NEUROLOGIC ASSESSMENT

ANATOMY AND PHYSIOLOGY

• Cerebrum-largest
part of brain.
Responsible for
reasoning, thought,
memory, speech,
sensation, etc.
• Divided into two
halves.
• Further divided into
lobes; occipital,
parietal, temporal
and frontal
• Cerebellum- Peripheral nervous system
responsible for
muscle coordination
• Somatic system
– 12 pairs cranial nerves
• Brain stem- most – 31 pairs spinal nerves
basic functions;
respiration,
• Autonomic
swallowing, blood
– Sympathetic
pressure. Lower part • Fight or flight
(medulla oblongata) is – Parasympathetic
continuous with spinal
cord
• Spinal cord- begins at
foramen magnum and
ends at second
lumbar vertebrae NEUROLOGICAL EXAMINATION
§ assessment of sensory neuron and motor responses,
• Contains both afferent especially reflexes
(to the brain) and § physical examination + medical history (but not deeper
investigation such as neuroimaging)
efferent (motor § can be used as both as a screening tool and as an
neurons- away from investigative tool
the brain)

NEUROLOGICAL ASSESSMENT HELPS TO:

1. identify which component of the neurological system

are affected
2. if possible, determine the precise location of the
problem.
3. Screening for the presence of discrete abnormalities
in patients at risk for the development of neurological
disorders

PATIENT SUFFERING UNDER DISEASES

a. Meningitis: inflammation of meninges

b. Head injury: concussion, contusion (general)
c. Brain tumor
d. Cerebrovascular accident
e. Unconscious patient
f. High grade fever: pt prone to seizure and convulsion

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- HYPERPYREXIA: 40 °C and ­ - There may be diabetes. (Blood is more viscous
- HYPERTHERMIA: 37 °C – 40 °C → slow vascular circulation → slow oxygen
delivery)
Tetanus: clostridium tetani → spinal cord → CSF; lock jaw § Ask about pregnancy, delivery, and neonatal health.
→ masseter o PREECLAMPSIA: edema
g. Coma o CS delivery: avoid artery/vein rupture

HEALTH HISTORY FAMILY HISTORY

1. Onset, character, severity, location, duration, and § Consider genetic basis or predisposition. Examples:
frequency of signs and symptoms - Huntington’s chorea is unusual in that it is a
a. Numerical Scale for adults familial disease that does not present until well
b. Wong-Baker Scale for children into adult life.
2. Complaints → death of brain cells; aging
3. Precipitating, aggravating, and relieving factors
4. Progression, remission, and exacerbation - A family history of:
→ CEREBRAL ANEURYSM: rupture of blood
vessel in the brain; triggered by extreme heat or
OTHER FEATURES/SYMPTOMS OF NEUROLOGICAL cold
DISEASES → EPILEPSY: imbalance of substances in the
brain
• Headache → MIGRAINE: can lead to cerebral aneurysm;
• Numbness, pins and needles, cold or warmth one side only
o Related to vitamin B deficiency → vitamin B → VASCULAR DISEASE: anemia, cancer
complex
o Peripheral neuropathy
• Weakness (electrolyte imbalance), unsteadiness, EQUIPMENT NEEDED
stiffness or clumsiness 1. Sheet for patient cover
• Nausea or vomiting: check if associated with 2. Gloves
headache, vertigo = NS 3. Reflex hammer
• Visual disturbance: pons 4. 128 and 512 (or 1024) Hz tuning forks
5. Snellen Eye Chart or Pocket Vision Card
• Altered consciousness: hemorrhage or jarring
6. Pen light or otoscope
(naalog) of the brain
7. Cotton swabs
8. Sphygmomanometer
SUBJECTIVE DATA COLLECTION
9. Stethoscope
10. Steel kidney tray
PRESENT HEALTH STATUS: changes the client /
11. Test tube – 4 (Cold Calorics)
significant others have noticed in their ability to move
12. Watch
13. Common pin or needle
• Chronic diseases
14. Coffee powder, sugar, salt, etc.
• Current medications 15. Pen or coin
• Alcohol consumption 16. Ishihara card – color test
• Headache (Frequent? Severe? Where? When did 17. Paper clip
it start? How often?)
• Vertigo (Lightheaded? Faint? How often?
Activity? When? Rotational spinning? COMPLETE NEUROLOGIC ASSESSMENT
• Difficulty speaking (Any problems? Forming
words? Saying what you want? How long?) I. Mental Status Exam
• Difficulty swallowing (Solids? Liquids? Excess II. Cranial Nerve Assessment
saliva? Drooling?) III. Motor System Assessment
IV. Sensory System Assessment
PAST HEALTH HISTORY V. Coordination and Gait
VI. Reflex Testing
§ Some neurological problems can present years after
a causative event,
§ Medical problems, past and present; example: PHYSICAL EXAMINATION CONSIDERATIONS
- A person in atrial fibrillation may be producing
multiple tiny emboli. (PULSE RATE: more than 6 LEVEL OF CONSCUOUSNESS
skip beats) o Most important aspect of neurologic examination
o LOC is first to deteriorate; changes often subtle,
therefore requiring careful monitoring.

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® Consciousness o “WORLD” backwards (any 5 letter word)
o Arousal (alertness) o Months of the year backwards
o Awareness (content)
- Assessment: Orientation vs. 2. MENTAL STATUS MEMORY
Disorientation o Immediate Recall: task of concentration (any
▸ Person, place and time statement or number)
▸Varying sequence of questions is o Short-Term Memory: 3/3 objects after 5
important minutes (3, 5, 7, 9 words)
- NOI, TOI, POI, DOI o Long-Term Memory: last thing to go
(memorable events)
o Mood and affect: anger, depression, euphoria
® Assessing LOC
3. MENTAL STATUS LANGUAGE
• Glasgow Coma Scale (GCS)
• Aphasia vs. Dysarthria
• Three Categories: Eye opening, Best motor
o APHASIA: loss of ability to understand or
response, Best verbal response
express speech, caused by brain damage
• Scoring:
o DYSARTHRIA: difficult or unclear articulation
o Highest or best possible score: 15
of speech (malayo ang sagot)
o A score of <8 indicates coma
• Receptive Language: command following
o Lowest or worst possible score: 3
• Expressive Language
o Fluency
NUMERICAL OBJECTIVE
o Word finding
(GCS?) DESCRIPTION
(LOC?) • Repetition: screens for receptive, expressive,
and conductive aphasias
3-5 Deep coma
o Receptive: difficulty understanding written and
6-8 Light coma
spoken language: Wernicke’s
9-11 Stupurous o Expressive: partial loss of the ability to produce
(nakakaramdam) language (spoken, manual, or written); Broca’s
12-13 Drowsy and o Conductive: fluent speech production, but poor
lethargic speech repetition (associative)
14-15 Conscious and
coherent

➠ Check automatically every after 15-30 minutes.

PUPILLARY EXAMINATION

§ Can be quickly and easily performed in the unconscious

or minimally responsive patient when a TBI is suspected
§ Progression or deterioration of condition
§ UNEQUAL SIZE: deterioration or serious brain damage
§ Several types of TBI’s may cause pupillary changes,
which indicate the need for rapid interventions to
decrease ICP caused by cerebral bleeding and/or
edema.
§ Nurses are in a key position to detect early changes in
a patient’s condition and administer or advocate for
immediate interventions.
o Check pupil size in lighted room, and reactivity to light
in a darkened room.
o Unequal pupil size can be a sign of a serious brain
injury.
I. MENTAL STATUS EXAM
General appearance and behavior: LOC, body posture,
dress and hygiene, speech pattern
1. MENTAL STATUS COGNITION
• Concentration
o Serial 5s or 3s (SUBTRACTION)
4. MENTAL STATUS
• Calculations, R-L confusion, finger
• AGNOSIA: inability to interpret sensation, and
hence to recognize things
• AGRAPHIA: loss or impairment of the ability to
produce written language
• Gerstmann’s Syndrome (dominant parietal lobe):
agraphia + finger agnosia
• Hemineglect (non-dominant parietal lobe): a part
of the body is paralyzed
• Delusional thinking, abstract reasoning, mood,
judgement, fund of knowledge, etc.
o Important for Psychiatry
o Does not localize well to one region of the
cortex
o Neurocognitive testing required to get at more
specific deficits

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II. CRANIAL NERVE ASSESSMENT masseter muscles, or to bite down on a
tongue blade.

b. Testing sensory function

o Ask patient to close eyes.
o Touch the face with the wisp of cotton.
o Instruct to tell you when he or she feels
sensation on the face.
o Repeat the test using sharp and dull stimuli
(toothpick or tongue blade)
o Instruct to say “Sharp” or “Dull” (be random)

c. Testing corneal reflex

o Gently touch cornea with cotton wisp.
- Touching cornea can cause abrasions.
- Alternative approach: Puff air across
cornea with a needless syringe, or gently
touch eyelash and look for blink reflex.
SENSORY: 1, 2, 8
MOTOR: 3, 4, 6, 11, 12
6. ABDUCENS
S & M: 5, 7, 9, 10
• Moves eyes outward
1. OLFACTORY

Sniff while occluding each nostril. → Close ® CRANIAL NERVE III, IV, VI
eyes. → Occlude. Sniff. Identify smell. → For both o Test for ocular rotations, conjugate
nostrils. movements, nystagmus
o Test for EXTRAOCCULAR MOVEMENT
® ANOSMIA: loss of sense of smell (EOMs): assessment of eye movements in
ALL directions

2. OPTIC
7. FACIAL
• Snellen Chart: to check for distant vision and
a. Testing motor function
color
• 20 feet distance from the chart
3. OCULOMOTOR
• Assess pupil size and light reflex.
• Unilaterally dilated pupil with unilateral absent
light reflex and/or if the eye will not turn
upwards could indicate an internal carotid
aneurysm or uncalherniation with increased
ICP
• Moves eyes in ALL directions, EXCEPT
outwards, down, and in.
• Opens eyelids and constricts pupil
o Ask patient to perfume these movements:
smile, frown, raise eyebrows, show upper
teeth, show lower teeth, puff out cheeks,
purse lips, close eyes tightly while nurse
tries to open them.
o Observe face for flaccid paralysis.
b. Testing sensory function
o Test taste on anterior two-thirds of the
tongue for sweet, sour, salty.
- Sweet: tip of tongue
- Sour: sides of back half of tongue
- Salty: anterior sides and tip of tongue
- Bitter: back of tongue

4. TROCHLEAR 8. VESTIBUCOCHLEAR/ACOUSTIC
• Pupillary Light reflex and Ptosis • Hearing and balance
• Moves eyes downwards and in o Patients will complain of tinnitus, hearing
loss, and/or vertigo

5. TRIGEMINAL • Weber and Rinne Test

Has 3 branches: sensation to the face, cornea and o Differentiates conductive vs Sensorineural
scalp, opens jaw against resistance hearing loss
a. Testing motor function
o Ask patient to move jaw from side to side • Afferent input to the Oculocephalic Reflex
against resistance, and then clench jaw as o Doll’s Eye Maneuver
you palpate contraction of temporal and o Cold Calorics

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o Not “COWS” III. MOTOR SYSTEM EXAMINATION
o “Hearing grossly intact AU” • Body positioning, involuntary movements,
muscle tone, and muscle strength
a. Weber and Rinne Test for hearing • TONE OF MUSCLE: flaccid, clonic, or normal
b. Watch-Tick test by holding watch close to • MUSCULARITY: wasted, highly developed,
patient’s ear. or normal
c. Rhomberg Test for balance: Ask patient to • STRENGTH
stand, with arms on the side, and close their 5/5 Full strength
eyes. 4/5 Weakness with resistance
3/5 Can overcome gravity
(nakakatayo lang)
9. GLOSSOPHARYNGEAL 2/5 Can move limb w/o gravity
• Moves the pharynx; swallow, speech, and gag (bumabagsak agad)
reflex 1/5 Can activate muscle
without moving limb
0/5 Cannot activate muscle
10. VAGUS
• Voice quality
1. DELTOID STRENGTH
Ask patient to raise both arms. → Examiner’s arms
® CRANIAL NERVES IX AND X on top + resistance simultaneously → Check for
a. Observe ability to cough, swallow, and talk. strength and imbalance.
b. Test motor function
- Ask the patient to open mouth and say “ah”
• Innervated by the C5 nerve root via the
while you depress the tongue with a tongue
axillary nerve
blade.
- Observe soft palate and uvula.
2. BICEPS
- Soft palate and uvula should rise medially.
Flex arms. → Ask patient to reach for his shoulders
c. Test sensory function of CN IC and motor
→ Examiner will apply resistance to the wrist (PULL).
function of CN X by stimulating gag reflex.
→ Compare.
- Tell patient that you are going to touch the
• Innervated by C5 and C6 nerve roots via the
interior throat.
musculocutaneous nerve
- Then lightly touch tip of tongue blade to
posterior pharyngeal movement.
3. TRICEPS
- Observe the pharyngeal movement.
Flex arms. → Ask patient to hyperextend his arms →
- Ask the client to drink a small amount of
Examiner will apply resistance (PUSH). → Compare.
water. Note the ease and difficulty of
swallowing. Also the quality of the voice or • Innervated by the C6 and C7 nerve roots via
hoarseness when speaking. the radial nerve

4. ADDUCTION OF LEGS
11. ACCESSORY ✓ medial thigh strength
• Sternocleidomastoid strength Instruct the patient to bring both legs together. →
• Trapezius strength Apply resistance.
• Turns head and elevates shoulder • Innervated by L2, L3, and L4 nerve roots
• Shoulder shrug
5. ABDUCTION OF LEGS
12. HYPOGLOSSAL ✓ gluteus maximus and minimus
• Protrudes the tongue to the opposite side Push legs apart. → Apply resistance.
• Tongue in cheek (strength) • Innervated by L4, L5, and S1 nerve roots
• Hemi-atrophy and fasiculations
6. GASTROCNEMIUS AND SOLEUS MUSCLE
Instrut the patient to press down the gas pedal +
• Ask the patient to stick their tongue straight out
resistance
of their mouth.
• Ankle plantar flexion is innervated by the S1
• If there is any suggestion of deviation to one
and S2 nerve roots via the tibial nerve.
side/weakness, direct them to push the tip of
their tongue into either cheek while you provide
7. HALUCIS LONGUS MUSCLE
counter pressure from the outside.
Ask the patient to point the largest toe to the
nurse → Apply resistance.
• Almost completely innervated by the L5
nerve root

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IV. SENSORY SYSTEM EXAMINATION + Present but diminished
1. TACTILE SENSATION ++ Normal
Stimulate skin randomly. → Dull or sharp +++ Increased but not necessarily pathologic
++++ Hyperactive or clonic
2. SUPERFICIAL PAIN (AND TEMPERATURE) SUPERFICIAL REFLEX GRADES
Use 4 different test tubes to stimulate the skin. 0 absent
→ COLD CALORICS (hot, cold, warm, or + present
neutral)
NEUROLOGICAL PROBLEMS COMMON IN CHILDREN
3. VIBRATION AND PROPRIOCEPTION
Use a tuning fork. → Joints → Can you feel it? Fetal Alcohol Syndrome: caused when a woman
→ If not, proceed to distal joints. consumes alcohol during pregnancy. The alcohol passes to
the fetus and deprives it of nutrients and oxygen. As a
4. POSITION SENSE result, the alcohol damages several organs.
• STEREOGNOSIA: recognize form in the
absence of visual and auditory ADHD (Attention deficit hyperactivity disorder): begins
o Close eyes. → Place an object on the in childhood and may be carried on to one’s adulthood.
patient’s palm. → Identify the object.
• GRAPHETHESIA: skin Cerebral Palsy: most common indication of cerebral palsy
o Close eyes. → Draw/write something on is a delayed development. This is when infants are unable
the skin. → Identify. to sit, crawl and walk. Also they are unable to cross other
developmental milestones at the right age. Other symptoms
of the condition are here:
V. COORDINATION AND GAIT
1. ALTERNATE HANDS Epilepsy: involves seizures. It affects different aspects of a
• Thigh, raise, backward, thigh child’s life including social behaviour and learning
• Like the game Nanay-Tatay capabilities. However, the medical researchers have
• Increasing speed observed that 70 % of the children with epilepsy recover
2. POINT-TO-POINT MOVEMENTS from the condition as they grow older.
Ask the patient to put a pointing finger on the tip of
the nose. → Using that finger, touch the moving NEUROLOGICAL PROBLEMS COMMON IN ADULTS
finger of the nurse. Then, immediately return it to
the tip of the nose. Huntington’s Disease: An inherited gene defect creates a
3. RHOMBERG TEST: for balance mutant protein that wipes out brain neurons and, over a
4. TANDEM WALKING period of up to 25 years, leads to issues such as involuntary
5. HEEL TO TOE WALKING jerking, impaired speech and balance, and psychiatric
6. HEEL WALK problems like extreme impulsiveness.
7. TOE WALK
8. SHALLOW KNEE BEND Alzheimer’s: Researchers suspect rogue proteins cause
9. SHALLOW KNEE BEND + SHALLOW WALKING tangles and plaque deposits between the brain’s nerve
cells, blocking communication in areas related to memory
and movement, a progression that can take up to 20 years.
VI. REFLEXES
1. BICEP REFLEX: (C5, C6) Parkinson’s: Neurons in the brain that produce dopamine
2. TRICEP REFLEX: 90° / dangling (C6, C7) —a.k.a. the “happy hormone” that also helps control muscle
3. PATELLAR REFLEX: sit, dangling (L3, L4) movement—die off. Once 80 % are gone, a process that
can take 15 years, patients experience tremors, rigid
4. ANKLE/ACHILLES REFLEX: (S1, S2)
muscle movement, and cognitive impairment.
5. SUPERFICIAL REFLEX: abdomen; use sharp
part; < diagonal until umbilical Dementia: Decline in mental ability severe enough to
6. BABINSKI REFLEX: sharp part; “7” lateral to interfere with daily life. Memory loss is an example.
medial Alzheimer's is the most common type of dementia. It is
7. *BRUDZINSKI SIGN: hands on nape + sit ups; associated with a decline in memory or other thinking skills
knee flex (+) severe enough to reduce a person's ability to perform
8. *KERNIG’S SIGN: elevate legs at 90°; abdominal everyday activities.
and sacral area pain (+)

** to check for meningitis Cerebrovascular Accident: Dangerous, life-threatening

event occurs when the blood supply to a part of the brain is
GRADING suddenly interrupted or when a blood vessel in the brain
DEEP TENDON REFLEX GRADES bursts. Warning signs include face drooping, arm
0 Absent weakness, and speech difficulty.

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Myasthemia Gravis: Chronic autoimmune disorder, this 3. Impaired physical mobility
disease blocks the signals from the nerves to the muscles ® Screen for mobility skills. (bed mobility,
and makes the muscles unable to move. A key indication of un/supported sitting, transition movements)
the disease is muscle weakness that increases during ® Observe client for cause of impaired mobility.
periods of activity and improves after periods of rest. ® Monitor and record client’s ability to tolerate activity
® and use all four extremities.
LABORATORY AND DIAGNOSTIC TESTING ® Obtain assistive devices such as walking belts,
walkers, and wheelchairs.
1. EMG (Electromyography)
2. NCV (Nerve Conduction Velocity) 4. Deficient knowledge:
3. Nerve Biopsy ® Observe client’s ability and readiness to learn.
4. MRI (Magnetic Resonance Imaging) ® Assess barriers to learning.
5. Computed Tomography Scan (CT Scan)
® Determine client’s previous knowledge of or skills
6. Electroencephalogram (EEG)
® related to the diagnosis.
7. Arteriogram / Angiogram
8. Neurosonography ® Involve clients in writing specific outcomes.
® Build on client’s literacy skills
DESIRED PATIENT OUTCOMES ® Determine client’s understanding of common
nursing
The client should be able to: ® medical terminologies.

1. Explain signs of neurovascular compromise and 5. Self-care deficit:

ways to prevent venous stasis (Long term) ® Observe inability to feed self independently.
2. Maintain circulation, sensation, and ® Test gag reflex bilaterally and note specific deficits.
movement of an extremity within client's own ® Ask client for input on methods to facilitate eating.
normal limits by end of shift (Short Term) ® Ensure client has dentures, hearing aids, and
3. Maintain or improve by sensation, movement glasses in place.
within normal range (Patient functional status)
4. Identify individual risk factors 6. Impaired verbal communication:
5. Demonstrate/ participate in behaviors and ® Understand the frequent patient needs and
activities to prevent complications nonverbal
6. Relate signs/symptoms that require medical cues.
reevaluation. ® Provide alternative means of communication.
® Use electronic speech generator.
COMMON NURSING DIAGNOSIS ® Eliminate distractions
1. Ineffective Airway Clearance FOR RETURN DEMONSTRATION
2. Ineffective Breathing Pattern
3. Impaired Physical Mobility 1. CHECK MEDICAL RECORD
4. Deficient Knowledge 2. HAND WASHING. EQUIPMENT.
5. Self-Care Deficit 3. INTRODUCTION + VERIFICATION +
6. Impaired Verbal Communication PROCEDURE EXPLANATION
4. CHANGE INTO HOSPITAL GOWN → EXPLAIN
5. MENTAL STATUS
NURSING INTERVENTIONS a. LOC
b. Appearance and behavior
1. Ineffective airway clearance: c. Mood, feelings, and expressions
®
Auscultate breath sounds. d. Thought processes & perception
®
Monitor respiratory patterns, including rate, depth, i. Memory (3)
®
and effort. 1. Immediate Recall:
®
Monitor blood gas values and pulse oxygen number
saturation levels. 2. Short Term: set of
® Position client to optimize respiration. words
® Help client to deep breathe and perform controlled 3. Long Term: story
coughing. e. Cognitive abilities: backwards, aphasia
2. Ineffective breathing pattern: and/or dysarthria, subtraction/addition
® Monitor respiratory rate, depth, and ease of
respiration. 6. CRANIAL NERVES
® Note pattern of respiration. a. I: Sniff and identify fragrance
® If client is dyspneic, determine if it is physiological b. II: Snellen Chart
or psychogenic in cause c. III, IV, VI
i. Rotation

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 NEUROLOGIC ASSESSMENT
ii. PERRLA e. Abdomen: sharp part
Nystagmus and Ptosis f. Plantar
iii. Cardinal Gaze Fields g. *Brudzinski’s Sign: + knee reflex
iv. Peripheral vision h. *Kernig’s Sign: + abdominal/sacral pain
d. V: Jaw Movements + Clenched jaw
(palpate) + Wisp of cotton and blink
(corneal reflex)
e. VII: facial expressions + taste test
f. VIII:
i. Weber and Rinne Test (sensory
and conductive hearing)
ii. Romberg Test (balance; 5
seconds)
iii. Doll’s Eye Movement
iv. Watch-Tick Test

g. IX and X
i. Inspection: palate (soft and
hard), uvula
ii. Swallow with TD inside + speak
iii. Swallow without TD + speak
h. XI
i. Turn head L-R and U-D
ii. Shoulder shrug
iii. Shoulder shrug + resistance
i. XII
i. Tongue strength R-L
ii. Cheek
iii. Cheek + resistance

7. MOTOR SYSTEM ASSESSMENT

a. Deltoid muscles
b. Touch shoulders + resistance
c. Extend arms + resistance
d. Gastrocnemius and soleus: gas pedal
e. Halucis longus: point toe + resistance
f. Adduction: together
g. Abduction: apart

8. COORDINATION AND GAIT

a. Tandem walking
b. Heel to toe
c. Heel walk
d. Toe walk
e. Deep knee bending walk: lunges
f. DKB + shallow walk
g. Alternate (nanay-tatay, varying speed)
h. Point-to-point (nose)

9. SENSORY SYSTEM ASSESSMENT

a. Sharp or Dull (face)
b. Cold Calorics
c. Vibratory sensation on joints (hands and
feet)
d. Position sensation: identify object
e. Tactile discrimination: identify drawing

10. REFLEXES
a. Biceps
b. Triceps
c. Patellar
d. Ankle/ Achilles

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