You are on page 1of 4

ASSESSING THE NEUROLOGIC SYSTEM

Definition:

The nervous system can be divided into two parts – central and peripheral. The CNS includes the brain and spinal cord.

The PNS includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.

Purpose:

• Assess condition of client's neurologic system by gathering subjective and objective data.

• Use collected data to help assess client's general health.

• Differentiate expected from unexpected findings in physical assessment.

Interview Assessment:

• Determine any significant medical history such as seizures, headaches, head injury, mental, or emotional problems.

If any are identified, conduct a more thorough symptom analysis.

• Note general appearance, grooming, personal hygiene.

• Note the client's speech and language abilities. Throughout the assessment, note the client's rate of speech, ability

to pronounce words, loudness or softness, and ability to talk smoothly and clearly.

• Assess the client's cognitive ability by choice of words, ability to respond to questions, and degree of ease with

which the client responds.

• Assess the client's orientation to person, place, and time.

• Ask about any numbness, tingling, or weakness of the arms, legs, hands, or feet.

• Ask about any vision, taste, or hearing problems.

• Determine any history of balance problems or unsteadiness when walking.

Equipment:

• Examination gown

• Examination gloves

• Percussion hammer

• Tuning fork

• Sterile cotton balls

• Penlight

• Stethoscope

• Sterile needle

• Tongue blade

• Cotton tipped applicator

• Hot and cold water in test tubes

• Objects to touch such as coins, a paper clip, or safety pin

• Substances to smell, such as vanilla, mint, or coffee

• Substances to taste such as sugar, salt, lemon, or grape

Preparation:

• Knowledge of norms or expected findings is essential in determining the meaning of the data as one proceeds.

• Identify client and introduce self.

• Explain each step of the procedure, including specific instructions about what is expected of the client.

• Explain the purposes of each procedure and when and if discomfort will accompany any procedure. Tell the client to

inform you of any discomfort or difficulty at any point during the assessment.

• Provide for client privacy.

• Perform hand hygiene and adhere to standard precautions.

a change in health status. Full alertness. lower eyelids sagging. Atrophy . PROCEDURE ABNORMAL FINDINGS 1.) 3. nasal twang occurs with weakness of soft palate 9. Grade the level of alertness on a scale from full alertness to coma. 6. For example. Assess abstract thinking ability The client should demonstrate an ability to think abstractly. Assessing mood and emotions Moods and emotions should reflect the current situation or response to events that trigger mood change or call for an emotional response. Testing trigeminal nerve Observe for symmetry of movement of the mandible without Decreased strength on one or both sides deviation from midline. Inability to process information during questioning. Assessing judgment ability The client's responses should reflect the reality of the client's health and psychological stability. The facial expression and tone of voice should be congruent with the content and context of the communication. as well as family situation and obligations. and escape of air from only one cheek that is pressed in Loss of movement and asymmetry of movement occur with both central nervous system and peripheral nervous systems lesions 8. Muscle weakness is shown by loss of the nasolabial fold. Testing accessory nerve by testing the trapezius muscle Observe the equality of the shoulders. Asymmetry in jaw movement Pain with clenching of teeth 7. 2. Assessing the client's sensorium Impairment noted by short or long term memory difficulty. 4. Assessing perceptions and thought processes The client's statements should be logical and relevant. (Be aware that age and culture influence the ability to explain proverbs. 5. Asymmetry of tonsillar pillar movement Hoarse or brassy voice occurs with vocal cord dysfunction. the soft palate rises and the uvula remains in the Uvula deviates to the side midline. drooping of one side of the face. The client should complete thoughts. Testing facial nerve Look for symmetry of facial movements. or stressful event. a loss. symmetry of action. Testing motor activity of the glossopharyngeal and vagus nerves Absence or asymmetry of soft palate movement Normally.

hyper. • 2+ = normal • 3+ = brisk. 15.6 cm graphesthesia. Performing the heel-to-shin test The client should be able to move the heel in a straight line so Lack of coordination that it doesn't fall off the lower leg. not stiffness. Worsening of coordination when the eyes are movement. percussion of the tendon reflexes along with weakened or spastic muscle response. spastic muscle response. Swaying normally Sways. Performing the Romberg test With eyes open. pain. Assessing gait and balance The posture should demonstrate relaxation. or unequal responses to Contraction of the triceps muscle with extension of the lower percussion of the tendon reflexes along with weakened or arm.3-0. Assessing the brachioradialis reflex Hypo. 19. the smoothness of the Misses nose.and lack of fasciculations. 17. or unequal responses to . the client is able to perceive two discrete points at Impaired sensory response such as inability to discriminate the following distances and locations: touch. Assessing the biceps reflex Hypo. hyper. the toe walking or difficulty with any of the screening evaluations position and coordination of arms when walking. or unequal responses to • 0 = no response percussion of the tendon reflexes along with weakened or • 1+ = diminished spastic muscle response. Performing the finger-to-nose test Observe the movement of the arms. or objects or sensations as in stereognosis or • Finger tips 0. Assessing the ability to discriminate between two points Normally.5-2 cm • Lower leg 4 cm • Note the smallest distance between the points at which the client can perceive two distinct stimuli. the pace of walking. Testing reflexes with a reflex hammer • Evaluate the response on a scale from 0 to 4+: Hypo. spastic muscle response. Inability to maintain gait or balance. 11. or unequal responses to Contraction of the biceps muscle and slight flexion of the percussion of the tendon reflexes along with weakened or forearm. and the ability such as rapid rhythmic alternating movement evaluation. Loss to maintain balance during all activities. 18. Heel falls off shin 14.. and the point of contact of finger. Muscle weakness or paralysis 10. hyper. 13. falls. of position sense. above normal • 4+ = hyperactive 16. hyper. The finger closed occurs with cerebellar disease should touch the nose. the client should not sway. 12. Assessing the patellar reflex Hypo. hyper. or unequal responses to Flexion of the lower arm and supination of the hand. Inability to perform heel- Note the equality of steps taken. • Hands and feet 1. widens base of feet to avoid falling increases slightly when the eyes are closed. Assessing the triceps reflex Hypo.

tract 23. Assessing the plantar reflex Except in infancy. abnormal sign is dorsiflexion of the big toe Plantar flexion.Extension of lower leg and contraction of the quadriceps percussion of the tendon reflexes along with weakened or muscle. Performing meningeal assessment • The client should be able to flex the neck about 45 May indicate presence of meningeal irritation degrees without pain. Assessing the Achilles tendon reflex Hypo. hyper. 20. spastic muscle response. the heel will "jump" from your percussion of the tendon reflexes along with weakened or hand. in which the toes curl toward the sole of the and fanning of all toes which is a positive Babinski’s sign and foot occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract. or unequal responses to Plantar flexion of the foot. Assessing the abdominal reflexes Muscular contraction and movement of the umbilicus toward Superficial reflexes are absent with disease of the pyramidal the stimulus. . • The Brudzinski's sign is noted when the neck flexion causes flexion of the legs. 22. 21. spastic muscle response.