Chapter (25)

Assessing Neurologic System

Dr. Fidaa Abu ali

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 Structure and Function:
The very complex neurologic system is responsible
for coordinating and regulating all body functions.
It consists of two structural components: the central
nervous system (CNS) and the peripheral nervous
system.

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3 Structures of the brain
4 Lobes of the brain
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6
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 Cranial Nerves (CN)

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Test CN I (olfactory):
Ask the client to clear the
nose to remove any mucus,
then to close eyes, occlude
one nostril, and identify a
scented object that you are
holding such as soap, coffee,
or vanilla.
Repeat procedure for the
other nostril.
 Client correctly identifies
presented to each nostril.
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 Test CN II (optic):
Use a Snellen chart to assess vision in each eye.
 Client has 20/20 vision OD (right eye) and OS (left eye).
Ask the client to read a newspaper or magazine
paragraph to assess near vision.
 Client reads print at 14 inches without difficulty.
Assess visual fields of each eye by confrontation.
Use an ophthalmoscope to view the retina and optic disc
of each eye.

10 Fadi J. Zaben RN MSN

 Assess CN III (oculomotor), IV
(trochlear), and VI (abducens):
Inspect margins of the eyelids of each eye:
 Eyelid covers about 2 mm of the iris.
 Ptosis (drooping of the eyelid) is seen with weak eye
muscles.

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 Assess extraocular movements. If nystagmus is
noted, determine the direction of the fast and slow
phases of movement.
 Eyes move in a smooth, coordinated motion in all directions.
Assess pupillary response to light (direct and indirect)
and accommodation in both eyes:
 Bilateral illuminated pupils constrict simultaneously.
 Pupil opposite the one illuminated constricts simultaneously.

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 Assess CN V (trigeminal):
 Test motor function:
Ask the client to clench the
teeth while you palpate the
temporal and masseter
muscles for contraction.
 Temporal and masseter
muscles contract bilaterally.

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Test sensory function:
Tell the client: “I am going to
touch your forehead, cheeks,
and chin with the sharp or dull
side of this paper clip.
Please close your eyes and
tell me if you feel a sharp or
dull sensation.
Also tell me where you feel
it”.
 The client correctly identifies
sharp and dull stimuli and light
touch to the forehead, cheeks, and
chin.
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 Test corneal reflex:
Ask the client to look
away and up while you
lightly touch the cornea
with a fine wisp of cotton.
Repeat on the other side.
 Eyelids blink bilaterally.

15 Fadi J. Zaben RN MSN

Test CN VII (facial):
Test motor function:
Ask the client to:
Smile.
Frown and wrinkle forehead.
Show teeth.
Puff out cheeks.
Purse lips.
Raise eyebrows.
Closed eyes tightly against resistance.
 Movements are symmetric.

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 Frowning and
17 wrinkling forehead
Puffing out cheeks
 Test CN VIII (acoustic/vestibulocochlear):
Test the client’s hearing ability in each ear and perform
the Weber and Rinne tests to assess the cochlear
(auditory) component of cranial nerve VIII

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Test CN IX ()
and X (vagus):glossopharyngeal
Test motor function:
Ask the client to open
mouth wide and say “ah”
while you use a tongue
depressor on the client’s
tongue.
 Uvula and soft palate
rise bilaterally and
symmetrically on
phonation.
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Test the gag reflex:
• By touching the posterior pharynx with the tongue
depressor.
 Gag reflex intact.
Check the client’s ability to swallow:
• By giving the client a drink of water.
• Note the client’s voice quality.
 Client swallows without difficulty.
 No hoarseness noted.

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Test CN XI (spinal accessory):
• Ask the client to shrug the shoulders against resistance
to assess the trapezius muscle.
 There is symmetric, strong contraction of the trapezius
muscles.

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 Ask the client to turn the
head against resistance,
first to the right then to the
left, to assess the
sternocleidomastoid
muscle.
 There is strong contraction
of sternocleidomastoid
muscle on the side opposite
the turned face.

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Test CN XII (hypoglossal):
To assess strength and mobility of the tongue, ask
the client to protrude tongue, move it to each side
against the resistance of a tongue depressor, and then
put it back in the mouth.
 Tongue movement is symmetric and smooth, and
bilateral strength is apparent.

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 Motor and Cerebellar Systems

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Assess condition and movement of muscles:
Assess the size and symmetry of all muscle
groups.
Muscles are fully developed and symmetric in size (bilateral
sides may vary 1 cm from each other).
Assess the strength and tone of all muscle groups:
All muscle groups equally strong against resistance, without
flaccidity, spasticity, or rigidity.
Note any unusual involuntary movements such as
fasciculations, tics, or tremors.
No fasciculations, tics, or tremors are noted.

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 Evaluate gait and balance:
Ask the client to walk naturally
across the room. Note posture,
freedom of movement, symmetry,
rhythm, and balance.
 Gait is steady; opposite arm swings.
Ask the client to walk in heel-to-toe
fashion (tandem walking), next on
the heels, then on the toes.
 Client maintains balance with
tandem walking.
 Walks on heels and toes with little
difficulty. Tandem walking

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 Perform the Romberg
test.
Ask the client to stand erect
with arms at side and feet
together.
Note any unsteadiness or
swaying.
Then with the client in the
same body position, ask the
client to close the eyes for
20 seconds.
Note any imbalance or
swaying
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 Assess Coordination:
Demonstrate the finger-to-nose test to assess
accuracy of movements:
Ask the client to extend and hold arms out to the side
with eyes open.
Next, say, “Touch the tip of your nose first with your
right index finger, then with your left index finger.
Repeat this three times”.
Next, ask the client to repeat these movements with
eyes closed.

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29 Testing coordination: the finger-to-nose test
Assess rapid alternating movements:
Have the client sit down.
First, ask the client to touch each finger to the thumb
and to increase the speed as the client progresses.
Repeat with the other side.
Next, ask the client to put the palms of both hands
down on both legs, then turn the palms up, then turn the
palms down again.
Ask the client to increase the speed.

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 Testing rapid alternating movements: palms
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 Perform the heel-to-shin test. Ask the client to lie down
(supine position) and to slide the heel of the right foot
down the left shin.
Repeat with the other heel and shin.
 Client is able to run each heel smoothly down each shin.

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Performing the heel-to-shin test
 Sensory System

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 Assess light touch, pain, and temperature
sensations:
Ask clients to close both
eyes and tell you what
they feel and where they
feel it.
To test light touch
sensation, use a wisp of
cotton to touch the client.
 Client correctly identifies
light touch.

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To test pain sensation, use the blunt and sharp ends of
a safety pin or paper clip.
 Client correctly differentiates between dull and sharp
sensations over various body parts.

35 Dull stimulus Sharp stimulus

To test temperature sensation, use test tubes filled with
hot and cold water.
 Client correctly differentiates between hot and cold
temperatures over various body parts.

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 Test vibratory
sensation:
Strike a low pitched tuning
fork on the heel of your hand
and hold the base on the
distal radius.

37 Distal radius
 Strike a low pitched tuning fork on the heel of your
hand and hold the base on forefinger tip.

38 Forefinger tip
 Strike a low pitched tuning fork on the heel of your hand
and hold the base on medial malleolus.

39 Fadi J. Zaben RN MSN Medial malleolus

 Strike a low pitched tuning fork
on the heel of your hand and
hold the base on the tip of the
great toe.

Ask the client to indicate

what he or she feels.
Repeat on the other side.
Client correctly identifies
sensation.

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Tip of the great toe
 Test sensitivity to position:
Ask the client to close both eyes.
Then hold the client’s toe or a finger on the lateral sides
and move it up or down.
Ask the client to tell you the direction it is moved.
Repeat on the other side.
Client correctly identifies directions of movements.

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 Assess tactile discrimination (fine touch):
Remember that the client should have eyes closed.
To Test Stereognosis, place a familiar object such as a
quarter, paper clip, or key in the client’s hand.
Ask the client to identify it.
Repeat with another object in the other hand.
Client correctly identifies object.

Stereognosis
Test
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 Graphesthesia Test:

• Use a blunt instrument to write a number, such as 2, 3,

or 5, on the palm of the client’s hand.
• Ask the client to identify the number.
• Repeat with another number on the other hand

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 Reflexes

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 Test deep tendon reflexes:
Position client in a comfortable sitting position.
Use the reflex hammer to elicit reflexes.
 Normal reflex scores range from (Used for all tests):
 1+ (present but decreased).
 2+ (normal).
 3+ (increased or brisk, but not pathologic)

45 Fadi J. Zaben RN MSN

Test biceps reflex (C5 and C6):
Ask the client to partially bend arm at elbow with palm up.
Place your thumb over the biceps tendon and strike your
thumb with the pointed side of the reflex hammer.
Repeat on the other side.
 Elbow flexes and contraction of the biceps muscle is seen
or felt.

Eliciting
the
biceps
reflex
46 Fadi J. Zaben RN MSN
Assess brachioradialis reflex (C5 & C6):
Ask the client to flex elbow with palm down and hand resting
on the abdomen or lap.
Use the flat side of the reflex hammer to tap the tendon at
the radius about 2 inches above the wrist.
Repeat on other side.
 Flexion at elbow and supination of forearm.

Eliciting the
brachioradialis
reflex
47 Fadi J. Zaben RN MSN
Test triceps reflex (C6, C7, and C8):
Ask the client to hang the
arm freely while you support
it with your nondominant
hand.
With the elbow flexed, use
the flat side of the reflex
hammer to tap the tendon
above the olecranon process.
Repeat on the other side.
 Elbow extends, triceps
contracts.

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Assess Patellar reflex (L2, L3, and L4):
Ask the client to let both legs
hang freely off the side of the
examination table.
Using the flat side of the
reflex hammer, tap the
patellar tendon, which is
located just below the patella.
Repeat on the other side.
 Normal response is plantar
flexion of the foot.

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 For the client who cannot sit up, gently flex the
knee and strike the patella.

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Test Achilles reflex (S1 and S2):
With the client’s leg still hanging freely, dorsiflex the
foot.
Tap the Achilles tendon with the flat side of the reflex
hammer.
Repeat on the other side.
 Plantarflexion of foot.

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 For assessing the reflex in the client who cannot sit up,
have the client flex one knee and support that leg against
the other leg.
Dorsiflex the foot and tap the tendon using the flat side
52 of the reflex hammer.
Test ankle clonus:
Place one hand under the knee to support the leg, then
briskly dorsiflex the foot toward the client’s head.
Repeat on the other side.
Not routine used; when the other reflexes tested have
been hyperactive
No rapid contractions or oscillations (clonus) of the ankle
are elicited.

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 Test superficial reflexes

54 Fadi J. Zaben RN MSN

Assess Plantar Reflex (Babinski reflex):
With the end of the reflex hammer, stroke the lateral
aspect of the sole from the heel to the ball of the foot,
curving medially across the ball.
Repeat on the other side.

 Flexion of
the toes
occurs

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 Eliciting the plantar Normal plantar response
reflex

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Test abdominal reflex:
Lightly stroke the abdomen on each side, above and
below the umbilicus.

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 Tests for Meningeal Irritation or
Inflammation

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 Positive sign; Kering (hip
flexed to 90 angle, complete
extension of the knee is
restricted & painful) and
Brudzinski signs (an
attempt to flex the neck
produces flexion at the knee
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& thigh)