Chapter 25

Assessing Neurologic System

Structure and Function

 Neurologic system
o Responsible for coordinating and regulating all
body functions
o Consists of:
 Central nervous system
 Peripheral nervous system

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Central Nervous System (CNS)

 Composed of brain and spinal cord

 Covered with meninges: protect and nourish CNS
 Subarachnoid space: surrounds brain and spinal
cord, filled with cerebrospinal fluid (CSF), cushions
brain and spinal cords, nourishes CNS, removes
waste products
 Neurons: govern electrical activity throughout
sensory and motor neural pathways
 Upper motor neurons in CNS influence lower motor
neurons in peripheral nervous system

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Brain #1

 Composed of cerebrum, diencephalon, brain stem,

cerebellum
 Cerebrum: consists of four lobes: frontal, parietal,
temporal, occipital (see Table 25-1 for functions)
 Diencephalon: consists of thalamus, hypothalamus
 Brain stem: consists of midbrain, pons, medulla
oblongata
 Cerebellum: has two hemispheres

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Brain #2

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Brain #3

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Spinal Cord #1

 Located in vertebral
canal
 Extends from medulla
oblongata to the first
lumbar vertebra
 Consists of two pairs of
columns
 Conducts nerve
impulses

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Spinal Cord #2

 H-shaped appearance
 Sensory neuron—
afferent
 Motor neuron—efferent
 Synapse—junction

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Neural Pathways

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Question #1

Which lobe is responsible for interpreting tactile

sensations such as pain and temperature?
A. Frontal
B. Parietal
C. Occipital
D. Temporal

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Answer to Question #1

B. Parietal

The parietal lobe interprets tactile sensations. The

frontal lobe directs voluntary, skeletal actions,
communication, emotions, intellect, judgment, and so
on. The occipital lobe is the primary visual receptor
center. The temporal lobe receives and interprets
impulses from the ear.

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Peripheral Nervous System

 Carries information to CNS

 Consists of 12 pairs of cranial nerves and 31 pairs of
spinal nerves
 Types:
o Somatic: carries CNS impulses to voluntary
skeletal muscles; mediates conscious or
voluntary activities
o Autonomic: carries CNS impulses to smooth,
involuntary muscles; mediates unconscious or
involuntary activities

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Cranial Nerves #1
Nerve Mnemonic Impulse type Mnemonic
I. Olfactory On Sensory Some
II. Optic Old Sensory Say
III. Oculomotor Olympus Motor Marry
IV. Trochlear Towering Motor Money,
V. Trigeminal Top Both But
VI. Abducens A Motor My
VII. Facial Finn Both Brother
VIII. Acoustic, And Sensory Says
vestibulocochlear
IX. Glossopharyngeal German Both Bad
X. Vagus Viewed Both Business
XI. Spinal accessory Some Motor Marries
XII. Hypoglossal Hops Motor Money
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Cranial Nerves #2

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Spinal Nerves #1

 Composed of 8 cervical, 12 thoracic, 5 lumbar, 5

sacral, 1 coccygeal nerves
 Named after vertebrae below each one’s exit point
along spinal cord
 Attached to spinal cord with two nerve roots
o Sensory (afferent) enters through dorsal roots
o Motor (efferent) exits through ventral roots
 Dermatome

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Spinal Nerves #2

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Autonomic Nervous System

 Impulses carried to smooth, involuntary muscles of

heart and glands
 Maintains internal homeostasis of body
 Incorporates
o Sympathetic nervous system: “fight or flight”,
activated during stress, arise from T1 to L2 level
o Parasympathetic nervous system: restore and
maintain normal body functions, arise in S1 to S4
and cranial nerves III, VI, IX, and X

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Question #2

Is the following statement true or false?

The sympathetic nervous system is activated during

stress.

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Answer to Question #2

True

The sympathetic nervous system is activated during

stress and elicits responses such as decreased gastric
secretions, bronchiole dilatation, increased pulse rate,
and pupil dilatation.

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Biological (Genetic) and Cultural Behavior
Variations

 Same patterns of ethnic variation that occur in CVD,

occur with stroke
 “Stroke belt” in the United States: NC, SC, GA, AL,
MS, LA, AR, TN
 “Stroke buckle”: NC, SC
 “Nerves” or “bad nerves” more a mental condition,
than of nerves, common in rural U.S. South,
symptoms similar to anxiety or worry
 Culture-bound syndrome ataque de nervios (nerve
attack) mostly Latina Americans, has various
expressions

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Older Adult Considerations #1

 Normal decrease in older person’s ability to hear,

see, taste, and smell
 May experience intentional tremors, when
extending hands, nodding “yes” or “no,” extending
one’s tongue
 Reduced muscle mass from degeneration of muscle
fibers
 Have hand or head tremors or dyskinesia
 Slow and uncertain gait, base may become wider
and shorter, and hips and knees may be flexed for
bent-forward appearance.
 Walking heel to toe may be difficult.
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Older Adult Considerations #2

 Unable to hop from one foot to another, performing

this test puts client at risk.
 Rapid alternating movements are difficult because
of decreased reaction time and flexibility.
 Light touch and pain sensation may be decreased.
 Increased risk for foot and ankle pathologies and
decrease or loss of vibratory sense is one of earliest
signs of sensory loss.
 Sense of position of great toe may be reduced.
 Usually have intact deep tendon reflexes (DTRs) but
decrease in reaction time may slow response.

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Older Adult Considerations #3

 Reinforcement techniques when conducting DTRs

may help older client who is having difficulty
relaxing.
 Decreased DTRs and unstable balance may be due
to peripheral neuropathy, also causes disturbed
proprioception, loss of vibratory and temperature
sense, possible pain, tingling, and distal weakness.
 Achilles reflex may be absent or difficult to elicit.
 Flexion of the toes may be difficult to elicit and may
be absent.

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Collecting Subjective Data: The Nursing
Health History #1
 History of present health concern
o Headaches
o Seizures
o Dizziness
o Numbness, tingling/prickling (paresthesias)
o Senses
o Difficulty speaking
o Difficulty swallowing (dysphagia)
o Muscle control
o Memory loss

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Collecting Subjective Data: The Nursing
Health History #2

 Past health history

 Family history
o Lifestyle and health practices

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General Routine Screening

 Assess level of consciousness.

 Observe behavior and affect.
 Observe dress, grooming, and hygiene.
 Observe facial expressions.
 Observe speech.
 Assess mood feelings and expressions.
 Assess cranial nerve II.
 Evaluate posture, gait, balance, and involuntary
movements.
 Assess light touch and pain.

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Focused Specialty Assessment #1

 Assess thought processes and perception.

 Assess orientation, concentration, recent and
remote memory, use of memory to learn, abstract
reasoning, judgment, SLUMS test, and visual,
perceptual, and constructional ability.
 Comprehensive testing of cranial nerves I through
XII.
 Perform the Romberg test.
 Assess coordination.
 Assess rapid alternating movements.

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Focused Specialty Assessment #2

 Assess light touch, pain, and temperature

sensations.
 Test vibratory sensation, sensitivity to position,
tactile discrimination, point localization,
graphesthesia, and extinction.
 Test superficial and deep tendon reflexes.
 Test for meningeal irritation (Brudzinski sign and
Kernig sign).

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Question #3

Is the following statement true or false?

Some assessments are challenging to complete on the

older adult client due to the increased risk of falling.

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Answer to Question #3

True

Some testing maneuvers such as standing on one foot

and hopping to the other foot or completing the heel-
to-toe maneuver present an increased risk of falling in
the older adult due to normal changes that occur with
the body as the individual ages. The individual may
not be able to complete them due to this reason and
not necessarily a disease process.

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Collecting Objective Data: Physical
Examination #1

 Complete neurologic assessment consists of

evaluating
o Mental status
o Cranial nerves
o Motor and cerebellar systems
o Sensory system
o Reflexes
 Neuro check: level of consciousness, pupillary
checks, movement and strength of extremities,
sensation in extremities, vital signs

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Collecting Objective Data: Physical
Examination #2

 Preparing the client

o Remove all clothing and jewelry, put on
examination gown.
o Start with client sitting, with several position
changes throughout assessment.
o Examination will take time, can provide rest
periods.
 Equipment
o General: examination gloves

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Collecting Objective Data: Physical
Examination #3

 Equipment—(cont.)
o Cranial nerve examination: cotton-tipped
applicators, newsprint to read, ophthalmoscope,
paper clip, penlight, Snellen chart, sterile cotton
ball, substances to smell or taste, tongue
depressor, tuning fork
o Motor and cerebellar examination: tape measure
o Sensory examination: cotton ball, objects to feel,
paper clip, test tubes containing hot and cold
water, tuning fork (low pitched)
o Reflex examination: cotton-tipped applicator,
reflex (percussion) hammer
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Collecting Objective Data: Physical
Examination #4

 Assess cranial nerves (CN)

o Test CN I (olfactory).
o Test CN II (optic).
o Assess CN III (oculomotor), CN IV (trochlear), and
CN VI (abducens).
o Assess CN V (trigeminal).
o Test Sensory function.
o Test Corneal reflex.
o Test CN VII (facial).

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Collecting Objective Data: Physical
Examination #5

 Assess cranial nerves (CN)—(cont.)

o Test CN VIII (acoustic/vestibulocochlear).
o Test CN IX (glossopharyngeal) and CN X (vagus).
o Test motor function.
o Test gag reflex.
o Check ability to swallow.
o Test CN XI (spinal accessory).
o Test CN XII (hypoglossal).

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Collecting Objective Data: Physical
Examination #6

 Motor and cerebellar systems

o Note any unusual involuntary movements.
o Evaluate gait and balance.
o Perform the Romberg test.
o Assess coordination.
o Assess rapid alternating movements.

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Collecting Objective Data: Physical
Examination #7

 Sensory system
o Assess light touch, pain, and temperature
sensations.
o Test vibratory sensation.
o Test sensitivity to position.
o Assess tactile discrimination (fine touch).
o Test point localization.
o Test graphesthesia.
o Test extinction (see Table 25-3).

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Collecting Objective Data: Physical
Examination #8

 Reflexes
o Test DTRs.
o Test biceps reflex.
o Assess brachioradialis reflex.
o Test triceps reflex.
o Assess patellar reflex.
o Test Achilles reflex.
o Test ankle clonus.
o Test superficial reflexes.

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Collecting Objective Data: Physical
Examination #9

 Reflexes—(cont.)
o Assess plantar reflex
o Test abdominal reflex
o Test cremasteric reflex in male clients
 Tests for meningeal irritation or inflammation
o Assess neck mobility
o Test for Brudzinski sign
o Test for Kernig sign

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Validating and Documenting Findings #1

 Validate assessment data collected.

 Verify all data are reliable and accurate.

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Validating and Documenting Findings #2

 Document data following health care facility or

agency policy:
o COLDSPA
o SBAR
o Summary sheet of International Standards for
Neurological and Functional Classification of
Spinal Cord Injury

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Analyzing Data to Make Informed Clinical
Judgments

 Selected client concerns

o Opportunity to improve health
o Risk for client concerns
o Actual client concerns
 Selected collaborative problems
o RC: Risk for Complications
 Medical problems

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Question #4

Is the following statement true or false?

The nurse should use a high-pitched tuning fork to

evaluate the client’s sensory functions.

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Answer to Question #4

False

The nurse should use a low-pitched tuning fork to

evaluate the client’s sensory functions.

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Cerebrovascular Accident (Stroke) #1
 Occurs when blood flow to portion of brain is interrupted or
stopped, deprives brain cells of oxygen; cells begin to dead
resulting in permanent damage
 Types:
o Hemorrhagic: rupture or leakage of blood vessel
o Ischemic: blood clot blocks blood vessel; may be result of
emboli or thrombi
o Transient ischemic attack (TIA): mini-stroke
 Fifth leading cause of death in the United States; leading cause
of disability (2016)
 Can occur in persons with no known risk factors

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Cerebrovascular Accident (Stroke) #2

Myth Fact
Cannot be prevented Up to 80% are preventable
No treatment available At any sign, call 911 immediately,
treatment may be available
Only affects older adult Can happen to anyone at any time
Happens to heart Is “brain attack”
Recovery only happens for the first Is a lifelong process
few months after stroke
Are rare In the United States, nearly 7
million stroke survivors; fifth
leading cause of death
Are not hereditary Family history increases chance
If symptoms go away, no need to TIAs are warning signs of pending
call doctor stroke, need immediate care

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Cerebrovascular Accident (Stroke) #3
 Risk assessment
o Hypertension
o Diabetes mellitus
o Heart disease and blood vessel disease
o Smoking and exposure to secondhand smoke
o Brain aneurysms or atriovenous malformations
o Infections or conditions that cause inflammation
o Age and gender
o Race and ethnicity
o Personal or family history

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Cerebrovascular Accident (Stroke) #4

 Client education
o Do not smoke, quit if do.
o Control cholesterol levels, hypertension, and/or
diabetes with diet, exercise, and medicines, if
needed.
o Exercise at least 30 minutes a day.
o Maintain healthy weight.
o Choose diet rich in fruits, vegetables, and whole
grains, lean proteins, and low-fat dairy products.
o Avoid sodium and fats found in fried foods,
processed foods, and baked goods.
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Cerebrovascular Accident (Stroke) #5

 Client education—(cont.)
o Eat fewer animal products and foods that contain
cheese, cream, or eggs.
o Read labels, stay away from saturated fat,
partially hydrogenated or hydrogenated fats.
o Limit amount of alcohol.
o Avoid cocaine and other illegal drugs.
o Talk to doctor about risk of taking birth control
pills.

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Cerebrovascular Accident (Stroke) #6

 Teach clients to recognize symptoms of stroke and

Act FAST!
o FACE drooping: ask the person to smile. Does
one side of the face droop?
o ARMS weakness: Ask the person to raise both
arms. Does one arm drift downward?
o SPEECH: Ask the person to repeat a simple
phrase. Is speech slurred or strange?
o TIME to call 911! If you observe any of these
signs, call 9-1-1 immediately to avoid a lifelong
disability.

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Cerebrovascular Accident (Stroke) #7

 Teach clients to recognize additional symptoms of

stroke
o Sudden numbness or weakness of face, arm, or
leg (especially on one side of body)
o Sudden confusion, trouble speaking, or
understanding speech
o Sudden trouble seeing in one or both eyes
o Sudden trouble walking, dizziness, loss of
balance, or coordination
o Sudden severe headache with no known cause

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Abnormal Motor and Sensory Findings in
Spinal Cord Injuries #1
 Major tracts of spinal Brown-Séquard
cord syndrome

Figures used with permission from Frymoyer, J. W., & Wiesel, S. W. (2004). The adult and pediatric spine. Lippincott
Williams & Wilkins.

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Abnormal Motor and Sensory Findings in
Spinal Cord Injuries #2

 Central cord syndrome Anterior cord syndrome

Figures used with permission from Frymoyer, J. W., & Wiesel, S. W. (2004). The adult and pediatric spine. Lippincott
Williams & Wilkins.

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Abnormal Motor and Sensory Findings in
Spinal Cord Injuries #3

Posterior cord syndrome

Figures used with permission from Frymoyer, J. W., & Wiesel, S. W. (2004). The adult and pediatric spine. Lippincott
Williams & Wilkins.

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Abnormal Muscle Movements #1

 Atrophy and fasciculations Eye tic

of the tongue

Reprinted with permission from Campbell, W. W. Figures used with permission from Frymoyer, J. W., &
(2013). DeJong’s the neurologic examination (Fig. 20- Wiesel, S. W. (2004). The adult and pediatric spine.
4). Wolters Kluwer. Lippincott Williams & Wilkins.

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Abnormal Muscle Movements #2

 Choreiform
movements of the Resting (static) tremors
hand

Reprinted with permission from Bickley, L. S., & Szilagyi, P. (2003). Bates’ guide to physical examination and history
taking (8th ed.). Lippincott Williams & Wilkins.

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Abnormal Muscle Movements #3
Intention tremor of a
 Postural tremor pointed finger

Reprinted with permission from Bickley, L. S., & Szilagyi, P. (2003). Bates’ guide to physical examination and history
taking (8th ed.). Lippincott Williams & Wilkins.

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Abnormal Muscle Movements #4

 Athetosis

Reprinted with permission from Bickley, L. S., & Szilagyi, P. (2003). Bates’ guide to physical examination and history
taking (8th ed.). Lippincott Williams & Wilkins.

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Abnormal Muscle Movements #5

 Pathway of tremor impulse down the arm of

a male figure

Anatomical Chart Company.

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Abnormal Gaits #1

 Cerebellar ataxia Parkinsonian gait

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Abnormal Gaits #2

 Scissors gait Spastic hemiparesis

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Abnormal Gaits #3

 Footdrop

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Abnormal Postures in Unconscious
Clients

Decorticate posturing Decerebrate posturing

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Additional Abnormal Findings

 Muscular eye weakness seen in myasthenia gravis

Used with permission from Tasman, W., & Jaeger, E. [2009]. The Wills Eye Hospital atlas of clinical ophthalmology
[2nd ed.]. Lippincott Williams & Wilkins.)

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Question #5

Is the following statement true or false?

A potential warning sign of a stroke is sudden

weakness on one side of the body.

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Answer to Question #5

True

Sudden weakness on one side of the body is a warning

sign and possible indication that the client is having a
stroke and needs immediate care. If the individual is
not at appropriate medical facility, then call 9-1-1 to
transport the client immediately.

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