or the background illumination is high, take patient
into a darkened room for the examination.
• If this fails to dilate the pupils sufficiently, then a mydriatic, for example, Mydrilate,
can be instilled.
• This should never be done in the unconscious patient and must always be recorded in
the patient's notes.
• Do not use mydriatics in a patient with glaucoma.
• Remember to reverse the effects of the mydriatic at the end of the examination by
instilling 2% pilocarpine.
• The direct ophthalmoscope incorporates a light source, which is directed on to the retina
via a mirror, together with a series of lenses of varying strength, which allow the
reflected light to be focused on to the examiner's own retina.
• The field of view extends over about 6.5 degree and the image is upright.
• If the patient wears glasses with a substantial correction, it sometimes facilitates the
examination to perform it with the patient's glasses in place.
• Ask the patient to fixate on a distant target.
• The optic disk is examined first to assess its shape, color and clarity. The temporal
margin of the disk is slightly paler than the nasal margin.
• The physiological cup varies in size, but seldom extends to the temporal and never to
the nasal margins of the disk.
• The blood vessels are not obscured as they cross the disk margin, nor are they elevated.
• The vessels are examined next. The arteries are narrower than the veins and a brighter
color. They possess a longitudinal pale streak as a consequence of light reflecting from
their walls. The retinal veins should be closely inspected where they enter the optic
disk.
• In around 80% of normal individuals the veins pulsate, their walls alternately
expanding and collapsing. This pulsation ceases when cerebrospinal fluid (CSF)
pressure exceeds 200 mm of water.
• Therefore, the presence of retinal venous pulsation in these individuals is a very
sensitive index of normal intracranial pressure.
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• The fundus is examined for the presence of haemorrhages and exudates, the positions
of which are best shown by a small diagram in the patient's notes or by a description,
which uses the optic disk as a clock face for localization purposes; for example, "one
large haemorrhage at 6 O'clock, one disk diameter from the disk."
• Finally, the pattern of the retinal nerve fibres can be assessed using a red-free light.

Papilledema

• Patients with papilledema often have no visual complaints, though some describe
transient obscuration of vision either occurring spontaneously or being triggered by
postural change. It is usually bilateral, though sometimes asymmetrical.
• , Pathogenesis remains unsettled.
• The term papilledema is best reserved for cases where the disc swelling is secondary to
raised intracranial pressure. Transmission of the raised intracranial pressure, via the
subarachnoid space of the optic nerve, results in venous stasis and also interrupts both
fast and slow axoplasmic flow in the optic nerve.

OCULOMOTOR, TROCHLEAR AND ABDUCENS

PERRLA

• PERRLA stands for pupils equal, round and reactive to light and accommodation.
• Direct and consensual accommodation is present.
• Eye opening movements are intact without nystagmus and corneal light reflections
symmetrical.
• Cranial nerves III, IV and VI are motor nerves that arise from the brainstem and
innervate the six extraocular muscles attached to the eyeball.
• These muscles function as a group in the coordinated movement of each eyeball is the
six cardinal fields of gaze, giving the eye both straight and rotary movement.
• The four straight or rectus, muscles are the superior, inferior, lateral and medial rectus
muscles.
• The two slanting or oblique muscles are the superior and inferior. Since these three
cranial nerves all help move the eye, they are tested together.
• The patient is asked to follow the examiner's finger as it moves horizontally and
vertically (making cross) and diagonally (making an X).
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• If there is weakness or paralyzes in one of the eye muscles, the eyes do not move
together and the patient has a deconjugate gaze.
• The presence and direction of nystagmus (fine, rapid, jerking movements of the eyes)
is observed at this time even though it is most often indicated to vestibular cerebellar
problems.
• Double vision (diplopia)squint(strabismus)and involuntary rhythmic movement of the
eyeballs (nystagmus) may indicate weakness of some of the extraocular muscles
because of deficits of these motor nerves.
• Ptosis or drooping of the upper eyelid over the globe may be caused by damage to the
oculomotor nerve.
• Other function of the oculomotor nerve is tested by checking for pupillary constriction
and for convergence (eye turning inward) and accommodation (pupil constricting with
near vision).

Third Nerve

• The 3rd nerve nucleus is located in the midbrain at the level of the superior colliculus.
• All the neurons project ipsilaterally apart from those passing to the contralateral
superior rectus muscle.
• The levators of the upper lids are supplied by a single midline nucleus.
• The 3rd nerve emerges from the anterior aspect of the midbrain and lies close to the
posterior communicating artery before entering the cavernous sinus in which it runs
superiorly.
• It terminates in superior and inferior divisions, the latter containing pupillomotor
fibres.

Fourth Nerve

• The 4th nerve decussates before exiting from the dorsal aspect of the midbrain,
eventually innervating the contralateral superior oblique muscle.
• It lies immediately below the 3rd nerve in the cavernous sinus and enters the orbit
through the superior orbital fissure, along with the other nerves supplying the eye
muscles.
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Sixth Nerve

• The 6th nerve emerges from the lower border of the pons, run beneath the petroclinoid
ligament then lies close to the internal carotid artery in the medial aspect of the
cavernous sinus.
• It supplies the lateral rectus muscle. Nystagmus is a repetitive to-and-fro movement of
the eyes.
• In pendular nystagmus the phases are of equal velocity in phasic (Jerk) nystagmus they
differ.
• The slow phase of jerk nystagmus may show linear or non-linear time coarse.
• Vestibular dysfunction, either centrally or peripherally, is the usual cause of a jerk
nystagmus in which the slow phase is linear.
• In gaze evoked nystagmus the eye drift back forms an eccentric position with a non-
linear velocity, followed by a saccadic correction.
• This type of nystagmus is thought to result from dysfunction of the neural integrator,
the mechanism, which sustains a tonic discharge of neuronal activity during eccentric
gaze.

CHARACTERISTIC FEATURES OF 3RD NERVE PALSY OR

OCULOMOTOR NERVE PALSY

1. Ptosis or drooping of upper eyelid caused by paralysis of levator palpebrae superioris

(Note: A part of the levator palpebrae superioris-the Muller's muscle-is supplied by
sympathetic fibres. These fibres are not paralyzed. So, there is only partial drooping of
the upper eyelid).
2. Absence of pupillary reflex or light reflex (i.e. constriction of pupil in response to bright
light), due to paralysis of constrictor (sphincter) pupillae.
3. Dilation (dilatation) of pupil: Due to the unopposed action of dilator pupillae (supplied
by sympathetic fibres).
4. Absence of accommodation of lens because of paralysis of the ciliary muscle.
5. Squint: The eyeball is abducted and directed inferiorly due to the unopposed actions of
lateral rectus and superior oblique muscles.
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TRIGEMINAL NERVE
• Cranial nerve V is a mixed nerve with motor and sensory components.
• It is the largest cranial nerve.
• The motor part innervates the temporal and masseter muscles, the sensory part supplies
the cornea, face, head and mucous membranes of the nose and mouth.
• The sensory component of the trigeminal nerve is tested by having the patient identify
light touch (cotton) and pinprick in each of the three divisions (ophthalmic maxillary
and mandibular) of the nerve on both sides the face
• The patient's eyes should be closed during this part of the examination.
• The corneal reflex test evaluates trigeminal nerves and facial simultaneously. It
involves applying a cotton wisp strand to the cornea.
• The sensory components of the reflex (cornel sensation) are innervated by the
ophthalmic division of CN V.
• The motor component (eye blink) of thin reflex is innervated by facial nerve.
• Normally, the person blanks laterally.
• This is especially important reflex to assess in persons with decreased level of
consciousness because the absence of the blink reflex can result in corneal damage.

Corneal Reflex

• Test corneal sensation by touching with wisp of wet cotton wool.

• A blink response should occur bilaterally.
• Afferent route-ophthalmic division V (light touch-main sensory nucleus).

Afferent Route

Facial nerve VII: This test is the most sensitive indicator trigeminal nerve damage.

Motor Examination

• Observe for wasting the thinning of temporalis muscle- ‘hollowing out ‘ the temporalis
fossa.
• Ask the patient to clamp jaw together. Feel temporalis and masseter muscles. Attempt
to open patient’s jaws by applying pressure to chin.
• Ask patient to open mouth. If pterygoid muscle is weak, the jaw will deviate to the
weak side, being pushed over by the unopposed pterygoid muscle of the good side.
 22

• Jaw jerk: Ask patient to relax jaw. Place finger on the chin and tap with hammer.
• Slight or absent jerk- normal
• Increased jerk: upper motor neuron lesion

Disease/Injuries Related to Trigeminal Nerve Injury

• Cranial nerve may be injured in trauma, tumours or meningeal infections.

• Its nuclei, situated in the pons and medulla may be destroyed by vascular lesions or
tumours.
• Results of injury: As follows:
1. Paralysis of muscles of mastication, with deviation of mandible to the same
side of lesion.
2. Loss of sensation from areas supplied by the nerve.
3. Loss of corneal reflex (blinking in response to the cornea being touched by a
wisp of cotton).

Trigeminal Neuralgia (Tic Douloureux)

• The main disease affecting the trigeminal nerve is characterized by attacks of severe
pain in the areas of distribution of maxillary and mandibular divisions.

Mandibular Nerve Block

• A needle is introduced through the mandibular notch into the infratemporal fossa and
the anaesthetic agent is injected.
• This is to anesthetize the branches of mandibular nerve.

Inferior Alveolar Nerve Block

• Inferior alveolar nerve block is commonly used by dentists while extracting or repairing
the mandibular teeth.
• The injection is given around the mandibular foramen.

Lingual Nerve

• Lingual nerve can get injured, while extracting the third molar tooth, because the nerve
lies just inferior to the third molar tooth.
 23

FACIAL NERVE

• Facial nerve is a mixed nerve that is concerned with facial movement and sensation of
taste.
• It innervates the muscles of facial expression.
• The inability to smile, close both eyes, slightly look upward, wrinkle the forehead, show
the teeth, purse the lips and blow out the cheeks constitutes weaknesses or paralysis of
the facial muscle innervated by this nerve.
• The function of facial nerve is tested by asking the patient to raise the eyebrows; close
the eyes tightly, purse the lips, draw back the comers of the mouth in an exaggerated
smile and frown.
• The examiner should note any asymmetry in the facial movements, because they can
indicate damage to the facial nerve.
• The sensation of taste is tested by placing salty sweet, bitter and sour substances, in turn
on the side of the protruded tongue for identification.
• A loss of task over the anterior two third of the tongue is present when this nerve is
diseased, as occurs in mastoid canal lesions.
• Observe patient as the talks and smiles, watching for
1. Eye closure.
2. Asymmetrical elevation of one comer of mouth.
3. Flattening of nasolabial fold.
• Patient is then instructed to: Taste may be tested by using sugar, tartaric acid or sodium
chloride. A small quantity of each substance is placed on the appropriate side of the
protruded tongue.

ACOUSTIC/AUDITORY NERVE

• Acoustic/auditory nerve is composed of a cochlear division related to hearing and a

vestibular division related to equilibrium.
• The cochlear portion of this nerve 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 as the
stimulus is brought closer to the ear.
• Each ear rested individually and the distance from the patient's ear to sound source
when first hand is retarded.
 24

• A more complete examination, including bone and air conduction of sound involves
assessment with a tuning fork and audiometric testing.
• The vestibular portion of this nerve is not routinely tested unless the patient complains
of dizziness, vertigo or unsteadiness or has auditory dysfunctioning.
• There is variety of ways in testing this portion of the nerve.
• In the past-pointing test, the person is asked to raise the arms and bring the index
fingers down on the examiner's finger with the arm outstretched, first with the eyes
open and then with the eyes closed.
• Normally, the person's fingers touch the examiners without difficulty. In vestibular
disease, the finger points to one side or the other consistently.
• The person is also assessed for nystagmus.

Cochlear Component

• Test by whispering numbers into one ear while masking hearing in the other ear by
occluding and rubbing the external meatus.
• If hearing is impaired, examine external meatus and the tympanic membrane with
auroscope (otoscope) to exclude wax or infection.
• Differentiate conductive (middle ear) deafness from perceptive (nerve) deafness by
Weber and Rinne test.
Weber Test
Hold base of tuning fork against the vertex. Ask patient if sound is heard more loudly
in one ear.
Rinne Test
Hold the base of a vibrating tuning fork against the mastoid bone. Ask the patient if
note is heard. When note disappears-hold tuning fork near the external meatus. Patient
should hear sound again since air conduction via the ossicles is better than bone
conduction
1. In conductive deafness, bone conduction is better than air conduction.
2. In nerve deafness, both bone and air conduction are impaired
• Further auditory testing and examination of the vestibular component requires
specialized investigation.
 25

Injury

• Injury of the vestibulocochlear nerve may cause:

1. Tinnitus: Ringing in ears.

2. Vertigo: Giddiness or loss of balance.

3. Impairment or loss of hearing.

• Sensorineural deafness is the result of disease in the cochlea or in the pathway from the
cochlea to the brain.
• Acoustic neuroma is a slow growing tumour of the neurolemma cells, covering the
vestibular nerve. This results in compression of vestibular as well as cochlear nerves,
resulting in loss of hearing, tinnitus and loss of equilibrium.
• Cochlear branch injury causes:
1. Tinnitus.
2. Nerve deafness.
• Causes
1. At cochlear level: Otosclerosis, Meniere's syndrome, drugs such as salicylates,
streptomycin, quinine, prolonged exposure to noise.
2. In nerve trunk: old age, inflammatory or toxic lesions, cerebellopontine angle
tumours.
3. In brainstem: Pontine vascular lesions, severe demyelination, rarely tumours.
4. Vestibular branch: Vertigo, nystagmus, general symptoms such as sweating,
nausea, vomiting.

GLOSSOPHARYNGEAL AND VAGUS NERVE

• Glossopharyngeal and vagus nerve - these two cranial nerves are tested together
because both innervate the pharynx.
• Both nerves supply the posterior pharyngeal wall and normally when the wall is
touched, there is contraction of these muscles on both sides with or without gagging.
• This test is unreliable for either nerve alone, because the vagus nerve is chief motor
nerve and the soft palatal, pharyngeal and laryngeal muscles assessment include testing
voice and cough sounds.
 26

• In unilateral movement of the motor portion of the vagus nerve, the voice is harsh and
nasal.
• Bilateral involvement produces more severe speech problems, swallowing difficulty
and fluid regurgitation through nose. Sensory function of the vagus is usually not tested.
• These nerves are considered jointly since they are examined together and their actions are
seldom individually impaired.
• Note patient's voice, if there is vocal cord paresis (X), voice may be high pitched (vocal cord
examination is best left to an ENT specialist).
• Note any swallowing difficulty or nasal regurgitation of fluids.
• Ask patient to open mouth and say 'ah'. Note any asymmetry of palatal movements (X
nerve palsy)

Gag Reflex

• Depress patient’s tongue and touch palate, pharynx or tonsil on one side until the patient
'gags'.
• Compare sensitivity on each side (afferent route-IX nerve) and observe symmetry of
palatal contraction (efferent route-X nerve).
• Absence of gag reflex = loss of sensation and/or loss of motor power.
• Taste in the posterior third of the tongue (IX) is impractical to test.

Disorders

Paralysis of Palate

1. Unilateral paralysis: No symptoms. Positive ah' test.

2. Bilateral paralysis: Nasal regurgitation, nasal twang, no elevation of palate on

phonation.

Pharyngeal weakness

1. Unilateral: Pharyngeal wall droops on affected side.

2. Bilateral: Marked dysphagia.

Paralysis of Larynx

1. Unilateral total paralysis: Affected vocal cord in cadaveric position. Unilateral

anaesthesia of larynx if lesion above origin of superior laryngeal nerve.
 27

2. Unilateral abductor paralysis or bilateral total paralysis if recurrent laryngeal nerve

involvement.
3. No laryngeal anaesthesia.

Causes

1. Nuclear lesions: Syringobulbia, posterior inferior cerebellar artery thrombosis, encephalitis,

progressive bulbar paralysis, diphtheria.
2. Tumours, meningovascular syphilis, extension of infection from middle ear.
3. Trunk: Penetrating wounds and tumours.
4. Recurrent laryngeal nerve.
• Aortic aneurysm enlarged left atrium, mediastinal mass or glands, enlarged thyroid, carcinoma
of oesophagus.

SPINAL ACCESSORY NERVE

Sternomastoid and the upper part of the trapezius muscles. This nerve tested by asking the
patient to shrug the shoulders against resistance and to turn the head to either side against
resistance. There shall be smooth contraction of the above-said muscles. Symmetry, atrophy or
fasciculation of the muscle should be noted.

Sternomastoid

Ask patient to rotate head against resistance. Compare power and muscle bulk on each side.
Also compare each side with the patient pulling head forward against resistance. The left
sternomastoid turns the head to the right and vice versa.

Trapezius

Ask patient to 'shrug' shoulders and to hold them in this position against resistance. Compare
power on each side. Patient should manage to resist any effort to depress shoulders.

Disorders

• Paralysis of sternomastoid (weakness of rotation to opposite side) and of upper fibres

of trapezius (lowering of shoulder, winging of scapula).
• The supranuclear connections act on the ipsilateral sternomastoid (turning the head to
contralateral side) and on contralateral trapezius.
 28

• This results in head turning away from the relevant hemisphere during a seizure and
turning toward the relevant hemisphere with cerebral infarct.

Causes

1. Lesions: Poliomyelitis, motor neuron disease, syringomyelia, cervical spinal cord

tumours.
2. Lesions of nerve trunk:
a) Within posterior fossa-tumours near jugular foramen, granulomatous
meningitis or basal carcinoma (usually with 9th, 10th and 12th nerves).
b) After exit from the skull: Compression by enlarged deep cervical glands or
injury by penetrating wounds or during operations in cervical region.

HYPOGLOSSAL NERVE

• Hypoglossal nerve is purely motor nerve.

• The person's tongue is first inspected at rest.
• Any asymmetry unilaterally decreased bulk, deviations or fasciculation (fine
twitching) are noted.
• When the nerve is involved, the tongue deviates toward the side of the lesion.
• In an upper motor neuron lesion, the tongue is affected on the side opposite the lesion
(contralateral).
• Atrophy of the tongue shown through wrinkling and loss of substance on the affected
side.

Ask the patient to open mouth; inspect tongue and look for:

1. Evidence of atrophy (increased folds, wasting).

2. Fasciculation (small wriggling movements).

Disorders

1. Unilateral paralysis: Wasting of tongue. Tongue becomes sickle shaped with concave
on paralyzed side. Deviation toward paralyzed side on protrusion.
2. Bilateral paralysis: Marked wasting, protrusion not possible. Fasciculations of
progressive bulbar paralysis dysarthria. In pseudobulbar palsy tongue is somewhat
smaller than normal owing to spastic contraction of the muscles.
 29

Causes

1. Unilateral lower motor neuron lesions:

a) Hypoglossal nucleus or fibres of the nerve in the course through medulla- poliomyelitis,
Syringobulbia, thrombosis of median branches of vertebral artery.
b) Between medulla and hypoglossal canal- glomus tumour, meningioma or aneurism of
vertebral artery, granulomatous or carcinomatous meningitis. Congenital anomalies in
neighbourhood of foramen magnum, e.g., basilar impression. Periostitis of hypoglossal
canal; rarely head injury.

2. Bilateral lower motor neuron lesion: Progressive bulbar paralysis.

3. Bilateral upper neuron paralysis: Pseudobulbar palsy due to double hemiplegia, multiple
sclerosis, motor neuron disease, tumours of brain stem.

NEUROLGICAL EXAMINATION OF DIFFERENT BODY PARTS

EXAMINATION OF MOTOR STATUS

• Function of the nervous system is assessed through gait and stance, muscle strength,
muscle tonus, coordination involuntary movement and muscle stretch reflexes.
• Gait and stance are complex activities that require muscle strength, coordination
balance, proprioception and vision.
• Ataxia is general term, meaning lack of coordination in performing planned, purposeful
motion such as walking or gait. It is caused by disturbance of position sense or by
cerebellar or other diseases.
• To evaluate the gait, the person is asked to walk freely and naturally and then walk heel
to toe in a straight line, tandem walk, because this exaggerates abnormality.
• To evaluate stance, the person is asked to perform the Romberg standing with the feet
close together, first with eyes open and then with eyes closed. Patients with problem
and proprioception have difficulty in maintaining balance with their eyes closed.
Patients with cerebellar disease have difficulty even with their eyes open.
• A variety of distinctive gait characterizes specific neurological disorder (Parkinsonism)
 30

Muscle Strength or Power

• Muscle strength or power is assessed systematically; including trunk and extremity

muscles.
• One common assessment of muscle strength is asking the patient to grasp both hands
of the nurse or doctor and squeeze them simultaneously. The nurse or doctor compares
the Squeezing ability of one hand to another.
• Assessment muscular strength of the feet can be performed by plantar flexion and
dorsiflexion.

Assessment Scale for Muscle Strength

Muscle strength is assessed and rated on a 5-point scale in all four extremities comparing one
side to the other as follows:

• 5/5 Normal full strength. Muscle is able to move actively through full range of motion
against the effects of gravity and applied resistance
• 4/5 Muscle is able to move actively through full range of motion against the effects of
gravity with weakness to applied resistance
• 3/5 Muscle is able to move actively through full range of motion against the effects of
gravity alone.
• 2/5 Muscle is able to move with support against the effects of gravity.
• 1/5 = Muscle contraction is palpable and visible: trace or flicker movement occurs.
• 0/5 Muscle contraction or movement is undetectable.

Assessment of specific muscle groups can be completed to assess deficits in certain areas, such
as spinal cord disorders. If an asymmetry is detected, the client or family is asked if this is a
long standing or new finding.

To Test Muscle Tonus

• The nurse passively moves the person's limbs through a full range of motion.
• A skilled examiner can differentiate hypertonic from hypotonic muscles.
• Hypertonic extremities are in fixed positions and feel firm; hypotonic extremities
assume a position governed by gravity, overextension and over flexion.
 31

Coordination

Coordination can be tested in several wavs.

• The finger to-nose test involves having the patient alternately touch the nose with index
finger then touch the examiner's finger.
• Other tests include asking the patient to pronate and supinate both hands rapidly and
to do a shallow knee bend, first on one leg and then on another.
• Dysarthria is a sign of incoordination of speech muscles.

Involuntary Movement

• Involuntary movement is important to observe the location of muscle involved,

amplitude of movement, speed of onset, duration of contraction and relaxation, and
rhythm.
• The effects of posture, rest, sleep, distraction, voluntary movement and emotional stress
on involuntary movement are determined. Emotional stress usually increases
involuntary movement and they may subside during sleep.
• Abnormal movement may be the result of organic disease or psychosomatic in origin.
examples for involuntary movements are tremor, chorea and arthrosis.

EXAMINATION OF UPPER LIMBS

Motor System

Appearance

1. Any asymmetry or deformity, muscle wasting: If in doubt, measure circumference at

fixed distance above/below joint. Note muscle group.
2. Muscle hypertrophy is involved.
3. Muscle fasciculation: Irregular, non-rhythmical contraction of groups of motor units,
increased alter exercise and on smacking muscle surface.

Note: Fasciculation may occur in normal individuals, particularly in the orbicularis oculi.
Distinguish from fibrillation', which is excessive activity of a single motor unit and is only
detectable with electromyography.
 32

Tone

Ensure that the patient is relaxed and assess tone by alternately flexing and extending the elbow
or wrist. Note decrease in tone.

Increase in tone the following phenomena are observed:

1. 'Clasp-knife': The initial resistance to the movement is suddenly overcome (upper

motor neuron lesion).
2. ‘Lead-pipe': A steady increase in the resistance throughout the movement
(extrapyramidal lesion).
3. 'Cogwheel': Ratchet-like increase in resistance (extrapyramidal lesion).

Power

If a pyramidal weakness is suspect (1.e. a weakness arising from damage to the motor cortex
or motor descending tracts), the following test is simple, quick, yet sensitive.

• Ask the patient to hold arms outstretched with the hands supinated for upto 1minute.
The eyes are closed (otherwise visual compensation occurs).
• The weak arm gradually pronates and drifts downwards.
• With possible involvement at the spinal root or nerve level (lower motor neuron), it is
essential to test individual muscle groups to help localize the lesion.
• When testing the muscle groups, think of root supply and nerve supply.
 33

Sl no Muscle group Diagrammatic presentation

testing

1. Test for C5, C6, C7 roots

serratus long thoracic nerve
anterior Patient presses arms against wall. Look for winging of scapula

2. Shoulder Deltoid: X5. C6 roots: axillary nerve

abduction Arm (at more than 15° from the vertical)
abducts against resistance
 34

3. Elbow flexion Biceps: C5, C6 roots: musculocutaneous nerve

Arm flexed against resistance with the hand fully supinated

4. Elbow Triceps: C6, C7 roots; radial nerve

extension Patient extends arm against resistance
 35

5. Brachioradialis Brachioradialis: C5, C6 roots; radial nerve

Arm flexed against resistance with hand in mid-position between
pronation and supination

EXAMINATION OF SENSATION

Pain

• Pinprick with a sterile pin provides a simple method of testing this important modality.
Firstly, check that the patient detects the pin as 'sharp', 1.e. painful and then rapidly test
each dermatome in turn.
• Memorizing the dermatome distribution is simplified by noting that 'C7 extends down
the middle finger.
• If pinprick is impaired, then more carefully map out the extent of the abnormality,
moving from the abnormal to the normal area.

Light Touch

Light touch is tested in a similar manner, using tor unit and is a wisp of cotton wool.
 36

Temperature

Temperature testing seldom provides any additional information. If required, use cold object
or hot and cold test tubes.

Joint position sense

• Hold the sides of the patient's finger or thumb and demonstrate 'up and down'
movements. Repeat with the patient's eyes closed. Ask patient to specify the direction
of movement.
• Ask the patient, with eyes closed, to touch the nose with the forefinger or to bring
forefingers together with the arms outstretched.

Limb Weakness

• Detect by comparing the response of the limbs to painful stimuli.

• If pain produces an asymmetric response, then limb weakness is present.
• If the patient 'localizes' with one arm, hold this down and retest to ensure that a similar
response cannot be elicited from the other limb.
• Pain stimulus applied to the toenails or Achilles tendon similarly tests power in the
lower limbs.
• Variation in tone, reflexes or plantar responses between each side also indicates a focal
deficit.
• In practice if the examiner fails to detect a difference in response to painful stimuli,
these additional features seldom provide convincing evidence.

Vibration

• Place a vibrating tuning fork [usually 128 cycles/second (c/s)] on a bony prominence,
e.g. radius.
• Ask the patient to indicate when the vibration, if felt, ceases.
• If impaired, move more proximally and repeat.
• Vibration testing is of value in the early detection of demyelinating disease and
peripheral neuropathy, but otherwise is of limited benefit.
 37

Other Tests for Cortical Lesions

If the above sensory functions are normal and a cortical lesion is suspected, it is useful to test
for the following:

Two-point Discrimination

• The ability to discriminate two blunt points when simultaneously applied to the finger,
5 mm apart.
• Patient should be able to distinguish points 2-10 mm apart on finger and hands. This
can be up to 75 mm on thigh and back. Compare patient's two sides.

Sensory Inattention (Perceptual Rivalry)

The ability to detect stimuli (pinprick/touch) in both limbs, when applied to both limbs
simultaneously.

Stereognosis

• The ability to recognize objects placed in the hand. With eyes closed, patient identities
pen, paper clip or coin placed in hand.
• This tests the parietal sensory cortex and posterior columns.

Graphesthesia

• The ability to recognize numbers or letters traced out on the palm.

• With eyes closed, patient identifies numbers written on palm.
• This tests the sensory cortex and integration.

EXAMINATION OF UPPER LIMB REFLEXES

• The reflex is a predictable response that results from a nerve input over a reflex arc.
• Tendons attached to skeletal muscles have receptors that are sensitive to stretch.
• A reflex contraction of the skeletal muscles occurs when the tendon is stretched.
• A simple muscle stretch reflex is initiated by briskly tapping the tendons of a stretched
muscle, usually with reflex hammer.
• Assessment of reflexes requires an experienced examiner, a reflex hammer and a
relaxed patient.
 38

• The reflex is elicited by striking the hammer on to the muscle insertion tendon.
Comparison of right and left sides should reveal equal responses.

Clonus, an abnormal response, is a continued rhythmic contraction of the muscle alter the
stimulus has been applied. In general, the biceps, triceps, brachioradialis, and patellar and
Achilles tendon reflexes are tested.

Sl. Reflex Procedure

No
1. Biceps jerk: Ensure patient's arm is relaxed and slightly flexed. Palpate the
C5, C6 roots biceps tendon with the thumb and strike with tendon hammer.
Musculocutaneous Look for elbow flexion and biceps contraction.
nerve Biceps reflex refers to tapping of biceps tendon in elbow
produces contraction of brachialis and biceps muscle, producing
flexion at elbow. Absence of reflex may indicate damage at the
C5 or C6 vertebral level.

2. Supinatory jerk: Strike the lower end of the radius with the hammer and watch
C6, C7 roots; for elbow and finger flexion.
radial nerve
 39

3. Triceps jerk: Strike the patient's elbow a few inches above the olecranon
C6, C7 roots; process. Look for elbow extension and triceps contraction.
radial nerve Triceps reflex refers to tapping of triceps tendon at elbow that
causes contraction of triceps muscle producing extension at
elbow. Absence of reflex may indicate damage at C6, C7 or C8
vertebral level.

4. Hoffman's reflex Flick the patient's terminal phalanx, suddenly stretching the
C7, C8 flexor tendon on release. Thumb flexion indicates hyperreflexia
(May be present in normal subjects with brisk tendon reflexes)

Coordination

Incoordination (ataxia) is often a prominent feature of cerebellar disease. Prior to testing,

ensure that power and proprioception are formal.
 40

Sl Coordination
No
1. Incoordination
Finger-nose testing:
• Ask patient to
touch the nose with
finger (eyes open):
look for jerky
movement-
dysmetria or
an intention tremor (tremor
only occurring on
voluntary movement)
• Ask patient to
alternately touch
his own nose, then
the examiner's
finger as fast as he
can; this
may exaggerate the
intention tremor and may
demonstrate
dysdiadochokinesia, an
inability to
perform rapidly alternating
movements
 41

2. This may also be shown by

asking the patient to
rapidly supinate and
pronate the forearms or to
perform rapid and repeated
tapping movements

3. Rebound phenomenon Ask the patient to flex elbow against resistance;

sudden release may cause the hand to strike the face due
to delay in triceps contraction.

SENSATION

Test pinprick and light touch in dermatome distribution as for the upper limb. Levels to
remember:

T5: At nipple

T10: At umbilicus

T12: At inguinal ligament.

 42

Abdominal Reflexes

• Stroke or lightly scratch the skin toward the umbilicus in each quadrant in turn.

Abdominal reflexes: 17-T12 roots.

• Look for abdominal muscle contraction and note if absent or impaired.

Note: Reflexes may be absent in obesity, after pregnancy or after abdominal operations.

Cremasteric Reflex

• Scratch inner thigh. Observe contraction of cremasteric muscle causing testicular

elevation.
• Cremasteric reflex: LI root.

Sphincters

1. Examine abdomen for distended bladder.

2. Note evidence of urinary or fecal incontinence.
3. Note the tone of anal sphincter during rectal examination.

Anal Reflex

• A scratch on the skin beside the anus causes a reflex contraction of the anal sphincter.
• Anal reflex: S4, S5 roots.

Test

• Pain
• Light touch
• Temperature.

Joint position sense:

• Firstly, demonstrate flexion and extension movements of the big toe.

• Then ask patient to specify the direction with the eyes closed.
• If deficient, test ankle joint sense in the same way.
 43

Vibration:

• Test vibration perception by placing at tuning fork on the malleolus; if deficient, move
up to the head of the fibula or to the anterior superior iliac spine.

EXAMINATION OF LOWER LIMB MOTOR SYSTEM

Appearance

Note the following features:

1. Asymmetry or deformity.
2. Muscle wasting
3. Muscle hypertrophy.
4. Muscle fasciculation.

Testing tone

• Try to relax the patient, and alternately flex and extend the knee joint.
• Note the resistance. Roll the patient’s legs from side to side.

Clonus

• Ensure that the patient is relaxed.

• Apply sudden and sustained flexion on the ankle.
• A few oscillatory beats may occur in the normal subject, but where this persists it
indicates increased tone.

Power

When testing each muscle group, think of root and nerve supply.
 44

Sl No Lower limb Diagrammatic representation

Movements

1. Hip flexion Iliopsoas L1, L2, L3

Roots femoral nerve

Hip flexed against resistance.
2. Hip extension Gluteus maximus: L5, S1, S2 roots:
inferior gluteal nerve Patient attempts to keep heel on bed against
resistance
 45

3. Hip Gluteus Medius and minimus, and tensor fasciae latae: L4, L5,
abduction S1 roots;
Superior gluteal nerve
Patient lying on back tries to abduct the leg against resistance

4. Hip Adductors:
adduction L2, L3, L4 roots;
obturator nerve
Patient lying on back tries to pull knees together against resistance
 46

5. Knee flexion Hamstrings: L5, S1, S2 roots, sciatic nerve

Patient pulls heel toward the buttock and tries to maintain the
position against resistance.

6. Knee Patient tries to extend knee against resistance

extension Quadriceps: L1, L2, L3roots; femoral nerve.
 47

7. Dorsiflexion Tibialis anterior

L4, L5 roots;
deep peroneal nerve.
Patient dorsiflexes the ankle against resistance may have difficulty
in walking on heels.

8. Plantar Gastrocnemius, soleus: S1, $2 roots; tibial nerve

flexion Patient plantar flexes the ankle against resistance, may have
difficulty in walking on toes before weakness and can be directly
detected
 48

9. Toe extension Extensor hallucis longus, extensor digitorum longus: L5, S1 roots,
deep peroneal nerve
Patient dorsiflexes the toes against resistance

10. Inversion Tibialis posterior L4, L5 roots; tibial nerve

Patient inverts foot against resistance

11. Eversion Peroneus longus and brevis: L5, S1 roots

superficial peroneal nerve
Patient everts foot against resistance

Test for the following:

• Pain
• Light touch.
• Temperature.
 49

ASSESSING DEEP TENDON AND PLANTAR REFLEXES

Knee Jerk (Patellar Tendon)

• Ensure that the patient's leg is relaxed by resting it over examiner's arm or by hanging
it over the edge of the bed.
• Tap the patellar tendon with the hammer and observe quadriceps contraction.
• Note impairment or exaggeration.
• With the patient supine on the bed flex the knee, place hand under the calf just below
the knee and strike the patellar tendon just below the kneecap; the leg should jerk to
extend at the knee.
• Knee jerk: L2, L3, L4 roots.

Ankle Jerk (Achilles Tendon)

• Externally rotate the patient's leg. Hold the foot in slight dorsiflexion. Ensure the foot
is relaxed by palpating the tendon of tibialis anterior. If this is taut, then no ankle jerk
will be elicited.
• Tap the Achilles tendon and watch for calf muscle contraction and plantar flexion.
• With the patient supine on bed, bend one knee to cross the leg to be tested over the shin
of the sound limb. Stretch the foot in slight dorsiflexion, lightly strike the heel cord of
the leg to be tested, just above the heel; the foot jerk toward plantar flexion.
• Ankle jerk: S1, S2 roots.

Biceps Jerk

• The patient's arm should be flexed slightly with the palm facing up. Hold the arm with
thumb in the antecubital space ham over the biceps tendon. Strike thumb with hammer;
the arm should flex slightly.

Triceps Jerk

• The patient's arm should be flexed 90⁰.

• Support the arm and strike it just above the elbow, between the epicondyles, on the
triceps tendon; the arm should extend at the elbow.
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Plantar Response

• Check that the big toe is relaxed.

• Stroke the lateral aspect of the sole and across the ball of the foot.
• Note the first movement of the big toe. Flexion should occur.
• Extension due to contraction of extensor hallucis longus (a Babinski' reflex) indicates
an upper motor neuron lesion.
• This is usually accompanied by synchronous contraction of the knee flexors and tensor
fasciae latae.
• To avoid ambiguity, do not touch the innermost aspect of the sole or the toes
themselves.
• Patient supine on bed, stimulate the outer border of the sole with a pointed object, like
a key, drawing it with firm pressure from heel toward the little toe.
• Normal response will be indicated by curling of the toes; plantar flexor response.

EXAMINATION OF COORDINATION

• Ask patient to repeatedly run the heel from the opposite knee down the shin to the big
toe .
• Look for ataxia (incoordination). Ask patient to repeatedly tap the floor with the foot
• Note any dysdiadochokinesia (difficulty with rapidly alternating movement).

EXAMINATION OF POSTURE AND GAIT

Romberg's Test

• Ask patient to stand with the heels together, first with the eyes open, then with the eyes
closed.
• Note any excessive postural swaying.

Gait

Length of step and width of base:

1. Abnormal leg movements (e.g., excessively high step).

2. Instability (gait ataxia).
3. Associated postural movements (e.g., pelvic swinging)
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CONCLUSION

A neurological exam is used to help find out if you have a disorder of the nervous system. Early
diagnosis can help you get the right treatment and may decrease long-term complications.
Although a full neurological examination with its specific maneuvers and domains is within
the comfort zone of neurologists, it is an essential tool in the arsenal of primary care physicians.
Localizing a disease to the neuroaxis will assist them in the appropriate management and
referral to appropriate specialties. Also, basic neurologic assessment should be a point of
emphasis for other health care professionals, especially in areas with a high likelihood of seeing
neurologic cases such as in emergency rooms, intensive care units, and post-operative
monitoring.

RESEARCH REFERENCE

• Bae KS, Roh YS. Training needs analysis of Korean nurses' neurological assessment
competency. Nurs Health Sci. 2020 Mar;22(1):99-107. doi: 10.1111/nhs.12654. Epub
2019 Oct 14. PMID: 31609541.
Despite the importance of neurological assessment, there is a lack of research directed
at nurses' competency in performing these assessments. We aimed to identify nurses'
competency levels in performing neurological assessments and prioritize their related
training needs using importance-performance analysis. This survey research was
conducted and reported based on the enhancing the quality and transparency of health
research (EQUATOR) guidelines. A total of 213 nurses participated in a descriptive,
cross-sectional survey study. Exploratory factor analysis identified seven factors that
together accounted for 70.34% of the variance: cerebral function, signs and symptoms,
pathologic reflexes, motor strength, assessment of an unconscious patient, reporting
and documentation, and neurological assessment scales. [Correction added on 10
February 2020, after first online publication: the value of the variance has been
corrected from '7.34%' to '70.34%' in the preceding sentence.] There were significant
gaps between importance and performance for all seven factors. The importance-
performance matrix identified the neurological assessment scales factor as a high
priority for continuing education. Emergency department nurses reported lower
neurological assessment competency when compared with ward and intensive care unit
nurses. The analysis of training needs is beneficial for developing programs to enhance
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neurological assessment competency. Training in neurological assessment scales is a

priority for nurses, and they prefer simulation- and practicum-based methods.

• Gocan S, Fisher A. Neurological assessment by nurses using the National Institutes of

Health Stroke Scale: implementation of best practice guidelines. Can J Neurosci Nurs.
2008;30(3):31-42. PMID: 18856096.
Assessment is an essential nursing skill that gathers clinical information to strengthen
decisions about health interventions and priorities inpatient care delivery. Neurological
assessment of the acute stroke survivor provides the cornerstone for early diagnosis,
appropriate prognostic evaluation, and optimal management to obtain favourable
patient outcomes. The nursing approach to neurological assessment has been enhanced
in recent years through the development of new evidence-based assessment tools and
the support of best practice guidelines. Based on gaps seen in clinical practice and
current best practice guideline recommendations, neurological nurses from The Ottawa
Hospital (TOH) identified the need to assess acute stroke survivors using a standardized
neurological assessment tool. In 2004, a Registered Nurses of Ontario (RNAO) nursing
advanced clinical practice fellowship provided the opportunity for the development of
expertise in stroke assessment and establishment of recommendations for neurological
nursing assessment at TOH. As a result, standards for nursing neurological assessment
have been adopted at TOH using the National Institutes of Health Stroke Scale
(NIHSS). This paper will review current evidence and best practice guidelines for
neurological assessment. The significances of using the NIHSS for nurses in the context
of the provision of acute stroke care will be presented. Knowledge transfer, application
and evaluation of best practice guidelines (BPGs) in clinical nursing practice will also
be discussed.

REFERENCE

• I Clement textbook on neurological and neurosurgical nursing,1st edition

2015, Jaypee brothers’ medical publishers New Delhi, page:272-305
• Lewi’s Medical-Surgical Nursing assessment and management of clinical
problems, 3rd edition 2018, Elsevier RELX India Pvt. Ltd
Haryana,Page:1260-67