Prepared by: Robert Adrian L.

Peñaranda
The Neurologic System
 responsible for many functions including
initiation and coordination of movement,
reception and perception of sensory
stimuli, organization of thought process,
control of speech, and storage of
memory
 assessment of neurological function can
be time consuming
 a client’s LOC influences the ability to
follow directions
The neurologic exam
 A thorough neurologic exam takes about
2-3 hours; however, routine tests are
done first. If the tests raised questions,
more extensive neurologic exam is
performed.
Three major considerations
 The client’s chief complains
 Client’s physical condition
 Client’s willingness to participate
Examination of the neurologic
system includes assessment of:
 Mental status including the level of
consciousness
 The cranial nerves
 Reflexes
 Motor function
 Sensory function
Mental Status
 Reveals the general Cerebral functions
 These functions include intellectual
(cognitive) as well as emotional
(affective) functions
 Major areas of mental status
assessment includes language,
orientation, memory, and attention span
and calculation.
Language
 Aphasia
Loss of power to express oneself by speech,
writing or signs, or to comprehend spoken or
written language due to disease or injury of
the cerebral cortex
Could be categorized as sensory or
receptive and motor or expressive aphasia
Orientation
 Determines the person’s ability to
recognize familiar persons, awareness
to where and when they presently are
(time and place), and who they,
themselves, are (self).
Memory
 Assessment of recall of information
presented seconds previously
(immediate recall), events or information
earlier in the day or examination (recent
memory) and knowledge recalled from
months or years ago (remote or long
term memory)
Attention Span and Calculation
 Determines the client’s ability to focus
on a mental task that is expected to be
performed by person of normal
intelligence
Level of Consciousness
 Anywhere along a continuum from a
state of alertness to coma.
Level Description
Conscious Normal
Disoriented; impaired
Confused
thinking and responses
Disoriented; restlessness,
Delirious hallucinations, sometimes
delusions
Decreased alertness;
Obtunded slowed psychomotor
responses
Sleep-like state (not
Stuporous unconscious); little/no
spontaneous activity
Cannot be aroused; no
Comatose
response to stimuli
 The Glasgow Coma Scale
1 2 3 4 5 6

Opens eyes in Opens eyes in

Does not open Opens eyes
Eyes response to response to N/A N/A
eyes spontaneously
painful stimuli voice

Utters Oriented,
Makes no Incomprehensi Confused,
Verbal inappropriate converses N/A
sounds ble sounds disoriented
words normally

Abnormal
Extension to Flexion /
Makes no flexion to Localizes Obeys
Motor painful stimuli Withdrawal to
movements painful stimuli painful stimuli Commands
(decerebrate) painful stimuli
(decorticate)
Cranial Nerves
 The nurse needs to know the specific
functions and assessment methods of
cranial nerves to detect abnormalities. In
some cases, each nerve is assessed; in
other cases only selected nerve
functions are evaluated
Cranial nerves
Name Type Function Method
I Olfactory Sensory Sense of smell Ask client to identify different nonirritating aromas
such as coffee & vanilla

II Optic Sensory Visual acuity Use Snellen Chart or ask client to read printed
material while wearing glasses
III Oculomotor Motor Extraocular eye movement; Assess directions of gaze
Pupil constriction and dilation Measure papillary reaction to light reflex and
accommodation
IV Trochlear Motor Upward & downward movement of Assess directions of gaze
eyeball
V Trigeminal Sensory Sensory nerve to skin of face Lightly touch cornea with wisp of cotton. Assess
& Motor Motor nerve to muscles of jaw corneal reflex. Measure sensation of light pain & touch
across skin of face
Palpate temples as client clenches teeth

VI Abducens Motor Lateral movement of eyeballs Assess directions of gaze

VII Facial Sensory Facial expression As client smiles, frowns, puffs out cheeks, & raises &
& Motor Taste lowers eyebrows, look for asymmetry
Have client identify salty or sweet taste in front of
tongue

VIII Auditory Sensory Hearing Assess ability to hear spoken word

IX Glossopharyngeal Sensory Taste Ask client to identify sour or sweet taste on back of
& Motor Ability to swallow tongue
Use tongue blade to elicit gag reflex
X Vagus Sensory Sensation of pharynx Ask client to say “ah”. Observe movement of palate
& Motor Movement of vocal cords and pharynx
Assess speech for hoarseness
XI Spinal Accessory Motor Movement of head & shoulders Ask client to shrug shoulders and turn head against
passive resistance
XII Hypoglossal Motor Position of tongue Ask client to stick out tongue to midline and move it
from side to side
Reflexes
 An automatic response of the body to a
stimulus.
 The deep tendon reflex (DTR) can be
activated by tapping the tendon and its
associated muscles contract
 Reflexes are tested using a percussion
hammer.
Motor Function
 Evaluates proprioception and cerebellar
functions
 Proprioceptors are sensory nerve terminals
occurring chiefly on muscles, tendons,
joints and the internal ear, that give
information about movements and the
position of the body
 Cerebellar functions include posture
control, coordination and smoothness of
movements (work together with the
cerebral cortex) and maintenance of the
skeletal muscle equilibrium
Sensory Function
 Includes touch, pain, temperature,
position and tactile discrimination
 Tests for sensory function include one-
and two-point discrimination,
stereognosis and extinction
Assessment Proper
 Language
If the client displays difficulty speaking
○ Point to a common objects and ask the client
to name them
○ Ask the client to read some words and match
written words to pictures
○ Ask the client to respond to simple verbal
commands like asking the client to point to his
toes or raise an arm
Orientation
 Determine if the client is oriented to
person, place and time by asking tactful
questions.
 Ask the client his state or city of
residence, time of the day, day of the
week, duration of illness, and names of
family members
 If the client cannot answer the questions
correctly, include questions about
himself like his name for example
Memory
 Listen for lapses in memory. Ask client
about difficulty with memory. If problems
are apparent, three categories of
memory are tested: Immediate recall,
recent memory and remote memory
To assess immediate recall:
 Ask the client to repeat series of three
digits. E.g. 7-4-3 spoken slowly
 Gradually increase the number of digits.
E.g. 7-4-3-4, 7-4-3-4-5, 7-4-3-4-5-6-7
 Start again with a series of three digits,
but this time ask the client to repeat it
backwards. An average person is able
to repeat series of five to eight digits in
sequence and four to six digits in
reverse order
To assess recent memory
 Ask the client what happened earlier
such as how he got to the clinic.
 Ask the client to recall information given
earlier like the doctors name.
 Ask the client to remember three facts (a
color, an object or an address; or a three
digit number) and ask the client to
repeat all three facts later at the
interview.
Remote memory
 Ask the client to describe a previous
illness or surgery. E.g. 5 years ago, or
anniversary or birthday
Attention span and calculation
 Test the clients ability to concentrate or
maintain attention span by asking the
client to recite the alphabet or to count
backwards from 100.
 Test the client’s ability to calculate by
asking the client to subtract 7 or 3
progressively from 100.
Level of Consciousness
 Apply the Glasgow Coma Scale
 A score of 15 indicates that the client is
alert and completely oriented.
 A comatose patient scores 7 or lower
Cranial Nerves
Name Type Function Method
I Olfactory Sensory Sense of smell Ask client to identify different nonirritating aromas
such as coffee & vanilla

II Optic Sensory Visual acuity Use Snellen Chart or ask client to read printed
material while wearing glasses
III Oculomotor Motor Extraocular eye movement; Assess directions of gaze
Pupil constriction and dilation Measure papillary reaction to light reflex and
accommodation
IV Trochlear Motor Upward & downward movement of Assess directions of gaze
eyeball
V Trigeminal Sensory Sensory nerve to skin of face Lightly touch cornea with wisp of cotton. Assess
& Motor Motor nerve to muscles of jaw corneal reflex. Measure sensation of light pain & touch
across skin of face
Palpate temples as client clenches teeth

VI Abducens Motor Lateral movement of eyeballs Assess directions of gaze

VII Facial Sensory Facial expression As client smiles, frowns, puffs out cheeks, & raises &
& Motor Taste lowers eyebrows, look for asymmetry
Have client identify salty or sweet taste in front of
tongue

VIII Auditory Sensory Hearing Assess ability to hear spoken word

IX Glossopharyngeal Sensory Taste Ask client to identify sour or sweet taste on back of
& Motor Ability to swallow tongue
Use tongue blade to elicit gag reflex
X Vagus Sensory Sensation of pharynx Ask client to say “ah”. Observe movement of palate
& Motor Movement of vocal cords and pharynx
Assess speech for hoarseness
XI Spinal Accessory Motor Movement of head & shoulders Ask client to shrug shoulders and turn head against
passive resistance
XII Hypoglossal Motor Position of tongue Ask client to stick out tongue to midline and move it
from side to side
Reflexes
 Assess the reflexes using a percussion
hammer
 The grading for reflex are as follows:

0 - no response
1+ - Low normal with slight muscle
contraction
2+ - Normal with visible muscle twitch and
movement of the arm or leg
3+ - Brisker than normal; may not indicate
disease
4+ - Hyperactive and very brisk; often
associated with spinal cord disorders
Biceps Reflex
 Tests the spinal cord level c5 and c6
 Slightly flex the arm with the forearm
resting over the thumb with the palm of the
hand down
 Place your nondominant hand horizontally
over the biceps tendon
 Deliver a blow with the percussion hammer
over your thumb
 Observe for the slight flexion of the elbow
and fell the biceps contract with your thumb
Triceps Reflex
 Tests the spinal cord c7 and c8
Flex the clients arm at the elbow, and
support it in the arm of your nondominant
arm
Palpate the triceps tendon about 2-5cm (1 to
2in.) above the elbow
Deliver a blow with the percussion hammer
directly to the tendon
Observe the slight extension of the elbow
Brachioradialis Reflex
 Tests the spinal cord c5-c6
Rest the client’s forearm in a relaxed
position externally rotated on a firm surface
Deliver a blow directly on the radius 2 to
5cm (1 to 2 in.) above the wrist or the stylus
process
Observe the normal flexion or supination of
the forearm. The fingers of the hand may
also extend slightly
Patellar Reflex
 Tests the spinal cord L2, L3 and L4
Ask the client to sit on the edge of the examining
table so the legs would hang freely
Locate the patellar tendon directly below the
patella
Deliver a blow with the percussion hammer
directly to the tendon
Observe the normal extension or kicking out of
the leg as the quadriceps muscle contracts
If no response occurs and you suspect that your
client is not relaxed, ask the client to interlock
the fingers and pull (Jendrassik’s maneuver)
Achilles Reflex
 Tests the spinal cord S1 and S2
With the client in the same position as in the
patellar reflex, slightly dorsiflex the client’s
ankle by supporting the ball of the foot lightly
in the hand
Deliver a blow with the percussion hammer
directly to the Achilles tendon just above the
heel
Observe the normal plantar flexion
(downward jerk) of the foot
Plantar or Babinski Reflex
 The plantar or babinski reflex is
superficial and may be absent to adults
without pathology or is overridden by
voluntary control
Motor Function
 Walking Gait
Ask the client to walk across the room and
back. Observe for the client’s gait.
Normally, the client stands in an upright
position with the arms swinging in opposite
direction, walks unaided and maintains
balance
Romberg Test
 Ask the client to stand with feet together
first with eyes open and then closed
 Negative Romberg: may sway a bit but
maintains upright posture and foot stance
 Positive Romberg: cannot maintain foot
stance, presence of ataxia or lack in the
coordination of the voluntary muscles, and
cerebellar ataxia or the inability to maintain
stance with the eyes open or shut.
Standing on one foot with eyes
shut
 Ask the client to close eyes and stand
with only one foot.
 Normally, the client should be able to
maintain stance at least for 5 seconds
Heel-Toe Walking
 Ask the client to walk a straight line with
the advancing foot’s heel touching the
toes of the other foot.
 A client assumes a larger foot gait to
stay upright if she cannot perform this
procedure
Toe or Heel Walking
 Ask the client to walk several steps on
the toes and then on the heels
Fine motor tests for the upper
extremeties
 Finger-To-Nose test
Ask the client to abduct and extend the arms
at shoulder height and then rapidly touch the
nose alternatively with one index finger and
then the outer. The client repeats the test
with the eyes closed if the test is performed
easily
Normally, the movements are coordinated
and the finger do not miss the nose
Alternating Supination and
Pronation of Hands on Knees
 Ask the client to pat both knees with the
palm of the hands and then with the
backs of the hands alternatively at an
ever-increasing rate
Assessment of the Nose and to the
Nurse’s Finger
 Ask the client to touch the nose and
then your index finger, held at a distance
about 45cm (18in.) at a rapid and
increasing rate
Fingers to Fingers
 Ask the client to spread the arms
broadly at shoulder height and then
bring the fingers together at the midline,
first with the eyes open and then closed,
first slowly, then rapidly
Fingers to Thumb (Same Hand)
 Ask the client to touch each finger of
one hand to the thumb of the same hand
as rapidly as possible
Fine motor tests for the Lower
extremities
 Heel Down Opposite Shin
Ask the client to place the heel of one foot
just below the opposite knee and run the
heel down the shin to the foot. Repeat with
the other foot. The client may also sit for this
test
Toe or Ball of Foot to the Nurse’s
Finger
 Ask the client to touch your finger with
the large toe of each foot
Light-Touch Sensation
 Compare the light-touch sensation of
symmetric areas of the body
 Ask the client to say “yes” or “now”
whenever the client feels the cotton wisp
touching the skin
 Test areas in the forehead, cheek, hand,
lower arm, abdomen, foot and lower leg.
 Ask the client to point to the area where
he felt the cotton wisp
Light-Touch Sensation
 If areas of sensory dysfunction are
found, determine the boundaries of
sensation by testing responses about
every 2.5cm (1 in.) in the area
 Make a sketch of the sensory loss area
for recording purposes
Pain Sensation
 Assess pain sensation by asking the client
to say “sharp”, “dull” or “don’t know” when
the sharp or dull end of the tongue
depressor is felt.
 Alternately, use the sharp and dull end to
slightly prick the designated anatomic
areas at random, e.g. hand, forearm, lower
leg, abdomen. The face is not tested in this
manner
 Give at least two seconds at each prick to
prevent summation of stimuli
Temperature Sensation
 If pain sensation is intact, temperature
sensation tests are no longer performed.
If there are pain sensation
abnormalities, then the temperature
sensation test is performed.
 Touch skin with test tubes containing hot
or cold water and ask the client to
respond with “hot”, “cold” or “don’t know”
Position or Kinesthetic Sensation
 Commonly, the middle fingers and the
large toes are tested for kinesthetic
sensation (sense of position)
Support client’s arm and hand, or place the
client’s heel on the examining table
Ask client to close eyes
Grasp the finger with your thumb and index
finger, and exert the same pressure on both
sides of finger or toe while moving it
Move finger or toe until it is up, straight or down
and ask the client to identify the position
Tactile Discrimination
 For all tests, the clients eyes must be
closed
 Kinds of Tactile Discrimination Tests
One- and two- point discrimination
Stereognosis
Extinction Phenomenon
One- and Two- Point
Discrimination
 Alternatively stimulate the skin with two pins
simultaneously and then with one pin. Ask
whether the client feels one or two pins
Perception varies widely in adults over different
parts of the body. The common sites for this test
are:
○ Fingertips, 2.8 mm
○ Palms of the hands, 8-12 mm
○ Chest, forearm, 40mm
○ Back, 50-70 mm
○ Upper arm, Thigh, 75 mm
○ Toes, 3-8 mm
Stereognosis
 Ability to recognize objects by touching
them
Place familiar objects such as a key, paper
clip, or coin, in the client’s hand and ask the
client to identify them
If the client cannot move the hands, write a
number on the client’s palm using a blunt
object and ask the client to identify it
(graphesthesia)
Extinction Phenomenon
 Simultaneously stimulate two symmetric
areas of the body, such as the thighs,
the cheeks or the hands
 The client should be able to feel both
stimulus