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Definition:
The nervous system can be divided into two parts – central and peripheral. The CNS includes the brain and spinal cord.
The PNS includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.
Purpose:
• Assess condition of client's neurologic system by gathering subjective and objective data.
Interview Assessment:
• Determine any significant medical history such as seizures, headaches, head injury, mental, or emotional problems.
• Note the client's speech and language abilities. Throughout the assessment, note the client's rate of speech, ability
to pronounce words, loudness or softness, and ability to talk smoothly and clearly.
• Assess the client's cognitive ability by choice of words, ability to respond to questions, and degree of ease with
• Ask about any numbness, tingling, or weakness of the arms, legs, hands, or feet.
Equipment:
• Examination gown
• Examination gloves
• Percussion hammer
• Tuning fork
• Penlight
• Stethoscope
• Sterile needle
• Tongue blade
Preparation:
• Knowledge of norms or expected findings is essential in determining the meaning of the data as one proceeds.
• Explain each step of the procedure, including specific instructions about what is expected of the client.
• Explain the purposes of each procedure and when and if discomfort will accompany any procedure. Tell the client to
inform you of any discomfort or difficulty at any point during the assessment.
coma.
(Be aware that age and culture influence the ability to explain
proverbs.)
Observe for symmetry of movement of the mandible without Decreased strength on one or both sides
Look for symmetry of facial movements. Muscle weakness is shown by loss of the nasolabial fold,
lesions
Normally, the soft palate rises and the uvula remains in the Uvula deviates to the side
muscle
The posture should demonstrate relaxation, not stiffness. Inability to maintain gait or balance. Inability to perform heel-
Note the equality of steps taken, the pace of walking, the toe walking or difficulty with any of the screening evaluations
position and coordination of arms when walking, and the ability such as rapid rhythmic alternating movement evaluation. Loss
movement, and the point of contact of finger. The finger closed occurs with cerebellar disease
The client should be able to move the heel in a straight line so Lack of coordination
that it doesn't fall off the lower leg. Heel falls off shin
points
Normally, the client is able to perceive two discrete points at Impaired sensory response such as inability to discriminate
the following distances and locations: touch, pain, or objects or sensations as in stereognosis or
• Lower leg 4 cm
• Evaluate the response on a scale from 0 to 4+: Hypo, hyper, or unequal responses to
• 2+ = normal
• 4+ = hyperactive
Contraction of the biceps muscle and slight flexion of the percussion of the tendon reflexes along with weakened or
Contraction of the triceps muscle with extension of the lower percussion of the tendon reflexes along with weakened or
Flexion of the lower arm and supination of the hand. percussion of the tendon reflexes along with weakened or
20. Assessing the Achilles tendon reflex Hypo, hyper, or unequal responses to
Plantar flexion of the foot; the heel will "jump" from your percussion of the tendon reflexes along with weakened or
21. Assessing the plantar reflex Except in infancy, abnormal sign is dorsiflexion of the big toe
Plantar flexion, in which the toes curl toward the sole of the and fanning of all toes which is a positive Babinski’s sign and
Muscular contraction and movement of the umbilicus toward Superficial reflexes are absent with disease of the pyramidal
• The client should be able to flex the neck about 45 May indicate presence of meningeal irritation