HEALTH HISTORY

- The nurse may elicit information from the patient, family, witnesses, or
emergency rescue personnel. Immediate health history should include the
following questions:
1. When did the injury occur?
2. What caused the injury?
3. What was the direction and force of the blow?
4. If the patient loss his consciousness? If yes, duration period?

Physical Assessment
HEAD
 Assess if there is  to evaluate if it is
Inspection any penetration or closed(blunt) brain
Palpation laceration, cuts, injury or open brain
bruises in the scalp injury
and skull

EYES

Technique Abnormal Analysis

findings
Visual  If you have
Inspection acuity 20/40 vision, for  Subdural hematomas can
example, that affect vision through
 Using snellen means you need compression or vascular
chart, ask the to be 20 feet compromise at many points
patient to stand away to see an along the visual pathway.
object that
 14 to 20 feet people can
away from the normally see
chart and by from 40 feet
viewing the chart away.
with one eye,
covering the
other eye at the  The left direct
same time.ask reflex is lost. When
the patient to the left eye is
read the letters. stimulated by light,
20/20 is the neither pupils
normal vision constrict.
Pupillary  The right
light reflex consensual reflex is  Afferent signals from the left
 Using penlight, lost. When left eye eye cannot pass through the
Gently point the is stimulated by transected left optic nerve to
focal light into light, reach the intact efferent limb on
one eye, this is  The left direct the left.
known as the reflex is lost. When
direct pupillary the left eye is  afferent signals from the left
light reflex. stimulated by light, eye cannot pass through the
Then, withdraw left pupil does not transected left optic nerve to
the light for few constrict reach the intact efferent limb on
seconds, the right.
followed by  the efferent signals cannot pass
stimulating the from midbrain, through left CN
same eye again III, to the left pupillary
but this time sphincter.
observe the
indirect, or
consensual, PLR
in the opposite
eye. It may be
helpful to have  The patient was not
the nurse control able to follow the
the light stimulus directions of the
while you penlight
observe the accordingly
unstimulated eye.
6 cardinal
field of gaze  The motor function
Position the of CN III, IV, VI is damaged
penlight 12-14 due to injury or compression
inches from
the patient’s
face.
 Then have the
patient follow
your penlight
in the
following
directions
(always start
in the
midline)
 right upper to left
lower
 left upper to right
lower
 right side to left
side

GAG REFLEX
Technique Abnormal findings Analysis
 Stimulate the posterior  Does not elicit a  assess the ability of the
pharynx by using reflexive patient to swallow. If
tongue depressor constriction of this declines, damage of
Inspectio
which will usually the pharynx with the cranial nerve IX and
n elicit a reflexive elevation of the X
constriction of the uvula. 
pharynx with elevation
of the uvula. 
Sensation is
predominantly due to
CN IX
(glossopharyngeal
nerve), whereas the
pharyngeal
musculature is mostly
controlled by CN X
(vagus nerve).
Palatal reflex
 Stimulate the soft  No upward  Alteration of the cranial
palate by using tongue movement of nerve V
depressor soft palate
Face
Technique
Inspection  by using a pinprick to test
Palpation facial sensation and by
brushing a wisp of cotton
against the lower or
lateral cornea to evaluate
the corneal reflex
 Trigeminal motor
function is tested by
palpating the masseter
muscles while the patient
clenches the teeth and by
asking the patient to open
the mouth against
resistance.
 The 7th (facial) cranial
nerve is evaluated by
checking for hemifacial
weakness.
Abnormal findings Analysis
 Diminished  If facial sensation
facial sensation is lost, the angle
 Weak blink reflex of the jaw should
be examined;
sparing of this
area suggests a
trigeminal deficit.
 A weak blink due
to facial weakness
(eg, 7th cranial
nerve paralysis)
should be
distinguished
from depressed or
absent corneal
 Asymmetry of sensation, which
facial movements is common in
is often more contact lens
obvious during wearers. A patient
spontaneous with facial
conversation, weakness feels
especially when the cotton wisp
the patient smiles normally on both
or, if obtunded, sides, even
grimaces at a though blink is
noxious stimulus; decreased.If a
pterygoid muscle
on the weakened
is weak, the jaw
side, the deviates to that
nasolabial fold is side when the
depressed and the mouth is opened.
palpebral fissure  If the patient has
is widened only lower facial
weakness (ie,
furrowing of the
forehead and eye
closure are
preserved),
etiology of 7th
nerve weakness is
central rather than
peripheral.
Ear s
Technique Abnormal findings Analysis
Whisper test
 Stand 1-2 feet  The patient  Decreased or loss
behind client so wasn’t able to of hearing may
they can not read repeat the word be caused by
your lips. correctly compression of
 Instruct client to cranial nerve
place one finger VIII
on tragus of left (vestibulocochlea
ear to obscure r)
sound.
 Whisper word with
2 to 3 distinct
syllables towards
client's right ear.
 Ask client to
repeat word back.
 Repeat test for left
ear.
 Client should
correctly repeat 2
syllable word.
Rinne test  This indicates
 The Rinne test is there is
performed by placing a  If the patient is something
512 Hz vibrating tuning not able to hear inhibiting the
fork against the the tuning fork passage of sound
patient's mastoid bone after it is moved waves from
and asking the patient from the the ear canal,
to tell you when the mastoid to the
sound is no longer through
pinna, it means the middle
heard. Once the patient
that their bone ear apparatus and
signals they can't hear
conduction is into
it, the still vibrating
tuning fork is then greater than the cochlea (i.e.,
placed 1–2 cm from the their air there is
auditory canal. The conduction a conductive
patient is then asked (BC>AC). hearing loss).
again to indicate when
 In sensorineural
they are no longer able 
to hear the tuning fork. hearing loss the
ability to sense
 the tuning fork
by both bone
and air
conduction is
equally
diminished,
implying they
will hear the
tuning fork by
air conduction
after they can
no longer hear it
through bone
conduction.
Weber test
 In the Weber test, the
base of a gently  With  Decreased or loss
vibrating tuning fork is unilateral sensor of hearing may
placed on the mid- ineural hearing be caused by
forehead or the vertex. loss, sound is compression of
The patient is asked heard better in cranial nerve
which ear hears the the unaffected VIII
sound better. Normally, ear. With (vestibulocochlea
the sound is heard unilateral r)
equally in both ears.  conductive 
hearing loss,
sound is heard
better in the
affected ear.

Neck
Technique Abnormal findings Analysis
Test the patient’s Impaired movement of compressed
ability to rotate the head, neck, and accessory nerve
head and shrug shoulder, difficulty may lead to
shoulder against shrugging shoulder on impaired motor
resistance damaged side function .
MOTOR FUNCTION
 Muscle size  Motor dysfunction
Inspection  Muscle strength may indicate injury of the
 tested by having the cerebral cortex due to
patient resist your force as compression or
you attempt to move their
inadequate blood supply
body part against the
direction of pull of the
muscle that you are
evaluating. 
 This is graded on a scale
of 0-5, with "0"
representing absolutely no
visible contraction and
“5” being normal. A grade
of "1" means that there is
visible contraction but no
movement;"2" is some
movement but insufficient
to counteract gravity;"3"
is barely against gravity
(with inability to resist
any additional force); and
"4" being less than normal
(but more than enough to
resist gravity).
 Muscle tone
Muscle tone is assessed
by asking the patient to
relax completely while the
examiner moves each
joint through the full
range of flexion and
extension. Patients vary in
 their ability to relax.
Generally, it is easier for
them to relax the lower
extremities in the sitting
position, whereas the
upper limbs can be
examined in either the
sitting or the lying
position
 Muscle co-ordination
Ask the patient to place
their hands on their thighs
and then rapidly turn their
hands over and lift them
off their thighs. Once the
patient understands this
movement, tell them to
repeat it rapidly for 10
seconds. Normally this is
possible without
difficulty. This is
considered a rapidly
alternating movement.
 Gait and movement

VITAL SIGNS
 BP is >  it may indicate
120/80mmhg increased in
 Pulse rate is <60 Intracranial Pressure
beats per minute
 Respiratory
rate < 12 breaths per
minute

DEEP TENDON REFLEXES

Inspection  Jaw jerk reflex  Reflexes are the most
objective part of the
 Biceps and triceps neurologic examination
 reflex and they are very helpful
in helping to determine
 Brachioradialis reflex the level of damage to the
nervous system
 Finger jerk  There are
intrasegmental and
 Knee jerk
intersegmental
 Ankle jerk connections in the spinal
cord, as well as
descending influences
from the brain stem,
cerebellum, basal ganglia
and cerebral cortices. All
of these can influence the
excitability of motor
neurons, thereby altering
reflex response.

Gait
Technique Abnormal findings Analysis