Neurological

Assessment

By: Jamal Tango P. Alawiya, RN

 The Central Nervous System
The Brain
- Accounts for approximately 2% of the total
body weight.
- The brain is divided into three major areas
• Cerebrum
• Brain stem
• Cerebellum
Cerebrum
- the largest part of the brain.
- it is composed of two hemispheres.
- each cerebral hemisphere is divided into
lobes, which are named for the skull bones
overlying them.
Cerebral hemispheres:
1. Frontal Lobe: largest lobe located in the front of the brain.
- Function: control of voluntary muscle, concentration,
abstract thought, information storage or memory, motor
function, motivation, mood and Olfactory reception. Critical
for motor control of speech.

2. Parietal Lobe: predominantly sensory lobe posterior to frontal

lobe.
-Function: analyzes sensory information and relays the
interpretation of this information such as touch, pain,
temperature .
Cerebral hemispheres:
3. Temporal Lobe: Located inferior to the frontal and parietal
lobe
-Function: olfactory (smell), Auditory (hearing) sensation and
plays important role in memory of sound and understanding
of language and music.

4. Occipital Lobe: located posterior to the parietal lobe

-Function: responsible for visual interpretation and memory.
Brain Stem
- connects the spinal cord to the remainder of the
brain.
- consists of the midbrain, pons, and medulla
oblongata.
-involved in vital body functions such as the
control of heart rate, BP & breathing.
-damage to small areas of the brainstem can
cause death.
Cerebellum
-located posterior to the midbrain and pons
and below occipital lobe.
- controls fine movement, balance, and
position sense or proprioception.
NEUROLOGICAL
ASSESSMENT
Neurological Assessment
it is a thorough examination of the neurological function of
the patient that involves assessment of the following areas:
cerebral function, cranial nerve function, motor function, sensory
function and reflexes.

Three major things to consider:

1. The client’s chief complaints.

2. The client’s physical condition.
3. The client’s willingness to participate and cooperate.

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Common Symptoms of Neurologic disorders

1. Pain
2. Seizures
3. Dizziness & vertigo
4. Visual Disturbances
5. Muscle weakness
6. Abnormal sensation.
Components of a Neurological Assessment:

1. Mental status
2. Cranial nerves
3. Reflexes
4. Motor Function
5. Sensory Function

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1. Mental Status
Assessment of mental status reveals the clients cerebral
function. These functions include intellectual (cognitive) as
well as emotional (affective) functions.

Major Areas:
a. Language
b. Orientation
c. Memory
d. Attention span and Calculation

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a. Language
The nurse assesses the patient’s ability to response
through Speech, writing, signs, to comprehend spoken or
written language.

Two Types of Aphasia:

• Sensory/Receptive Aphasia – loss of the ability to comprehend

Two Types of Aphasia:
written or spoken words
• Motor/Expressive Aphasia – inability to express oneself by
Auditory – inability to understand sounds
writing, making signs or speaking.
Visual – inability to understand printed or written
figures.

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b. Orientation
The aspect of the assessment determines the client’s
ability to recognize other person(s), awareness of when and
where they presently are and who they are.

c. Memory
The Nurse assess the client’s recall of information
presented second previously (IMMEDIATE RECALL), events or
information from earlier in the day (RECENT MEMORY) and
knowledge recalled from months or years ago
(REMOTE/LONG-TERM MEMORY)

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c. Attention Span & Calculation
The client’s ability to focus on a mental task that is
expected to be able to be performed by persons of normal
intelligence.

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2. Level of Consciousness
In this components, the nurse assesses the client’s eye
response, motor response and verbal response using the
Glasgow Coma Scale.

3. Cranial Nerve

The nurse needs to be aware of specific nerve functions

and assessment methods for each cranial nerve to detect
abnormalities.

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4. Reflexes
to assess the response of the body to a stimulus using a
percussion hammer.

5. Motor Function
neurological assessment of the motor system evaluates
proprioception and cerebellar functions. It also includes
assessment if muscle size tone.

6. Sensory Function
Sensory function include touch, pain, temperature,
position and tactile discrimination.

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NEURO ASSESSMENT
PROCEDURE

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EQUIPMENT:

Tongue depressors
Cotton
Test Tubes of Hot & cold

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 PROCEDURE
Refer to your Manual page 21.

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 Cranial Nerve Assessment
Cranial Nerve Type Function
Olfactory Sensory Smell
Optic Sensory Vision & visual fields
Oculomotor Motor Etraocular movement
Trochlear Motor EOM, movement of the eyeball

Trigeminal Sensory Sensation of cornea,

Abducens Motor EOM, moves eyeball laterally
Facial BOTH Facial Expression; Taste
Auditory Sensory Equilibrium; Hearing
Glossopharyngeal BOTH Swallowing ablaity; tongue movement
taste
Vagus BOTH Sensation of pharynx and larynx;
swallowing; vocal cord movement.
 Cranial Nerve Assessment
Cranial Nerve Type Function
Accessory Motor Head movement;
shrugging of
shoulder
Hypoglossal Motor Protrusion of
tongue, moves
tongue up & down
and side to side
MENTAL STATUS
 MENTAL STATUS
1. Pay close attention to the patient’s general appearance, posture, and grooming.
2. Assess the patient’s level of consciousness, facial expression, mood and
affect.
3. Observe the patient’s speech and language during the interview.
4. Pay attention to the patient’s speech volume, speech rate, articulation and
fluency.
PROCEDURE
5. Assess patient’s thought process and content, his perception, insight and
judgment.
6. Ask patient what he is feeling or his feelings to his surroundings or the world.
7. Observe if the patient’s thoughts are logical, relevant, organized and coherent.
8. Ask if the patient has any abnormal perceptions, such as illusions or
hallucinations.
9. Check if the patient is oriented to person, place and time.
10. Test the patient’s attention span. Like backwards spelling and new learning
ability. Test his remote memory; ask events relevant to his past. Test his recent
memory like asking what he had for breakfast.
11. Assess patient’s knowledge of information, vocabulary, and complexity of
thoughts. Like calculating ability, abstract thinking and constructional ability.
CRANIAL NERVES
ASSESSMENT
 CRANIAL NERVES ASSESSMENT
1. OLFACTORY (CN I)
Test sense of smell on each nostril separately. Have the patient occlude the
opposite nostril and use various scents.
2. OPTIC (CN II)
Check the patient’s visual acuity using the Snellen Chart. If the patient uses eye
glasses or contact lens let him wear it.
Test visual fields. Let the patient follow your finger coming into the visual field
from all directions.
Inspect the optic discs with an ophthalmoscope.
3. OPTIC& OCCULOMOTOR (CN II & III)
Check papillary reaction to light in both eyes.
4. OCCULOMOTOR, TROCHLEAR, and ABDUCENT (CN III, IV, and VI)
Ask the patient to follow your finger as you trace an “H” in mid air.
5. TRIGEMINAL (CN V)
Ask patient to clench his jaw, feel for strength and bulk of the temporalis and
masseter muscles.
6. TRIGEMINAL & FACIAL (CN V & VII)
Check the corneal reflex by lightly touching the cornea with a wisp of cotton.
7. FACIAL (CN VII)
Ask the patient to raise his eyebrows, to close eyes tightly, puff of cheeks, smile, frown, and
show teeth.
8. VESTIBULOCOCHLEAR (CN VIII)
Test hearing by rubbing hairs together or whispering a word into each ear.
Do the Rinne and Weber test as well.
Weber’s Test
A. Using a 512 Hz tuning fork
B. Place vibrating fork mid line skull • Sound should be heard equally R and L for bone
conducts to both sides.
C. If conductive hearing loss (e.g. obstructing wax in canal on L) since it is louder on L as less
competing noise.
D. If sensorineural on L then it is louder on R (Finger in ear mimics conductive loss)
Rinne’s Test
E. Place vibrating 512 hz tuning fork on mastoid bone (behind ear)
F. Patient states when can’t hear sound.
G. Place tines of fork next to ear so that the pt should hear it again – as air conducts better
then bone.
H. If BC better then AC, suggests conductive hearing loss.
I. If sensorineural loss, then AC still > BC (pattern is similar to what is found in people with
normal hearing wherein AC>BC, but patients with sensorineural hearing loss will indicate
that the sound has stopped much earlier)
9. GLOSSOPHARYNGEAL and VAGUS (CN IX and X)
Assess and listen to the patient’s voice. Have the patient drink a glass of
water and check if the uvula is midline when he swallows.
Have the patient say “ahh”, observe if the soft palate rises evenly.
Check the gag reflex on each side.
10. ACCESSORY (CN XI)
Have the patient turn his head and shrug his shoulders against a resistance.
11. HYPOGLOSSAL (CN XII)
Observe the patient’s tongue for any atrophy or fasciculation.
Have the patient stick out his tongue and check if it protrudes midline.
Have the patient press his tongue on the insides of his cheeks.
MOTOR EXAM
 MOTOR EXAM
1. Observe the patient’s posture and stance. Look for any involuntary movements or
tremors.
2. Assess muscle bulk, by inspecting the major muscle groups, and the intrinsic
muscles of the hands.
3. Assess muscle tone and range of motion by passively moving the limbs of a relax
patient.
PROCEDURE
4. Check muscle strength of the following major muscle groups:
Shoulder abduction; elbow flexion and extension;, wrist flexion and extension; thumb
opposition; grip; trunk flexion, extension and lateral movement; hip flexion and
extension; leg flexion and extension; foot dorsiflexion and plantar flexion.
5. Describe muscle strength on a scale from 1-5 as follows:
5/5 – full strength and movement against full resistance.
4/5 – movement against gravity and minimal resistance.
3/5 – movement against gravity only
2/5 – minimal movement present but unable to overcome gravity.
1/5 – tiny traces of detectable movement
0/5 – no detectable movement
6. Assess for pronator drift. Ask the patient to close his eyes and hold their arms out
straight in front with palms up. Keep the position for 30 seconds.
DEEP TENDON REFLEXES
 DEEP TENDON REFLEXES
1. Have the patient relax. Provide support for the extremity to be tested.
2. Compare reflex amplitude of the same tendons on either side of the body.
3. BICEPS
Place your right thumb on the patient’s right biceps tendon (located in the antecubital
fossa) with the patient’s arm slightly flexed.
Strike your thumb with the pointed end of the hammer head. Strike with the least amount of
pressure.
4. TRICEPS TENDON
Have the patient hang his arm freely; support the arm with your non-dominant hand.
With the elbow flexed, strike the elbow directly with the pointed end of the hammer.
5. BRACHIORADIALIS TENDON
Strike the forearm with the hammer about 1” above the wrist over the radius.
6. QUADRICEPS REFLEX
Have the patient sit with his legs hanging over the edge of the table.
Strike the tendon just below the patella.
PROCEDURE
7. ACHILLES REFLEX
Support the foot in dorsiflexed position.
Tap the Achilles tendon with the hammer.
8. PLANTAR REFLEX
Stroke the sole of the patient’s foot with a flat object.
 Documenting Reflexes:

Deep tendon reflexes are graded on a scale of 0-4

0 No response
1+ Diminished (hypoactive)
2+ Normal
3+ Increased (may be interpreted as normal)
4+ hypearctive (hyeprreflexia)

The deep tendon response and plantar reflexes are commonly recorder on
stick figures. The arrow points downward if the plantar response is normal
and upward if the response is abnormal.
SENSORY EXAM
 SENSORY EXAM
1. Patient’s eyes should be closed whenever possible and test should always be
bilateral. Always ask: “Does this feel normal and equal on both sides?”
2. LIGHT-TOUCH SENSATION
Ask the patient to close his eyes.
Let him respond “yes” or “now” when he feels the cotton wisp touching his skin.
With a cotton wisp, lightly touch one specific spot and then the same spot on the other
side of the body.
Ask the patient to point the spot where the touch was felt.
3. PAIN SENSATION
Ask the patient to close his eyes.
Let him respond “sharp”, “dull”, or “don’t know” when he feels the sharp or dull end of
a safety pin or needle is felt.
Alternately use the sharp and dull end of the sterile pin or needle to lightly prick the
hand, forearm, abdomen, lower leg and foot.
Do NOT test the face.
Allow at least 2 seconds between each test.
4. TEMPERATURE SENSATION
Touch skin areas with test tubes filled with either hot or cold water.
Let the patient respond “hot”, “cold”, or “don’t know”
5. KINESTHETIC SENSATION
Ask the patient to close his eyes.
Grasp the patient’s middle finger or big toe by the sides and move it up and down.
Have the patient tell you the orientation of the middle finger or big toe.
6. TACTILE DISCRIMINATION (ONE and TWO POINT DISCIMINATION)
Alternately stimulate the skin with two pins simultaneously and then with one pin.
Ask whether the patient felt one or two pinpricks.
PROCEDURE
7. TACTILE DISCRIMINATION (STEREOGNOSIS)
Place a distinct familiar object like a key in the patient’s palm, and then ask him to
identify it.
8. TACTILE DISCRIMINATION (EXTINCTION PHENOMENON)
Simultaneously stimulate two symmetric areas of the body, and ask the patient
where they were touched.
MOTOR FUNCTION TESTS
 MOTOR FUNCTION TESTS
1. WALKING GAIT
Ask the patient to walk across the room and back. Assess the patient’s gait.
2. ROMBERG TEST
Ask the patient to stand with feet together and arms at the sides.
First with eyes open, then eyes closed.
Let your patient do this for 30 seconds.
Stand close to the patient during this test.
3. STANDING ON ONE FOOT WITH EYES CLOSED
Ask the patient to close his eyes and to stand on one foot, and then with the other foot.
Stand close to the patient during this test.
4. HEEL TOE WALKING
Ask the patient to walk a straight line, placing the heel of one foot directly in front of the
toes of the other foot.
5. FINGER TO NOSE TEST
Have the patient touch your index finger, and then their nose with their index finger back
and forth.
6. ALTERNATING SUPINATION AND PRONATION OF HANDS AND KNEES
Ask the patient to pat both knees with the palms and back of both hands alternately at
an ever increasing rate.
7. FINGERS TO THUMB
Ask the patient to touch each finger of one hand to the thumb of the same
hand as rapidly as possible.
8. HEEL TO SHIN
Have the patient take the heel of one foot and slide it up and down the shin
of the other leg. Repeat with the other foot.
PROCEDURE
9. After the neurological assessment. Place the patient comfortably on bed.
10. Do aftercare.
11. Document all pertinent information, and if there were any abnormalities
noted refer it to the physician.