Neurological Assessment

Neurological
assessment
by
Yazew.B (Bsc, Msc in Adult Health
Nursing)
12/9/2022 Henok L.
Neurological assessment
Complete neurological examination includes assessment of

1. Mental status
2. Motor system
3. Sensory system
4. Cranial nerves
5. Reflexes
Neurological assessment…
Subjective data
• Headache, head injury
• Dizziness/vertigo, seizures, tremors
• Weakness or in-coordination
• Numbness or tingling
• Difficulty speaking
• Any surgery
Objective data
Equipment needed
• Penlight, tongue-blade
• Sterile needle, and cotton ball
• Tuning fork
• Percussion hammer
• Familiar aromatic substance like Coffee,
alcohol
• Safety pin
• Vision screeners
• Gloves
1. Mental health assessment
Mental status is a person’s emotional and cognitive
function Includes:
• Appearance
• Behavior
• Cognition
• Thought processes
• Perceptions
• Level of consciousness
1. Mental health assessment…
Appearance
• Posture is erect and position is relaxed
• Body movement are voluntary, deliberate, coordinated,
smooth and even
• Dress is appropriate for setting, season, age, gender, and
social group
• Grooming and hygiene should be noted
• Clean and well-groomed, hair is net and clean. Nails are
clean
Behavior
• Facial expression: look is appropriate to the situation and
changes appropriately with the topic
• Speech: speed of conversation is moderate, and stream of
talking is fluent. Articulation is clear and understandable.
• Mood and Affect: judge this by body language and facial
expression and by asking directly, "how do you feel today“
the mood should be appropriate to person’s place and
condition and change appropriately with topics.
Cognitive function
• The term "cognition" describes the mental processes
that allow us to perform day-to-day functions, such as the
ability to pay attention, to remember and to solve problems.
 Orientation: assess time, place, person
***Orientation is usually lost first to time, then to place, and
rarely to person
 Memory (recent and remote)
Thought process and perceptions
Thought process
• Ask your self ”Dose this person make sense?
• Can I follow what the person is saying?”
 The way the person thinks should be logical, goal
directed, coherent and relevant
Thought content
What the person says should be consistent and logical
1.Mental health
assessment… Thought process
and perceptions… Perception
The person should be consistently aware of reality and
congruent with yours
Ask how do people treat you?
Do other people talk about
you?
• Have you heard your name
alone? Obsessions
compulsions and
abnormalities of thought
content
• Illusions, hallucinations-
abnormalities of perception

Level of consciousness
• Level of consciousness is degree of responsiveness of the
patient to stimuli in the environment (internal and
external).
• It assessed in the following ways
• The Glasgow comma scale: is a standard assessment tool for
describing the degree of loss of consciousness in the
severely ill patient .This method is based on.
2. The eye opening - 4
3. Verbal responses- 5
4. Best motor responses- 6
Level of consciousness…
– The value in this scale range from 3 the deepest coma to 15
the fullest alertness [Mild: 13-15; Moderate: 9-12; Severe:
3-
8]
– The value for the three different response are listed below
with respect to different stimuli
 A score of 7 or less is accepted as coma and
requires the appropriate nursing management
• Eye opening
• Spontaneously =4
• To speech =3
• To pain =2
• No response at all =1
1.Mental health assessment…
Verbal responses
• Oriented
=5
• Confused conversation, but able to answer Q. =4
=3
• Inappropriate words/ words =2
• Incomprehensible sound/ sounds =1
• Nomotor
Best response
responses
• Obeys command
=6
• Localized pain/ localizing
=5
• Withdraws to pain/normal flexion
=2
=4
=1
• Abnormal flexion to pain (Decorticate)=3
12/9/2022 Henok L.
• The other method of assessing level of consciousness is
using certain criteria to define the summary word
Alert ----The patient is awake and verbally responsive
• When you speak to the alert patient in a normal tone voice
the patient.
 Opens his eyes
 Looks at you
 Responds fully and appropriately to the stimuli
Lethargy :-The patient is sleepy or drowsy and will awaken and
respond appropriately to command .
• When you speak to the lethargic patient loudly, the patient
– Open his eyes
– Looks at you
– Respond to question
– Appears drowsy
– Falls a sleep
Obtundation
• When you shake an obtundated
patient gently, the patient
– Opens his eye
– Looks at you
– Responds slowly
– Is some what confused
– Has decreased interest in the
environment
Stupor :-The patient becomes unconscious spontaneously and is very
hard to awaken
• When you apply stimuli to a stupor patient the patient
– Arouses from sleep after the pain
– Has slow or absent verbal response
– Lapses into unresponsiveness when stimuli stops
– Has minimal awareness of self or the environment
Coma
• When you apply repeated painful stimuli to a comatose patient, the
patient
– Remains unarousable
– Has no evident response to inner need or external stimuli
2. Motor system
• Cerebellar function: balance test
A. Gait: observe as the person walks and returns.
• Normally the gait is smooth, rhythmic and effortless.
• Ask the person to walk a straight line in a heel-to-toe fashion
(tandem walking)
• Normally the person can walk straight and stay balanced.
– Abnormal- staggering, loss of balance
2.Motor system…
Cerebellar function…
B. Romberg test
• Ask the person to stand up with feet together and arms at
the sides
 Once in a stable position, ask the person to close the eyes
and to
hold the position.(Wait about 20 seconds)
• Normal posture and balance are maintained
– Positive Romberg’s sign: is loss of balance with closing of
eyes that occurs with cerebellar ataxia and loss of
vestibular function
2. Motor system…
• Ask the person to jump, first on one leg, then the other. This
demonstrates muscle strength, and cerebellar function
2.Motor system…
C. Coordination and skilled movement
Rapid alternative movements (RAM)
• Ask the person to pat the knees with both hands, lift up ,turn
hands over, and pat the knees with the backs of hands
• Then ask the person to do this faster
 Normally ,this is done with equal turning and a quick
rhythmic pace.
2.Motor system…
C. Coordination and skilled movement…
• Alternatively, ask the person to touch the thumb to each
finger on the same hands, starting with the index finger,
then reverse direction.
 Observe the speed, rhythm, and smoothness of the
movements.
• Normally, this can be done quickly and accurately
– Abnormal: lack of coordination with cerebellar disease
2.Motor system…
Finger to finger test (point to point)
• With the person eye open
 Use the index finger to touch your finger, then the person
own nose
• After a few times move your finger to different spot
• Observe the accuracy and smoothness of movements and
watch
for any tremor.
• The person’s movement should be smooth and accurate.
– Abnormal: misses the mark
2.Motor system…
Heel to shin test
• Test lower extremity coordination by asking the person, who
is in a supine position, to place the heel on the opposite knee
and run it down the shin from the knee to ankle
• Normally: moves the heel in a straight line down the shin
– Abnormal: lack of coordination; heel falls off shin
3. Sensory system
Pain
• Pain is tested by the person’s ability to perceive a pin prick.
• Using a sterile needle lightly apply the sharp point or the
dull to the person’s body in a random and ask the person
to say ‘sharp’ or ‘dull’ depending on the sensation felt
– Abnormal: hypoalgesia, hyperalgesia (increase pain
sensation)
3. Sensory system…
Light touch
• Apply a wisp of cotton to the skin randomly including the
arms, forearms, hands, abdomen chest and legs
 Ask the person to say ’now’ or ‘yes’ when touch is felt.
Compare symmetric points.
Stereognosis
• Test the person’s ability to recognize objects by feeling their
forms, size, and weights
• With the eyes closed, place a familiar object (paper clip, key,
coin, cotton ball or pencil) in the person’s hand and ask the person
to identify it
• Normally will be explored and identified
– Astereognosis: unable to identify object correctly. occurs in
sensory cortex lesion
3. Sensory system…
Vibration
 Test the person’s ability to feel vibration of a tuning fork over
bony prominences
 Strike on the heel of your hand, and hold the base on the
bony surface of fingers and great toe.
 Ask the person to indicate when the vibration starts and stops
– Loss of vibration sense occurs with peripheral neuropathy
Ex. Diabetes
4. Cranial nerves
• Twelve pairs of special nerves called cranial nerves
emerge from within the skull or cranium.
Cranial nerve I (olfactory nerve)
Do not test routinely, test for those who report loss of smell
• First, assess patency by occluding one nostril at a time
and
asking the person to sniff
• Then with the person’s eye closed, occlude one nostril
and present an aromatic substance such as coffee ,orange
• Note any asymmetry in the sense of smell
– Anosmia (decrease or loss of smell)
4. Cranial nerves…
Cranial nerve II optic nerve
• Test for visual acuity and test visual fields by confrontation
(peripheral vision)
Cranial nerve III, IV, Vl (oculomotor, trochlear, and abducens
nerves)
Test for ocular movement of the eyes
• The cardinal position test
• The cover uncover test
• The corneal light reflex test
Check pupils to size, regularity, equality , light reaction,
and accommodation
– Abnormal: Ptosis, limited movement
Cranial nerve V-Trigeminal nerve
 Motor function: assess the muscles of mastication by
palpating the temporal and masseter muscles as the
person clenches the teeth
 Muscles should be feel equally strong on both side
• Try to separate the jaws by pushing down on the chin
normally you cannot
– Note: decrease strength on one or both sides, Asymmetry
in jaw movement, pain
Cranial nerve V-Trigeminal nerve…
 Sensory function
• With the person’s eyes closed, test light touch sensation by
touching a cotton wisp on forehead, cheeks and chin
• Ask the person to say ‘now’ whenever the touch is felt. This
tests all the three divisions of the nerve 1.ophthalmic
2.maxillary 3.mandibular
 Corneal reflex
• With the person looking forward bring a wisp of cotton and
touch gently the cornea on the outer aspect of each eye ;normally
the person will blink bilaterally
– No blink in cranial nerve V lesion /paralysis
Cranial nerve V-Trigeminal nerve…
Sensory function…
3
Cranial nerve VII- Facial nerve
 Motor function
• Note mobility and facial symmetry as the person smile,
frown, close eyes tightly, lift eyebrows, show teeth and puff
cheeks
• Press the puffed cheeks and air should escape equally from
both sides
– Abnormal- muscle weakness
 Sensory function
• Test for test ability of the anterior 2/3 of the tongue (sour and
salt)
• Not routine, if indicated test sense of test by applying to the
tongue a cotton applicator covered a small amount, salt or
lemon juice solution
• Ask the person to identify the test
Cranial nerve VIII-Acoustic nerve
• Test hearing acuity-voice test
• Weber and rinne’s test
Cranial nerve IX and X(glossopharyngeal and vagus nerves )
 Motor function
• Depress the tongue with tongue blade and note pharyngeal
movement as the person says "Ahhh "
• Note the raise of the palate and uvula
• Test for swallowing
• Test for gag reflex
Cranial nerve Xl-spinal accessory nerve
• Examine the sternomastoid and trapezius muscles for equal size
and strength by asking the person to rotate the head
forcibly against resistance applied to the side of chin
and shrug the shoulders against resistance
• Should feel equally strong
– Atrophy; muscle weakness/paralysis
Cranial nerve Xll- Hypoglossal nerve
• Inspect the tongue for symmetry and movement.
• Note midline positions as the person protrudes the tounge
Summarized functions of the cranial nerves (CN) most
relevant to physical examination
NO Cranial nerve Function
I Olfactory sense of smell
II Optic Vision
III Oculomotor Pupillary constriction, opening the eye, and most

extraocular movements
IV Trochlear Downward, inward movement of the eye
V Trigeminal Motor—temporal and masseter muscles (jaw

clenching), also lateral movement of the jaw
Sensory—facial. The nerve has three divisions:
(1) ophthalmic, (2) maxillary, and (3)
mandibular
VI Abducens Lateral deviation of the eye
12/9/2022 Henok L.
Summarized functions of the cranial nerves….
No Cranial nerve Function
VII Facial Motor- facial movements, including those of
facial expression, closing the eye, and closing the
mouth Sensory—taste for salty, sweet, sour, and
bitter substances on the anterior two thirds of the
tongue
VIII Acoustic Hearing (cochlear division) and balance (vestibular
division
IX Glossopharyngeal Motor—pharynx
Sensory—posterior portions of the eardrum and ear
canal, the pharynx, and the posterior tongue,
including taste (salty, sweet, sour, bitter)
X Vagus Motor—palate, pharynx, and larynx

Sensory—pharynx and larynx
XI Spinal accessory Motor—the sternomastoid and upper portion of the

trapezius
X12I/ 02 H2 ypoglossal Motor—tonguHeenok L. 39
I9/2
5. Test for reflexes
• Reflex testing is usually the last part of the
neurologic assessment (Spinal nerve assessment)
• Client is usually in sitting position but laying position
also possible
• Hold the reflex hammer in your dominant hand between
your
thumb and index finger
• Use your wrist, and stimulate the reflex arc with a brisk
tap to the
tendon, not the muscle
 Strong force will cause pain, and too little force will
not stimulate the arc
5. Test for reflexes…
 Evaluate the response on a scale from 0-4
• 0=no response
• 1+= diminished
• 2+=normal
• 3+ brisk, above normal
• 4+= hyperactive
– Neuromuscular disease, spinal cord injury, or lower motor
neuron disease may cause absent or diminished
reflex
– Hyperactive reflexes may indicate upper motor
neuron disease

 The biceps reflex (5th and 6th cervical nerves)
• Support the client’s lower arm with your non-dominant hand
and arm. the arm needs to be slightly flexed at the elbow
with palm up
• Place the thump of your non-dominant hand over the
biceps tendon
• Using the reflex hammer, briskly tap your thumb
 Look for contraction of biceps muscle and slight flexion of
the forearm
Technique of biceps
reflex
Patient sitting Patient lying down

 The triceps reflex (6th and 7th cervical nerves)
• Support the client’s elbow with your non dominant hand
• Sharply percuss the tendon just above the olecranon process with
the reflex hammer
 Observe contraction of triceps muscle with extension of the
lower arm
Technique of the triceps reflex
Patient sitting Patient lying down

 The brachio-radialis reflex (5th and 6th cervical nerves)
• Position the client’s arm so the elbow is flexed and the
hand is resting on the lap with the palm down (pronation).
• Using the reflex hammer, briskly strike the tendon toward
the radius about 2-3 inches above the wrist.
 Observe flexion of the lower arm and supination of the hand.
Technique of brachio-radialis reflex
 The patellar (knee) reflex (lumbar 2, 3 and 4)
• Flex the leg at the knee
• Palpate the patella to locate the patellar tendon inferior to the
patella
• Briskly strike the tendon with the reflex hammer
 Note extension of lower leg and contraction of the
quadriceps
muscles
Technique of patellar (knee) reflex
Patient sitting
Patient lying down
 The achilles tendon (ankle) reflex (S1)
• Flex the leg at the knee
• Dorsiflex the foot of the leg being examined
• Hold the foot lightly in the non-dominant hand
• Strike the achilles tendon with the reflex hammer
 Normally observe plantar flexion of the foot; the heel
will
‘jump’ from the hand
Technique of achilles tendon(ankle)reflex
Patient sitting
Patient lying down

 The plantar reflex (L5,S1)
• Position the leg with a slight degree of external rotation at
the hip
• Stimulate the sole of the foot from the heel to the ball of the
foot
on the lateral aspect
• Continue the stimulation across the ball of the foot to the
great
toe
 Normally observe the plantar flexion, in which the toes
twist toward the sole of the foot.
 It may be necessary to hold the ankle to prevent movement
Technique of the plantar reflex
Normal response ( dorsiflexion)

(plantar flexion) Babinski response
5.Test for reflexes…
 The plantar reflex…
Babinski response
• Is dorsiflexion of the big toe accompanied by fanning of the
other
toes.
• Normal during infancy
• It is abnormal in adult
– May indicate upper motor neuron disease (+ babinski sign)
The meningeal irritation

 Neck regidity
 Brudzinski sign
 Kernings sign
The meningeal irritation
 Neck rigidity
• With the patient supine, place your hand behind the patient
head and flex the neck forward until the chin touches the
chest if possible
• Normally the patient can easily touch his chest with his
chin
– Pain in the neck and resistant to flexion may suggest
meningeal irritation
The meningeal irritation…
 Brudzinski sign
– With the client in a supine position, assist the client with
the neck flexion
– Observe the leg
 The sign is positive when neck flexion causes flexion of
the leg and thighs
The meningeal irritation…
 Kernings sign
• With the patient supine position flex leg both at the knee
and the hip, and then straighten the knee
• Normally the patient feel no pain except some discomfort
behind the knee felt by some people during full extension
– Bilateral pain and increased resistance to extending the
knee
suggests meningeal irritation
END

Neurological Assessment

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Neurological

Complete neurological examination includes assessment of

1. Mental health assessment…

III Oculomotor Pupillary constriction, opening the eye, and most

IV Trochlear Downward, inward movement of the eye

V Trigeminal Motor—temporal and masseter muscles (jaw

X Vagus Motor—palate, pharynx, and larynx

XI Spinal accessory Motor—the sternomastoid and upper portion of the

5. Test for reflexes…

Patient sitting Patient lying down

Patient sitting Patient lying down

5. Test for reflexes…

Normal response ( dorsiflexion)

The meningeal irritation

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