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Neurological Assessment
Neurological Assessment
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Neurological Assessment: Medical- Volume 8, Number 3
© Red Flower Publication Pvt. Ltd
Surgical Nursing Perspective
Abstract
Neurological assessment includes a general physical examination pertaining to nervous system and a detailed
neurological examination. The purpose of neurological assessment in medical surgical nursing perspective is to
establish a nursing diagnosis to guide the nurse in planning and implementing nursing measures to help the patient
cope effectively with daily living activities, and monitor progression of the condition and gauge the patient’s
response to intervention. The frequency of neurological assessments depends on the patients’ admitting diagnosis,
the presence of any chronic neurological disorders and the current functioning of the patient’s neurologic functions.
However the information gathered in each assessment must be consistently communicated to all staff involved
in the patient care. The content of the neurological assessment will guide nursing teachers and students to proceed
the examination stepwise without any confusions and will assist in guiding the pathway to reach the goal.
Keywords: Neurological assessment; Nursing; Neurological conditions.
History
Subjective
data 1. Mental Status Assessment: the basic
Complete componets of mental status examination3are
Neurological
assessment
2. Cranial Nerve Examination: before • Ask the patient to cover his left eye with his
performing cranial nerve examination, collect all left hand and then cover your right eye with
articles required to test 12 cranial nerves. your right hand.
Proceed systematically from cranial nerve 1, 2 • Ask patient to indicate on which side the
so on, and chart the findings immediately after finger is moving.
each cranial nerve examination.
Fundoscopy: (Any abnormality detected)
• Dim the lights if possible.
Purpose of cranial nerve examination
• Have patient focus on distant wall.
• For determining symmetry in general.
• View optic disc using ophthalmoscope
• Asymmetrical findings indicate a pathological
process. • Note abnormality
• Articles needed for cranial nerve examination Cranial nerve (III, IV&VI) Oculomotor,
Trochlear and Abducent: eye movement and
• Coffee, lemon pupillary reflexes
8 Indian Journal of Surgical Nursing / Volume 8 Number 3 Suchana Roy Bhowmik
Cranial Nerve XII Hypoglossal: tongue position • Sensory testing of the extremities focuses on
and movement
the two main afferent pathways:
• Note tongue position at rest in the mouth a. Spinothalamics (detect pain, temperature
• Take out tongue and move it from side and crude touch)
to side. Observe strength and rapidity of b. Dorsal Columns (detect position,
movements.
vibratory sensation and light touch)
• Let the patient push tongue into each cheek
while you push from the outside. Note Spinothalamics
strength.
• Ask the patient to close his eyes so that he
Findings after cranial nerve assessment for is not able to get any visual clue regarding
normal patient and the pattern of writing the articles used to test his sensation.
result • Touch the patient’s upper limb and lower
• I can differentiate the smell of coffee/lemon limb by a needle prick or with cotton wisp
or brush and ask patient to differentiate
• II normal visual acuity is 20/20 bilaterally; between pain and light touch sensation.
visual fields full; optic discs sharp with
venous pulsations present bilaterally. • Touch one body part followed by the
corresponding body part on the other side
• III, IV, VI pupils are 4 mm dilated and
(e.g., the right upper arm with the left upper
reacting to light; extraocular movements
arm) with the same instrument. In this way
present; no ptosis found.
the patient the patient is able to compare
• V facial sensation equal to cotton sensation in the sensations and note any asymmetry if
all 3 divisions bilaterally. present.
• VII face symmetric in both sides with
normal eye closure and normal smile. Dorsal Columns
• VIII hearing normal to rubbing fingers or Proprioception: This refers to the body’s ability to
repeating words. know where it is in space or position check.
• IX, X palate elevates symmetrically;
phonation normal. Technique
• XII tongue midline with good movements • Tell the patient to close his eyes so that he is
and strength. not able to get any visual clue.
• With one hand, hold either side of great
3. Sensory and Motor functions toe at the interphalangeal (IP) joint. Place
your another hand on the lateral and medial
Sensory function assessment aspects of the great toe slightly distal to the
IP.
Sensory assessment evaluates bilateral pathways
of primary sensations. It mostly focuses on pain, • Bend the toe upwards and downward while
temperature (hot and cold), proprioception (i.e. informing him of which direction you’re
position sense) and light touch. moving it.
Articles needed for sensory assessment: • Alternately bend the toe up or down
without telling the patient in which
• Gloves
direction you are moving it.
• Needle
• They should be able to correctly identify the
• Cotton wisp/brush movement and direction.
• Tuning fork
Vibratory Sensation: it is done by vibrating turning
• 2 bowls, one for warm water and the other fork.
for cold water
• Technique.
Components of sensory assessment
• Start at the toes with the patient seated.
• Sensory testing of the face is done by cranial
nerves testing which is discussed earlier. • Tell the patient to close his eyes.
8 Indian Journal of Surgical Nursing / Volume 8 Number 3 Suchana Roy Bhowmik
• Grasp the tuning fork by the stem and strike • As per Medical Research Council scale5
the forked ends against the floor, causing it
to vibrate. Muscle Bulk and Appearance
• Place the stem on top of the interphalangeal
• Examine the major muscle groups of the
joint of the great toe.
upper and lower extremities.
• Put a few fingers of your other hand on the
• Fully expose the muscles of both extremities
bottom-side of this joint
(for comparison)
• Ask the patient if they can feel the vibration.
• The largest and most powerful groups are:
• You should be able to feel the same sensation biceps, triceps, quadriceps, deltoids, and
with your fingers on the bottom side of the hamstrings.
joint.
• Muscle groups should appear symmetrically
• The patient should be able to determine when developed when compared with their
the vibration stops, which will correlate counterparts on the other side of the body.
with when you are no longer able to feel it
transmitted through the joint. • There should be no muscle movement when
the limb is at rest.
• Repeat in both the legs
Muscle Tone: before initiating assessment of muscle
Findings after sensory function assessment for normal
tone:
patient and the pattern of writing the result: Patient is
able to detect the sensation of pain, temperature, • Tell the patient to relax himself and the joints
touch, position sense and vibratory sensation that is to be examined.
bilaterally equal in hands and legs.
• Carefully move the limb thoroughly to its
normal full range of motion,
4. Motor function assessment
• Each joint to be done separately
• Ask patient to relax at sitting or lying down • Instruct the patient squeezing their hand
on bed. around two of your fingers and make a tight
fist.
• Flex and extend patient’s wrists, elbows,
ankles, and knees. • If the grip is normal, you will not be able to
pull your fingers out of the grip.
• Look for resistance that is decreased
(hypotonia) or increased (throughout range
Wrist flexion
of motion=rigidity; spring-like=spasticity).
• Have the patient try to flex their wrist
Strength: against resistance and gravity
forward as you provide resistance as shown
• Grading system: in the figure.
Neurological Assessment: Medical-Surgical Nursing Perspective 8
• Then provide resistance as he try to further Observe and note the differences found between:
adduct at the shoulder. Right vs Left, Proximal muscles vs distal, upper
extremities vs lower and generalized weakness
Shoulder Abduction vs suggestive. There is no pronator drift of out-
stretched arms.
• Tell the patient to flex the elbow while the
arms is held out from the body at forty-five • Muscle bulk and tone are normal.
degrees in sitting position. • Strength is full bilaterally
• Then provide resistance on the hand as he try
to further abduct at the shoulder. 5. Reflex testing
Hip Flexion
Reflex testing helps to assess functions of both
• Tell the patient to be seated, keep your hand sensory and motor pathways. It gives important
on top of one thigh and instruct the patient to insights into the integrity of the nervous system at
lift the leg up from the table. many different levels.
of the great toe should be downwards (i.e. then the dorsal side of one hand repeatedly
plantar flexion), then the great toe will against their thigh.
dorsiflex and the remainder of the other toes
will fan out. • Then test the other hand.
The vigor of contraction3 is graded on the following Interpretation: The movement should be performed
scale
in a steady rate of speed and accurately.
0 No evidence of contraction
1+ Decreased, but still present (hypo-reflexic)
Heel to Shin Testing
2+ Normal
3+ Super-normal (hyper-reflexic) • In lying down or siting position tell the
Clonus: Repetitive shortening of the muscle after patient to move the heel of one foot up and
4+
a single stimulation down along the top of the other shin.
• Then repeat the test in other foot.
Findings after reflex testing for normal patient and
the pattern of writing the result: Interpretation: while the patient moves he should
Reflexes are 2+ and symmetric at the biceps, triceps, trace a straight line along the top of the shin and be
knees, and ankles. done with reasonable speed
Coordination2 based on following ideas: • Rapid alternating hand movements and fine
finger movements are intact.
• The cerebellum assists with balance.
• There is no lack of coordination of movement
• Dysfunction results in a loss of coordination on finger-to-nose and heel-knee-shin.
and problems with gait.
• There are no abnormal or extraneous
• The left cerebellar hemisphere controls the movements.
left side of the body and vice versa.
Article: NIL Gait testing
• The normal gait is effortless, with arms
Finger to nose testing swinging easily at the sides.
• In sitting position of the patient, position • Look for disturbances of posture, balance,
your index finger in front of the patient. loss of arm movement, or abnormal leg
• Instruct the patient to move his index finger movements.
between your finger and his nose. • Lack of balance and a wide based gait would
• Reposition your finger after each touch. suggest a cerebellar disorder.
Rapid Alternating Finger Movements • Have the patient stand in one place with feet
together with open eye.
• Ask the patient to touch the tips of each finger
• Later on tell the patient stand with closed eyes.
to the thumb of the same hand.
• It is scored by counting the seconds the
• Test both hands.
patient is able to stand with eyes closed
Interpretation: The movement should be accurate
following sequentially each fingers. Results
Rapid Alternating Hand Movements The Romberg test is positive when the patient
• Direct the patient to touch first the palm and is unable to maintain balance with their eyes
8 Indian Journal of Surgical Nursing / Volume 8 Number 3 Suchana Roy Bhowmik
Lower
Limb Hip Hip Hip Hip Knee Knee Ankle Ankle plantar
flexion extension Abduction Adduction flexion extension dorsiflexion flexion
Right Eg. 5
Left
7. Reflex testing:
• Achilles reflex
• Patellar reflex
• Biceps reflex
• Triceps reflex
• Babinski response
8. Coordination testing:
• Finger to nose
• Rapid alternating hand movement
• Heel to shin
9. Gait testing:
• Romberg test
• Heel to toe walking
Conclusion References
Practicing neurological assessment stepwise will 1. Williams LS, Hopper PD. Understanding medical
help us to pertain all the data of the patient and help surgical Nursing. Fifth edition, Jaypee Publication.
to correlate the data for diagnosing the condition of
2. Neurological assessments, https://www.
the patient. Once the abnormalities are identified as nurseslearning.com/courses/nrp
a nurse it helps us to plan of the care. Integrating
3. Charlie Goldberg C, UCSD’s Practical Guide to
the neurological health history and physical exam
Clinical Medicine,https://meded.ucsd.edu/
takes practice. Critically analyze all the data clinicalmed/neuro
obtained and synthesize the data.
4. Glasgow Coma Scale/Score (GCS), https://www.
mdcalc.com/glasgow-coma
5. Usker N, Andrew l, Sherman, Muscle Strength
Grading, Jan 2019. https://www.ncbi.nlm.nih.gov
6. Romberg test, https://www.physio-pedia.com/
Romberg_Test
9 Indian Journal of Surgical Nursing / Volume 8 Number 3 Suchana Roy Bhowmik