Assessment of the Mental

Status and Sensory Neuro

System
 Objectives

• Perform mental status examination of a client

• Assess cranial nerve, sensory, sense of
proprioception and cerebellar functions and deep
tendon reflexes.
• Document findings
• List the changes in the nervous system that are
characteristics of the aging process
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Spinal Nerves

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Subjective Data:
Nursing Health
History
 History Of Present Health Concerns
Headaches
Do you experience headaches? If Yes apply COLDERRA/COLDSPA
Seizures
Do you experience seizures? How often?
Describe what happens before you have the seizure and where on your body the seizure starts. Does anything seem
to initiate a seizure? Do you lose control of your bladder during the seizure? How do you feel afterward? Do you
take medications for the seizures? Do you wear medical identification to alert others that you have seizures? Do you
take safety precautions regarding driving or operating dangerous machinery?
Dizziness
Do you experience dizziness or lightheadedness or problems with balance or coordination? If so, how often? Does it
occur with activity? Or have you experienced any falling? Do you have any clumsy movement?
Numbness and Tingling
Do you experience any numbness or tingling? If Yes apply COLDERRA/ COLDSPA
Senses
Have you noticed a decrease in your ability to smell or to taste?
Have you experienced any ringing in your ears or hearing loss?
Have you noticed any change in your vision?
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 History Of Present Health Concerns
Difficulty Speaking
Do you have difficulty understanding when people are talking to you? Do you have difficulty making others
understand you? Do you have difficulty forming words or verbally interpreting your thoughts?
Difficulty Swallowing( Dysphagia)
Do you experience difficulty swallowing?
Muscle Control
Have you lost bowel or bladder control or do you retain urine?
Do you have muscle weakness? If so, where?
Do you experience any tremors? If so, where?
Memory Loss
Do you experience any memory loss?
PAST HEALTH HISTORY
Have you ever had any type of head injury with or without loss of consciousness (e.g., sports injury, auto accident,
fall)? If so, describe any physical or mental changes that have occurred as a result. What type of treatment did you
receive?
Have you ever had meningitis, encephalitis, injury to the spinal cord, or a stroke? If so, describe any physical or
mental changes that have occurred as a result. What type of treatment did you receive?
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 FAMILY HISTORY
Do you have a family history of high blood pressure, stroke, Alzheimer’s disease, epilepsy, brain cancer, or
Huntington’s chorea?
LIFESTYLE AND HEALTH PRACTICES
Do you take any prescription or nonprescription medications? How much alcohol do you drink? Do you use
recreational drugs such as marijuana, tranquilizers, barbiturates, or cocaine?
Do you smoke?
Do you wear your seat belt when riding in vehicles? Do you wear protective headgear when riding a bicycle or
playing sports?
Describe your usual daily diet.
Have you ever had prolonged exposure to lead, insecticides, pollutants, or other chemicals?
Do you frequently lift heavy objects or perform repetitive motions?
Can you perform your normal activities of daily living?
Has your neurologic problem changed the way you view yourself? Describe
Has your neurologic problem added much stress to your life? Describe.

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 COLLECTING OBJECTIVE DATA:
PHYSICAL EXAMINATION
A complete neurologic examination consists of evaluating the following five areas:
• Mental status
• Cranial nerves
• Motor and Cerebellar System
• Sensory system
• Reflexes
A neuro check includes the following assessment points:
• Level of consciousness
• Pupillary checks
• Movement and strength of extremities
• Sensation in extremities
• Vital signs
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 Preparing the Client
• Introduce yourself to patient
• Explain the procedure.
• Maintain privacy.
• Give gown to patient and remove
jewelry
• Assure the client about pre explaining
of every position.
• Explain and give clear instruction to
client about specific actions.

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 Equipment
Cranial Nerve
General Examination Sensory Examination
• Cotton-tipped applicators
• Examination Gloves • Cotton ball
• Newsprint to read
MOTOR AND • Objects to feel such as a
CEREBELLAR • Ophthalmoscope quarter or key
EXAMINATION • Paper clip • Paper clip
• Tape Measure • Penlight
• Test tubes containing hot
REFLEX EXAMINATION • Snellen chart and cold water
• Cotton-tipped applicator • Sterile cotton ball • Tuning fork (low-pitched
• Reflex( Percussion) • substances to smell or taste
hammer • Tongue depressor
• Tuning fork

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 How to Use the Reflex Hammer

The reflex (or percussion) hammer is used to elicit 5. Using a rapid wrist movement,
deep tendon reflexes. Proceed as follows to elicit a briskly strike the tendon. Observe the
deep tendon reflex: response. Avoid a slow or weak
1. Encourage the client to relax because tenseness movement for striking.
can inhibit a normal response. 6. Compare the response of one side
2. Position the client properly. with the other.

3. Hold the handle of the reflex hammer between 7. To prevent pain, use the pointed end
your thumb and index finger so it swings freely. to strike a small area, and the wider,
blunt (flat) end to strike a wider area or
4. Palpate the tendon that you will need to strike to a more tender area.
elicit the reflex.

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8. Use a reinforcement technique, which causes • Grade 2 Normal, usual response
other muscles to contract and thus increases
reflex activity, to assist in eliciting a response if • Grade 1 Decreased, less active than
no response can be elicited. normal
9. For arm reflexes, ask the client to clench his • Grade 0 No response.
or her jaw or to squeeze one thigh with the
opposite hand, then immediately strike the
tendon. For leg reflexes, ask the client to lock
the fingers of both hands and pull them against
each other, then immediately strike the tendon.
10. Rate and document reflexes using the
following scale and figure.
• Grade 4 Hyperactive, very brisk, rhythmic
oscillations (clonus); abnormal and indicative of
disorder
• Grade 3 More brisk or active than normal, but
not indicative of a disorder

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Assessment Procedure Normal Findings Abnormal Findings
Cranial Nerves (CN)
Test CN I(Olfactory) assess smell. Client correctly identifies scent presented Inability to smell(neurogenic anosmia).
to each nostril Nerve damage, sinuses problem,
congenital and infection .

Test CN II (optic). Newspaper or Client has 20/20 vision OD (right eye) Loss of visual fields may be seen in
Snellen Chart to assess vision in each and OS (left eye). retinal damage or detachment, with
eye, visual field, and with lesions of the optic nerve, or with lesions
opthalmoscope to view the retina and of the parietal cortex
optic dis.
Assess CN III (oculomotor), IV Eyelid covers about 2 mm of the iris. Ptosis (drooping of the eyelid) is seen
(trochlear), and VI (abducens). Inspect with weak eye muscles such as in
margins of the eyelids of each eye. myasthenia gravis
Assess extraocular movements. If Eyes move in a smooth, coordinated Nystagmus: rhythmic oscillation of the
nystagmus is noted, determine the motion in all directions (the six cardinal eyes), cerebellar disorders. Limited eye
direction of the fast and slow phases of fields). movement through the six cardinal fields
movement of gaze, increased intracranial pressure.
Assess pupillary response to light (direct Bilateral illuminated pupils constrict Dilated pupil (6 to 7 mm), oculomotor
and indirect) and accommodation in simultaneously. Pupil opposite the one nerve paralysis. Bilateral muscle
both eyes illuminated constricts simultaneously weakness is seen with peripheral or
central nervous system dysfunction. 16
Assessment Procedure Normal Findings Abnormal Findings
Assess CN V (trigeminal): Test motor Temporal and masseter muscles contract
function. Ask the client to clench the bilaterally.
teeth while you palpate the temporal and
masseter muscles for contraction.
Test sensory function: Touch cheeks, The client correctly identifies sharp and Inability to feel and correctly identify
chin, and forehead with sharp and dull dull stimuli and light touch to the facial stimuli occurs with lesions of the
side of safety pin and assess for response. forehead, cheeks, and chin trigeminal nerve or lesions in the
spinothalamic tract or posterior columns.

Test corneal reflex. Ask the client to look Eyelids blink bilaterally. An absent corneal reflex may be noted
away and up while you lightly touch the with lesions of the trigeminal nerve or
cornea with a fine wisp of cotton. Repeat lesions of the motor part of cranial nerve
on the other side VII (facial).

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Assessment Procedure Normal Findings Abnormal Findings
Test CN VII (facial): Patient can perform the symmetrical Bell’s palsy (a peripheral injury to cranial
• Smile movement nerve VII [facial]).
• Frown and wrinkle forehead. against the
• Show teeth resistance.
• Puff out cheeks
• Purse lips
• Raise eyebrows
• Close eyes tightly against resistance
Sensory function is not routinely tested. Client identifies correct flavor Inability to identify the taste indicates
If it is, however, touch the anterior two impairment of cranial nerve VII
thirds of the tongue with a moistened
applicator dipped in salt, sugar, or lemon
juice and ask the client to identify the
flavor
Test CN VIII Client hears whispered words from 1 to 2 Vibratory sound lateralizes to good ear in
(acoustic/vestibulocochlear). . Test the feet. Weber test: Vibration heard equally sensorineural loss. Air conduction is
client’s hearing ability in each ear and well in both ears. Rinne test: AC >BC longer than bone conduction but not
perform the Weber and Rinne tests to (air conduction is twice as long as bone twice as long, in a sensorineural loss
assess the cochlear (auditory) component conduction).
of cranial nerve VIII
Note: The vestibular component, responsible for equilibrium, is not routinely tested. In comatose clients, the test is used to
determine integrity of the vestibular system
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Assessment Procedure Normal Findings Abnormal Findings
Test CN IX (glossopharyngeal) and X Uvula is symmetric. soft palate does not rise with bilateral
(Vagus). Ask the client to say Ah and lesions of cranial nerve X(Vagus)
check Uvula. Lesion in cranial Nerve IX
Test the gag reflex Gag reflex intact Dysphagia is due to Nerve
Check the client’s ability to swallow. Can swallows without difficulty. IX( Glossopharyngeal)
Test CN XI (spinal accessory): Ask the There is symmetric, strong contraction of Asymmetric muscle contraction or
client to shrug the shoulders against the trapezius & sternocleidomastoid drooping of the shoulder may be seen
resistance to assess the trapezius muscle with paralysis or muscle weakness due to
muscle.to check sternocleidomastoid neck injury or torticollis
muscle ask client to move head on left
and right.
Test CN XII (hypoglossal): To assess Tongue movement is symmetric and Fasciculations and atrophy of the tongue
strength and mobility of the tongue, ask smooth and bilateral strength is apparent. may be seen with peripheral nerve
the client to protrude tongue, move it to disease. Deviation to the affected side is
each side against the resistance of a seen with a unilateral lesion
tongue depressor, then put it back in the
mouth

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Motor and Cerebellar Systems

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Assessment Procedure Normal Findings Abnormal Findings
Assess condition and movement of Muscles are fully developed and Muscle atrophy may be seen in diseases
muscles. Assess the size and symmetry symmetric in size (bilateral sides may of the lower motor neurons or muscle
of all muscle groups vary 1 cm from each other). disorders
Assess the strength and tone of all Relaxed muscles contract voluntarily and Soft, limp, flaccid muscles are seen with
muscle groups show mild, smooth resistance to passive lower motor neuron involvement. Spastic
movement. All muscle groups equally muscle tone is noted with involvement of
strong against resistance, without the corticospinal motor tract
flaccidity, spasticity, or rigidi
Note any unusual involuntary No fasciculations, tics, or tremors are Tic (twitch of the face, head, or shoulder)
movements such as fasciculations, tics, noted. from stress or neurologic.
or tremors. Unusual, bizarre face, tongue, jaw, or lip
movements from chronic psychosis.
Tremors (rhythmic, oscillating
movements) from Parkinson’s disease.

Evaluate balance. To assess gait, ask the Gait is steady; opposite arm swings. Gait and balance can be affected by
client to walk naturally across the room. disorders of the motor, sensory,
Note posture, freedom of movement, vestibular, and cerebellar systems
symmetry, rhythm, and balance.
Ask the client to walk in heel-to-toe Client maintains balance with tandem disease of the posterior columns,
fashion. walking. vestibular dysfunction, or cerebellar
Perform the Romberg test Client stands erect with minimal swaying disorders
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Assessment Procedure Normal Findings Abnormal Findings
Now ask the client to stand on one foot and Bends knee while standing on one foot; Inability to stand or hop on one foot is
to bend the knee of the leg he or she is hops on each foot without losing seen with muscle weakness or disease of
standing on balance. the cerebellum.
Assess coordination. Demonstrate the Client touches finger to nose with Loss of positional sense and inability to
finger-to-nose test to assess accuracy of smooth, accurate movements with little touch tip of nose are seen with cerebellar
movements then ask the client to extend hesitation. disease
and hold arms out to the side with eyes Dominant hand Is more coordinated
open. Next say “Touch the tip of your nose than non Dominant hand.
with Rt & Lt hand.
Assess rapid alternating movements. Client touches each finger to thumb Inability to perform rapid alternating
Have the client sit down. First ask the rapidly. movements may be seen with cerebellar
client to touch each finger to the thumb and disease, upper motor neuron weakness,
to increase the speed as the client or extrapyramidal disease.
progresses. Repeat with the other side.
Next ask the client to put the palms of both Client rapidly turns palms up and Uncoordinated movements or tremors are
hands down on both legs, then turn the down. abnormal findings. They are seen with
palms up, then turn the palms down again. cerebellar disease (dysdiadochokinesia)
Ask the client to increase the speed.
Perform the heel-to-shin test. Ask the client Client is able to run each heel Deviation of heel to one side or the other
to lie down (supine position) and to slide smoothly down each shin. may be seen in cerebellar disease.
the heel of the right foot down the left shin
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Sensory System

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Assessment Procedure Normal Findings Abnormal Findings
Assess light touch, pain, and Client correctly identifies light touch peripheral neuropathies (due to diabetes
temperature sensations. mellitus, folic acid deficiencies, and
To test light touch sensation, use a wisp alcoholism) and lesions of the ascending
of cotton to touch the client spinal cord,
To test pain sensation, use the blunt and Client correctly differentiates between Client reports
sharp ends of a safety pin or paper clip. dull and sharp sensations and hot and • Anesthesia (absence of touch sensation)
To test temperature sensation, use test cold temperatures over various body • Hypesthesia (decreased sensitivity to
tubes filled with hot and cold water. parts touch)
• Hyperesthesia (increased sensitivity to
touch)
• Analgesia (absence of pain sensation)
• Hypalgesia (decreased sensitivity to
pain) • Hyperalgesia (increased
sensitivity to pain)

Test vibratory sensation. Strike a low Client correctly identifies sensation. Inability to sense vibrations may be seen
pitched tuning fork on the heel of your in posterior column disease or peripheral
hand and hold the base on a bony surface neuropathy (e.g., as seen with diabetes or
of the fingers or big toe Ask the client to chronic alcohol abuse)
indicate what he feels. Repeat on the
other side
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Vibratory
Sensation
Assessment Procedure Normal Findings Abnormal Findings
Test sensitivity to position. Client correctly identifies directions of Inability to identify the directions of the
movements movements may be seen in posterior
In some older clients, the sense of column disease or peripheral neuropathy
position of great toe may be reduced (e.g., as seen with diabetes or chronic
alcohol abuse).

Assess tactile discrimination (fine touch). Client correctly identifies object Inability to correctly identify objects
Stereognosis test (astereognosis), area touched, number
written in hand, discriminate between
To test point localization, briefly touch two points, or identify areas
the client and ask the client to identify simultaneously touched may be seen in
the points touched lesions of the sensory cortex.

To test graphesthesia, use a blunt

instrument to write a number, such as 2,
3 or 5, on the palm of the client’s hand

To test extinction, simultaneously touch

the client in the same area on both sides
of the body at the same point. Ask the
client to identify the area touched. 28
Assessment Procedure Normal Findings Abnormal Findings
Reflexes
Test deep tendon reflexes. Normal reflex scores Absent or markedly decreased (hyporeflexia) deep
➤ Clinical Tip • If deep tendon reflexes range from 1+ (present tendon reflexes (rated 0) occur when a component of the
are diminished or absent, two but decreased) to 2+ lower motor neurons or reflex arc is impaired
reinforcement techniques may be used to (normal) to 3+(increased
enhance their response. When testing the or brisk, but not
arm reflexes, have the client clench his or pathologic)
her teeth. When testing the leg reflexes,
have the client interlock his or her hands.
Test biceps reflex. Ask the client to Elbow flexes and No response or an exaggerated response is abnormal
partially bend arm at elbow with palm up. contraction of the biceps
Place your thumb over the biceps tendon muscle is seen or felt.
and strike your thumb with the reflex Ranges from 1+ to 3+
hammer. (This evaluates the function of
spinal levels C5 and C6.)
Assess brachioradialis reflex. Ask the Forearm flexes and
client to flex elbow with palm down and supinates. Ranges from
hand resting on the abdomen or lap. Tap 1+ to 3+
the tendon at the radius about 2 inches
above the wrist. (This evaluates the
function of spinal levels C5 and C6.)

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Assessment Procedure Normal Findings Abnormal Findings
Test triceps reflex. Ask the client to hang his or Elbow extends, triceps No response or exaggerated
her arm freely (“limp like it is hanging from a contracts. response.
clothesline to dry”) while you support it with Ranges from
your nondominant hand. With the elbow flexed, 1+ to 3+
tap the tendon above the olecranon process.
(This evaluates the function of spinal levels C6,
C7, and C8.)
Assess patellar reflex. Ask the client to let both Knee extends, quadriceps muscle contracts. No response or an exaggerated
legs hang freely off the side of the examination Ranges from response is abnormal
table. Tap the patellar tendon, which is located 1+ to 3+
just below the patella. (This evaluates the
function of spinal levels L2, L3 & L4)

Achilles reflex. With the client’s leg still Normal response is No response or
hanging freely, dorsiflex the foot. Tap the plantar flexion of an exaggerated
Achilles tendon with the reflex hammer. (This the foot. Ranges response is
evaluates the function of spinal levels S1 & S2 from 1+ to 3+ Abnormal

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 Wellness Diagnoses
Selected • Readiness for Enhanced
Nursing Communication
Diagnoses • Readiness for Spiritual
Well-being
 • Risk for Injury related to disturbed
sensory-perceptual patterns

• Risk for Aspiration related to

impaired gag reflex
Risk
• Risk for Self-Directed Violence,
Diagnoses
related to depression, suicidal
tendencies, developmental crisis,
lack of support systems, loss of
significant others, poor coping
mechanisms and behaviors
 • Disturbed Thought Processes related to
abuse of alcohol or drugs, psychotic
disorder, or organic brain dysfunction

• Impaired Verbal Communication related

to aphasia, psychological impairment or
organic brain disorder

Actual • Impaired Memory related to dementia,

Diagnoses stroke, head injury, alcohol or drug abuse

• Impaired Environmental Interpretation

Syndrome related to dementia, depression,
or alcoholism

• Reflex Urinary Incontinence related to

spinal cord or brain damage
References
 Weber, J. R. (2018). Nurses' handbook of health assessment (6th ed).
Philadelphia: Lippincott.
 Bicklay, L. S. (2017). Bates’ guide to physical examination and history
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 Wilson, S. F; Giddens J. F. (2022). Health assessment for nursing practice
(7th ed.).St. Louis: Mosby.
 Cox, C. H. (2007). Clinical applications of nursing diagnosis (5th ed).
 DeGowin, R. L., & Brown, D. D. (2020). Degrowing's diagnostic
examination (11th ed.). New York: McGraw-Hill.
 Fuller, J. & Schaller Ayers, J. (2000). Health Assessment: A Nursing
approach. (3rd ed.). Philadelphia: J. B. Lippincott.
 Jarvis, C. (2020). Physical examination & health assessment (8th
ed).Philadelphia: Saunders.
 McFarland, G. K, et. al. (1997). Nursing diagnosis and intervention
planning for patient care chapter 1 & 2 (3rd ed).
 Munro, J. F., & Campbell, I. W. (2000). Macleod’s clinical examination
(10th ed). Edinburgh: Churchhill Livingstone.
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