Neurological Assessment

Objectives:
Review the Anatomy and physiology of the
CNS.
To familiarized with 12 Cranial Nerves and
their functions.
Students will performed Neurological
assessment.
Students will identify neurological deficit.
Application of nursing care to clients with
neurological deficiency.
Parts of Nervous System- CNS, PNS
1. CNS
1. Brain- lies inside the hard outer shell of the skull,
inside a protected cushion of cerebrospinal fluid.
1. Forebrain
a. Cerebrum – right hemisphere and left
hemisphere
 the largest part of the entire brain and is essential
to thought, memory, consciousness and higher
mental process
Has four lobes
The four lobes of cerebrum:
1. Frontal lobe –complicated thinking, speech,
areas controlling body movements

2. Temporal lobe- the center of hearing and smell

3. Parietal lobe – the center for taste, touch

4. Occipital lobe – visual center

4 lobes of the cerebrum
Human Brain
Frontal lobe
Functions-:
Initiation
Problem solving
Judgment
Inhibition of behavior
Planning/anticipation
Self-monitoring
Motor planning
Personality/emotions
Frontal lobe-
Awareness of abilities/limitations
Organization
Attention/concentration
Mental flexibility
Speaking (expressive language)

Observed Problems:
Emotion (i.e., depression, anxiety, personality
changes, aggression, acting out, and social
inappropriateness).
Occipital lobe
Functions
Vision
Reading (perception and recognition of printed
words)

Observed Problems
 Depth perception
Color perception
Difficulty tracking moving objects
Partial or total blindness
Parietal lobe
Functions
Sense of touch
Differentiation: size, shape, color
Spatial perception
Visual perception
Academic skills (reading)

Observed Problems
 Sensation (i.e., touch, taste, and smell)
Temporal lobe
Functions
Vision
Reading (perception and recognition of printed
words)

Observed Problems
 Depth perception
Color perception
Difficulty tracking moving objects
Partial or total blindness
1. CNS
b. Diencephalon or interbrain (between brain)
a. Thalamus - acts as the telephone
exchange between the spinal cord and the cerebral
hemisphere

b. Hypothalamus- concerned with the

control of vital functions such as eating, sleeping
and temperature control
2. Midbrain
a. two cerebral peduncle
b. four quadrigeminal bodies

3. Hindbrain
a. Pons
b. Medulla oblangata
c. cerebellum
3. Hindbrain / a.Pons
The pons – contains nuclei that relay
signals from the forebrain to the cerebellum,
along with nuclei that deal primarily with
sleep, respiration, swallowing,
bladder control, hearing, equilibrium,
taste, eye movement,
facial expressions, facial sensation,
and posture
3. Hindbrain / b. Medulla Oblangata
Medulla Oblangata – the brain stem that
connects the cerebrun and cerebellum with
the spinal cord

Functions:
Controls heart rate, respiration, vasomotor
and body temperature
3. Hindbrain / c. Cerebellum
Cerebelum – a mass that occupies the
posterior part of the cranium,
the largest part of the hindbrain
Functions:
Coordination of voluntary movement
Balance and equilibrium
Some memory for reflex motor acts
cerebellum
Observed Problems
Loss of ability to coordinate fine movements
Loss of ability to walk
Inability to reach out and grab objects
Tremors
Dizziness (vertigo)
Slurred speech (scanning speech)
Inability to make rapid movements
2. Spinal Cord –is within the vertebral column, a
continuation of the brain which provides pathways to
and from the brain, to and from the body.

 surrounded, protected, and nourished by CSF

vertebrae also serve as a bony protection to the
cord.

Functions:
1. Acts as a two-way conduction system between the
brain and the PNS.
2. To control simple reflex actions
11. PNS- peripheral nervous system
1. Cranial nerves - 12 pairs
2. Spinal nerves - 31 pairs
a. Cervical nerves - 8 pairs
b. Thoracic nerves 12 pairs
c. Lumbar nerves 5 pairs
d. Sacral nerves 5 pairs
e. Coccygeal nerves 1 pair
3. Automatic nervous system
a. Sympathetic or thoracolumbar
b. Parasympathetic or craniosacral
11. Peripheral Nervous System
References :
Anatomy and Physiology for Students of Medical
Radiation Technology – M. Mallett, M.D.

Atlas of Anatomy- Medical Book

Pictures and functions of 4 lobes taken from

internet

Idlatosa 2014
Mental Status: the degree of competence
shown by a person in:
intellectual,
emotional,
psychological
personality functioning as measured by
psychologic testing with reference to a
statistical norm
Mental Assessment
Indication:
part of the routine physical examination.
older patients
experienced head trauma
confuse/ disoriented

Assessment: an evaluation or appraisal of a

condition
 MENTAL STATUS ASSESSMENT
A.) APPEARANCE
 Posture – Posture is erect and position is relaxed.

 Movement – Body movement are voluntary,

deliberate, coordinated and even.

 Dress – Dress is appropriate for setting, season,

age, gender and social group.
 Grooming & Hygiene– Clean and well
groomed.
 MENTAL STATUS ASSESSMENT
B) BEHAVIOR
Level of Consciousness –
 The person is awake, alert, aware of stimuli
from the environment and within self and
responds appropriately to stimuli.

Facial Expression
 Appropriate to situation.
MENTAL STATUS ASSESSMENT
B) BEHAVIOR
Speech –
Speaks effortlessly and shares
conversation appropriately.
Words are clear and understandable.

Mood and Affect –

Mood and affect are consistent to place
and conditions.
 MENTAL STATUS ASSESSMENT
C) COGNITIVE FUNCTIONS
Orientation – Oriented to time, place, person.

Attention Span – Able to complete a thought

without wandering. Able to follow directions.

Recent Memory - Able to recall recent facts

(Verifiable)

Remote Memory - Able to recall past events

(Verifiable)
New Learning - Able to recall 4 unrelated words
(after 5, 10, 30 minutes)
MENTAL STATUS ASSESSMENT
D) Thoughts and Perceptions
a. What the person say is sensible
b. What the person says are
consistent and logical.
c. The person is consistently aware of
reality.
• Oh
• Oh
• Oh
• To
• Touch
• And
• Feel
• A
• Girls
• Vagina
• Ah
• Heaven
• SE
• Mo
• Mi
 • Se
• Se
• Mo
• Mo
• Mi
• Mo
• Mi
• Se
• MI

• To be sang with the tune of “London Bridge”

• Mi
• Mo
• Mo
Identifying common smells
Which cranial nerve is
tested?
a. Oculomotor nerve
b. Trochlear nerve
c. Abducens nerve
d. Olfactory nerve

Answer:
d. olfactory
CN I : Olfactorynerve
Client is asked to close his /
her eyes
Occlude one nostril at a time
Examiner places aromatic
and easily distinguishable
substance close to the client’s
nose
Ask client to identify the
odor.
Each side is tested
separately, ideally with two
different substances.
Olfactory nerve
Normal Findings
Normally, a person can identify an
odor on each side of the nose.

Smell normally is decreased

bilaterally with aging
Olfactory nerve
Abnormal Findings
Unilateral loss of smell in the absence of
nasal disease is neurogenic anosmia

Possible causes:
oUpper respiratory infection (temporary);
otobacco or cocaine use;
ofracture of cribriform plate or ethmoid area;
frontal lobe lesion;
o tumor in olfactory bulb or tract
CRANIAL NERVE 11

Answer:
 Optic
nerve
Has a standardized
number at the end of
each line of letters

These numbers
indicates the degree of
visual acuity when
measured at a distance
of 20 feet.
CN II: Optic nerve
Hand held visual acuity card
CN II: Optic nerve
Visual acuity is tested
using a Snellen Chart;

or those who are

illiterate and
unfamiliar with the
western alphabet,
the E chart, in which
the letter E faces in
different directions,
maybe used.
 The chart has a
. standard number at
the end of each line of
letters;
these numbers
indicates the degree
of visual acuity when
measured at a
distance of 20 feet
CN II: Optic nerve
The numerator 20 is the distance in feet
between the chart and the client or the
standard testing distance.

The denominator 20 is the distance from

which the client eye can read the lettering,
which correspond to the number at the end
of each letter line;

therefore the larger the denominator the

poorest the vision.
Measurement of 20/20 vision is an
indication of normal eye refraction
and optic pathway;

while measurement of less than

20/20 vision is an indication of
either refraction error or some
other optic disorder.
CN II: Optic nerve
IN TESTING FOR VISUAL ACUITY
YOU MAY REFER TO THE
FOLLOWING:

1 . The room used for

this test should be
well lighted.

2. A person who wears

corrective lenses
should be tested
with and without
them to check for
the adequacy of
correction.
.
CN II: Optic nerve
IN TESTING FOR VISUAL
ACUITY YOU MAY REFER
TO THE FOLLOWING:

3. Only one eye

should be tested
at a time, the
other eye should
be covered by an
opaque card or
eye cover, not
with client’s
fingers.
 IN TESTING FOR VISUAL ACUITY
CN II: Optic nerve YOU MAY REFER TO THE
FOLLOWING: (cont.)

4. Make the client read the

chart by pointing at a
letter randomly at each
line; maybe started from
largest to smallest or vice
versa.
CN II: Optic nerve IN TESTING FOR VISUAL ACUITY
YOU MAY REFER TO THE
FOLLOWING: (cont.)

5. A person who can read the

largest letter on the chart
(20/200) should be checked if
they can perceive hand
movement about 12 inches
from their eyes, or if they can
perceive the light of the
penlight directed to their
eyes.
PERIPHERAL VISION OR VISUAL FIELDS
The assessment of visual acuity is indicative of the
functioning of the macular area, the area of central
vision.
However, it does not test the sensitivity of the other
areas of the retina which perceive the more peripheral
stimuli.
The visual field confrontation test provides a rather
gross measurement of peripheral vision.

The performance of this test assumes that the examiner

has normal visual fields, since the client’s visual fields
are to be compared with the examiner’s.
The Visual Field Confrontation Test
STEPS IN CONDUCTING THE TEST:
1. The examiner and the client sit or stand
opposite each other, with the eyes at the
same horizontal level with a distance of
1.5 - 2 feet apart.

2. The client covers the eye with opaque

card, and the examiner covers the eye
that is opposite to the client’s covered
eye.

3. Instruct the client to stare directly at the

examiner’s eye, while the examiner
stares at the client’s open eye. Neither
looks out at the object approaching
from the periphery.
The Visual Field Confrontation Test
4. The examiner hold an object
such as pencil or penlight, in
his hand and gradually moves
it in from the periphery of both
directions horizontally and
from above and below.

5. Normally the client should see

the object at the same time the
examiners sees it. The normal
visual field is 180 degrees.
CN III, IV & VI: (Oculomotor, Trochlear, Abducens) 6
Cardinal position of gaze/ EOM (Extra Ocular
Movement)
MUSCLES OF EYE MOVEMENT
MUSCLE NERVE ACTIONS
Superior rectus SR Oculomotor n. Elevates eyeball
Inferior rectus IR Oculomotor n. Depresses eyeball
Medial rectrus MR Oculomotor n. Adducts eyeball
Lateral rectus LR Abducens n. Abducts eyeball
LR6
Levator palpebrae Oculomotor n. Elevates upper
superioris eyelid
III A pillar to open
the eyes
MUSCLES OF EYE MOVEMENT
MUSCLE NERVE ACTIONS
Superior oblique Trochlear n. Rotates downward
SO4 & medially,
depresses adducted
eye
Inferior oblique Oculomotor n. Rotates upward and
laterally; elevates
adducted eye
CN III, IV & VI- Oculomotor, Trochlear, Abducens
All the three cranial nerves are tested at the same
time by assessing the Extra Ocular Movement
(EOM) or the six cardinal positions of gaze.

Follow the given steps:

1. Stand directly in front of the client and hold a
finger or a penlight about 1 ft. from the client’s
eyes.
2. Instruct the client to follow the direction of the
object held by the examiner by eye movements
only; that is without moving the neck.
CN III, IV & VI- Oculomotor, Trochlear, Abducens
3. The nurse moves the object in a clockwise
direction hexagonally.

4. Instruct the client to fix his gaze momentarily on

the extreme position in each of the six cardinal
gazes.

5. The examiner should watch for any jerky

movements of the eye (Nystagmus).

6. Normally the client can hold the position and there

should be no nystagmus.
CN II: Optic nerve Abnormalities
TEST: visual acuity, visual fields, shine light in eye,
direct inspection

ABNORMAL FINDINGS:
defect or absent central vision,
 defect in peripheral vision,
hemianopsia,
absent light reflex,
papilledema,
optic atrophy,
retinal lesions
CN II: Optic nerve Abnormalities
TEST: visual acuity, visual fields, shine light in eye,
direct inspection

POSSIBLE CAUSES:
congenital blindness,
refractive error,
acquired vision loss from numerous diseases(e.g.
CVA, diabetes),
trauma to globe or orbit,
increased intracranial pressure,
 glaucoma,
diabetes
CN III: Oculomotor nerve Abnormalities
 TEST: inspection, extraocular muscle
movement, shine light in eye

ABNORMAL FINDINGS:
 dilated pupil,
 ptosis,
 eye turns out and slightly down,
 failure to move eye up, in, down,
 absent light reflex
CN III: Oculomotor -nerve Abnormalities
POSSIBLE CAUSES::
paralysis in CN III from internal carotid aneurysm,
tumor,
inflammatory lesions,
ptosis from myasthenia gravis,
occulomotor nerve palsy,
 horner’s syndrome;
blindness,
 drug influence,
increased intracranial pressure,
CNS injury,
circulatory arrest, CNS syphilis.
CN IV: Trochlear Nerve Abnormalities:
SO4
TEST: extraocular muscle movement (EOM)
ABNORMAL FINDINGS:
failure to turn eye down or out

POSSIBLE CAUSES:
fracture of orbit,
 brain stem tumor
CN VI: Abducens nerve Abnormalities
LR6
TEST: extraocular muscle movement to right and left
sides
ABNORMAL FINDINGS:
failure to move laterally, diplopia on lateral gaze

POSSIBLE CAUSES:
brain stem tumor or trauma,
fracture of orbit
Assessing facial sensation and corneal
reflexes- CN-v
Which cranial nerve is
responsible?
a. Facial nerve
b. Trigeminal nerve
c. Vestibulocochlear n.
d. Vagus n.

Answer:
Trigeminal nerve
CN V: Trigeminal nerve
A. Sensory function:
1. Ask the client to close the eyes.
2. Run cotton wisp over the forehead, cheek and
jaw on both sides of the face.
3. Ask the client if he/she feel it, and where she
feels it.
4. Check the corneal reflex using cotton wisp.
5. The normal response is blinking.
CN V: Trigeminal nerve
B. Motor function:

1. Ask the client to chew or

clench the jaw.

2. The client should be able to

clench or chew with strength
and force.
CN V: Trigeminal nerve
 TEST: superficial touch, corneal reflex, clench
teeth

ABNORMAL: FINDINGS:
 Absent touch and pain,
 paresthesias;
 no blink;
 weakness of masseter or temporalis muscles
CN V: Trigeminal nerve
Abnormalities
 POSSIBLE CAUSES:
 trauma, tumor,
 pressure from aneurysm,
 inflammation,
 sequelae of alcohol injection for trigeminal
neuralgia;
 unilateral weakness with cranial nerve V lesion,
bilateral weakness with upper or lower motor
neuron disorder
Assessing Facial Motor Function
Which cranial nerve is
involved?
a. Vagus nerve
b. Acoustic nerve
c. Glossopharyngeal n.
d. Facial nerve

Answer:
Facial Nerve
CN VII: Facial nerve
A. Sensory function:
This nerve innervate the anterior 2/3 of the
tongue.
1. Place a sweet, sour, salty, or bitter
substance near the tip of the tongue.
2. Normally, the client can identify the taste.

B. Motor function:
1. Ask the client to smile, frown, raise
eyebrow, close eyelids, whistle, or puff the
cheeks.
Cranial nerve VII : Facial -Motor
function
Normal Findings:
1. Shape of cheeks maybe oval or
rounded on both sides.
2. Face is symmetrical.
3. No involuntary muscle movements.
4. Can move facial muscles at will.
 CN VII: Facial Nerve
TEST:
Wrinkle forehead, close eyes tightly
Smile, puff cheeks, identify tastes

ABNORMAL FINDINGS:
Absent or asymmetric facial movement
Loss of taste
CN VII: Facial nerve
ABNORMAL FINDINGS: / Possible causes
Bell’s palsy (lower motor neuron lesion) causes
paralysis of entire half of face Cannot close the

eyes (hook to close’s eyes) 7

Upper motor neuron lesions (cerebrovascular
accident, tumor, inflammatory)

Other lower motor neuron causes of paralysis:

swelling from ear or meningeal infections
Identifying common sounds

Which cranial nerve is involved?

a. Vagus nerve
b. Hypoglossal nerve
c. Acoustic nerve
d. Spinal accessory nerve

Answer:
CN v111 - Acoustic nerve
CN VIII: Acoustic nerve (Vestibulocochlear nerve)

Examination of the cranial nerve VIII involves

testing for hearing acuity and balance.

HEARING ACUITY
A. Voice test
1. The examiner stands 2 ft. on the side of the ear to be
tested.
2. Instruct the client to occlude the ear canal of the
other ear.
 CN VIII: Acoustic nerve (Vestibulocochlear nerve)
Examination of the cranial nerve VIII involves
testing for hearing acuity and balance.

HEARING ACUITY
A. Voice test
3. The examiner then covers the mouth, and using a soft
spoken voice, whispers non-sequential number, e.g.
3, 5, 7, for the client to repeat.

4. Normally the client will be able to hear and repeat

the number.

5. Repeat the procedure on the other ear.

 CN VIII Acoustic nerve (Vestibulocochlear nerve)
B. Watch test
1. Ask the client to close the eyes.
2. Place a mechanical watch 1 – 2 inches
away the client’s ear.
3. Ask the client if he hears anything.
4. If the client says YES, the examiner
should validate by asking at “What are
you hearing?” and “On which side?”
Tuning Fork Test
This test is called?
a. Rinne test
b. Romberg test
c. Stereognosis test
d. Weber’s test

Answer :
Weber test
CN VIII Acoustic nerve (Vestibulocochlear nerve)
THERE ARE 2 TYPES OF TUNING FORK TEST BEING CONDUCTED
1. WEBER’S TEST – assesses bone conduction, this is a
test of sound lateralization; vibrating tuning fork is
placed on the middle of the forehead or top of the
skull.

Normal: The client hear sounds equally in both ears,

no lateralization of sound.

Conduction loss: Sound lateralizes to defective ear

(heard louder on defective ear) as few extraneous
sounds are carried through the external and middle
ear.

Sensorineural loss: Sound lateralizes on better ear.

WEBER’S TEST
Grasp the 512 Hz tuning fork by the stem and strike
it against the bony edge of your palm, generating a
continuous tone. Alternatively you can get the fork
to vibrate by “snapping” the ends between your
thumb and index finger.
Hold the stem against the patient’s skull, along an
imaginary line that is equidistant from either ear.
The bones of the skull will carry the sound equally to
both the right and left CN 8. Both CN 8, in turn will
transmit the impulse to the brain.
The patient should report whether the sound was
heard equally in both ears or better on one side than
the other (referred to as lateralizing to a side).
Tuning Fork Test
This test is called?
a. Weber’s test
b. Rinne test
c. Romberg test
d. Stereognosis test

Answer :
Rinne test
CN VIII Acoustic/Vestibulocochlear nerve
THERE ARE 2 TYPES OF TUNING FORK TEST BEING CONDUCTED:
(cont.)

2. RINNE TEST – Compares bone conduction with air

conduction.
a. Vibrating tuning fork placed on the mastoid
process.

b. Instruct client to inform the examiner when

he/she no longer hears the tuning fork sounding.

c. Position the tuning fork infront of the client’s ear

canal when he/she no longer hears it.
CN VIII Acoustic/Vestibulocochlear nerve
Rinne test
Normal:
Sound should be heard when tuning fork is placed in
front of the ear canal as air conduction > bone
conduction by 2:1 (positive Rinne Test).

Conduction loss: Sound is heard longer by bone

conduction than by air conduction.

Sensorineural loss: Sound is heard longer by air

conduction than by bone conduction.
CN VIII Acoustic/Vestibulocochlear nerve
Rinne test Ask the patient to inform you
when they can no longer
appreciate the sound.

When this occurs, move the

tuning fork such that the tines
are placed right next to (but not
touching) the opening of the ear.

At this point, the patient should

be able to again hear the sound.
This is because air is a better
conducting medium than bone.
CN VIII: Acoustic nerve

TEST:
Hearing acuity

ABNORMAL FINDINGS:
Decrease or loss of hearing

POSSIBLE CAUSES:
Inflammation, occluded ear canal, otosclerosis,
presbycusis, drug toxicity, tumor.
To test the gag reflex:
Which cranial nerve/s is
involved?
a. Hypoglossal nerve
b. Glossopharyngeal n.
c. Vagus nerve
d. Spinal accessory n.
e. b and c

Answer: Glossopharyngeal n.
Vagus nerve
CN IX and X: Glossopharyngeal & Vagus
Motor:
The uvula should rise
up straight and in the
midline

Sensory:
Mediate test on the
posterior one third of
the tongue
CN IX: Glossopharyngeal nerve
TEST:
Gag reflex

ABNORMAL FINDINGS:
No gag reflex

POSSIBLE CAUSES:
Vocal cord weakness
CN IX and X Gag Reflex Test Limitation
Two major clinical situations Gag reflex is not done:
If you suspect that the patient has suffered acute
dysfunction, most commonly in the setting of a stroke.
These patients may complain of/ be noted to cough
when they swallow or they may suffer from recurrent
pneumonia.
Both of these events are signs of aspiration of food
contents into the passageways of the lungs.
These patients may also have other cranial nerve
abnormalities as lesions affecting CN 9 and 10, often
affect CNs 11 and 12, which are anatomically nearby.
CN IX and X Gag Reflex Test Limitation
Two major clinical situations Gag reflex is not done:
Patient’s suffering from sudden decreased level
of consciousness.

In this setting, the absence of a gag might indicate

that the patient is no longer able to reflexively
protect their airway from aspiration.

Strong consideration should be given to intubating

the patient, providing them with a secure
mechanical airway until their general condition
improves.
To assess the patient’s ability to swallow :

Which cranial nerve is

involved?
a. Glossopharyngeal n.
b. Vagus nerve
c. Spinal accessory n.
d. Hypoglossal n.

Answer :
Glossopharyngeal
nerve & Vagus nerve
 CN X: Vagus nerve
TEST:
Phonates “ahh”
Gag reflex
Note voice quality
Note swallowing

ABNORMAL FINDINGS:
No gag reflex
Hoarse or brassy voice, nasal twang, husky
Dysphagia, fluids regurgitate through nose
 CN X: Vagus nerve
Abnormalities
POSSIBLE CAUSES:
Brain stem tumor, neck injury, cranial nerve x lesion

Vocal cord weakness

Soft palate weakness

Unilateral cranial nerve x lesion

Assessing shoulder muscle strength
Which cranial nerve is
involved?
A. Hypoglossal nerve
B. Spinal accessory n

Answer :
Spinal accessory n.
CN XI: Spinal accessory nerve
Innervates the muscles which permit shrugging
of the shoulders (Trapezius)

and turning of the head laterally

(Sternocleidomastoid).
CN XI: Spinal accessory nerve
Place your hands on top
of either shoulder and
ask the patient to shrug
while you provide
resistance.

Dysfunction will cause

weakness/absence of
movement on the
affected side.
CN XI: Spinal accessory nerve
Place your open right hand
against the patient’s left cheek
and ask the client to turn into
your hand while you provide
resistance.
Then repeat on the other side.
The right sternocleidomastoid
muscle (and thus right CN 11)
causes the head to turn to the
left, and vice versa.
CN XI: Spinal accessory nerve
Abnormalities
TEST:
Turn head, shrug shoulders against resistance.

ABNORMAL FINDINGS:
Absent movement of sternomastoid or trapezius
muscles

POSSIBLE CAUSES:
Neck injury, torticollis
Assess tongue movement
Inspect the tongue (there should be no
tremors, deviation to one side/
weakness).
Note the forward thrust in the midline as
the client protrudes the tongue.
Ask the client to say “light, tight, and
dynamite” the sounds ligual speech
(letter l, t, d) is clear.
Cranial nerve involve:
Hypoglossal nerve
CN XII: Hypoglossal nerve
Abnormalities
TEST
 Protrude tongue, wiggle tongue from side to side

ABNORMAL FINDINGS:
 Deviates to side
 Slowed rate of movement

POSSIBLE CAUSES:
 Lower motor neuron lesion
 Bilateral upper motor neuron lesion
Cranial Nerves
Name and number
Olfactory : Cranial nerve I
Optic: Cranial nerve II
Oculomotor:
Cranial nerve III
Function:
Sensory: carries
impulses for sense of
smell
Sensory: carries
impulses for vision
Motor: muscles for
pupillary constriction,
elevation of upper
eyelid; 4 out of 6
extraocular movements
Cranial Nerves
Name and number Function
Trochlear : Motor: muscles for
Cranial nerve IV downward, inward
movement of the eye
Trigeminal : Mixed: impulses from
Cranial nerve V face, surface of eyes
(corneal reflex), muscles
controlling mastication
Abducens: Motor: muscles for lateral
Cranial nerve VI deviation of eye
Cranial Nerves
Name and number Function
Facial : Mixed: impulses for
Cranial nerve VII taste from anterior tongue;
muscles for facial
movement
Acoustic : Sensory : impulses for
Cranial nerve VIII hearing (cochlear division)
and balance (vestibular
division)
Glossopharyngeal: Mixed: impulses for
Cranial nerve IX sensation to posterior
tongue & pharynx,
Cranial Nerves
Name and number Function
Glossopharyngeal: Mixed cont.: muscles for
Cranial nerve IX movement of pharynx
(elevation) and swallowing

Vagus: Mixed: impulses for

Cranial nerve X sensation to lower pharynx
& larynx, muscles for
movement of
Soft palate, pharynx and
larynx
Cranial Nerves
Name and number Function
Spinal accessory: Motor: movement of
Cranial nerve XI sternocleidomastoid
muscles and upper part
of trapezius muscles
Hypoglossal: Motor:
Cranial nerve XII movement of tongue
Test for Cerebellar Function
This balance test is called?
a. Tip toe
b. Slow walk
c. Tandem walking
d. Single walking

Answer:
Tandem walking
Tandem walking
Ask the person to walk a
straight line in a heel to toe
fashion.

This decreases the base of

support and will accentuate
any problem with
coordination.

Normally, the person can walk

straight and stay balanced.
Tandem walking
ABNORMAL FINDINGS:
Crooked line of walk.

Widens base to maintain balance.

Staggering, reeling, loss of

balance.

Inability to tandem walk is

sensitive for an upper motor
neuron lesion, such as multiple
sclerosis.
Test for Cerebellar Function
This balance test is called?
a. Stereognosis test
b. Graphestesia
c. Ronberg test
d. Romberg test

Answer:
Romberg test
The Romberg test
Ask the person to stand up with
feet together and arms at the sides.
Once in a stable position, ask the
person to close the eyes and hold
the position.
Wait for 20 seconds.

Normally, a person can maintain

posture and balance even with the
visual orientating information
blocked, although slight swaying
may occur.
Stand close to catch the person in
case he or she falls.
The Romberg test
ABNORMAL FINDINGS:
Sways, falls, widens base of feet to
avoid falling.

Positive Romcerebellar ataxia

(multiple sclerosis, alcohol
intoxication), loss of
proprioception, and loss of
vestibular berg sign is loss of
balance that occurs when closing
the eyes.

A positive Romberg sign occurs

with function.
Coordination tests: This coordination and
skilled movement test is
called?
a. Tapping test
b. Lap test
c. Palm to knee test
d. Rapid Alternating
Movements

Answer :
Rapid Alternating
Movements
Rapid alternating movements
Ask the person to pat the knees
with both hands, lift up, turn
hands over, and pat the knees with
the backs of the hands. Then ask
the person to do this faster.
Normally, this is done with equal
turning and a quick rhythmic pace.

ABNORMAL FINDINGS:
Lack of coordination
Slow, clumsy, and sloppy response
is termed dysdiadochokinesia and
occurs with cerebellar disease.
Rapid alternating movements
Alternatively, ask the person
to touch the thumb to each
finger on the same hand,
starting with the index
finger, then reverse
direction.

Normally, this can be done

quickly and accurately.
Coordination Tests:
This coordination test is
called?
a. Pin-point test
b. Finger test
c. Finger coordination test
d. Finger to finger test

Answer:
Finger to finger test
Finger to finger test
With the person’s eyes open,
ask that he or she use the index
finger to touch your finger,
then his or her own nose.

After a few times the examiner

moves his/ her finger to a
different spot that the client
still follows touching it.

The person’s movement should

be smooth and accurate.
Finger to finger test
ABNORMAL
FINDINGS:
Dysmetria is clumsy
movement with
overshooting the mark
and occurs with
cerebellar disorders.
Coordination test
This coordination test is
called?
a. Finger to finger test
b. Finger & arm
extension test
c. Finger to nose pointing
d. Finger to nose test

Answer:
Finger to nose test
Finger to nose test
Ask the person to close the eyes
and stretch out the arms. Ask the
person to touch the tip of his or
her nose with each index finger,
alternating hands and increasing
speed.
Normally this is done with
accurate and smooth movement.

ABNORMAL FINDINGS:
Misses nose
Worsening of coordination when
the eyes are closed occurs with
cerebellar disease.
Definition of terms
Alexia – inability to read

Agnosia – inability to recognize

Agraphia – inability to write

Aphasia – disorder of language affecting the

generation of speech and its understanding, not
simply a disorder of articulation

Ataxia – inability to coordinate voluntary muscle

movements
Definition of terms
Cerebellum – distinct lobes of the brain
concerned with coordinating movement

Clonus – rhythmical contraction of a muscle in

response to a suddenly applied and then sustained
stretch stimulus.

Conjugate gaze – normal state, both eyes look in

the same direction at the same time
Abdominal Reflex (T8 to T10)

The normal response is

ipsilateral contraction of
the abdominal muscle
with an observed
deviation of the
umbilicus toward the
stroke.
Abdominal Reflex (T8 to T10)
Have the person assume a
supine position, with knees
slightly bent.

Use the handle end of the

reflex hammer, a wood
applicator tip or the end of a
split tongue blade to stroke
the skin.

Move from the side of the

abdomen toward the midline
at both the upper and lower
abdominal levels.
Plantar reflex (L4 to S2)
 Position the thigh in
slight external rotation.
 With the reflex
hammer, draw a light
stroke up the lateral
side of the sole of the
foot and inward across
the ball of the foot, like
an upside-down J.
 The normal response is
plantar flexion of all the
toes and inversion and
flexion of the forefoot.
Plantar reflex (L4 to S2)
Except in infancy, the
abnormal response is
dorsiflexion of the big
toe and fanning of all
toes, which is a positive
Babinski sign, also
called “upgoing toes”.
This occurs with upper
motor neuron disease
of the corticospinal (or
pyramidal) tract.
Superficial reflexes
abnormal findings
Superficial reflexes are absent with diseases of the
pyramidal tract

Are absent on the contralateral side with brain

attack.
Glasgow Coma Scale
Most widely used scoring system in quantifying
level of consciousness following traumatic brain
injury.

It is used primarily because it is simple, has a

relatively high degree of interobserver reliability
and because it correlates well with outcome
following severe brain injury.
Glasgow Coma Scale
Eye Opening (E)
4 = spontaneous
3 = to voice
2 = to pain
1 = none
Verbal Response (V)
5 = normal conversation
4 = disoriented
conversation
3 = words, but not coherent
2 = no words, only sounds
1 = none
Motor Response (M)
6 = obey verbal
command
5 = localizes to pain
4 = withdraws to pain
3 = decorticate posture
2 = decerebrate posture
1 = no response
Fully alert – should have
scored 15
Coma – a score of 7 or
below
Abnormal postures:
Decorticate rigidity
Upper extremities-
flexion of arm, wrist, and
fingers; adduction of
arm.
Lower extremities-
extension, internal
rotation, plantar flexion.

This indicates
hemispheric lesion of
cerebral cortex.
 Abnormal
postures:
Decerebrate rigidity Upper extremities stiffly
extended, adducted,
internal rotation, palms
pronated.

Lower extremities stiffly

extended, plantar flexion;
teeth clenched;
hyperextended back.

Indicates lesion in brain

stem at midbrain or upper
pons.
Definition of terms:
Contralateral – pertaining to the opposite
side

Decerebrate – abnormal posture where

upper and lower limbs are rigidly extended

Decorticate – abnormal posture where lower

limbs are extended and upper limbs are flexed

Diplopia – double vision

Definition of terms:
Dysphasia – diminished ability to understand or
express written/ spoken language.

Dysphagia – difficulty in swallowing or chewing

Dysphonic – difficulty in speaking, quality of

speech

Hemianopsia – blindness involving one-half of

the visual field
Definition of terms:
Hemiparesis – muscle weakness on one side

Hemiplegia – paralysis on one side

Hyperesthesia- increased sensitivity to pain or

touch

Ipsilateral – pertaining to the same side of the

body

Nystagmus – oscillating eyeball movement,

involuntary and repetitive
Definition of terms:
Paresis – muscle weakness caused by brain and/ or
spinal cord involvement

Paresthesia – spontaneously occurring abnormal

skin sensation, sometimes described as pins and
needles

Ptosis – drooping

Spastic – abnormally increased muscle tone

 SENSORY FUNCTION,
TESTING STRETCH OR DEEP TENDON REFLEXES
Sensory Function
Sensation is tested by evaluating the patient’s
ability
to perceive a light touch,
 superficial pain (pin-prick),
differences in temperature,
vibration,
position sense and motion.
Sensory Function
If any abnormality is found,
it is important to identify the area of deficit
clearly and find the point where the
abnormal sensation becomes normal again.

This point is referred to as a sensory level.

Sensory Function
Touch the patient in various areas with
cotton (light touch) and with the tip of a
pin (pin-prick)

Typically begin with the face and move

down the body, noting any asymmetry
between the right and left sides.
Sensory Function: Stereognosis
Test the person’s ability to
recognize objects by feeling
their forms, sizes and
weights.

With eyes closed, placed a

familiar object (paper clip,
key, coin, cotton ball, or
pencil) in the person’s
hand and ask the person to
identify it.
Sensory Function: Stereognosis
Normally, a person will
explore it with the
fingers and correctly
name it.
Testing the left hand
assesses right parietal
lobe functioning.

Astereognosis – inability
to identify object
correctly. Occurs in
sensory cortex lesions
e.g. stroke
Sensory Function: Graphestesia
The ability to “read” a number
by having it traced on the skin.

With the person’s eyes closed,

use a blunt instrument to trace a
single digit number or a letter
on the palm.

Ask the person to tell you what

it is.

Inability to distinguish number

occurs with lesions of the
sensory cortex
Testing Stretch or deep Tendon reflexes
Evaluation of deep tendon reflexes (DTRs)
reveals the intactness of the spinal reflex arc at
specific spinal levels as well as the normal override
on the reflex of the higher cortical levels.
DTRs are usually tested by tapping on a tendon
with fingers or a reflex hammer.
This causes a stretching of certain muscles and
results in contraction.

When damage occurs to higher centers (upper

motor neurons), the spinal reflex arc is uninhibited
and the DTRs are hyperactive.
Grading Scale – Reflex
(4 Point Scale)
Reflexes are graded on a scale of 0 to 4.
4+ Very brisk, hyperactive with clonus, indicative
of disease

3+ Brisker than average, may indicate disease

2+ Average, normal

1+ Diminished, low normal

0 No response
Definition of terms:
Clonus – is a set of short jerking contractions of the same
muscle, is a repeated reflex muscular movements. A
hyperactive reflex with sustained clonus (lasting as long as
the stretch is held) occurs with upper motor neuron
disease.

Hyperreflexia – is the exaggerated reflex seen when the

monosynaptic reflex arc is released from the influence of
higher cortical levels. This occurs with upper motor
neuron lesions. e.g. stroke

Hyporeflexia – which is the absence of a reflex, is a lower

motor neuron problem. It occurs with interruption of
sensory afferents or destruction of motor efferents and
anterior horn cells e.g. spinal cord injury
Definition of terms:
Clonus – is a set of short jerking contractions of the same
muscle, is a repeated reflex muscular movements. A
hyperactive reflex with sustained clonus (lasting as long as
the stretch is held) occurs with upper motor neuron
disease.

Hyperreflexia – is the exaggerated reflex seen when the

monosynaptic reflex arc is released from the influence of
higher cortical levels. This occurs with upper motor
neuron lesions. e.g. stroke

Hyporeflexia – which is the absence of a reflex, is a lower

motor neuron problem. It occurs with interruption of
sensory afferents or destruction of motor efferents and
anterior horn cells e.g. spinal cord injury
Dermatomes A circumscribed skin area
that is supplied mainly from
one spinal cord segment
through a particular spinal
nerve.

The dermatomes overlap,

which is a form of biologic
insurance.

That is, if one nerve is

severed, most of the
sensations can be transmitted
by one above and the one
below.
Dermatomes
Landmarks
The thumb, middle finger and fifth finger are
each in the dermatomes of C6, C7 and C8.

The nipple is at the level of T4.

The umbilicus is at the level of T10.

The groin is in the region of L1.

Biceps Reflex (C5 to C6)
Support the person’s forearm
on yours; this position relaxes,
as well as partially flexes, the
person’s arm.

Place your thumb on the biceps

tendon and strike a blow on
your thumb.

You can feel as well as see the

normal response, which is
contraction of the biceps
muscle and flexion of the
forearm.
Triceps reflex (C7 to C8)
Tell the person to let the arm
“just go dead” as you suspend
it by holding the upper arm.
Strike the triceps tendon
directly just above the elbow.

The normal response is

extension of the forearm.

Alternately, hold the person’s

wrist across the chest to flex
the arm at the elbow, and tap
the tendon.
Brachioradialis reflex (C5 to C6)
Hold the person’s
thumbs to suspend the
forearms in relaxation.

Strike the forearm

directly, about 2 to 3 cm
above the radial styloid
process.

The normal response is

flexion and supination
of the forearm.
Quadriceps reflex “Knee jerk”
(L2 to L4)
Let the lower legs
dangle freely the
knee and stretch
the tendons.
Strike the tendon
directly just below
the patella.
Extension of the
lower leg is the
expected response.
Quadriceps reflex “Knee jerk”
(L2 to L4) For the person in
the supine position,
use your own arm as
a lever to support
the weight of one
leg against the other
leg.
This maneuver also
flexes the knee.
Achilles reflex “Ankle jerk”
(L5 to S2) Position the person with
the knee flexed and the
hip externally rotated.

Hold the foot in

dorsiflexion, and strike
the Achilles tendon
directly.

Feel the normal

response as the foot
plantar flexes against
your hand.
Achilles reflex “Ankle jerk”
(L5 to S2)
For the person in
the supine position,
flex one knee and
support that lower
leg against the
other leg so that it
falls “open.”

Dorsiflex the foot

and tap the tendon.
If there’s a beginning , there must be an
end.

Have a Nice Day and God Bless!!!!

Idlatosa 2014