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o CN8: vestibulocochlear (auditory)

I. Neurological o
o
CN9: glossopharyngeal
CN10: vagus

Assessment o
o
CN11: hypoglossal
CN12: accessory
Reference: Bates’ Nursing Guide to Physical Assessment
and History Taking
II. Peripheral Nervous System Anatomy
☼ Sensory/Afferent DIvision - sent to the
I. Central Nervous System Anatomy brain/spinal cord for interpretation
☼ neuron - smallest functional unit of the nervous o Senses
system ● sight
● hearing
☼ Cerebrum ● smell
o Frontal lobe ● taste
● personality ● touch
● judgement
● abstract reasoning o Internal environment
● sociobehavioral ● chemoreceptors
● Broca’s area (motor speech) ● baroreceptors
− alam gusto sabihin pero di masabi/ ● osmoreceptors
maverbalize
☼ Motor/Efferent Division
o Parietal lobe o Somatic (voluntary)
● interprets sensations ● skeletal muscles
● size
● shape o Autonomic (involuntary)
● distance ● cardiac muscle
● texture ● smooth muscle
● glands
o Temporal lobe − sympathetic division
● auditory stimuli − parasympathetic division
● Wernicke’s area (sensory speech)
− di makaintindi ng words III. Focused Interview
☼ Special Considerations
o Occipital lobe o Developmental
● receives & interprets visual output o Psychosocial
o Cultural & Environmental
☼ Diencephalon
o thalamus - relay center (crude recognition) ☼ History of Present Illness
o hypothalamus - control center(homeostasis) o Do you experience any numbness or
● limbic system (emotional responses) tingling? Where & When does this occur?
o epithalamus - secretes melatonin o Do you experience seizures? how often?
o Does anything seem to initiate a seizure?
☼ Brain Stem (aura)
o cardiorespiratory center of the brain o do you experience headaches/ when do
● medulla oblongata they occur & what do they feel like
● pons o Do you have muscle weakness?
● midbrain o Do you have slurring of speech?
☼ Cerebellum ☼ Past Health History
o Head injury w/ or w/o loss of
☼ Spinal Cord consciousness? What treatment did you
o Anterior/ventral portion of spinal cord receive?
● motor function o Have you ever had meningitis, encephalitis,
o Posterior/dorsal portion of spinal cord injury to spinal cord, stroke?
● sensory function o family history of hypertension, stroke,
Alzheimer's?
☼ CRANIAL NERVES
o CN1: olfactory ☼ Lifestyle & Health Practices
o CN2: optic o smoking
o CN3: oculomotor o usual diet
o CN4: trochlear o “do you lift heavy objects?”
o CN5: abducens
o CN6: trigeminal
o CN7: facial

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IV. Mental Status ☼ Cognition

o information about cerebral cortex function o Orientation - person, place, time
☼ Appearance o Attention Span - ability to concentrate
o Posture o Recent Memory
● erect & relaxed o Remote Memory - past events
o Body Movements o New learning - 4 unrelated words test
● voluntary, deliberate, coordinated and o Judgment - job plans, social/family
smooth obligations & plans for the future
o Dress
● appropriate for setting, age, season, ☼ Thought process
gender, and social group o Thought process - logical, coherent, and
o Grooming & Hygiene relevant
● clean & well-groomed, hair neat & clean o Thought content - ideas, beliefs, use of
words
☼ Behavior o Perceptions - awareness of reality
o Screen for suicidal thoughts

o Glasgow Coma Scale

● GCS = 15
− awake, conscious, coherent
● GCS = 10
− emergency situation
● GCS = 7
− poor prognosis
● GCS = 3
− comatose

o Facial Expression
o Speech
● Quantity
● Rate
● Volume
● Fluency & rhythm
o Mood & Affect
● mood - sustained state of inner feeling
● affect - how do the patient appear to you
− labile
− blunted
− flat

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● ask patient to cover their left eye while

V. Cranial Nerves examiner covers their right eye
o provide information regarding transmission ● ask patient to look at the examiner’s
of motor & sensory messages (head & neck) uncovered eye
o are evaluated during the head, neck, eye & ● fully extend your arm at midline and
ear examination slowly move one finger upward from
below until the patient sees your finger
− paharap, gilid, pataas, pababa
CN Test − repeat with the other eye

I Smell

II Visual acuity, visual fields & ocular

fundi

III, IV, VI pupillary reactions, extraocular

movements

V Corneal reflexes, facial sensation &

jaw movements

VII Facial movements

VIII Hearing

IX, X Swallowing & rise of the palate, gag

reflex ☼ Cranial Nerves III, IV, and VI - extraocular
movements
V, VII, X, Voice & Speech o inspect margins of eyelids (CN III) - eyelid
XII covers 2mm of iris
● ptosis (kirat/sleepy eye) = weak eye
XI trapezius & sternocleidomastoid muscles
contraction

XII inspection of the tongue

☼ Cranial Nerve I - olfactory

o ask patient to clean their nose and close
their eyes
o check for smell
● cover one nostril, then ask patient to take
a whiff of different odors
● anosmia - absence of smell
− possible brain tumor/lack of zinc

☼ Cranial Nerve II - optic

o visual acuity test
o Test for near vision o assess extraocular movements: 6 cardinal
● ask patient to read a magazine/any fields
material ● H method or wheel method
● observe closeness or distance of the ● eye moves in a smooth and coordinated
page to the patient’s face motion
− presbyopia - impaired near vision − nystagmus - rhythmic oscillation of the eyes
− strabismus - lack of muscle coordination
− diplopia - double vision
o Test for distant vision (Snellen’s chart)
● position the patient 20 feet from the
snellen chart
● ask them to read each line until they
cannot read the letters
− myopia - nearsightedness
− hyperopia - farsightedness

o Visual Fields by confrontation

● examiner must be about 2ft away from
patient at eye level

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o test for convergence
● hold finger or object 12-15 in from
patient
● instruct patient to remain focused on the
object as the instructor moves it closer
within 5-8mm of the nose
o assess pupillary response and
accommodation
● round, equal in size & shape, in the
center of the eye
● ANISOCORIA - pupil inequality of
<0.5mm
● direct light reflex = pupillary constriction
in the same eye
● consensual light reflex = pupillary
constriction in the opposite eye
− both pupils should constrict briskly
− sluggish - slow more than 1s
− fixed - non reactive
− abnormal = lesion in the nervous system
● PERRLA - Pupil Equal Round Reactive to
Light and Accommodation
VI. Motor and Cerebellar Function
o To determine functioning of the pyramidal
and extrapyramidal tracts
o to determine balance & coordination
o Focus on
● body position
● involuntary movements
● characteristics of the muscles
● coordination
☼ Gait and Balance
o ask the patient to walk naturally across the
room and back
● note the posture, freedom of movement,
symmetry, rhythm, and balance
− stiffness or relaxation
− equality of steps
− pace of walking
− position and coordination
− ability to maintain balance
● normal: steady; opposite arm swings
− patient should not be aware that you are
observing them
o Romberg’s test
● assess coordination & equilibrium (CN
VIII)
● ask patient to stand with feet together
and arms resting at the sides, with eyes
open then closed
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− stand close to the patient
− note any unsteadiness or swaying
● Normal: stands erect with minimal
swaying with eyes open or closed
● Abnormal: swaying greatly increases,
moving feet apart = disease of posterior
columns, vestibular dysfunctions or
cerebellar disorders
● cerebellar ataxia
− wide-based, staggering, unsteady gait
− (+) Romberg’s test
− cerebellar diseases or alcohol and drug intoxication
● Parkinsonian gait
− shuffling gait, turns in very stiff manner
− stooped-over posture with flexed hips & knee
− seen in Parkinson’s disease
− pill-rolling fingers
● Scissors gait
− stiff, short gait
− thighs overlap each other with each step
− seen in partial paralysis of the leg
● Spastic Hemiparesis
− flexed arm held close to body while client drags toe
of legs or circles it stiffly outward and forward
− lesions of the UMN = Cerebrovascular accident
● Footdrop (steppage gait)
− lifts foot & knee high with each step, then slaps the
foot down hard on the ground
− cannot walk on heels
− LMN disease
☼ Coordination and Equilibrium
o Fine motor test for UPPER EXTREMITIES
o Finger-to-nose test
● ask patient to abduct and extend arms at
shoulder height and rapidly touch nose
alternately with one index finger and
then the other
● pass-point test
− assesses coordination and equilibrium
− observe for movement of arms
− smoothness of finger
− point of contact of finger
● Normal: able to touch fingers to nose
with smooth accurate movements with
little hesitation
● abnormal: cerebellar disease
o Finger-to-nose and to the Nurse’s finger
● ask the patient to touch their nose and to
touch your index finger held about 45cm
at a rapid increasing rate at different
direction
b. ataxia c. intention tremor
o Test for Pronator Drift
● ask patient to supinate both arms then
instruct to close their eyes
− Normal: able to hold arm in this position well
− Abnormal: downward movement of arm w/
flexion of fingers and elbow

o Alternating supination and pronation of
hands on knees
● Ask the patient the pat both knees with
the palms of the hand alternate with the
back of the hands at an increasing rate
● observe rhythm, rate, and smoothness of
movement
o Finger to thumb
● ask the patient to touch each finger of
one hand to the thumb of the same hand
as rapidly as possible
− normal: rapidly turns palms up and down|
able to touch thumb rapidly
− abnormal: unable to perform rapid
alternating movements = cerebellar disease,
UMN weakness
− uncoordinated movements or tremors
(dysdiadochokinesia) - impairment of the
power to perform alternating movements in
rapid, smooth, and rhythmic succession
o Fine motor test for LOWER EXTREMITIES
o Heel to shin test
● ask patient to place heel of one foot just
below the opposite knee and run the
heel down the shin to foot
● repeat w/ the other foot. patient can be
in sitting position
− normal: able to run each heel smoothly down
each shin
− abnormal: deviation of heel to one side =
cerebellar disease
o Toe or ball of foot to the Nurse’s finger
● ask the patient to touch your finger with
the large toe of each foot with your
fingers moving at different directions
VII. Sensory Function
o Test several kinds of sensations
● pain and temperature - spinothalamic
tract
● position and vibration - posterior
columns
● light touch - both of these pathways
● discriminative sensations
o pay special attention to:
● where there are symptoms such as
numbness or pain
● where there are motor or reflex
abnormalities that suggest a lesion of the
spinal cord or PNS
● where there are trophic changes
☼ General approach
o instruct the patient to identify the
sensations as you change stimulus and
respond to your questions as needed
o keep the patient’s eyes closed
o do the procedures in random, letting the
patient assess location of the area tested
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SPINOTHALAMIC TRACT
☼ Light touch sensation
o . Ask the patient to close eyes and instruct
to say “yes” or “now” whenever the patient
feels the cotton wisp touching the skin.
o lightly touch one specific part of the body
and then the same spot on the other side
o test areas on the forehead, cheek, hand,
lower arm, abdomen, foot, and lower leg
● check a distal area of the limb first
− anesthesia- absence of touch sensation
− hypoesthesia - decreased sensitivity to touch
− hyperesthesia - increased sensitivity to touch
☼ Pain sensation/ Sharp and Dull test
o Ask the patient to close his/her eyes and to
say, “sharp,” “dull,” or “don’t know” when
the sharp or dull end of the paper clip is
felt.
o test and let the patient feel first before
proceeding
o alternately apply the sharp and dull end of
the paper clip at chosen anatomic areas
randomly (the face is not tested)
● allow at least 2 secs between each test
− analgesia - no pain felt
− hypoalgesia - decreased sensitivity to pain
− hyperalgesia - increased sensitivity to pain
☼ Temperature sensation
o Ask the patient to say “hot”, “cold” or
“don’t know” as you touch the areas of the
skin with hot or cold water - filled test
tubes.
POSTERIOR COLUMN TRACT
☼ Vibration
o tuning fork over bony prominences (toes,
ankle, knee, iliac crest, spinal process,
fingers, sternum, wrist, elbow)
o inability = posterior column disease or
peripheral neuropathy (DM, chronic alcohol
abuse)
● start at the distal end of the limbs
☼ Position or kinesthetic sensation
o middle finger/large toe is dorsiflexed,
plantar flexed or abducted
☼ one-and-two point discrimination
o ability to identify the smallest distance
between two points
● distances & locations
− fingertips - 0.3 to 0.6cm
− hands & feet 1.5-2cm
− lower leg - 4cm
☼ Stereognosis
o ask patient to close both eyes
o place familiar objects in the patient’s hand
and ask the patient to identify them
● ability to identify object without seeing it
− astereognosis - inability to identify the
object correctly
☼ Graphesthesia
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o ability to perceive writing on the skin

☼ Topognosis/ Extinction Phenomenon

o ability to identify an area that has been
touch
● simultaneously touch two symmetric
areas of the body
● ask patient to identify what part of the
body was involved
● ask patient to point the area you touched
− abnormal - sensory or cortical disease

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II. Musculoskeletal
System Assessment
Reference: Bates’ Nursing Guide to Physical Assessment
and History Taking

VIII. Muscular System Anatomy

☼ Functions
o Support
o Protection
o Movement
o Storage
o Blood cell production (hematopoiesis)

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