c
 





 

Objective:

{p |escribe the anatomy and physiology of the nervous system.

{p |evelop questions to be used when completing the focused interview.
{p |escribe the techniques required for assessment of the nervous system.
{p |ifferentiate normal from abnormal findings in physical assessment of the neurologic
system.
{p |escribe developmental, cultural, psychosocial, and environmental variations in
assessment techniques and findings of the neurologic system.

|iscussion:
{p  amination of the neurologic system includes assessment of a) mental status including
level of consciousness, b)the cranial nerve, c) refle es, d) motor function and e) sensory
function.

Materials Needed:
{p percussion hammer
{p tongue depressor(one broken diagonally for pain sensation)
{p wisps of cotton to assess light-touch sensation, test tubes of hot and cold water for skin
temperature assessment(optional)

Procedure Performed Mastered Remarks

Yes No

1.  plain to the client what you are

going to do, why it is necessary,
and how he or she can
cooperate. |iscuss how the results
will be used in planning further care
or treatments.

2.Wash hands and observe

appropriate infection control
procedures.

3. Provide for client privacy.

4. Inquire if the client has any history

of the following: presence of pain in
the back, or e tremities, as well as
onset and aggravating and
alleviating factors; disorientation to
time, place, or person; speech
disorder; any history of loss of
consciousness, fainting, convulsions,
trauma, tingling or numbness,
tremors or tics, limping, paralysis,
uncontrolled muscle movement,
loss of memory, mood swings, or
problems with smell, vision, taste,
touch or hearing.

›
 
5. Any defects in or loss of the
power to e press oneself by
speech, writing or signs or to
comprehend spoken or written
language due to disease or injury of
the cerebral corte is called
aphasia.
If the client displays difficulty
speaking:
{p Point to common objects
and ask the client to name
them.
{p Ask the client to read some
words and to match the
printed and written words
with pictures.
{p Ask the client to respond to
simple verbal and written
commands, e.g., ´point to
your toesµ or ´raise your left
armµ.



 


5. |etermine the client·s orientation
to time, place and person by
tactful questioning. Ask the client
the city and state or residence,
time of the day, date, day of the
week, duration of illness. And
names of family members. More
direct questioning may be
necessary for some people, e.g.,
´Where are you now?µ, ´What day
is it today?µ. Most people readily
accept these questions if initially
the nurse asks, ´|o you get
confused at times?µ If the client
cannot answer these questions
accurately, also include assessment
of the self by asking the client to
state his or her full name.

 
7. Listen for lapses in memory. Ask
the client about difficulty with
memory. If the problems are
apparent, three categories of
memory are tested: immediate
recall, recent memory, and remote
memory.

To assess immediate recall:

{p Ask the client to repeat a
series of three digits, e.g., 7-
4-3, spoken slowly.
{p àradually increase the
number of digits ,e.g., 7-4-3-
5, 7-4-3-5-6 and 7-4-3-5-6-7-
2, until the client fails to
repeat the series correctly.
{p atart again with a series of
three digits, but this time ask
the client to repeat them
backward. The average
person can repeat a series
of five to eight digits in
sequence and four to si
digits in reverse order.

To assess recent memory:

{p Ask the client to recall the
recent events of the day,
such as how the client got
to the clinic. This information
must be validated,
however.
{p Ask the client to recall
information given early in
the interview, e.g., the
name of a doctor.
{p Provide the client with three
facts to recall, e.g., a color,
an object, an address, or a
three digit number and ask
the client to repeat all three.
Later in the interview, ask
the client to recall all three
items.
To assess remote memory, ask the
client to describe a previous illness
or surgery, e.g., 5 years ago or a
birthday or anniversary.






 ›› 


8. Test the ability to concentrate or
attention span by asking the client
to recite the alphabet or to count
backward from 100. Test the ability
to calculate by asking the client to
subtract 7 or 3 progressively from
100, i.e., 100,93, 86, 79, or 100, 97,
94, 91(referred to as serial sevens or
serial threes). Normally an adult can
complete serial sevens test in about
90 seconds with three or fewer
errors. Because educational level
and language or cultural
differences affect calculating
ability, this test maybe in
appropriate for some people.

››


 

9. Apply àlasgow Coma acale: eye
response, motor response, and
verbal response. An assessment
totaling 15points indicates the client
is alert and completely oriented. A
comatose client scores 7 or less.



›
 
10. For the specific functions and
assessment methods of each
cranial nerve. Test each nerve not
already being evaluated in another
component in another component
of the health assessment.

›
11. Test refle es using a percussion
hammer, comparing one side of
the body with the other to evaluate
the symmetry of response.

X
  The biceps refle tests

the spinal cord level C-5, C-6.

{p Partially fle the client·s arm

at the elbow, and rest the
forearm over the thighs,
placing the palm of the
hand down.
{p Place the thumb of your
nondominant hand
horizontally over the biceps
tendon.
{p |eliver a blow(slight
downward thrust) with the
percussion hammer to your
thumb.
{p Observe the normal slight
fle ion of the elbow, and
 feel the bicep·s contraction
through your thumb


 The triceps refle test

the spinal cord level C-7, C-8.

{p Fle the client·s arm at the

elbow, and support it in the
palm of your nondominant
hand.
{p Palpate the triceps tendon 2
to 5 cm(1 to 2 inches)
above the elbow.
{p |eliver a blow with the
percussion hammer directly
to the tendon.
{p Observe the normal slight
e tension of the elbow.

X

    The
barchioradialis refle test the spinal
cord level C-3, C-6.

{p Rest the client·s arm in a

rela ed position on your
forearm or on the client·s
own leg.
{p |eliver a blow with the
percussion hammer directly
on the radius 2 to 5 cm (1 to
2 inches) above the wrist or
the styloid process, the bony
prominence on the thumb
side of the wrist.
{p Observe the normal fle ion
and suppination of the
forearm. The fingers of the
hand may also e tend
slightly.

c  The patellar refle

tests the spinal cord level
L-2, L-3, L-4.

{p Ask the client to sit on the

edge of the e amining
table so that the legs hang
freely.

{p Locate the patellar tendon

directly below the patella
 (kneecap)

{p |eliver a blow with the

percussion hammer directly
to the tendon.

{p Observe the normal

e tension or kicking out of
the legs as the quadriceps
muscle contracts.

{p If no response occurs and

you suspect the client is not
rela ed, ask the client to
interlock the fingers and
pull. This action often
enhances rela ation so that
a more accurate response is
obtained.

D
 . The Achilles refle

tests the spinal cord level a-1, a-2.

{p With the client in the same

position as for the patellar
refle , slightly dorsifle the
client·s ankle by supporting
the foot lightly in the hand.

{p |eliver a blow with the

percussion hammer directly
to the Achilles tendon just
above the heel.

{p Observe and feel the

normal plantar fle ion
(downward jerk) of the foot.

c X   . The

planter, or Babinski, refle is
superficial. It may be absent in
adults without pathology or
overridden by voluntary control.

{p Yse a moderately sharp

object, such as the handle
of the percussion hammer,
a key, or the dull end of a
pin or applicator stick.

{p atroke the lateral border of

the sole of the clients foot,
 starting at the heel,
continuing to the ball of the
foot toward the big toe.

{p Observe the response.

Normally, all five toes bend
downward; this reaction is
negative Babinski. In an
abnormal Babinski response
the toes spread outward
and the big toe moves
upward.

 




12. àross motor and Balance test
àenerally, the Romberg test and
one other gross motor function and
balance teste are used.

Ñ  

Ask the client to walk across the
room and back, and assess the
client s gait.


Ask the client to stand with feet
together and arms resting at the
sides, first with eyes open, then
closed. atand close during this test
to prevent the client from falling.

 

 

    



Ask the client to close the eyes and
stand on one foot and then the
other. atand close to the client
during this test.


 
Ask the client to walk a straight line,
placing the heel of one foot
directly infront of the toes of the
other foot.



  
Ask the client to walk several steps
on the toes and then on the heels.

13. Fine Motor Test for the Ypper

 tremities

 


Ask the client to abduct and
e tend the arms at shoulder height
and rapidly touch the nose
alternately with one inde finger
and then the other. The client
repeats the test with the eyes
closed if the test is performed easily.

D   

 



 

Ask the client to pat both knees
with the palms of both hands and
then with the backs of the hands
alternately at an ever increasing
rate.

  
 
  
   
 
Ask the client to touch the nose
and then your inde finger, held at
a distance at about 45 cm(18in), at
a rapid and increasing rate.

 
 :
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 and
then rapidly.

 
    
Ask the client to touch each finger
of one hand to the thumb of the
same hand as rapidly as possible.

14. Fine Motor Tests for the Lower

 tremities

Ask the client to lie supine and to

perform this test.




  
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 use
a sitting position for this test.



 
 

 
   
 
Ask the client to touch your finger
with the large toe of each foot.

15. Light-Touch sensation

Compare the light touch sensation
of symmetric areas of the body.

{p Ask the client to close the

eyes and to respond by
saying ´yesµ or ´nowµ
whenever the client feels
the cotton wisp touching
the skin.

{p With a wisp of cotton, lightly

touch one specific spot and
then the same the same
spot on the other side of the
body.

{p Test areas on the forehead,

cheek, hand, lower arm,
abdomen, foot, and lower
leg. Check a specific area
of the limb first (i.e, the hand
before the arm and the foot
before the leg), because
the sensory nerve maybe
assumed to be intact if
sensation is felt at its most
peripheral part.

{p Ask the client to point to the

spot where the touch was
felt. This demonstrates
whether the client is able to
determine tactile location
(point localization), i.e, can
accurately perceive where
the client was touched.

{p If areas of sensory
dysfunction are found,
determine the boundaries
of sensation by testing
responses about every 2,5
cm ( 1 in) in the area.
Make a sketch of the
sensory loss area for
recording purposes.
16. Pain aensation

Assess pain sensation as follows:

{p Ask the client to close the
eyes and to say ´sharpµ
´dullµ or ´don·t knowµ when
the sharp or dull end of the
broken tongue depressor is
felt.

{p Alternately, use the sharp or

dull end of a sterile pin or
needle to lightly prick
designated anatomic areas
at random, e.g, hand,
forearm, foot, lower leg,
abdomen. The face is not
tested in this manner.
Alternating the sharp and
dull end of the instrument
accurately evaluates the
client s response.

{p Allow at least 2 seconds

between each test to
prevent summation effects
of stimuli, i.e., several
successive stimuli perceived
as one stimulus.

17. Temperature aensation

Temperature sensation is not

routinely tested if pain sensation is
found to be within normal limits. If
pain sensation is not normal or is
absent, testing sensitivity to
temperature may prove more
reliable.

{p Touch skin areas with test

tubes filled with hot or cold
water.

{p mave the client respond by

saying ´hotµ , ´coldµ or
´don·t knowµ

18. Position or Kinesthetic aensation

Commonly, the middle fingers and

the large toes are tested for the
kinesthetic sensation (sense of
position)

{p To test the fingers, support

the client s palm in the
other. To test the toes, place
the client s heels on the
e amining table.

{p Ask the client to close the

eyes.

{p àrasp a middle finger or a

big toe firmly between your
thumb and inde finger,
and e ert the same pressure
on both sides of the finger or
toe while moving it.

{p Move the finger or toe until

it is up, down, or straight out,
and ask the client to identify
the position.

{p Yse a series of brisk up ² and

² down movements before
bringing the finger or toe
suddenly to rest in one of
the three positions.

19. Tactile |iscrimination

For all tests, the client s eyes needs

to be closed.

   
  

 
 

Alternately stimulate the skin with
two pins simultaneously and then
with one pin. Ask whether the client
feels one or two pinpricks.



     
 

 




  
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 has a motor impairment

of the hand and is unable to
manipulate an object, write a
number or letter on the client s
palm, using a blunt instrument, and
ask the client to identify it.

 

 


aimultaneously stimulate two
symmetric areas of the body, such
as the thighs, the cheek, or the
hands.

20. |ocument findings in the client

record using forms or checklist
supplemented by narrative notes
when appropriate. |escribe any
abnormal findings in objective
terms, e.g, ´When asked to count
backwards by threes, client made
seven errors and completed the
task in 4 minutes.