NEUROLOGIC SYSTEM

ASSESSING THE CRANIAL

NERVES
CN I—Olfactory Nerve
• Before testing nerve
function, ensure patency Testing the olfactory
of each nostril by nerve
occluding in turn and
asking patient to sniff.
• Once patency is
established, ask patient
to close eyes.
• Occlude one nostril and
hold aromatic substance
such as coffee beneath
nose.
• Ask patient to identify
substance.
• Repeat with other nostril.
• Patient is able to identify
CNs II, III, IV, and VI—Optic, Oculomotor,
Trochlear, and Abducens Nerves
Testing visual acuity

• Test visual acuity,

peripheral vision,
eye movements,
and pupil
accommodation
CNs II, III, IV, and VI—Optic, Oculomotor,
Trochlear, and Abducens Nerves
Testing pupil
Testing eye movements accommodation
CNs II, III, IV, and VI—Optic, Oculomotor,
Trochlear, and Abducens Nerves

• Test oculocephalic
reflex (“doll’s
eyes”) in
unresponsive
patient. Rotate
head quickly from
side to side.
Testing oculocephalic
reflex
CNs II, III, IV, and VI—Optic, Oculomotor,
Trochlear, and Abducens Nerves

• Visual acuity intact 20/20, both eyes;

PERRLA direct and consensual; EOM
intact.
• Hippus phenomenon: Brisk
constriction of pupils in reaction to
light, followed by dilation and
constriction; may be normal or sign of
early CN III compression.
• Normal doll’s eyes: Eyes deviate to
CN V—Trigeminal Nerve
Testing CN V motor
function
• Testing motor
function: Ask
patient to move
jaw from side to
side against
resistance and
then clench jaw as
you palpate
contraction of
temporal and
CN V—Trigeminal Nerve
Testing CN V sensory
function
• Testing sensory
function: Ask
patient to close
eyes and tell you
when he or she
feels sensation on
the face. Touch jaw,
cheeks, and
forehead with
CN V—Trigeminal Nerve

Testing corneal reflex

• Testing corneal
reflex: Gently
touch cornea with
cotton wisp.
CN V—Trigeminal Nerve

• Full range of motion (ROM) in jaw and 15

strength.
• Patient perceives light touch and
superficial pain bilaterally.
CN VII—Facial Nerve
Testing CN VII motor
function
• Testing motor
function: Ask
patient to perform
these movements:
smile, frown, raise
eyebrows, show
upper teeth, show
lower teeth, puff
out cheeks, purse
lips, close eyes
CN VII—Facial Nerve

Testing taste sensation

• Testing sensory
function: Test
taste on anterior
two-thirds of
tongue for sweet,
sour, salty.
CN VII—Facial Nerve

• Facial nerve intact; able to make faces.

Taste sensation on anterior tongue intact.
• Taste decreased in older adults.
CN VIII—Acoustic Nerve

Watch-tick test
• Perform Weber
and Rinne tests
for hearing.
• Perform
watch-tick test by
holding watch
close to patient’s
ear.
CN VIII—Acoustic Nerve

Cold caloric test

• Perform Romberg
test for balance.
• If patient is
unresponsive,
perform cold
caloric test for
oculovestibular
reflex (tests CNs
III, VI, and
CNs IX and X—Glossopharyngeal and
Vagus Nerves
Testing CN IX and X
motor function
• Observe ability to
cough, swallow,
and talk.
• Test motor function:
Ask patient to open
mouth and say “ah”
while you depress
the tongue with a
tongue blade.
CNs IX and X—Glossopharyngeal and
Vagus Nerves

• Test sensory • Swallow and cough

function of CN IX reflex intact.
and motor function
of CN X by Speech clear.
stimulating gag • Elevation and
reflex. constriction of
• Tell patient that you pharyngeal
are going to touch
interior throat, then musculature and
lightly touch tip of tongue retraction
tongue blade to indicate positive
CN XI—Accessory Nerve
Testing CN XI motor
function
• Test motor function
of shoulder and
neck muscles: Ask
patient to shrug
shoulders upward
against your
resistance.
• Then ask her or him
to turn head from
side to side against
CN XI—Accessory Nerve

• Movement symmetrical, with patient

moving against resistance without pain.
• Full ROM of neck with +5/5 strength.
 CN XII—Hypoglossal Nerve
Testing CN XII motor
function
• Have patient say “d, l,
n, t” or a phrase
containing these
letters. The ability to
say these letters
requires use of the
tongue.
• Ask the patient to
Canprotrude
protrude tongue
the tongue.
medially. No atrophy,
• Observe
tumors, any
or lesions.
deviation from
ASSESSING SENSORY FUNCTION
Light Touch
Testing superficial light
touch
• Brush a light
stimulus such as a
cotton wisp over
patient’s skin in
several locations,
including torso
and extremities.
Pain
• Stimulate skin lightly with sharp and dull
ends of toothpick.
• Apply stimuli randomly and ask patient to
identify whether sensation is sharp or dull.

• Identifies areas stimulated and type of

stimulation.

Assessing pain in the Assessing pain in the

upper extremity lower extremity
• Touch patient’s skin with test tubes filled with hot
or cold water.
• Apply stimuli randomly, and ask patient to identify
whether sensation is hot or cold.

• Identifies areas stimulated and type of stimulation.

Testing temperature in the Testing temperature in the lower

upper extremity extremity
 Vibration
• Place a vibrating tuning fork over a finger joint, and then over a toe
joint.
• Ask patient to tell you when vibration is felt and when it stops.
• If patient is unable to detect vibration, test proximal areas as well.
• Vibratory sensation intact bilaterally in upper and lower extremities.

Vibrating the upper Vibrating the lower

extremity extremity
 Kinesthetics (Position Sense)
• Determine patient’s ability to perceive passive movement of
extremities. Hold fingers on sides and move up and down, and have
patient identify
Testing direction
position senseof movement.
in Testing position sense in
• the
Flexfinger
and extend patient’s big toe, and
the ask
toepatient to describe
movement as up or down.
• Position sensation intact bilaterally in upper and lower extremities.
Stereognosis
The faculty of recognising the solidity of objects, and thus their nature, by handling
them.

• With patient’s eyes

closed, place a Testing stereognosis
familiar object,
such as a coin or a
button, in patient’s
hand, and ask
patient to identify it.
• Test both hands
using different
objects.
• Stereognosis intact
Graphesthesia

Testing graphesthesia
• With patient’s
eyes closed, use
point of a
closedpen to trace
a number on
patient’s hand,
and ask patient to
identify the
number.
 Two-Point Discrimination
• Ability to differentiate between two
points of simultaneous stimulation.
• Using ends of two toothpicks,
Testing two-point
stimulate two points on fingertips discrimination
simultaneously.
• Gradually move toothpicks
together, and assess smallest
distance at which patient can still
discriminate two points (minimal
perceptible distance).
• Document distance and location.
• Discriminates between two points
on fingertips no more than 0.5 cm
apart and on hands no more than
2 cm apart.
Point Localization

Testing point localization

• Ability to sense and
locate area being
stimulated.
• With patient’s eyes
closed, touch an
area; then have
patient point to
where he or she
was touched.
• Test both sides and
Sensory Extinction

Testing extinction
• Simultaneously
touch both sides
of patient’s body
at same point.
• Ask patient to
point to where she
or he was
touched.
ASSESSING REFLEXES
Deep Tendon Reflexes

• DTRs are graded as follows:

– 0: No response detected.
– 1: Response present but diminished
(hypoactive).
– 2: Response normal.
– 3: Response somewhat stronger than normal.
– 4: Response hyperactive with clonus.
Deep Tendon Reflexes

• Grades 1 and 3 are usually considered

normal.
• Even grade 0 may occur symmetrically in
some patients in the absence of any
underlying neurologic disorder.
• Grade 4 usually indicates pathology.
• Sustained clonus confirms CNS
involvement
Deep Tendon Reflexes

Testing biceps reflex

• Biceps Reflex
• Rest patient’s
elbow in your
nondominant
hand, with your
thumb over biceps
tendon.
• Strike your
thumbnail.
Deep Tendon Reflexes

Testing triceps reflex

• Triceps Reflex
• Abduct patient’s
arm and flex it at
the elbow.
• Support the arm
with your
nondominant hand.
• Strike triceps
tendon about 1 to 2
inches above
olecranon process,
Deep Tendon Reflexes

Testing patellar reflex

• Patellar Reflex
• Have patient sit
with legs dangling.
• Strike tendon
directly below
patella.

• Contraction of
quadriceps with
Deep Tendon Reflexes

Testing Achilles reflex

• Achilles Reflex
• Have patient lie
supine or sit with
one knee flexed.
• Holding patient’s
foot slightly
dorsiflexed, strike
Achilles tendon.
Deep Tendon Reflexes

• Test for Ankle

Clonus
• If you get 4
reflexes while
supporting leg and
foot, quickly
dorsiflex
Testing for foot.
clonus
Superficial Reflexes

Testing abdominal reflex

• Abdominal
Reflex
• Stroke patient’s
abdomen
diagonally from
upper and lower
quadrants toward
umbilicus.
Superficial Reflexes

• Anal Reflex • Cremasteric

• Gently stroke skin Reflex
around anus with • Gently stroke
gloved finger. inner aspect of a
male’s thigh.
• Anus puckers.
• Testes rise.
Superficial Reflexes

Testing plantar reflex

• Plantar Reflex
• Stroke sole of
patient’s foot in an
arc from lateral
heel to medial
ball.

• Flexion of all toes.

Meningeal Signs
• Kernig’s sign
• Have the patient lie Kernig’s sign.
supine with one leg
flexed.
• Tell him or her to try
to extend the leg
while you apply
pressure to the
knee.
• Contraction and
pain of the
hamstring muscles
Meningeal Signs

• Brudzinki’s sign Brudzinski’s sign.

• Have the patient lie
supine with her or
his head flexed to
her or his chest
• Flexion of the
hips is a positive
sign of
meningitis.
Assessing Cerebral Function

• Behavior
• Watch patient’s facial expression as she or
he responds to questions.
• Note his or her posture, grooming, and
affect.

• Well-groomed, erect posture, pleasant

facial expression, appropriate affect.
Assessing Cerebral Function

• Level of Consciousness
• Test orientation to time, place, and person.

• Awake, alert, and oriented to time, place,

and person
Assessing Cerebral Function
• Mental Status and Cognitive Function
• Memory
• Test immediate recall: Ask patient to repeat three
numbers, such as “4, 9, 1.” If patient can do so,
ask her or him to repeat a series of five digits.
• Test recent memory: Ask what patient had for
breakfast.
• Test long-term memory: Ask patient to state his or
her birthplace, recite his or her Social Security
number, or identify a culturally specific person or
event, such as the name of the previous president
of the United States or the location of a natural
disaster.
Assessing Cerebral Function

• Mathematical and Calculative Ability

• Ask patient to perform a simple
calculation, such as adding 4 4. If
successful, proceed to more difficult
calculation, such as 11 9.

• Mathematical/calculative ability intact and

appropriate for patient’s age, educational
level, and language facility.
Assessing Cerebral Function

• General Knowledge and Vocabulary

• Ask how many days in a week and months
in a year.
Assessing Cerebral Function

• Thought Process
• Ask patient to define familiar words such
as “apple,” “earthquake,” and “chastise.”
Begin with easy words and proceed to
more difficult ones.
• Remember to consider the patient’s age,
educational level, and cultural background.

• Thought process intact.

Assessing Cerebral Function

• Abstract Thinking
• Ask patient to interpret a culturally
appropriate proverb.

• Able to generalize from specific example

and apply statement to human behavior.
Children should be able to distinguish like
from unlike as appropriate for their age
and language facility.
Assessing Cerebral Function

• Judgment
• Observe patient’s response to current
situation.
• Ask patient to respond to a situation or
hypothetical situation.

• Judgment appropriate and intact.

Assessing Cerebral Function

• Communication
• Speech and Language
• Listen to patient’s rate and ease of
speech, including enunciation.

• Speech flows easily; patient enunciates

clearly.
• Sophistication of speech matches age,
education, and fluency.
Assessing Cerebral Function

• Spontaneous Speech
• Show patient a picture and have him or
her describe what he or she sees.

• Spontaneous speech intact.

Assessing Cerebral Function

• Motor Speech
• Have patient repeat, “do, ray, me, fa, so,
la, ti, do.”

• Motor speech intact.

Assessing Cerebral Function

• Automatic Speech
• Have patient say something that is
committed to memory, such as days of
week or months of year.

• Automatic speech intact.

Assessing Cerebral Function

• Sound Recognition
• Have patient close eyes and identify
familiar sound such as clapping hands.

• Sound recognition intact.

Assessing Cerebral Function

• Auditory-Verbal Comprehension
• Ask patient to follow simple directions or
explain meaning of a series of words.

• Auditory-verbal comprehension intact.

Assessing Cerebral Function

• Visual Recognition
• Have patient identify familiar object by
sight (e.g., cup, pencil, pen).

• Visual recognition intact.

Assessing Cerebral Function

• Visual-Verbal Comprehension
• Have patient read sentence from
newspaper and explain meaning.

• Visual-verbal comprehension intact.

Assessing Cerebral Function

• Writing
• Have patient write name, address, simple
sentence, one word with eyes open and
then closed, name of an object.

• Writing ability intact.

Assessing Cerebral Function

• Copying Figures
• Show patient several figures and ask her
or him to copy them, increasing in
complexity. (e.g., circle, X, square,
triangle, star).

• Able to copy figures.

Glasgow Coma Scale

• The Glasgow Coma Scale (GCS) provides

a more objective way to assess the
patient’s LOC.
• It evaluates:
– best eye response
– best motor response
– best verbal response.
Glasgow Coma Scale

• Fifteen (highest score) indicates that the

patient is awake, alert, oriented, and able
to follow simple commands.
• Three (lowest score) indicates that the
patient does not respond to any stimulus
and has no motor or eye response,
reflecting a very serious neurologic state
with poor prognosis.
Glasgow Coma Scale
Glasgow Coma Scale
Glasgow Coma Scale
Glasgow Coma Scale

• “Identifies localized pain” denotes that

the patient is not fully conscious but is
aware enough to respond to an annoying
stimulus.
• “Flexes and withdraws” is a lower-level
motor response and indicates that the
patient pulls away from painful stimuli.
Glasgow Coma Scale
• In flexion (decorticate) posturing, the
arms are flexed to the chest and the
hands are clenched and internally
rotated as a result of a lesion at or
above the brainstem in the cerebral
cortex.
Glasgow Coma Scale
• In extension (decerebrate) posturing,
the arms are extended and the hands
are clenched and hyperpronated as a
result of a midbrain (brainstem) lesion.
Pupils

• Pupillary size, equality, and light reactions

help in assessing the cause of coma and in
determining the region of the brain that is
impaired.
• Observe the size and equality of the pupils
and test their reaction to light.
• The presence or absence of the light reaction
is one of the most important signs
distinguishing structural from metabolic
causes of coma.
• The light reaction often remains intact in
Pupils

Small or Pinpoint Pupils Midposition Fixed Pupils

Pupils

Large Pupils One Large Pupil