University of the East Ramon Magsaysay Memorial Medical Center, Inc.

Aurora Boulevard, Quezon city College of Nursing

Systematic Comprehensive Assessment of Neurologic System (SCANS)

Components I. Mental Status (Cerebral function) Content a. Level of consciousness Eye response Verbal response Motor response Procedure Normal Findings Deviations from Normal Lethargic: Opens eyes, responds to question then fall asleep Obtunded: Responds to loud voice, responds slowly with confusion Stuporous: Awakens to vigorous shake or painful stimuli, then goes back to sleep Comatose: Unarousable with eyes closed. Use Glasgow Coma Scale Compute for the total best GCS score of the patient based on Eye response (4), Verbal response (5), and Motor See GCS Table See GCS Table

Alert: Responds to calling Call the clients name Ask the about the patients and performs simple instructions condition (e.g. How are you?...) Ask the client to perform simple instruction (e.g. Make a fist, and then show palms)

response (6) b. Orientation Time Place Person c. History Risk factors (Hx of trauma) Changes in mental status Presence of pain Problems with speech Disorientation Problems with senses Loss of consciousness Sudden weakness Tingling sensation/ numbness Paralysis/ uncontrolled movements d. Memory Immediate recall Ask the patient: What is the date and time today? Where do you live? Can you spell your first name? Perform interview to the patient. Inquire history of unusual changes. Confirm subjective data from patient to family members/ significant others. Knows who he is and where he lives, and can tell you the date. Unable to express where he or she is, time, and does not follow instructions

Ask the client to repeat a sequence/phrase (e.g. 3-2-1) What is the previous meal? Ask the patient to recall

Correctly answers the question about recent activities and can recall past events.

Inappropriate answer to questions testing memory and recall

Recent memory

information given earlier in the interview. What are the names of your family members? Observe patients responses throughout the procedure. Reactions and responses were appropriate for the situation Expresses feeling inappropriate to situation

Remote memory

e. Mood/Affect Expressions Feeling Non-verbal cues Behavior f. Attention Span/Cognitive abilities II. Cranial Nerve Function a. Cranial Nerve I Olfactory b. Cranial Nerve II Optic

Instruct the client to recite the alphabet or solve simple mathematical problem

Able to perform desired action with appropriate responses.

Did not perform instruction. Answered incorrectly to the question.

Hold scent under nostril with the other occluded while clients eye closed. Use Snellen chart to check visual acuity. Each eye should be tested separately. (Allow the client to wear corrective lenses or glasses) Assess visual fields by confrontation. (Seat close to the patient. Instruct the client to look in the examiners eyes then cover the eye not being tested. The examiner shall do

Distinguished scent in each nostril correctly 20/20 (Client will be able to see objects within 20 feet that a normal person can see at same distance) Client will be able to identify objects at peripheral vision equally with an examiner having normal vision.

Unable to identify correct odor Missed any letters on 20/20 line or above. Client leans forward while reading. Client does not report seeing the object at the same time as the examiner.

the same. Bring two wagging fingers in from the periphery in a plane equidistant from the patient and you) in all quadrants of the visual field and ask the patient to tell you when he sees your wagging fingers.) c. Cranial Nerve III Oculomotor Assess six extraocular movements. (Instruct client to follow the tip of your penlight and direct it to each of the 6 ocular points always starting at the point of start.) Convergence test. (try to direct the penlight toward the nose of the patient) Pupillary reaction to Light. (Instruct the client to place the fingers of one hand in-line with the nose bridge then look directly to the examiners eyes. shine light to each of the clients eye in an inverted-7 maneuver while observing for papillary constriction of the same eye (direct reaction) and the other eye (consensual reaction. Note also the pupil size.) Both eyes move in a smooth, Failure to follow object coordinated manner in all with one or both eyes directions indicates muscle weakness or cranial nerve dysfunction. Pupils converge and constricts as object moves in towards the nose. Reflections noted at same location on both eyes. Illuminated pupils and opposite eye constricts simultaneously. Pupils do not converge or constrict. Unequal pupil responses. Reflections were seen at different location on both eyes. Illuminated eye (efferent nerve defect) and opposite eye of the illuminated (afferent nerve defect) failed to constrict simultaneously.

d. Cranial Nerve IV Trochlear e. Cranial Nerve V Trigeminal

Pupillary reaction to accommodation. (instruct patient to place 1 finger 10cm from the nose. Then ask the client to alternately look at a distant object and the finger). Tested with CN III

Pupils dilates when looking at a distant object and constricts when focusing on near objects.

Pupils do not constrict nor dilate.

Absent blink of eyelids. Assess corneal reflex (touch the cornea lightly with a wisp of cotton) Eye blinks bilaterally

Asymmetrical or no Muscle strength in the face muscle contraction. Palpate for contraction of temporal and massester muscle should be present and should strength (place each thumb on be symmetric. both sides of the patients temple and the rest of the finger on the angle of the jaw) Sensory function of ophthalmic, maxillary and mandibular branch (pin test) f. Cranial Nerve VI Abducens g. Cranial Nerve VII Facial Tested with CN III Sensation should be present and symmetrical. Patient was able to identify characteristic of stimuli Unable to identify or feel facial sensation

Instruct the client to perform gestures (e.g. Smile, frown, raise eyebrows, tightly close eyes)

The facial muscles should look symmetric when the patient frowns, closes his

Unable to perform facial movements as instructed, or movements asymmetrical on one side

eyes, and smiles. h. Cranial Nerve XII Hypoglossal Ask the client to stick out the tongue and to move it from side to side and up and down. Ask client to open mouth and say Ahh (observe the reaction of soft palate and uvula) (Cranial Nerve VII Facial ) Check for the gag reflex.

of the face. Asymmetrical tongue; deviation to one side seen with unilateral lesion. Unequal or absent rise of soft palate and uvula

The tongue should be symmetric and should not deviate. Bilateral, symmetrical rise of soft palate and uvula.

i. Cranial Nerve X Vagus

Absent gag reflex Gag reflex present Identifies taste correctly Unable to taste or to identify taste correctly

Perform taste test (apply tastes on the tip and sides of the clients tongue with eyes closed. Then ask the client to identify the taste) Assess hearing (ask the client to close eyes and determine on which ear did he/she heard the sound) Weber test (place the vibrating tuning fork on the forehead of the client with eyes closed. Then ask the client on which ear did he/she heard the vibrations)

j. Cranial Nerve VIII Auditory/Acoustic/ Vesibulocochlear

Client was able to hear sound or watch tick on both ears. Vibration heard equally in both ears

Client was unable to hear sound or watch tick. Unequal response Vibratory sound lateralized to poor ear (conductive hearing loss) or to good ear (sensorineural hearing loss) BC>AC: conductive

 Rinne (ask the client to notify the examiner if he/she can no longer hear the sound produced by tuning fork. First place the tuning fork on the mastoid process, then remove it and place it close to the clients ear after) k. Cranial Nerve XI spinal Accessory Palpate strength of Trapezius muscle (ask the client to shrug shoulders against your hands. Assess each and both of the shoulders at a time) Palpate the strength of Sternocleidomastoid muscle (ask the client to turn head from side to side against your hand) Place partially flexed arm of the client over the thigh with palms down. Place the thumb above the biceps tendon then deliver a blow with a use of reflex hammer. Support the flexed arm of the client. Palpate for the triceps tendon about 2-5cm above the elbow. Then deliver a blow directly to the tendon

AC>BC

hearing loss. AC longer than, but not twice as long as BC: sensorineural hearing loss.

Neck and shoulder muscle strength should be symmetric.

Neck and shoulder muscle strength should be symmetric.

III. Reflexes

a. Biceps reflex (C-5, C-6)

++

b. Triceps reflex (C-7, C8)

(-) absent (+) hyporeflexia (+++) mild hyperreflexia without clonus (++++) hyperreflexia with clonus

c. Patellar reflex (L-2, L3, L-4)

d. Plantar (Babinskis) reflex

using reflex hammer. Instruct the client to sit on the edge of the examining table or chair so that the legs hang freely. Palpate for the patellar reflex directly below the patella. Directly deliver a blow to the tendon with the use of reflex hammer. Use a moderately sharp object to stroke on the patients foot. Stroke the lateral border of the sole starting at the heel, to the ball of the foot and to the big toe. (Inverted letter J) Palpate both upper extremities at the same time. Start from the upper arm to the wrist and ask the client to alternately open and close hands while palpation. Note for symmetry of both extremities. Instruct client to raise both hands to the front, then to the side and above the head. Ask the client to repeat the steps with application of resistance. Palpate both lower extremities at the same time. Start from the thigh to the

IV. Motor Function

a.

Muscle condition Muscle tone Muscle mass Muscle Strength Range of motion

Symmetrical muscle tone and mass. Muscle strength: 0/5 no contraction 1/5 no visible contraction but with palpable muscle movements 2/5 can partially move extremity against gravity 3/5 can perform full ROM against gravity 4/5 can move extremity against partial resistance 5/5 can move extremity against full resistance

b. Fine and Gross motor

knees and to the ankle. Ask the client to alternately flex and extend foot while palpating. Note for symmetry of both extremities. Client was able to perform movements as instructed Alternating pronation and supination of hands Alternating rotation of feet (clockwise - counter clockwise) Ask client to touch each finger of one hand to the thumb of the same hand as rapidly as possible Ask the client to spread arms broadly at shoulder and then bring fingers at the midline, first with eyes opened then closed. Ask the client to alternately touch nose and then your index finger rapidly as possible while moving it to other directions. Ask client to place heel of one foot just below the opposite knee and run heel down the shin to foot. Client was able to perform movements as instructed Client was able to perform movements as instructed

Limited movement or no movement at all.

V. Coordination and Gait (Cerebellar function)

a. Coordination test for the upper extremity Finger to thumb

Finger to finger

Finger to nose test

Client was able to perform movements as instructed

b. Coordination test for the lower extremity Heels down opposite shin

Client was able to perform movements as instructed

c. Balance Walking Gait VI. Sensory Function Heel-toe walking Rombergs test

Walk 10 steps in a straight line Walk in a heel-to-toe fashion Stand with feet together. Ask the client to close eyes and respond by saying yes whenever light sensation is felt. Ask the client to close eyes and respond by saying dull, sharp or dont know whenever pain sensation is felt. Support clients arm with one hand. Ask the client to close eyes then move and hold the middle finger up, down, left, and right, and ask client to identify the position. Place familiar objects in the clients hand, then ask the client to identify them.

Steady gait with opposite arm swing Maintains balance while walking Slight swaying may occur, but the patient should not fall.

Unsteady gait. Uncoordinated arm swing Unsteady walking Client sways and moves feet apart to prevent fall

a. Light touch sensation

b. Pain sensation (dull/sharp)

c. Kinesthetic sensation

d. Tactile discrimination Stereogenesis

Prepared by:

Christian Rodel Perez, MSN, RN Level III Faculty