Neurologic Assessment

Jeselo O. Gorme, RN, MN

Assessment – Basic Conepts in
Neurologic Functioning
 Normal functioning of the NS
requires the following:
1. Oxygen Supply
• The brain requires 20% of the O2 in the body.
2. Glucose Supply
• The brain requires 65-70% of the glucose in the body.
3. Blood Supply
• The brain requires 1/3 of the cardiac output.
4. Acid-Base Balance
• Acidosis causes cerebral vasodilation and increases ICP. It is also CNS
depressant and may lead to coma.
• Alkalosis causes cerebral vasoconstriction and increases ICP. It is also
called a CNS stimulant and may lead to seizure.
5. Blood Brain Barrier
• Intact BBB protects the brain from certain drugs, chemicals, and
microorganisms.
6. CSF Volume
• CSF cushions and nourishes the brain and determine the ICP.
Neurologic Assessment:
OVERVIEW
MENTAL STATUS AND
LEVEL OF
CONSCIOUSNESS
For mental status,
observe the following
 Orientation
 People, time & place
 Memory
 Short term, recent and remote
memory
Level of Consciousness
 single most sensitive indicator of changes in
the neurologic status of the client
 LOC:
 Level I – conscious, coherent, cognitive
(3Cs)
 Level II – confused, drowsy, lethargic,
somnolent, obtunded
 Level III – stuporous, responds only to
noxious, strong or intense stimuli (ex.
sternal pressure, trapezius pinch,
pressure at the base of the nail or
supraorbital area; very strong or very
light sound.
Level of Consciousness
 LOC:
 Level IV
 Light Coma – response is only grimace
or withdrawing limb from pain, primitive
and disorganized response to painful
stimuli.
 Deep Coma – absence of response to
even the most painful of stimuli.

 GCS – an objective measure to describe

LOC
• Decorticate posture is
an abnormal posturing that
involves
• rigidity, flexion of the arms,
• clenched fists,
• extended legs (held out
straight).
• arms are bent inward toward
the body
• wrists and fingers bent and
held on the chest.
• Decerebrate posture is an
abnormal body posture that
involves
• arms and legs being held
straight out,
• toes being pointed
downward,
• head and neck being arched
backwards.
• muscles are tightened and
held rigidly.
6/26/2011 http://loyaldavis.com/images/dec_1.jpg 13
Maria Carmela L. Domocmat, RN, MSN
 For children under 5, the verbal response
criteria are adjusted as follow
SCORE 2 to 5 YRS 0 TO 23 Mos.

5 Appropriate words or phrases Smiles or coos appropriately

4 Inappropriate words Cries and consolable

Persistent inappropriate crying

3 Persistent cries and/or screams
&/or screaming

2 Grunts Grunts or is agitated or restless

1 No response No response
Interpretation
 1-3 Deep Coma
 4-6 Light Coma
 7-9 Stuporous
 10-12 Confused
 13-15 3Cs
SENSORY SYSTEM
 tests for sensory function assesses the
functioning of the parietal lobe
 tests are done with the client’s eyes closed
 ex. placing cold and warm fluid in test tubes
over the skin, pricking the skin; coffee to smell;
giving cinnamon to taste.)
 Light Touch, Pain, and Temperature Sensations
 Vibratory sensations
 Proprioception (sensitivity to position)
 Tactile discrimination (fine touch)
Light Touch, Pain, and Temperature
Sensations
scatter stimuli – distal and proximal parts of all
extremities and trunk to cover most of dermatomes
Dermatomes
• Stereognosis – ability to perceive
stimuli
o abnormal finding
 anesthesia – absence of touch sensation
 hypesthesia – decreased sensitivity to touch
 hyperesthesia –increased sensitivity to touch
 analgesia – absence of pain sensation
 hypalgesia – decreased sensitivity to pain
 hyperalgesia – increased sensitivity to pain
 agnosia – inability to perceive stimuli
 Vibratory sensations
o tuning fork – bony surface fingers or big toe
o usually decreased by 70
 Proprioception (sensitivity to position)
o Note: if position sense is intact distally, then it is
intact proximally
normal finding
 some – sense position of great toe may be reduced
o abnormal finding
 inability to identify directions – posterior column dse,
peripheral neuropathy (e.g., diabetes, chronic alcohol
abuse)
MOTOR AND
CEREBELLAR SYSTEMS
Condition and movement of muscles
• If frontal lobe is affected, client experiences
inability to perform motor activities.
• Apraxia – inability to perform fine motor activities.
• Agraphia – inability to write.
 Balance, Gait
o walk normally
o tandem walk – heel-to-toe walk
o hop with one foot
o elderly – may be difficult to perform
 Balance, Gait
• Romberg Test – done to assess cerebellar
function (sense of equilibrium)
• ask client to stand with feet together, arms at the
side and eyes closed and as client to walk in a
straight imaginary line.
o normal finding:
 steady gait, opposite arms swing
 maintains balance with little difficulty
 elderly – may be very difficult
 (-) Romberg test - erect with minimal swaying
 hops without losing balance
o abnormal finding
 (+) Romberg test – swaying, moving feet apart to
prevent fall – dse of posterior columns, vestibular
dysfunction, cerebellar disorders
 Ataxia – uncoordinated movement, characterized
by wide-base stance and swaying manner of
walking
Condition and movement of muscles
o size and symmetry muscle grps
o strength and tone
o note unusual involuntary movement (i.e,
fasciculations, tics, tremors)
o normal finding
 muscles- fully developed
 symmetric size (bilateral sides may vary 1 cm from
each other)
 relaxed muscles contract voluntarily; show mild,
smooth resistance to passive movement
 equally strong against resistance, without flaccidity,
spasticity, rigidity
 no fasciculations, tics, tremors
 elderly –hand tremor or dyskinesia (repetitive
movements of lips, jaw, tongue)
o abnormal finding
 muscle atrophy – dses of lower motor neurons or
muscle disorders
 soft, limp, flaccid muscles
 fasciculations - muscle twitching
 tics – twitch of face, head or shoulders – stress,
neurologic disorder
 tremors – rhythmic, oscillating movements –
Parkinson’s dse, cerebellar dse, multiple sclerosis (with
movement), hyperthyroidism, anxiety
 paresis – weakness; plegia – paralysis
 Akinesia – absence of muscle movement not associated
with weakness
 Bradykinesia – slowed muscle movement not associated
with aging
o abnormal finding
 unusual bizarre face, tongue, jaw, lip
movements – chronic psychosis, long term
use of psychotropic drugs
 slow, twisting movements in extremities and
face – cerebral palsy
 brief, rapid, irregular, jerky movements (at
rest) - Huntington’s chorea
 Coordination
Point-to-point
Rapid Alternating Movements (RAM)
o Point-to-point
 finger-to-nose test
 Finger- nose- to-finger
 heel-knee-toe test
 Note: dominant side may be more coordinated than
nondominant side
 Rapid Alternating Movements
(RAM)
 Thumb to Fingers
 Hands on Lap
 Rapid Alternating Movements
(RAM)
 normal finding:
 elderly – may be difficult – bcoz decreased reaction
time and flexibility
 abnormal finding:
 inability to perform – cerebellar dse, upper motor neuron
weakness, extrapyramidal dse
 Dysdiadochokinesia
impairment of the ability to make movements
exhibiting a rapid change of motion that is caused by
cerebellar dysfunction
REFLEXES
 Pupillary Reflexes
• Pupillary reflexes
1. Direct Light Reflex
2. Consensual Light reflex
3. Accommodation
• PERRLA
• A fixed and dilated pupil is a NEUROLOGIC
EMERGENCY
Corneal Reflexes
 Deep tendon reflexes
o biceps
o brachioradialis
o triceps
o patellar
 Biceps reflex
elicited by placing your thumb on the biceps
tendon and striking your thumb with the reflex
hammer and observing the arm movement.
Briceps reflex
 Brachioradialis reflex
striking the brachioradialis tendon directly
with the hammer when the patient's arm is
resting.
Note the reflex supination. Repeat and
compare to the other arm.
The biceps and brachioradialis reflexes are
mediated by the C5 and C6 nerve roots.
Brachioradialis reflex
 Triceps reflex
strike the triceps tendon directly with the
hammer while holding the patient's arm with
your other hand.
The triceps reflex is mediated by the C6 and C7
nerve roots, predominantly by C7.
Triceps reflex
 Patellar reflex
 With the lower leg hanging freely off the edge of the bench, the
knee jerk is tested by striking the quadriceps tendon directly
with the reflex hammer. Repeat and compare to the other
leg.The knee jerk reflex is mediated by the L3 and L4 nerve
roots, mainly L4.
 Patellar reflex

http://

6/26/2011 Maria Carme

 Ankle reflex
elicited by holding the relaxed foot with one
hand and striking the Achilles tendon with the
hammer and noting plantar flexion. Compare to
the other foot.The ankle jerk reflex is mediated
by the S1 nerve root.
Plantar or Achilles
 Rate the reflex with the following scale:

5+ Sustained clonus

4+ Very brisk, hyperreflexive, with clonus

3+ Brisker or more reflexive than normally.

2+ Normal

1+ Low normal, diminished

0.5+ A reflex that is only elicited with reinforcement

6/ 26/02011 No response 105

Maria Carmela L. Domocmat, RN, MSN
 Superficial reflexes
• Plantar reflex
• Abdominal reflex
• Cremasteric reflex
 Plantar reflex
The plantar reflex (Babinski) is tested by coarsely
running a key or the end of the reflex hammer up
the lateral aspect of the foot from heel to big toe.

 Normal finding : toe flexion.

 Abnormal finding:
 (+) Babinski's sign - toes extend and separate
indicative of an upper motor neuron lesion affecting
the lower extremity in question.
6/ 26/ 2011 109
Maria Carmela L. Domocmat, RN, MSN
Plantar reflex
Abdominal reflex

• results to contraction of the side of the abdomen stroked

with blunt object.
Cremasteric reflex

• Elicited by downward stroking of the inner thigh of the

male; elevation of the scrotum on the same side occurs
• done only in unconscious males
Reflexes to assess meningeal
irritation
• Kernig’s sign
• the client is placed in supine position. Flex the knee,
attempt to extend the left. Pain is experienced. (positive
result – abnormal)
Reflexes to assess meningeal
irritation
• Brudzinski’s sign
• the client is placed in supine position.
• passively flex the neck, spontaneous flexion of the hips
occurs. (positive result – abnormal)
 Oculocephalic Reflex (Doll’s Eye
Phenomenon)
 demonstrated by holding the person’s eyelids open and
rotating the head from side to side.
 Positive or normal doll’s eye is demonstrated by conjugate
movement of the eyes towards the opposite side.
 Dysconjugate movement of the eyes indicates brainstem function
impairment
Oculovestibular Reflex (Caloric Ice Water
Test)
 done by irrigating the semi-circular canals of the ear with
ice water. It normal causes nystagmus of the eyes.
 nystagmus – oscillations of the eyes, either horizontal,
vertical or mixed.
 accurate method to assess brainstem functioning.
Language and
Speech
• Broca’s Area (motor speech center)
• impairment results to expressive/motor apahasia – inability to
speak and make gestures
• Wernicke’s Area (auditory speech center)
• impairment results to receptive/auditory aphasia – inability to
understand sounds or language
• Global aphasia – inability to use and understand
language which results form impairment of both
areas
• Visual speech center (occipital lobe)
• impairment results to alexia – inability to read
Bowel and
Bladder Function
• SNS is the inhibitory impulse
• impairment leads to bowel and bladder retention

• PNS is the motor impulse

• impairment leads to bowel and bladder incontinence
CRANIAL NERVES
 CN I (olfactory)
o abnormal finding:
 inability to smell : neurogenic anosmia, olfactory
tract lesion, tumor or lesion of frontal lobe
 loss of smell: congenital, nasal dse, smoking, use
of cocaine
 CN II (optic)
o visual acuity – both far and near
o scotoma – characterized by a shimmering film in
the field of vision
o asses retina using ophthalmoscope
o OD – R eye; OS – L eye; OU - both eyes
Papilledema
III (oculomotor), IV (trochlear), VI
(abducens)
o (a) inspect margin of eyelids
o (b) extraocular muscles
o (c) pupillary response to light
 CN III, IV, VI
o abnormal finding:
 (a) ptosis (drooping of eyelids) – myasthenia
gravis
 (b) abnormal eye movements
 nystagmus (rhythmic oscillation of the eyes) -
cerebellar disorder
 limited eye movement – increased ICP
 paralytic strabismus – paralysis of oculomotor, trochlear
or abducens nerves
 CN III, IV, VI
 (c) dilated pupil (6-7 mm) – oculomotor
nerve paralysis
 Argyll Robertson pupils – CNS syphilis,
meningitis, brain tumor, alcoholism
 Anisucuria
Argyll Robertson pupils
 CN III, IV, VI
 constricted, fixed pupils – narcotics abuse, damage
to pons
 unilaterally dilated pupil unresponsive to light or
accommodation – damage to CN III
 constricted pupil unresponsive to light or
accommodation – lesions of the SNS (sympathetic
nervous sys)
 CN V (trigeminal)
omotor function
 temporal and masseter muscles contraction
 (Note: may be difficult to perform and evaluate
in client without teeth)
 CN V (trigeminal)
o sensory function :
 sharp or dull sensation and light touch on
forehead, chin and cheeks
 safety pin, paper clip, or cut tongue depressor; wisp
of cotton
 corneal reflex (blinking reflex)
 (Note: may be absent or reduced in clients who
wear contact lenses)
 CN V
o normal finding:
 temporal and masseter muscles contract bilaterally
 correctly identifies sharp or dull, light touch
 CN V
o abnormal finding:
 inability to identify – lesions in trigeminal nerve,
lesions in spinothalamic tract or posterior columns
 absent corneal reflex – lesions of CN V, lesions of
motor part of CN VII
 CN VII (facial)
o motor function
o sensory function
 CN VII (facial)
o motor function
 smile, frown, wrinkle forehead, show teeth, puff out
cheeks, purse lips, raise eyebrows, close eyes tightly
against resistance
 CN VII (facial)
o sensory function
 taste test – anterior 2/3 of tongue – salt, sugar, or
lemon juice
 CN VII
o abnormal finding:
 inability to close eyes, wrinkle forehead, or raise
forehead along with paralysis of lower part of face
on affected side – Bell’s palsy (peripheral injury to
CN VII)
 paralysis of lower part of face on opposite side
affected - central lesions that affects the upper
motor neurons ex: CVA
 Ageusia – loss of sense of taste
 Bell’s palsy

6/26/2011 50
CN VIII acoustic/vestibulocochlear)
o hearing: acoustic/ cochlear
 Whisper, Weber, Rinne tests

 balance: vestibular
 CN IX (glossopharyngeal),
CN X (Vagus)
 uvula and soft palate
 gag reflex
 ability to swallow
 CN IX & X
o abnormal finding:
 soft palate does not rise – bilateral lesion of CN X
 unilateral rising of soft palate, deviation of uvula to
normal side –unilateral lesion CN X
 dysphagia or hoarseness – lesion CN IX or X
 dysphonia – abnormality in the voice like
hoarseness
 dysarthria – poorly articulated speech
 CN XI (spinal accessory)
o trapezius muscle - shrug shoulders against
resistance
o sternocleidomuscle – turn head against
resistance
 CN XI
o abnormal finding:
 asymmetric, drooping of shoulders – paralysis or
muscle weakness due to neck injury or torticollis
 atrophy with fasciculations – peripheral nerve dse
 CN XII (hypoglossal)
o strength and mobility tongue
o protrude tongue, move to side against resistance,
put back in mouth
 CN XII
o normal finding: symmetric and smooth, bilateral
strength
o abnormal finding:
 atrophy with fasciculations – peripheral nerve dse
 deviation to affected side – unilateral lesion