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ASSESSING THE NEUROLOGIC SYSTEM

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.

• Use collected data to help assess client's general health.

• Differentiate expected from unexpected findings in physical assessment.

Interview Assessment:

• Determine any significant medical history such as seizures, headaches, head injury, mental, or emotional problems.

If any are identified, conduct a more thorough symptom analysis.

• Note general appearance, grooming, personal hygiene.

• 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

which the client responds.

• Assess the client's orientation to person, place, and time.

• Ask about any numbness, tingling, or weakness of the arms, legs, hands, or feet.

• Ask about any vision, taste, or hearing problems.

• Determine any history of balance problems or unsteadiness when walking.

Equipment:

• Examination gown

• Examination gloves

• Percussion hammer

• Tuning fork

• Sterile cotton balls

• Penlight

• Stethoscope

• Sterile needle

• Tongue blade

• Cotton tipped applicator

• Hot and cold water in test tubes

• Objects to touch such as coins, a paper clip, or safety pin

• Substances to smell, such as vanilla, mint, or coffee

• Substances to taste such as sugar, salt, lemon, or grape

Preparation:

• Knowledge of norms or expected findings is essential in determining the meaning of the data as one proceeds.

• Identify client and introduce self.

• 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.

• Provide for client privacy.

• Perform hand hygiene and adhere to standard precautions.


PROCEDURE ABNORMAL FINDINGS
1. Assessing the client's sensorium Impairment noted by short or long term memory difficulty.

Full alertness. Inability to process information during questioning.

Grade the level of alertness on a scale from full alertness to

coma.

2. Assess abstract thinking ability

The client should demonstrate an ability to think abstractly.

(Be aware that age and culture influence the ability to explain

proverbs.)

3. Assessing mood and emotions

Moods and emotions should reflect the current situation or

response to events that trigger mood change or call for an

emotional response. For example, a change in health status, a

loss, or stressful event.

The facial expression and tone of voice should be congruent

with the content and context of the communication.

4. Assessing perceptions and thought processes

The client's statements should be logical and relevant. The

client should complete thoughts.

5. Assessing judgment ability

The client's responses should reflect the reality of the

client's health and psychological stability, as well as family

situation and obligations.

6. Testing trigeminal nerve

Observe for symmetry of movement of the mandible without Decreased strength on one or both sides

deviation from midline. Asymmetry in jaw movement

Pain with clenching of teeth

7. Testing facial nerve

Look for symmetry of facial movements. Muscle weakness is shown by loss of the nasolabial fold,

drooping of one side of the face, lower eyelids sagging, and

escape of air from only one cheek that is pressed in

Loss of movement and asymmetry of movement occur with

both central nervous system and peripheral nervous systems

lesions

8. Testing motor activity of the glossopharyngeal and

vagus nerves Absence or asymmetry of soft palate movement

Normally, the soft palate rises and the uvula remains in the Uvula deviates to the side

midline. Asymmetry of tonsillar pillar movement

Hoarse or brassy voice occurs with vocal cord dysfunction;

nasal twang occurs with weakness of soft palate

9. Testing accessory nerve by testing the trapezius

muscle

Observe the equality of the shoulders, symmetry of action, Atrophy


and lack of fasciculations. Muscle weakness or paralysis

10. Assessing gait and balance

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

to maintain balance during all activities. of position sense.

11. Performing the Romberg test


With eyes open, the client should not sway. Swaying normally Sways, falls., widens base of feet to avoid falling

increases slightly when the eyes are closed.

12. Performing the finger-to-nose test


Observe the movement of the arms, the smoothness of the Misses nose. Worsening of coordination when the eyes are

movement, and the point of contact of finger. The finger closed occurs with cerebellar disease

should touch the nose.

13. Performing the heel-to-shin test

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

14. Assessing the ability to discriminate between two

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

• Finger tips 0.3-0.6 cm graphesthesia.

• Hands and feet 1.5-2 cm

• Lower leg 4 cm

• Note the smallest distance between the points at

which the client can perceive two distinct stimuli.

15. Testing reflexes with a reflex hammer

• Evaluate the response on a scale from 0 to 4+: Hypo, hyper, or unequal responses to

• 0 = no response percussion of the tendon reflexes along with weakened or

• 1+ = diminished spastic muscle response.

• 2+ = normal

• 3+ = brisk, above normal

• 4+ = hyperactive

16. Assessing the biceps reflex Hypo, hyper, or unequal responses to

Contraction of the biceps muscle and slight flexion of the percussion of the tendon reflexes along with weakened or

forearm. spastic muscle response.

17. Assessing the triceps reflex Hypo, hyper, or unequal responses to

Contraction of the triceps muscle with extension of the lower percussion of the tendon reflexes along with weakened or

arm. spastic muscle response.

18. Assessing the brachioradialis reflex Hypo, hyper, or unequal responses to

Flexion of the lower arm and supination of the hand. percussion of the tendon reflexes along with weakened or

spastic muscle response.

19. Assessing the patellar reflex Hypo, hyper, or unequal responses to


Extension of lower leg and contraction of the quadriceps percussion of the tendon reflexes along with weakened or

muscle. spastic muscle response.

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

hand. spastic muscle response.

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

foot occurs with upper motor neuron disease of the corticospinal

(or pyramidal) tract.

22. Assessing the abdominal reflexes

Muscular contraction and movement of the umbilicus toward Superficial reflexes are absent with disease of the pyramidal

the stimulus. tract

23. Performing meningeal assessment

• The client should be able to flex the neck about 45 May indicate presence of meningeal irritation

degrees without pain.

• The Brudzinski's sign is noted when the neck flexion

causes flexion of the legs.

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