Neurologic Assessment

Caytiles, Joessel Marie T.
BSN 701
MEDSURG II - Mr. Carlo Jason Badajos
NEUROLOGIC ASSESSMENT
Learning Objectives:
After the presentation, we should be able to:
• Perform a physical assessment of the neurologic system
• Document neurologic system findings
• Differentiate between normal and abnormal finding
INRODUCTION
• The human nervous system is a unique system that allows the body to
interact with the environment as well as to maintain the activities of internal
organs.
• The nervous system acts as the main “circuit board” for every body system.
Because the nervous system works so closely with every other system, a
problem within another system or within the nervous system itself can cause
the nervous system to “short-circuit.”
• A major goal of nursing is early detection to prevent or slow the progression
of disease.
• So it is important for nurses to accurately perform a thorough neurologic
assessment and to understand the implications of subtle changes in
assessment findings. By doing so, we can initiate timely interventions that
can save lives.
REVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE NEUROLOGIC SYSTEM
General functions of the neurologic system include:

• Cognition, emotion, and memory.
• Sensation, perception, and the integration of sensoryperceptual experience.
• Regulation of homeostasis, consciousness, temperature, BP, and other bodily
processes.
There are two types of nerve cells:

1. NEUROGLIA
Functions:
a. act as supportive tissue, nourishing and protecting the neurons
b. maintain homeostasis in the interstitial fluid around the neurons and account for
about 50 percent of the central nervous system (CNS) volume
c. have the ability to regenerate and respond to injury by filling spaces left by
damaged neurons.
2. NEURONS
Functions:
a. have the ability to produce action potentials or impulses (excitability or irritability)
and
b. to transmit impulses (conductivity)
Caytiles, Joessel Marie T. BSN 701
Neurons band together into

- peripheral nerves,
- spinal nerves,
- spinal cord, and
- tissues of the brain.
These structures make up the neurologic system, which is divided into

- the CNS and
- the peripheral nervous system (PNS).
CENTRAL NERVOUS SYSTEM

• consists of the brain and spinal cord.
THE SPINAL CORD

• The spinal cord descends through the foramen magnum (large aperture) of
the occipital bone of the skull, through the first cervical vertebra (C1), and
through the remainder of the vertebral column to the first or second
lumbar vertebra.
• conducts sensory information from the peripheral nervous system (both
somatic and autonomic) to the brain
• conducts motor information from the brain to our various effectors
- skeletal muscles
- cardiac muscles
- smooth muscles
-glands
• serves as a minor reflex center
SENSORY PATHWAYS
• Pathways,either ascending or afferent,allow sensory data, such as the feeling
of a burned hand, to become conscious perceptions.
MOTOR PATHWAYS
• Motor pathways (descending or efferent) transmit impulses from the brain to
the muscles
SPINAL REFLEXES
• Spinal reflexes do not depend on conscious perception and interpretation of

stimuli, nor on deliberate action; in other words, they do not involve the brain.
• They occur involuntarily, with lightning speed, and are identical in all healthy
children and adults, although they are less developed
• in infants.
PERIPHERAL NERVOUS SYSTEM

• The peripheral nervous system consists of
- the cranial
- spinal nerves and the
- peripheral autonomic nervous system.
CRANIAL NERVES
The 12 pairs of cranial nerves originate from the brain and are called the peripheral
nerves of the brain.
I-Olfactory nerve – Smell (S)

II-Optic nerve - Vision (S)
III-Oculomotor nerve (M) - Eye movement; pupil constriction
IV-Trochlear nerve (M) - Eye movement
V-Trigeminal nerve (B) - Somatosensory information (touch, pain) from the
face and head;
muscles for chewing.
VI-Abducens nerve - Eye movement (M)
VII-Facial nerve (B) - Taste (anterior 2/3 of tongue); somatosensory
information from ear;
controls muscles used in facial expression.
VIII-Vestibulocochlear nerve
/Auditory nerve (S) - Hearing; balance
IX-Glossopharyngeal nerve (B) - Taste(posterior 1/3 of tongue);
- Somatosensory information from tongue, tonsil,
pharynx;
- controls some muscles used in swallowing.
X-Vagus nerve (B) - Sensory, motor and autonomic functions of viscera
(glands, digestion,
heart rate)
XI-Accessory nerve/Spinal accessory nerve (M) - Controls muscles

used in head movement.
XII-Hypoglossal nerve (M) - Controls muscles of tongue
SPINAL AND PERIPHERAL NERVES
• Branching from the spinal cord are 31 pairs of spinal nerves: 8 cervical, 12
thoracic, 5 lumbar, 5 sacral, and 1 coccygeal
• The spinal nerves contain both ascending and descending fibers, and
although there is some overlap,each is responsible for innervation of a
particular area of the body.
Dermatomes - are regions of the body innervated by the

cutaneous branch of a single spinal nerve.
Components of Neurologic Exam
• Mental Status
a. Appearance/ Hygiene/ Grooming/ Odor
b. Behavior
c. Speech/ Communication
d. Level of Consciousness
e. Memory
f. Cognitive function
• Cranial Nerve Function (12 cranial nerves)
• Sensory Function
a. Light touch e. Streognosis
b. Pain f. Graphesthesia
c. Vibration g. Two-point discrimination
h. point localization
d. Kinesthetics i. Sensory Extinction
• Reflex Function
a. Deep tendon reflexes
b. Superficial reflexes
 Ensure proper hygiene before seeing a client

 Ensure all equipment is properly cleaned
Equipment Needed:
- BP cuff - Objects to touch: coin,
- Tuning fork (128 or 256 button, key or paperclip
Hz) - Something fragrant:
- Penlight rubbing alcohol or coffee
- Nonsterile gloves - Something to taste: such
- Wisp of cotton as lemon juice, sugar or
- Tongue blade salt
- Reflex hammer - Two taste tubes or other
- Sharp object such as vials
toothpick or sterile needle - Ophthalmoscope
 Introduce self to the client.
PHYSICAL EXAMINATION
1. Vital signs 5. Motor system
2. Pupils 6. Sensory Function
3. Mental Status 7. Reflexes
4. Head, neck and back 8. Cranial Nerves
VITAL SIGNS
• Hypotension, bradycardia, hypothermia – tirad in spinal cord
injuries
• Increase in pulse pressure – increase ICP
PUPILS
• Evaluation of eyes provides information about cranial nerve

function, intracranial pressure, ability to follow commands.
– Reactivity of pupils to light is first assessed.
• Approx. 20% of entire population has
ANISOCORIA
– Consensual response is assessed
• CN3
• First indication of hICP is HIPPUS
• BLOWN PUPIL
– Assess extraocular movements
• CN 3,4 and 6
• Gaze palsy
– Assess accomodation
• If blind??
• Nystagmus
MENTAL STATUS
1. Level of Conciousness
– Most sensitive indicator in changes of neurologic
status
• Confusion
• Disorientation
• Lethargy
• Obtundation
• Stupor
• Coma
2. Establish orientation to person, place and time
3. Assess mood and affect
4. Intellectual performance
– Identify commonly known people, places events
– Calculation ability100-7
5. Assess reasoning
– Lion, leopard
6. Language and Communication
– Speech or language
HEAD, NECK AND BACK

• IPPA
– Raccoon eyes
– Battle’s Sign
MOTOR SYSTEM
1. Muscle Size
2. Muscle Strength:
a. 5/5 move actively, full ROM against gravity and
applied resistance
b. 4/5 move actively, full ROM against gravity and
weakness to applied resistance
c. 3/5 move actively against effect of gravity alone
d. 2/5 move with support against effect of gravity
e. 1/5 muscle contraction is palpable
f. 0/5 no muscle movement
3. Muscle Tone
- Resistant to movement, rigid or spastic
4. Muscle coordination
- Rapid alternating movements
- Point-to-point maneuvers
- Truncal balance and head position
5. Gait and Station
GAIT STATION
a. Ataxic • Akinesia
b. Double step • Athetosis
c. Dystonic • Ballismus
d. Dystrophic • Bradykinesia
e. Equine • Chorea
f. Festinating • Myoclonus
g. Helicopod • Tic
h. Hemiplegic • Tremors
i. Parkinsonian
j. Scissors
k. Spastic
l. Steppage
m. Tabethic
ASSESSING THE MENTAL STATUS
1. APPEARANCE/ HYGIENE/ GROOMING/ ODOR

• Begin the assessment as the patient approaches you.
• Observe the general appearance, hygiene, grooming
and the odor of the client.
Normal:
 good grooming,
 dress in appropriate to temperature & weather,
 no offensive or unpleasant odor
 hair well kept or tied
Abnormal:
 Poor hygiene
 Unpleasant or offensive body odor
2. BEHAVIOR
• Assess the client’s mood and emotions
• Observe body language and facial expression or
affect
• Note his or her posture
Normal:
 Verbal expressions match with the nonverbal
behavior
 Mood is appropriate to the situation
 Standing in upright stance with parallel alignment of
hips &shoulders
Abnormal:
 Lack of facial expression
- Possible psychological disorder (e.g., depression or
schizophrenia) or neurologic impairment affecting cranial
nerves.
 Masklike expression:
- Parkinson’s disease.
 Slumped posture:
- Depression if psychological in origin; or stroke with
hemiparesis if physiological in origin.
3. SPEECH/ COMMUNICATION
a. Speech and Language
 Listen to patient’s rate and ease of speech, including
enunciation.
Normal:
 Speech flows easily; patient enunciates clearly.
 Sophistication of speech matches age, education, and fluency.
Abnormal:
■ Hesitancy, stuttering, stammering, unclear speech:
- Lack of familiarity with language, deference or shyness, anxiety,
neurologic disorder.
■ Dysphasia/aphasia:
- Neurologic problems such as stroke.
■ Drugs and alcohol can also cause slurred speech.
b. Spontaneous Speech & Motor Speech

 how patient a picture and have him or her describe what he
or she sees
 Have patient repeat, “do, ray, me, fa, so, la, ti, do.”
Normal:
 Spontaneous speech intact.
 Motor speech intact.
Abnormal:
■ Impaired spontaneous speech:
- Cognitive impairment.
■Impaired motor speech (dysarthria):
-Problem with CN XII
c. Autonomic Speech
 Have patient say something that is committed to memory,
such as days of week or months of year.
Normal:
■ Automatic speech intact.
Abnormal:
■ Impaired automatic speech: Cognitive impairment or
memory problem.
4. LEVEL OF CONSCIOUSNESS
a. Test orientation to time, place, and person
Normal:
 Awake, alert, and oriented to time, place, and person (AAO
x 3)
 Responds to external stimuli
Abnormal:
 Disorientation may be physical in origin
 Disorientation can also be psychiatric in origin
(schizophrenia)
 Lathargic or somnolent
 Obtunded
 Stupor
 Coma
Glasgow Coma Scale

- A standardized objective assessment that defines the LOC
by giving it a numeric value.
- Most often after brain surgery
- Document as E_V_M_; for example, E4V5M6.
GLASGOW COMA SCALE

■
E Spontaneously . . . . . . .. . . Findings
Eyes open 4
■ To command . . . . . . . . . .
3
■ To pain . . . . . . . . . . . . . . .
2
■ Unresponsive. .. . . . . . . . .
1
■
V Oriented . . . . . . . . . . . . . . . Findings
Best verbal 5
response ■
Confused . . . . . . . . . . . . . . .
4
■ Inappropriate . . . . . . . . . .
..3
■
Incomprehensible . . . . . . . .
2
■
Unresponsive. . . . . . . . . .. .
.1
■ Obeys
M commands . . . . . . . .. 6 Findings
Best motor ■ Localizes pain. . . . . . . . . .
response .5
■ Withdraws from pain. . . .
…. 4
■ Abnormal flexion . . . . . . ..
..3
■ Abnormal
extension . . . . . . . 2
■ Unresponsive. . . . . . . . . . .
..1
TOTAL: _________
• The three numbers are added; the total score reflects the
brain functional level.
• A fully awake person = 15
• Coma = 7 or less
• The GCS assesses the functional state of the brain as a
whole, not of any particular site in the brain. (Juarez and
Lyon,1995)
Four Score Coma Measurement Scale
EYE RESPONSE
4 Eyelids open or opened, tracking or blinking to command
3 Eyelids open but not tracking
2 Eyelids closed but open to loud voice
1 Eyelids closed but open to pain
0 Eyelids remain closed with pain
MOTOR RESPONSE
4 Thumbs up, fist, or peace sign to command
3 Localizing to pain
2 Flexion response to pain
1 Extensor posturing
0 No response to pain or generalized myoclonus status
epilepticus
BRAINSTEM
REFLEXES Pupil and corneal reflexes present
4 One pupil wide and fixed
3 Pupil or corneal reflexes absent
2 Pupil and corneal reflexes absent
1 Absent pupil, corneal, and cough reflex
0
RESPIRATION
4 Not intubated, regular breathing pattern
3 Not intubated, Cheyne-Stokes breathing pattern
2 Not intubated, irregular breathing pattern
1 Breathes above ventilator rate
0 Breathes at ventilator rate or apnea
5. MEMORY
a. Test immediate recall:
Ask patient to repeat three numbers, such as “4, 9, 1.” If
patient can do so, ask her or him to repeat a series of five digits.
b. Test recent memory:

Ask what patient had for breakfast.
c. Test long-term memory:

Ask patient to state his or her birthplace, recite his or her
Social Security number, or identify a culturally specific person or
event, such as the name of the previous president of the United
States or the location of a natural disaster.
Normal:
 Immediate, recent, and remote memory intact.
Abnormal:
 Memory problems can be benign or signal a more
serious neurologic problem
- such as Alzheimer’s disease.
 Forgetfulness - especially for immediate and recent events
- often in older adults.
- With benign forgetfulness, person can retrace or use memory
aids to help with recall.
 Pathological memory loss
- as inAlzheimer’s disease
 Temporary memory loss
- may occur after head trauma.
 Retrograde amnesia
- for events just preceding illness or injury.
 Postconcussion syndrome
- can occur 2 weeks to 2 months after injury and may cause short-
term memory deficits.
6. COGNITIVE FUNCTION
a. Mathematical and Calculative Ability
Ask patient to perform a simple calculation, such as adding
4 x 4. If successful, proceed to more difficult calculation, such as
11 9.
Normal:
 Mathematical/calculative ability intact and appropriate for
patient’s age, educational level, and language facility.
Abnormal:
 Inability to calculate at level appropriate to age,
education, and language ability requires evaluation for neurologic
impairment.
b. General Knowledge and Vocabulary

Ask how many days in a week and months in a year.
c. Thought Process
Ask patient to define familiar words such as “apple,”
“earthquake,” and “chastise.”
Begin with easy words and proceed to more difficult ones.
Remember to consider the patient’s age, educational level,
and cultural background.
Normal:
 Thought process intact
Abnormal:
 Incoherent speech
 illogical or unrealistic ideas
 repetition of words and phrases
 repeatedly straying from topic
 suddenly losing train of thought (examples of altered
thought processes that indicate need for further evaluation)
 Inability to define familiar words - requires further
evaluation
d. Abstract Thinking
Assess the client to think abstractly.
Quote a proverb and ask the client to explain it’s meaning
Normal:
 Able to generalize from specific example and apply
statement to human behavior.
 Children should be able
to distinguish like from unlike as appropriate for theirage and
language facility.
Abnormal:
■ Impaired ability to think abstractly:
- Dementia, delirium, mental retardation, psychoses.
e. Judgment
Observe patient’s response to current situation.
Ask patient to respond to a situation or hypothetical
situation.
Normal:
 Judgment appropriate and intact.
Abnormal:
 ■ Impaired judgment can be associated with dementia,
 psychosis, or drug and alcohol abuse.
Assessing the CRANIAL NERVES
1. CN I—Olfactory Nerve
a. Before testing nerve function, ensure patency of each nostril by
occluding in turn and asking patient to sniff.
b. Once patency is established, ask patient to close
eyes.
c. Occlude one nostril and hold aromatic substance
such as coffee beneath nose.
d. Ask patient to identify
substance.
e. Repeat with other nostril.
Normal:
■ Patient is able to identify substance.
(Bear in mind that
some substances may be unfamiliar, especially to
children.)
Abnormal:
■ Anosmia is loss of sense of smell.
- May be inherited and nonpathological: chronic rhinitis,
sinusitis, heavy smoking, zinc deficiency, or cocaine use.
- It may also indicate cranial nerve damage from facial
fractures or head injuries, disorders of base of frontal lobe
such as a tumor, or artherosclerotic changes.
- Persons with anosmia usually also have taste problems.
2. CNs II, III, IV, and VI—Optic, Oculomotor, Trochlear, and

Abducens Nerves
a. Ask the client to read a printed material, observe the
distance between the printed material and the client’s eyes.
b. Use the snellen chart to check/ test:
- distant vision
- color
Client should be 20 feet distant from the chart
Use an object to occlude one eye
Evaluate the vision one eye at a time
c. Evaluate the Extra Ocular Movements of the Eyes

d. Convergens & Accomodation
e. Pupillary Light Reflex
- using direct and consensual pupillary reaction to light
Normal:
■ Able to read without difficulty
■ Visual acuity intact 20/20, both eyes
 Hippus phenomenon: - Brisk constriction of pupils in
reaction to light, followed by dilation and constriction
- may be normal or sign of early CN III compression.
Abnormal:
■ CN II deficits
- can occur with stroke or brain tumor.
■ Changes in pupillary reactions
- can signal CN III deficits.
■ Increased ICP causes changes in pupillary reaction.
As pressure increases, response becomes more sluggish
until pupils finally become fixed and dilated.
3. CN V—Trigeminal Nerve
a. Testing motor function:
- Ask patient to move jaw from side to side against
resistance and then clench jaw as you palpate contraction of
temporal and masseter muscles, or to bite down on a tongue
blade.
b. Testing sensory function:

- Ask patient to close eyes
- Touch the face with the wisp of cotton
- Instruct to tell you when he or she feels sensation on
the face.
- Repeat the test using sharp and dull stimuli
(toothpick)
- Instruct to say “Sharp” or “Dull”
(Be random, don’t establish a pattern)
- Compare both bilaterally.
c. Testing corneal reflex:

- Gently touch cornea with cotton wisp.
(Touching cornea can cause abrasions. Alternative approach is to)
> puff air across cornea with a needles, syringe, or
> gently touch eyelash and look for blink reflex
Normal:
 Full range of motion (ROM) in jaw and 15 strength.
 Patient perceives light touch and superficial pain bilaterally.
Abnormal:
 Weak or absent contraction unilaterally:
- Lesion of nerve, cervical spine, or brainstem.
 Inability to perceive light touch and superficial pain
- may indicate peripheral nerve damage.
■ Tic douloureux:
- Neuralgic pain of CN V caused by the pressure of degeneration of
a nerve.
■ Corneal reflex test used in patients with decreased LOC
- to evaluate integrity of brainstem.
4. CN VII—Facial Nerve
a. Testing motor function:
- Ask patient to perform these movements: smile, frown,
raise eyebrows, show upper teeth, show lower teeth, puff out
cheeks, purse lips, close eyes tightly while nurse tries to open
them.
b. Testing sensory function:

- Test taste on anterior two-thirds of tongue for sweet,
sour, salty.
 Sweet: Tip of the tongue
 Sour: Sides of back half of tongue
 Salty: Anterior sides and tip of tongue

 Bitter: Back of tongue
Normal:
 Facial nerve intact; able to make faces.
 Taste sensation on anterior tongue intact.
(Taste decreased in older adults.)
Abnormal:
 Asymmetrical or impaired movement:
- Nerve damage, such as that caused by Bell’s palsy or stroke.
■ Impaired taste/loss of taste: - Damage to facial nerve,
chemotherapy or radiation therapy to head and neck.
5. CN VIII—Acoustic Nerve
a. Perform Weber and Rinne tests for hearing
b. Perform watch-tick test by holding watch close to patient’s
ear.
c. Perform Romberg test for balance
- Nurse at the back or side of the pt.
- Instruct client to stand straight, feet together, hands at the
side and eyes closed.
(Evaluates the balancing function of the CN VIII)
Normal:
 Hearing intact.
 Negative Romberg test.
Abnormal:
 Hearing loss, nystagmus, balance disturbance,
dizziness/vertigo:
- Acoustic nerve damage.
■ Nystagmus:
- CN VIII, brainstem, or cerebellum problem or
phenytoin (Dilantin) toxicity.
6. CNs IX and X—Glossopharyngeal and Vagus Nerves

a. Observe ability to cough, swallow, and talk.
b. Test motor function:
- Ask patient to open mouth and say “ah” while you depress
the tongue with a tongue blade.
- Observe soft palate and uvula. Soft palate and uvula
should rise medially.
c. Test sensory function of CN IX and motor function of CN X by
stimulating gag reflex.
- Tell patient that you are going to touch interior throat
- then lightly touch tip of tongue blade to posterior
pharyngeal wall.
- Observe the pharyngeal movement.
- Ask the client to drink a small amount of water
Note the ease & difficulty of swallowing
Note quality of the voice or hoarseness when

speaking
Normal:
 Swallow and cough reflex intact.
 Speech clear.
 Elevation and constriction of pharyngeal musculature and
tongue retraction indicate positive gag reflex.
Abnormal:
 Unilateral movement:
- Contralateral nerve damage.
- Damage to CNs IX and X also impairs swallowing.
■ Changes in voice quality (e.g., hoarseness): CN X damage.
- CN X damage may also affect vital functions, causing
arrhythmias because vagus nerve innervates most of viscera
through parasympathetic system.
■ Diminished/absent gag reflex: Nerve damage.
- Evaluate further because patient is at increased risk for
aspiration.
■ Impaired taste on posterior portion of tongue: Problem with CN
IX.
7. CN XI—Accessory Nerve
a. Test motor function of shoulder and neck muscles:
- Ask patient to shrug shoulders upward against your
resistance. (Trapieze muscle)
- Then ask her or him to turn head from side to side against
your resistance.
(Strenoclaidomastoid msucle)
- Observe for symmetry of contraction and muscle strength.
Normal:
■ Movement symmetrical, with patient moving against resistance
without pain.
■ Full ROM of neck with +5/5 strength.
Abnormal:
 Asymmetrical
 Diminished
 Absent movement
 Pain
 unilateral or bilateral weakness: - Peripheral nerve CN XI
damage.
8. CN XII—Hypoglossal Nerve
a. Have patient say “d, l, n, t” or a phrase containing these letters.
- The ability to say these letters requires use of the
tongue.
b. Ask the patient to protrude the tongue.
Observe any deviation from midline, tumors, lesions, or
atrophy.
Now ask the patient to move the tongue from

side to side.
Normal:
 Can protrude tongue medially.
 No atrophy, tumors, or lesions.
Abnormal:
■ Asymmetrical/diminished/absent movement/deviation from
midline/protruded tongue: - Peripheral nerve CN XII damage.
■ Tongue paralysis results in dysarthria.
Assessing Sensory Function

1. Light Touch
- Brush a light stimulus such as a cotton wisp over patient’s skin in
several locations, including torso and extremities.
Normal:
 Identifies areas stimulated by light touch.
Abnormal:
■ Diminished/absent cutaneous perception:
-Peripheral nerve damage or damage to posterior column of spinal
cord.
- Peripheral neuropathies can also cause sensory deficits.
■ Hypesthesia: Increased sensitivity.
■ Paresthesia: Numbness and tingling.
■ Anesthesia: Loss of sensation.
2. Pain
- Stimulate skin lightly with sharp and dull ends of toothpick/ paper
clip
-Apply stimuli randomly and ask patient to identify whether
sensation is sharp or dull.
-Touch patient’s skin with test tubes filled with hot or cold water.
-Apply stimuli randomly, and ask patient to identify whether
sensation is hot or cold.
Normal:
 Identifies areas stimulated and type of stimulation.
Abnormal:
■ Diminished or absent pain perception:
- Peripheral nerve damage or damage to lateral spinothalamic
tract.
■ Hyperalgia:
Increased pain sensation.
■ Hypoalgesia:
Decreased pain sensation.
■ Analgesia: No pain sensation.
■ Diminished/absent temperature perception:
- Peripheral nerve damage or damage to lateral spinothalamic

tract
3. Vibration
-Place a vibrating tuning fork over a finger joint, and then over a
toe joint.
- Ask patient to tell you when vibration is felt and when it
stops.
- If patient is unable to detect vibration, test proximal areas
as well.
Normal:
 Vibratory sensation intact bilaterally in upper and lower
extremities.
Abnormal:
 Diminished/absent vibration sense:
- Peripheral nerve damage caused by alcoholism, diabetes, or
damage to posterior column of spinal cord.
4. Kinesthetics (Position Sense)

- Determine patient’s ability to perceive passive movement of
extremities.
- Hold fingers on sides and move up and down, and have
patient identify direction of movement.
Flex and extend patient’s big toe, and ask patient to
describe movement as up or down.
• Avoid moving the patient’s finger by placing your finger on

top of the patient’s because the
patient may sense the pressure of your finger rather than a true
position change.
• If position sensation is intact distally, it is intact
proximally.
Normal:
 Position sensation intact bilaterally in upper and lower
extremities.
Abnormal:
 Diminished or absent position sense:
 Peripheral nerve damage or damage to posterior column of
spinal cord.
5. Stereognosis
-With patient’s eyes closed, place a familiar object, such as a coin
or a button, in patient’s hand, and ask patient to identify it.
-Test both hands using different objects.
Normal:
 Stereognosis intact bilaterally.
Abnormal:
 ■ Abnormal findings suggest a lesion or other disorder

involving sensory cortex or a disorder affecting posterior
column.
6. Graphesthesia
- With patient’s eyes closed, use point of a closed
pen to trace a number on patient’s hand
- Ask patient to identify the number.
Normal:
Graphesthesia intact bilaterally
Abnormal:
■ Abnormal findings suggest lesion or other disorder involving
sensory cortex or disorder affecting posterior column.
7. Two-Point Discrimination
Ability to differentiate between two points of
simultaneous stimulation.
- Using ends of two toothpicks/ paper clip, stimulate two
points on fingertips simultaneously.
- Gradually move toothpicks together, and assess
smallest distance at which patient can still discriminate two
points (minimal perceptible distance).
- Document distance and location.
Normal:
■ Discriminates between two points on fingertips no
more than 0.5 cm apart and on hands no more than 2 cm apart.
Abnormal:
■ Abnormal findings suggest lesion or other disorder involving
sensory cortex or disorder affecting posterior
column.
8. Point Localization
■ Ability to sense and locate area being stimulated.
■ With patient’s eyes closed, touch an area; then have
patient point to where he or she was touched.
■ Test both sides and upper and lower extremities.
Normal:
 Point localization intact.
Abnormal:
 Abnormal findings suggest lesion or other disorder involving
sensory cortex or disorder affecting posterior column.
9. Sensory Extinction
■ Simultaneously touch both sides of patient’s body
at same point.
■ Ask patient to point to where she or he was
touched.
Normal:
 Extinction intact.
Abnormal:
 Identification of stimulus on only one side suggests lesion or
other disorder involving sensory cortical region in opposite
hemisphere.
REFLEXES
Documenting Reflex Findings
• Use these grading scales to rate the strength of each reflex
in a deep tendon and superficial reflex assessment.
Deep tendon reflex grades

0 absent
+ present but diminished
+ + normal
+++ increased but not necessarily pathologic
++++ hyperactive or clonic (involuntary
contraction and relaxation of skeletal muscle)
Superficial reflex grades

0 absent
+ present
• Documentation of reflex finding
ASSESSING REFLEXES
1. Deep Tendon Reflexes
a. Biceps Reflex
■ Rest patient’s elbow in your nondominant hand,
with your thumb over biceps tendon.
■ Strike your thumbnail.
Normal:
■ Contraction of biceps with flexion of forearm.
■ +2
b. Triceps Reflex
■ Abduct patient’s arm and flex it at the elbow.
■ Support the arm with your nondominant hand.
■ Strike triceps tendon about 1 to 2 inches above olecranon
process, approaching it from directly behind.
Normal:
■ Contraction of triceps with extension at elbow.
■ +2
c. Patellar Reflex
■ Have patient sit with legs dangling.
■ Strike tendon directly below patella..
Normal:
■ Contraction of quadriceps with extension of knee.
■+2
d. Achilles Reflex
■ Have patient lie supine or sit with one knee flexed.
■ Holding patient’s foot slightly dorsiflexed, strike Achilles tendon.
Normal:
■ Plantar flexion of foot.
■+2
e. Test for Ankle Clonus

■ If you get 4 reflexes while supporting leg and foot, quickly
dorsiflex foot.
Normal:
■ No contraction
Abnormal:
■ Absent/diminished DTRs:
- Degenerative disease; damage to peripheral nerve such as
peripheral neuropathy; lower motor neuron disorder, such as ALS
and Guillain-Barré syndrome.
■ Hyperactive reflexes with clonus:
- Spinal cord injuries, upper motor neuron disease such as MS.
■ Rhythmic contraction of leg muscles and foot is positive sign of
clonus
- indicates upper motor neuron disorder.
2. Superficial Reflexes
a. Abdominal Reflex
■ Stroke patient’s abdomen diagonally from upper and lower
quadrants toward umbilicus.
■ Contraction of rectus abdominis. Umbilicus moves toward
stimulus.
a. Abdominal Reflex
■ Gently stroke skin around anus with gloved finger.
Normal:
■ Anus puckers.
b. Cremasteric Reflex
■ Gently stroke inner aspect of a male’s thigh.
Normal:
■ Testes rise.
c. Bulbocavernosus Reflex
■ Gently apply pressure over bulbocavernous muscle on dorsal
side of penis.
Normal:
■ Bulbocavernosus muscle contracts.
d. Plantar Reflex (Babinski’s Response)

■ Stroke sole of patient’s foot in an arc from lateral heel to medial
ball.
Normal:
■ Flexion of all toes.
Assessing the Cerebellar Function

1. Balance tests
a. Gait
Observe as the person walks 10-20 feet, turns, and returns
to the starting point.
Normal:
 Person moves with a sense of freedom.
 Gait is smooth, rhythmic, and effortless
 Opposing arm swing is coordinated
 The turns are smooth
Abnormal:
 Stiff, immobile posture. Staggering or reeling. Wide base of
support
 Lack of arm swing or rigid arms
 Unequal rhythm of steps. Slapping of foot. Scraping of toe of
shoe
 Ataxia – uncoordinated or unsteady gait.
Perform 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.
Normal:
 Person can walk straight and stay balanced
Abnormal:
 Crooked line walk
 Widens base to maintain balance
 Staggering, reeling, loss of balance
 An ataxia that did not appear now. Inability to tandem walk
is sensitive for an upper motor neuron lesion, such as
multiple sclerosis.
b. The Romberg Test

(discussed previously)
• Ask the person to perform a shallow knee bend or hop in
place, first on one leg, then the other.
- this demonstrates normal position sense, muscle strength,
and cerebellar function.
(some individuals cannot hop owing to aging or obesity)
Normal:
 Negative Romberg test
Abnormal:
 Sways, falls, widens base of feet to avoid falling
 Positive Romberg sign
- Loss of balance that occurs when closing the eyes.
- Occurs with cerebellar ataxia (multiple sclerosis,
alcohol intoxication)
- Loss of proprioception, and loss of vestibular function
2. Coordination and Skilled Movements

a. Rapid Alternating Movements (RAM)
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 to do this faster.
Normal:
 done with equal turning and quick rhythmic pace
Abnormal:
 Lack of coordination
 Dysdiadochokinesia
- Slow, clumsy, and sloppy response
- occurs with cerebellar disease
b. Finger-to-Finger test
With the persons eyes open, ask that he or she use index
finger to touch your finger, then his or her own nose.
After a few times move your finger to a different spot.
Normal:
 Movement is smooth and accurate
Abnormal:
 Dysmetria
- clumsy movement with overshooting the mark
- occurs with cerebellar disorder
 Past-pointing
- constant deviation to one side
c. Finger-to-nose test
Ask the person to close the eyes and to 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.
Normal:
 Done with accurate and smooth movement
Abnormal:
 Misses nose.
 Worsening of coordination when the eyes are closed
- occurs with cerebellar disease

Neurologic Assessment

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Neurologic Assessment

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Caytiles, Joessel Marie T.

REVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE NEUROLOGIC SYSTEM

General functions of the neurologic system include:

There are two types of nerve cells:

Neurons band together into

These structures make up the neurologic system, which is divided into

CENTRAL NERVOUS SYSTEM

THE SPINAL CORD

• Spinal reflexes do not depend on conscious perception and interpretation of

PERIPHERAL NERVOUS SYSTEM

I-Olfactory nerve – Smell (S)

XI-Accessory nerve/Spinal accessory nerve (M) - Controls muscles

SPINAL AND PERIPHERAL NERVES

Dermatomes - are regions of the body innervated by the

Components of Neurologic Exam

 Ensure proper hygiene before seeing a client

 Introduce self to the client.

• Evaluation of eyes provides information about cranial nerve

HEAD, NECK AND BACK

ASSESSING THE MENTAL STATUS

1. APPEARANCE/ HYGIENE/ GROOMING/ ODOR

 Unpleasant or offensive body odor

b. Spontaneous Speech & Motor Speech

Glasgow Coma Scale

GLASGOW COMA SCALE

Four Score Coma Measurement Scale

b. Test recent memory:

c. Test long-term memory:

b. General Knowledge and Vocabulary

Assessing the CRANIAL NERVES

2. CNs II, III, IV, and VI—Optic, Oculomotor, Trochlear, and

c. Evaluate the Extra Ocular Movements of the Eyes

b. Testing sensory function:

c. Testing corneal reflex:

b. Testing sensory function:

 Salty: Anterior sides and tip of tongue

6. CNs IX and X—Glossopharyngeal and Vagus Nerves

Note quality of the voice or hoarseness when

Now ask the patient to move the tongue from

Assessing Sensory Function

- Peripheral nerve damage or damage to lateral spinothalamic

4. Kinesthetics (Position Sense)

• Avoid moving the patient’s finger by placing your finger on

 ■ Abnormal findings suggest a lesion or other disorder

Deep tendon reflex grades

Superficial reflex grades

• Documentation of reflex finding

e. Test for Ankle Clonus

d. Plantar Reflex (Babinski’s Response)

Assessing the Cerebellar Function

Perform Tandem Walking

b. The Romberg Test

2. Coordination and Skilled Movements

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