I.

ASSESSMENT
1. Assess client’s readiness for the procedure

2. Assemble equipment and supplies

 Percussion Hammer
 Tongue Depressir ( one broken diagonally, for ttesting pain
sensation)
 Wisp of cotton to assess light touch sensation
 Test tube for hot and cold water, for skin temperature
assessment
 Cologne,perfume,alcohol,mint,vinegar
 Coffee, salt,sugar
 Pencil for sharp and dull
 Gloves

II. PLANNING
1. Explain to the client what you are going to do, why it is
necessary, and how can cooperate.

2. Wash hands and observe other appropriate infection

control procedures

3. Provide for client privacy

4. Determine client’s history of the following

 Presence of pain in the head, back or extremities as
Well as onset and aggravating and alleviating factors
 Disorientation to time, place, or person
May tanong ako i want you to answer it what time is
it?, where are you right now?, ano ang iyong
pangaln, pangalan ng kasama mo?
-the patient is oriented to time, place and person
 Speech disorders
The patient is alert can able to to respond
attentively to the question
 Any history of loss of consciousness, fainting,
convulsions, trauma, tingling sensation or
numbness, tremors or tics, limping, paralysis,
uncontrolled muscle movements, loss of memory of
mood swings.
 Alterations in smell, vision, taste, touch or hearing
III. IMPLEMENTATION
LANGUAGE
1. Client displays difficulty speaking:
a. To common objects and ask the client to name them
I want you to say what i pointed object. Books, papel,
pencil
The patient can able to identify the object that i
pointed.
b. Ask the client to read some words and to match the
printed and written words with pictures
c. Ask the client to respond to simple verbal and written
commands, eg.,” point to your toes” or “ raise your left
arm”.
The patient are able to respond to my command and
able to follow the test

ORIENTATION
2. Determine the client’s orientation to time, place, and
person by tactful questioning
a. Ask the client’s the city of residence, time of the date,
day to day of the week, duration of illness and names of
family members.
b. More direct questioning may be necessary for some
people. Eg. “where are you now? “ what day is it
today?”
3. Listen for lapses in memory
Ask the client about difficulty with memory. If problems are
apparent three categories of memory are tested
To assess Immediate Recall:
a. Ask client to repeat a series of three digit eg. 7-4-3 spoken
slowly
b. Gradually increase the number of digit eg. 7-4, 3-5, 7-4-3-5-
6-7-2 until the client fails to repeat the series correctly
c. Start again with a series of three digits, but this time ask the
client repeat them backward
d. The average person can repeat a series of five tonight digits
in sequence, and four to six digits in reverse order
To assess recent memory:
a. Ask the client to recall the recent events of the day, such as
how he got to the clinic.
This information must be validated, however
 b. Ask the client to recall information given early in the
interview, eg. The name of the doctor
c. Provide the client with three facts to recall eg. A color, an
object, an address, or a three-digit number and ask the
client to repeat all three. Later in the interview, ask the
client to recall all three items.
To assess remote memory
a. Ask the client to describe a previous illness or surgery

ATTENTION SPAN AND CALCULATION

4. Test the ability to concentrate or attention span by asking
the client to recite the alphabet or to count backward from
100.
5. 7 or 3 progressively from 100 eg. 100, 93,86,79, or 100,
97,94
LEVEL OF CONSCIOUNESS
CRANIAL NERVES
1. CRANIAL NERVE I 0 OLFACTORY (Sensory)
a. Check nasal patency
b. Ask the client to close eyes and identify the odor of
at least two different mild aromas, such as coffee,
vinegar or vanilla
2. CRANIAL NERVE II – OPTIC (Sensory )
a. Testing for visual acuity
1. Informal assessment:
- Using newspaper
2. formal assessment:
- Using Snellen chart
b. Testing the visual fields:
1. Confrontation technique

c. Fuduscopic Exam
- Using the ophthalmosocope

3.CRANIAL NERVE III-OCULOMOTOR (Motor)

Assess six ocular movements and pupil reaction

4.CRANIAL NERVE IV – TROCHLEAR (Motor)

SOT Assess six ocular movements

5.CRANIAL NERVE V – TRIGEMINAL (Mixed)

While client looks upward, lightly touch lateral sclera of eye
to elicit blink reflex
- To test light sensation: have client close eyes a wipe
 a wisp of cotton, over client’s forehead and
paranasal sinuses.
6. CRANIAL NERVE VI – ABDUCNES ( Motor)
Assess direction of gaze
LRA
1. Note for Ptosis
2. Note for papillary constriction
Ask the patient to follow fingers through the six cardinal
positions of gaze
7. CRANIAL NERVE VII- FACIAL

8. CRANIAL NERVE VIII- AUDITORY (Sensory)

Assess client’s ability to hear spoken word and vibrations of
tuning fork
9. CRANIAL NERVE IX- GLOSSOPHARYNGEAL (Mixed)
Apply taste on posterior tongue for identification
Ask client to move tongue from side to side and up and
down
10. CRANIAL NERVE X- VAGUS (Mixed)
Assessed with CN IX, assess client’s speech for hoarseness

11. CRANIAL NERVE XI- ACCESSORY (MOTOR)

Ask client to shrug shoulders against resistance from your
hands and to turn his head to side against resistance from
your hand. Repeat for other side.
12. CRANIAL NERVE XII- HYPOGLOSSAL (Motor)
Ask the client to protrude tongue at midline, then move it
side to side
MOTOR FUNCTION
GROSS MOTOR AND BALANCE TEST
Walking Gait
Ask the client to walk across the room and back, and asses the client’s gait
Romberg’s Test
Ask the client to stand with feet together and arms resting at the side, first
with eyes open then closed.
Standing on One Foot with Eyes Closed
Ask the client to close eyes and stand on one foot, then the other, stand
close to the client during this test.
Heal- Toe-Walking
Ask the client to walk a straight line, placing the heel of one foot directly
in front of the toes of the other foot
Toe or Heel Walking
Ask the client to walk several steps on the toes and then on the heels

FINE MOTOR TEST FOR THE UPPER EXTERMITIES

Finger- to Nose- Test

Ask the client to abduct and extend arms at shoulder height and rapidly
touch nose alternately with one index finger and then the other, have the
client repeat the test with eyes closed if the test is performed easily.
Alternating Supination and Pronation of Hands on Knees
Ask the client to pat both knees with the palms of both hands and then
with the backs of hands, alternately, at an ever increasing rate
Fingers to Nose and to the Nurses’s Finger
Ask the client to touch nose and then your index finger, held at a distance
at about 45 cm at a rapid and increasing rate.
Fingers to Fingers
Ask the client to spread arms broadly at shoulder height and then bring
fingers together at the midline, first with eyes open and then closed, first
slowly and then rapidly
Fingers to Thumb (Same Hand)
Ask the client to touch each fingers of the hand to the thumb of the same
hand as rapidly as possible
FINE MOTOR TEST FOR THE LOWER EXTREMITIES
HEEL DOWN OPPOSITE SHIN
Ask the client to place the heel of one foot just below the opposite knee
and run the heel down the shin to foot. Repeat with the other foot, the
client may also use a sitting position for this test
TOE OR BALL OF FOOT TO THE NURSE’S FINGER
Ask the client to touch your fingers with the large toe or each foot

LIGHT TOUCH SENSATION

A. Ask the client to close eyes and to respond by saying “yes” or “no”
whenever the client feels the cotton wisp touching the skin.
B. With a wisp of cotton, lightly touch one specific spot and then the
same spot on the other side of the body

C. Test areas on the forehead, cheek, hand, lower arm, abdomen,

foot and lower leg.
Check the distal area of the limb first
D. Ask the client to point to the spot where the touch was felt

E. If areas of sensory dysfunction are found, determine the

 boundaries of sensation by testing responses approximately every
2.5 cm ( 1 inch) in the area. Make a sketch of the sensory loss area
for recording purposes.
PAIN SENSATION
a. Ask the client to close his/ her eyes and t say “sharp”. “dull” or
“down know” when the sharp or dull end of the broken tongue
depressor is felt
b. Alternately, use the sharp and dull end of the sterile pin or needle
to lightly prick designated anatomic areas at random.
Face is not tester in this manner
TEMPERATURE SENSATION
a. Touch skin areas with test tube filled with hot or cold water

b. Have the client respond say “hot” ,“cold” or “ don’t know”

POSITION OR KINESTHETIC SENSATION

a. Ask the client to close his eyes
b. Grasp the middle finger or a big toe firmly between your thumb
and index finger, and exert the same pressure on both sides of the
finger or toe while moving it.
TACTILE DISCRIMINATION
A. ONE and TWO POINT DISCRIMINATION
B. STEGEOGNOSIS
C. EXTINCTION PHENOMENON
Document findings in the client’s record