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NERVOUS SYSTEM ● Alzheimer’s disease is associated with
● Central Nervous System
● Peripheral Nervous System
Stimuli (sensory output) 🡪 Integration (decisions)
🡪 Response (Motor output)
NEURONS
Nerve cells – nerve cells in the nervous system
send signals called action potentials
Axons – conducts impulse away from cell body
(passes the message)
Dendrite – conducts impulse toward cell body
(receives message)
Action potential – electrical signal traveling down
the axon
Myelin sheath – covers the axon of some neurons
and helps speed neural impulses (Myelin
destroyed impulse transmission is slowed or
stopped)
NEUROTRANSMITTERS
● substance secreted at the synapse
o absent/decreased stimulus cannot
travel
● When not signaling, a neuron is
hyperpolarized, meaning it has a negative
charge when compared to the outside
● Transmission is accomplished by the
NEUROTRANSMITTERS, which can
excite or inhibit neurons.
NEUROTRANSMITTER
● used in the spinal cord and motor neurons
to stimulate muscle contractions.
● used in the brain to regulate memory,
sleeping, and dreaming.
a. Acetylcholine – major transmitter of the
parasympathetic nervous system
an undersupply of acetylcholine.
Nicotine is an agonist that acts like
acetylcholine.
b. Serotonin – inhibitory helps control mood,
appetite, sleep, and aggression
● inhibits pain pathways
● Low levels - associated with
depression, and some drugs designed
to treat depression (known as
selective serotonin reuptake inhibitors,
or SSRIs) serve to prevent their
reuptake.
c. Dopamine – affects behavior (attention,
emotions) and fine movements
● Involved in movement, motivation, and
emotion.
● Produces feelings of pleasure when
released by the brain’s reward system,
and it’s also involved in learning.
● Schizophrenia is linked to increases
in dopamine, whereas Parkinson’s
disease is linked to reductions in
dopamine (and dopamine agonists
may be used to treat it).
d. Glutamate is a powerful excitatory
neurotransmitter that is released by nerve
cells in the brain. It is responsible for sending
signals between nerve cells, and under
normal conditions it plays an important role in
learning and memory
● Excess glutamate can cause
overstimulation, migraines and
seizures
● Monosodium glutamate (MSG) is a
flavor enhancer commonly added to
Chinese food, canned vegetables,
soups and processed meats.
e. Norepinephrine binds to adrenergic
receptors resulting in relaxation of the
bronchioles, increased heart rate and blood
pressure, and a generally increased state of
arousal.
● These effects are sometimes called an
“adrenaline rush”
● important for attentiveness, emotions,
sleeping, dreaming, and learning.
Neurotransmitter Decreased Increased
Serotonin Depression Mania
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Acetylcholine Dementia
Dopamine Parkinson’s Schizophrenia Temporal Lobe
Endorphin Stress ● process smell and taste stimuli
Norepinephrine/ Depression Mania ● process hearing stimuli
Epinephrine
● memory storage of sound
GABA Anxiety Mania
● understanding of language and music

BRAIN Occipital Lobe

● Cerebrum ● visual center
● Cerebellum
● understanding of written material
● Brainstem
o Visual interpretation and memory

1. Cerebrum Wernicke’s Area

● Largest part of the brain ● Associated with language comprehension.
o Right and left hemispheres ● When damage in the dominant
o Thalamus hemisphere, receptive aphasia results.
o Hypothalamus ● The person hears sound but, but it has no
o Basal ganglia meaning like hearing a foreign language
● Center of intellect and consciousness
● Governs sensory, motor activity, thought & Broca’s Area
learning ● Mediates motor speech.
● When injured in the dominant hemisphere,
R And L Hemispheres expressive aphasia results, the person
● connected by corpus callosum (allows cannot talk.
communication) o The person can understand language
● receives sensory /motor impulses – and knows what he/she wants to say
opposite side of the body but can produce a garbled sound.
Right hemisphere – controls:
Thalamus
✔ Visual spatial information
● Relays sensory impulse to the cortex
✔ Surrounding physical environment
● Provides a pain gate
✔ Art
● Part of the reticular activating system
✔ Music
Left hemisphere – responsible for: Hypothalamus
✔ Speech Regulates:
✔ Reasoning ● Body temperature
✔ Calculations ● Autonomic responses (SNS and
✔ Problem solving PSNS)
● Stress response
Frontal Lobe
● Emotions
● Controls voluntary motor control on the
● Sleep
opposite of the body
● Appetite
● Ability to write words
● Fluid balance
● Motivations – determine
● Responsible for the production of
● Emotions – determine
hormones secreted by the pituitary
● Personality gland and the hypothalamus.
● Judgement formation
● Abstraction 2. Cerebellum
● Conceptualization Coordinates:
● Movement (smooth)
Parietal Lobe
● Balance (equilibrium)
● Interprets sensation – pain, touch,
temperature pressure ● Posture
● Discrimination of Left vs right ● Spatial orientation
● Ability to recognize body parts o When damaged – movements that
were once smooth and refined
● Determines where the body is in relation to become jerkier and rougher
the environment
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o RAS (reticular activating system) – ● Controls body movement
connects the brain stem, to the ● Regulates visceral function
cerebral cortex, through various ● Exits the skull through the foramen
neural paths. magnum and extends to the 2nd lumbar
vertebra – ENDS in the CAUDA EQUINA
3. Brainstem
Midbrain (Cranial nerves III & IV) – Mediator
● Motor coordination
● Visual reflex center
● Auditory relay centers
Pons (Cranial nerves V → VIII)
● Respiratory center (breathing)
Medulla Oblongata (Cranial nerves IX → XII)
● Contains all afferent/efferent tracts and
cardiac, respiratory, vomiting, and
vasomotor centers.
● Controls HR, RR, blood vessel diameter,
sneezing, swallowing, vomiting, and PERIPHERAL NERVOUS
coughing
SYSTEM
BONES AND SUTURES OF THE SKULL
● Skull – protects the brain from injury 1. Cranial Nerves
● Meninges – covers the brain & spinal cord , ● Emerge from the lower surface of the brain
provides protection, support and nourishment and pass through the base of the skull
● Cerebrospinal fluid
o Clear and colorless fluid produced in the
choroid plexus of the ventricles.
o Has high glucose content
o Normal pressure is 50 -175 mm H2O
o Normal vol. is 125 -150 ml.
● Functions:
o Buoyancy: maintain density
o Protection: brain tissue from injury when
jolted or hit
o Chemical Stability: rinsing the metabolic
waste from the central nervous system
through the blood-brain barrier
o Prevention of Brain Ischemia

ARTERIAL BLOOD SUPPLY OF THE BRAIN

● Needs constant blood supply for glucose
metabolism - brain cannot store oxygen or
glucose
● Oxygen Supply – 20% of the cardiac
output (Neurons cannot survive anoxia for
more than 4-6 minutes)
● Circle Of Willis – arteries (anastomosis)
at the base of the brain
● Protective Function – prevents (filters)
macromolecules and many compounds in
entering the brain. Allows only glucose,
some amino acids, respiratory gases, and
water
● Vertebral Column – surrounds and
protects the spinal cord
SPINAL CORD
2. Spinal Nerves
Each spinal nerve:
● DORSAL ROOT(sensory)
- Transmit sensory impulses from specific
areas of the body known as dermatomes
- Dermatome – an area of skin supplied by
a single spinal nerve. Useful in locating
pain sites and neurologic lesions)
● VENTRAL ROOT (motor)
- Transmit impulses from the spinal cord to
the body (somatic or visceral)

Principal Spinal Nerve Motor Levels
3. Autonomic Nervous System
● regulates activities of internal organs
(heart, lungs, blood vessels, digestive
organs, and glands)
● maintains internal homeostasis
2 Major Divisions:
1. Sympathetic NS – prepares the body to
handle stress- excitatory responses (fight
or flight response), main neurotransmitter
is norepinephrine
2. Parasympathetic NS – operates during
non-stressful situations (rest) and
conserves the body’s energy by regulating
digestion, elimination, and other activities.
Main neurotransmitter is acetylcholine
Parasympathetic VS Sympathetic
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ASSESMENT OF THE
NERVOUS SYSTEM
Mental Health Gap Action Programme (mhGAP)
MENTAL HEALTH ASSESSMENT
● MENTAL STATUS – is a person’s
emotional and cognitive functioning.
● Optimal functioning aims toward
simultaneous life satisfaction in work, in
caring relationships, and within the self.
THERE IS NO HEALTH IF THERE IS
NO MENTAL HEALTH
● MENTAL HEALTH is a precondition to
active ageing and quality of life
Aging and Mental Health. Most older people face
life challenges with equanimity, good humor and
courage and manage transition and stressors with
resilience, resourcefulness and hardiness.
MENTAL HEALTH
● MENTAL HEALTH is a precondition to
active ageing and quality of
● Psychological,social and emotional well
being
● Refers to our ability to manage thoughts,
feelings and behavior so that we can
o experience satisfaction and
happiness
o cope with stress and sadness
o achieve our goals and potentials
o maintain positive connections with
others
● Changes over time
MENTAL HEALTH PROBLEMS
● Barrier to active and satisfying
aging/negative impact on quality of life
● Prolongs stays in general hospital and
increases recovery time from physical
health problems

● Negative impact on motivation and
compliance with rehabilitation(e.g.
Diabetes, medication,diet)
● Increases mortality from natural
compliance
● SUICIDE in older age a major problem
DEVELOPMENTAL CONSIDERATIONS:
Aging Adult
● Loss of neurons but no loss in intellectual
function.
● ↓dendrites = slower reaction/response
time
● ↓ blood flow to the brain = ↑ risk brain
damage
● Recent memory (medication instructions,
24-hour diet recall, names of new
acquaintances), is somewhat decreased
with aging.
● Remote memory not affected.
● Processing of information takes longer
● Age related changes in sensory
perceptions affects mental status.
MENTAL DISORDER – person’s response is
much greater than the expected reaction to a
traumatic life event.
o Distress( a painful symptom)
o Disability (impaired functioning)
Employment
● People with mental, neurological and
substance use disorders may be denied
work opportunities.
● Studies have shown that people with
mental, neurological and substance use
disorders experience unemployment rates
of up to 90% in many countries.
Education
● Children with mental disorders are
excluded from educational opportunities.
● In many countries children with mental or
intellectual disorders are
INSTITUTIONALIZED in facilities that do
not offer education.
● There is little hope of being able to find
employment, integrate into society and
lead fulfilling lives in the community.
Civil/Family Rights
● People experience restrictions in the right
to marry and start a family
● In some countries, people can be placed
under guardianship which prevent them
from marrying or filing for divorce without
approval.
Political Rights
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● People also experience restrictions in the
right to vote.
● In some countries, people cannot vote if
deemed of “unsound mind or mental
infirmity” (e.g., Thailand) or if under
guardianship (e.g., Hungary).
Abuse
Stigma & Discrimination
● Many individuals with mental, neurological
or substance use disorders are perceived
by the community as weak, inhuman,
dangerous, or inferior because of their
symptoms.
● As a result of stigma, these people are
excluded, or they exclude themselves
What are the effects of stigma & discrimination?
- Emotional state? Affects sense of
self-worth
- Prognosis? Contributes to shortened life
expectancy. Slows recovery
- Access and quality of treatment? Limits
access and quality of health care
- Human rights? Can lead to abuse
- Family? Disrupts relationships
Stigma and discrimination in the health care
system
● People with mental, neurological and
substance use disorders can experience
stigma and discrimination from the health
system
As health providers we can:
- Change our own perception and attitude
towards people with mental, neurological
and substance use disorders
- Respect and advocate for the
implementation of relevant international
conventions, such as the United Nations
Convention on the Rights of Persons
with Disabilities
- Reaffirm that all persons with all types of
disabilities must enjoy all human rights and
fundamental freedoms.
- Play a large part in fulfilling these rights
Mental Health Gap Action Programme (mhGAP)
● mhGAP is the WHO programme to scale
up care for mental, neurological and
substance use disorders
● mhGAP was launched by the WHO
Director-General in 2008
Key Objectives Of mhGAP
● To reinforce the commitment of
governments, international organizations,
and other stakeholders to increase the
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allocation of financial and human ● Reflexes – DTRs, abdominal, and plantar
resources for care of MNS disorders (Babinski)
● To achieve much higher coverage with key
interventions in low- and middle-income MENTAL STATUS
countries. ● Appearance and behaviour
- posture
- body movements
- facial expressions
HEALTH HISTORY TAKING - note dressing
- grooming and hygiene
- explore the patient’s current condition and
related events.
Appearance and Behavior
- include details:
Normal:
Character
● POSTURE – erect
Onset ● Position – relaxed
Location
Abnormal Findings:
Duration
● Sitting on edge of chair or curled in bed,
Severity tense muscles frowning, darting watchful
Pattern eyes
Associated Factors ● Sitting slumped in chair, slow walk,
- frequency of S/S dragging feet occur with depression and
some organic brain diseases.
- remissions/exacerbations
- similar S/S among family members
Normal:
● Body Movements
- voluntary, deliberate, coordinated, and
COMMON SYMPTOMS smooth and even.
1. Pain – brain hemorrhage, trigeminal ● Dress
neuralgia - appropriate for setting, season, age,
gender, social group.
2. Seizures – induced by high fever, alcohol,
drug withdrawal - Clothing fits and is put on appropriately
3. Dizziness and Vertigo – hot weather, ear Abnormal Findings:
infections ● Restless, fidgety movements, hyperkinetic
4. Visual Disturbances – lesions of the eye appearance (anxiety)
(cataract), lesions along the pathway (tumor) ● Facial grimace
5. Muscle Weakness – sudden and permanent ● Inappropriate dress, eccentric dress
(stroke), progressive (amyotrophic lateral combination and bizarre makeup
sclerosis)
Normal:
6. Abnormal Sensation – lack of sensation →
● Grooming And Hygiene
risk of fall/ injury
- clean, well groomed
5 COMPONENTS OF NEUROLOGIC - hair is neat and clean
ASSESSMENT - Women with little or no make-up
● Consciousness and cognition – cerebral - Men are shaved, beard or mustached
function mental status, intellectual function are well groomed.
thought content, emotional status, perception, - A dishevelled appearance in a
motor ability, and language ability previously well-groomed
o Note the impact of any neurologic appearance is significant. Note:
impairment on lifestyle and patient consider economic status and
abilities and limitations fashion trend
● Cranial nerves ● Facial Expressions
● Motor system – posture, gait, muscle tone - Client maintains good eye contact ,
and strength, coordination and balance, smiles and frowns appropriately
Romberg test ● Observe Speech
● Sensory system – tactile sensation, - Speech is in moderate tone, clear, and
superficial pain, vibration, and position sense with moderate pace
Abnormal Findings:

● Inappropriate dress, poor hygiene, lack of
concern in appearance (Alzheimer’s
disease).
● Unilateral neglect (CVA)
● Slow repetitive speech – depression or
Parkinson disease.
● Loud, rapid speech – manic phases of
bipolar disorder
ASSESSMENT PROCEDURE
If with speech difficulty:
– Ask client to name objects in the room
– Ask client to read from printed material
appropriate for his educational level.
– Ask the client to write a sentence
Normal
● Can name familiar objects without difficulty.
● Read age-appropriate written print
● Writes coherently, correct spelling and
grammar
Abnormal
● Unable to name objects correctly, read
print correctly or write a basic correct
sentence.
Moods, Feelings & Expressions
– Ask how are you feeling today?
– What are your plans for the future?
Normal
● Cooperative or friendly
● Expresses feelings appropriate to situation
● Verbalizes positive feelings regarding
others & the future
● Expresses positive coping mechanisms
(sports, hobbies, support groups, exercise)
Abnormal
● Expression of prolonged negative
despairing feelings – depression
● Expression of elation & grandiosity, high
energy level – manic
● Excessive worry – anxiety
● Eccentric moods not appropriate to the
situation – schizophrenia
MENTAL STATUS EXAMINATION
● Thought Content and Processes
- Content (what client is thinking)
- Process (how client is thinking)
- Clarity of ideas
- Self-harm or suicide urges
Thought Process and Perception
– Observe for clarity, content, and perception
by inquiring about client’s thoughts &
perceptions expressed.
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– “Tell me more about what you just said”.
Normal
● Expresses full, free flowing thoughts;
follows direction accurately, expresses
realistic perceptions, easy to understand
and makes sense, does not voice suicidal
thoughts.
Abnormal
● Delusions
● Illusions
● Clang association
● Flight of ideas
● Avoidance – phobias
MENTAL STATUS ASSESSMENT
– Flight of ideas – excessive amount and
rate of speech characterized by shifting
from one topic to the other and
fragmenting ideas.
Mental status examination:
Thought Processes Descriptors
Neologism – new word or words created by the
client often a blend of other words
- The popskis are looking for you, you better
charibaba
Word salad – flow/chaining of unconnected words
that convey no meaning to the listener
- Batista, apple, kobe, mosquito, ocean,
boxing, sinigang
Thought process and perception
– Identify possibly destructive or suicidal
tendencies in the client’s thoughts by
asking “How do you feel about the future”?
– “May mga pagkakataon bang gusto mong
saktan ang sarili mo”?
Normal
● Verbalizes positive, healthy thoughts about
the future and self.
Abnormal
● May share past attempts of suicide
● Suicidal plans
● Verbalizes worthlessness about self
● Joke about death frequently
o Note: hopeless, depressed – high risk
Observe Cognitive Abilities
Orientation
– Ask for the client’s name, name of family
members(person) the time such as hour,
day, date, or where the client lives or now
(place)
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Normal – Have the client repeat these words in 5
minutes, again in 10 minutes and again in
● Client is aware of self, others, time, home
30 minutes
address, location
Normal
Abnormal
● Client is able to recall words correctly after
● Reduced degree of orientation,
a 5, a 10, and a 30 min period.
hallucinations
● 80 y/o – should recall 2-4 words after 5
MENTAL STATUS min,10 min,30 min- with hints
– Assess orientation to time, place, and
person Abnormal
● Inability to recall words after a delayed
period – anxiety, depression, Alzheimer’s
disease.

Concentration
– Note the client’s ability to focus and stay
attentive to you.
– Give client directions such as “ Please pick
up the pencil with your left hand, place it in
your right hand, then hand it to me.”
Normal
● Client listens and can follow directions
without difficulty.
Abstract Reasoning:
– Ask the client to compare objects.
˃ “How are an apple and orange the
same?”
˃ “How are they different?”
˃ Proverbs: “Time is gold.”
Normal
● Can explain similarities and differences
between objects and proverbs correctly
Abnormal
● Cannot explain similarities and differences
between objects and proverbs correctly –
mental retardation, schizophrenia

Abnormal o Schizophrenia – It is a devastating mental

disorder characterized by abnormal social
● Distraction and inability to focus at hand –
behavior and failure to understand reality.
anxiety, fatigue, attention deficit
o It is a group of interrelated symptoms with a
number of common features involving
disorders of mood, thought content, feelings,
perception and behavior.

MENTAL STATUS
– Assess orientation to time, place and
person Judgement
– Assess remote and immediate memory – Ask the client: “What do you do if you have
pain?”
QUESTION FUNCTIONED SCREENED
What year is it? Orientation to time Normal
Where are you now? Orientation to place ● Answers to questions are based on sound
What is your name? Orientation to person rationale
What is your mother’s name? Orientation to other Abnormal
people
● Impaired judgement – mental retardation,
Where were you born? Remote memory
schizophrenia
What did you have for Recent memory
breakfast?
Visual Perceptual and Construction
Use of Memory To Learn New Ability
Information – Ask the client to draw the face of the clock
– Ask the client to repeat 4 unrelated words. or copy simple figures.
The words should not rhyme & they cannot Normal
have the same meaning (rose, hammer, ● Draw the face of the clock fairly well.
automobile brown) ● Can copy simple figures

Abnormal
● Inability to draw the face of the clock or
copy simple figures correctly – mental
retardation, dementia
Mini Mental State Examination
Perform the Mini Mental State Examination if
time is limited and a quick standard measure is
needed to evaluate or re-evaluate cognitive
function.
Normal
● Scores between 24 and 30 are normal
Abnormal
● Scores <21 (dementia)
● Scores 21-24 needs further evaluation
Intellectual Function
Average IQ – can repeat 7 digits and can recite 5
digits backward
● Serial 7s as a test of attention and
calculation – ask to subtract 7 from 100 &
continue to subtract 7 from each
subsequent remainder until told to stop.*
● Registration of 3 words – say backwards
the 3 words
● Naming (pencil, watch)
● Recognition of similarities (dog and cat)
● Interpretation of well-known proverbs and
abstract reasoning
● Making judgements about situations
Thought Process
● Is the patient’s thoughts spontaneous,
natural, clear, relevant, coherent?
● illusions? Hallucinations?
● preoccupation with death or morbid
situations?
Emotional status
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● Irritable and angry
● Anxiety
● Euphoric
● Mood swings ( joy to sadness)
● Affect appropriate to words and content
Language Ability
NORMAL:
– Can understand and communicate spoken
and written language
– Can read newspaper? Can explain what
was read?
– Can he write his name?
– Can he copy a simple figure that was
drawn?
Impact on lifestyle
- issues that affect his/her role in society,
family, and community.
UNDERSTANDING ICP
INCREASED INTRACRANIAL PRESSURE
● ICP – is the pressure exerted within the intact
skull by the intracranial volume.
- BRAIN – 84%
- BLOOD – 4%
- CSF – 12%
● If one or more of these increases significantly
without a decrease in either of the 2, ICP
becomes elevated – monro-kellie
hypothesis
● Brain compensates for increases in ICP by
autoregulation
● Regulating the volume of the 3 substances in
the following ways:
✔ Limiting blood flow to the head
✔ CSF production ↓, or may displace CSF
into the spinal canal
✔ Increasing absorption or decreasing
production of CSF – withdrawing water
from brain tissue and excreting it to the
kidneys.
ICP
● Usually measured in the lateral ventricle
● Normal pressure 0-10 mm Hg & 15 mm Hg
upper limit to ensure normal cerebral
perfusion pressure of 70 -100 mm Hg
● Adult and older children: < 10 -15 mm Hg
● Young children: 3 – 7 mm Hg
● Infants: 1.5 – 6.0 mm Hg
o cerebral vasoconstriction 🡪 decreased
blood flow
Autoregulation is maintained with a mean arterial
pressure (MAP) of 50 – 70 mm Hg.
MAP
- Average arterial blood pressure during a

single cardiac cycle.
- Reflects the hemodynamic perfusion
pressure of the vital organs.
Cerebral Perfusion Pressure (CPP)
● pressure gradient across the brain
● difference between arterial blood entering
and the return of venous blood exiting the
neurovascular system.
CPP = MAP (mean arterial pressure) – ICP
Normal CPP is 70 -100
“A CPP of 70 mm Hg or higher is acceptable for
patients recovering from a brain injury; if the CPP
gets too low, then the brain is not getting enough
oxygen and the patient can suffer hypoxic brain
injury.”
A CPP < 50 results in permanent neurologic
damage
UNRELIEVED PRESSURE
● brain tissue will herniate or shift
intracranially and extracranially.
● Brain stem herniation with compression
● RR, HR, BP, and the functions of the
ascending and descending nerve fibers are
affected.
Early Signs and Symptoms – Inc. ICP
● Changes in the LOC
- Lethargy and decreasing consciousness
(earliest signs)
● Changes in speech (slurred, inappropriate,
aphasia)
- Irritable
- Decrease GCS score
- Headache (early morning, especially upon
waking)
- Vomiting (frequently without nausea)
Late Manifestations of Increased ICP:
● Projectile vomiting – with increasing
pressure
● Further deterioration of LOC; stupor to
coma
● Hemiparesis, hemiplegia, decortication,
decerebration, or flaccidity
● Respiratory pattern alterations including
Cheyne-Stokes breathing and arrest
● Loss of brainstem reflexes - pupil, gag,
corneal, and swallowing, Babinski
STROKE
● Ischemic Stroke – a clot blocks blood flow
to an area of the brain.
- Penumbra region – area of low
cerebral blood flow
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- Ischemia results in cerebral infarction.
- Tissue injury triggers an
- inflammatory response that in turn
increases ICP.
● Hemorrhagic Stroke – bleeding occurs
inside or around the brain tissue.
CEROBROVASCULAR ACCIDENT
● Signs and symptoms
● Visual deficits
● Motor deficits
● Sensory deficits
● Verbal deficits
● Cognitive deficits
● Emotional deficits
MANIFESTATIONS OF ISCHEMIC STROKE
● Symptoms depend upon the location and
size of the affected area
● Numbness or weakness of face, arm, or
leg, especially on one side
● Confusion or change in mental status
● Trouble speaking or understanding speech
● Difficulty in walking, dizziness, or loss of
balance or coordination
● Sudden, severe headache
● Perceptual disturbances
Neurologic Deficits – Visual
Neurologic Deficit:
HOMONYMOUS HEMANOPSIA
(Loss of ½ of the visual field)
Manifestations:
● Unaware of persons, objects on side of
visual loss
● neglect on one side of the body
● difficulty judging distances
Nursing actions:
● Place objects within intact field of vision
● approach the patient from side of intact
field of vision
● instruct /remind the patient to turn head in
the direction of visual loss to compensate
for loss of visual field.
● Encourage the use of eyeglasses if
available.
● when teaching the patient do so within the
patient’s intact visual field.
o May leave half the plate (mealtime)
untouched, the half on the affected
side.
INATTENTION OR NEGLECT
Unaware of the affected side of the body and the
space around them on the affected side.
- May sit facing away from the affected side
 Neurologic Assessment | Page 11 of 29
of the body.
Example: Neurologic Deficits – Motor
● If the affected side is on the left, the person
Neurologic Deficit:
will sit with their head turned to the right.  
HEMIPARESIS
● May comb only half of their hair or
Manifestations:
consistently only attempt to shave the
unaffected side of the face.  ● Weakness of the face, arms, and legs on
the same side (due to lesion on the
● May only eat half the food on their plate.
opposite hemisphere)
● May hear you approaching on the affected
Nursing actions:
side but not see you until you are in line
with their unaffected side ● Place objects within the patient’s reach on
the nonaffected side.
VISUO SPATIAL LOSS ● Instruct the patient to exercise and
Spatial awareness is the perceptual ability to ● Increase the strength on the unaffected
know where objects are located, including their side.
own body, to the space they are in. 
Neurologic Deficit:
- may have problems following a familiar
route walking to a local shop. HEMIPLEGIA
Manifestations:
- may knock over objects by overreaching.
- can have problems sorting clothes and ● Paralysis of the face , arm, and leg on the
same side (due to a lesion on the opposite
putting them on.
hemisphere)
- difficulty to judge how near or far moving
objects are, example when crossing a ● Flaccid bladder – cannot empty
road. completely bladder
● Dyssynergia – the coordination to be able
Figure ground is our ability to identify an object to store urine in the bladder or wait once
from its background. the urge to void is felt is LOST.
- A white t-shirt on white bed sheet. Which Nursing actions:
objects are in the foreground and which ● Encourage the patient to provide range of
are in the background. motion exercises to the affected side.
- On a moving escalator, judging when to ● Provide immobilization as needed to the
step on and off, the depth of the step and affected side.
the movement as it changes. 
● Maintain body alignment in functional
position
Neurologic Deficit: ● Exercise unaffected limb to increase
LOSS OF PERIPHERAL VISION mobility and use.
Manifestations:
● Difficulty seeing at night Neurologic Deficit:
ATAXIA
● Unaware of objects or the borders of
objects Manifestations:
● Staggering unsteady gate
Nursing actions:
● Unable to keep feet together, needs a
● Place objects in center of the patient’s broad base to stand
intact visual field
Nursing actions
● Encourage the use of a cane or other
objects to identify objects in the periphery ● Support patient during the initial
of the visual field. ambulation phase
● Driving ability will have to be evaluated ● Provide supportive device for ambulation
(walker, cane)
Neurologic Deficit: ● Instruct patient not to walk without
DIPLOPIA assistance or supportive device.
Manifestations:
Neurologic Deficit:
● Double vision
DYSARTHIA
Nursing Actions: – Upper motor neurons (location of
● Explain to the patient the location of an lesion)
object when placing it near the patient. – normal control of muscles for speech is
● Consistently place patient care items in the damaged
same location.
 Neurologic Assessment | Page 12 of 29
frustration, and fear)
Manifestations: ● Risk of aspiration
● Difficulty in forming words but understand ● Interferes with adequate nutrition
what is said. Nursing actions:
● Speaks slowly with great effort, words ● Test the patient’s pharyngeal reflexes
prolonged hard to understand before offering foods and fluids.
Nursing actions: ● Assist the patient with meals
● Provide alternative means of ● Place food on the unaffected side of the
communicating. mouth
● Allow him to have sufficient time to ● Allow ample time to eat.
communicate verbally. ● Gastrostomy Tube – long-term feeding
● support patient/family to alleviate purposes
frustration related to difficulty in
communicating
Neurologic Deficits – Sensory
Dysarthria Neurologic Deficit:
● A person with dysarthria may not be able PARESTHESIA
to do the following: – Occurs on the side opposite of the
- Make certain sounds lesion
- Speak whole sentences clearly
Manifestations:
- Control his or her tone of voice, volume,
or breaks between words ● Numbness & tingling of extremity
- Realize his or her speech is hard to ● Difficulty with proprioception
understand ● The sense of the relative position of
- Speak certain sounds louder than others neighboring parts of the body and strength
- Sound harsh or raspy during speech of effort being employed in movement.
- Pause for breath in the wrong places
Nursing actions:
- Drop or slur parts of words
- Speak slowly or in a way that sounds ● Instruct patient that sensation may be
hesitant or halting altered.
- Speak without moving the mouth ● Provide ROM to affected areas and apply
corrective devices as needed.
Apraxia
● Inability to perform a previously learned Neurologic Deficit:
action RECEPTIVE APHASIA
● When a patient makes verbal substitutions – Location of lesion – Wernicke area
for desired syllables or words Manifestations:
● Unable to comprehend the spoken or
Dyspraxia  written words; can speak but may not
● Reduced ability to coordinate, perform, make sense
plan, or carry out specific movements even Nursing actions
when there is no paralysis. ● Speak slowly and clearly to help the
● May perform a motor act but cannot initiate patient in forming the sounds.
act WILFULLY. ● Explore the patient’s ability to read as an
● CONTRADICTING BEHAVIOR uninformed alternative means of communication
persons – assume patient is DIFFICULT.
● ADL affected Neurologic Deficit:
GLOBAL APHASIA (mixed aphasia)
Example:
Manifestations:
- The person may recognize all the
● Combination of both expressive and
individual items of clothing but unable to
receptive aphasia
put them on in the right order.
Nursing actions:
- May not be able to walk or transfer to a
chair without assistance even though he is ● Speak clearly and in simple sentences,
NOT PARALYZED. use gestures or pictures when able.
● Established an alternative way of
Neurologic Deficit: communication.
DYSPHAGIA
Manifestations:
● Difficulty in swallowing (choking, AGNOSIA
 Neurologic Assessment | Page 13 of 29
● Comes from the Greek word for ignorance
or absence of knowledge Neurologic Deficit:
● Is the loss of ability to recognize objects, EMOTIONAL
people, sounds, shapes, or smells while Manifestations:
the specific sense is not defective nor is ● Loss of self-control
there any significant memory loss. ● Emotional lability
Types of Agnosia ● Decrease tolerance to stressful situations
● VISUAL AGNOSIA – may have difficulty ● Depression
recognizing objects ● Withdrawal
- May not recognize faces of the family ● Fear, hostility
or even their own face in a mirror. ● Angry outburst
- May not be able to work out what facial ● Feelings of isolation
expressions mean such as fear, joy, ● Childlike behavior
anger, sadness.
● Inappropriate sexual behavior
● AUDITORY – the person may hear the Nursing actions:
telephone ring but not recognize what this is. ● Support patient during uncontrollable
They may have difficulty telling the difference outburst
between the telephone and the doorbell ● Discuss with the patient and family that the
sounds. outburst is due to the disease process.
● TACTILE – the person may hear the telephone ● Encourage the patient to participate in group
ring but not recognize what this is. They may activity
have difficulty telling the difference between ● Provide stimulation for the client
the telephone and the doorbell sounds. ● Control stressful situations, if possible
● BODY PARTS AND RELATIONSHIPS – the ● Provide a safe environment
person may experience difficulty identifying ● Encourage patient to express feelings and
parts of their own body. frustration related to the disease process.
- Affected arm may not be recognized as
TRAUMATIC BRAIN INJURY
their own. Sometimes the person may
think their own arm is someone else ● Happens when a bump, blow, jolt or other
next to them. head injury causes damage to the brain
● Resulting in concussion and post concussive
Neurologic Deficit: syndrome with significant headaches and
COGNITIVE short-term memory loss
- Assault (sickle injuries)
Manifestations:
- Sport injuries
● Short- and long-term memory loss - Road traffic crashes
● Decreased attention span
● Impaired ability to concentrate
● Poor abstract reasoning
● Altered judgement
Nursing actions:
● Reorient patient to time, place, and
situation frequently
● Use verbal and auditory cues to orient
patient
● Provide familiar objects (family
photographs, favorite objects)
● Use noncomplicated language
● Match visual task with a verbal cue;
holding a toothbrush, simulate brushing of
teeth while saying “ I would like you to
brush your teeth now.”
● Minimize distracting noise and views when
teaching the patient.
● Repeat and reinforce instructions
frequently.

OCULOCEPHALIC REFLEX
A similar result is seen when the head is flexed
and extended — a positive result is downward
deviation of the eyes during extension, and upward
deviation during flexion (the eyelids, if closed, may
also open as part of the ‘doll’s head
phenomenon’). These vertical responses indicates
that the brainstem (CN3,4,8) is intact.
The eyes should gradually return to the
mid-position in a smooth, conjugate movement if
the brainstem is intact.
VESTIBULO-OCULOGYRIC REFLEX
Neurologic Assessment | Page 14 of 29
OCULOVESTIBULAR REFLEX (CALORIC
STIMULATION)
Head is elevated to 30 degrees above horizontal
so that the lateral semicircular canal is vertical,
and so that stimulation with generate a maximal
response.
check that the tympanum is intact and that the
external ear canal is clear — C-spine clearance is
not necessary.
If the brainstem is intact, cold water causes the
eyes to deviate downwards and warm water
causes the eyes to deviate upwards.
SKULL FRACTURES
● Depressed skull fracture – surgery
● Basilar skull fracture (base of the skull)
a. bullet wound
b. ice pick wound
- Bleeding from nose, pharynx, ears or under
the conjunctiva
- Battle’s sign – ecchymosis behind the ear
- CSF leak – halo sign — ring of fluid around
the blood stain from drainage
HEAD INJURY
● Battle's sign is bruising over the mastoid
sinus (just behind the auricle) and is a delayed
physical finding associated with basilar skull
fractures.
● Hemotympanum (blood behind the ear drum)
and "raccoon eyes" (periorbital bruising) are
other delayed findings consistent with basilar
skull fractures."
● Raccoon eyes – may indicate a forceful
impact elsewhere on the skull
● Open brain injury – object penetrates the
brain or trauma is so severe that the scalp and
skull are opened

Location of Subdural, Intracerebral and
Epidural Hemorrhages
INTRACRANIAL SURGERY
LEVEL OF CONSCIOUSNESS
● awake, alert, aware of stimuli from the
environment and within the self and
responds appropriately to stimuli.
Neurologic Assessment | Page 15 of 29
● A change in the LOC is the first indication
that central neurologic function has
decline.
● First sign is restlessness.
A. DETERMINE MENTAL STATUS
1. Voice – (auditory stimuli) with normal tone of
voice, call patient’s name. If no response
proceed to 2.
2. Shout – (auditory stimuli) with an aggressive
voice, shouts patient’s name. If no response
proceed to 3.
3. Shake – touch, shake patient gently as you
would to awaken a child. If no response
proceed to
4. Pain (applying painful stimulus 20-30 seconds
demonstrates patient can localize or withdraw)
a. Peripheral stimulation
● Pencil pressure – place pencil on the
fingertips of the patient, pinch hard to inflict
pain.
b. Central stimulation
● Supraorbital pressure – place 2 fingers
(thumb and index) on the supraorbital area
and press it a bit hard, as if pushing
upwards to stimulate the supraorbital
nerve.
● Pinch the earlobe (facial fractures or
gross eye swelling) – the patient bends the
arms at the elbow. It is a rapid withdrawal
(likened to withdrawing from touching
something hot)
● Trapezius squeeze – pinch the trapezius
muscle doing a Z track. This is a painful
stimulus that stimulates the brain.
● Sternal Rub – placed a clenched fist over
the sternum. Rub the knuckles of the hand
against the sternum in a twisting motion,
hard enough through and from.
Note: The tissue in this area is tender and
bruising is unusual
B. DETERMINE MENTAL CATEGORY
Category Response
ALERT (Conscious Responds fully and
and Coherent) appropriately to stimuli
Drowsy, responds to
LETHARGIC
questions then fall asleep
Opens eyes, responds slowly,
OBTUNDED
confused
Aroused from sleep only after
STUPOROUS
a painful stimulus
COMATOSE
Unarousable, with eyes
4-7 – Light Coma
closed
3 – Deep Coma
 Neurologic Assessment | Page 16 of 29

GLASGOW COMA SCALE

EYE OPENING
Score Response
4 – SPONTANEOUS Spontaneous eye opening
3 – TO SPEECH (by Opens eyes when called
request)
2 – TO PAIN Opens eyes only when
inflicted with pain
1 – NO RESPONSE No eye opening, even after
stimulated deeply

VERBAL RESPONSE
Score Response
5 – Oriented Conversant, oriented, and
coherent
4 – Confused Conversant but confused
Note: To further assess this
response, the pt. is asked in
3 spaces of question: 1.
Birth date 2. Present date 3.
Place
3 – Words Conversant but seems to
utter words that are
inappropriate (not related to
each other)
2 – Sounds Mumbles incomprehensible
sounds
1 – No Verbal Response No verbal response, without
effort to speak or with effort
to speak but can’t express
or utter words

MOTOR RESPONSE
Score Response
6 – OBEYS COMMAND Obeys commands
COLLECTING SUBJECTIVE
appropriately, e.g., raises DATA
arms when told to do so
5 – LOCALIZES PAIN Can’t obey command. Inflict NURSING ASSESSMENT
pain, pt. will remove your Question Rationale
hand, or will reach for the
Numbness and ● Loss of sensation or
place where you tried to
Tingling tingling
inflict pain
- Experienced? ● Damage:
4 – WITHDRAWS TO Can’t obey command. Can’t
PAIN even localize pain. - When and where - Brain
Withdraws from pain upon does it occur? - Spinal cord
introduction.
- Peripheral nerves
3 – FLEXION TO PAIN Upon introduction of pain,
(DECORTICATE) the pt. only flexes arms or Seizures ● Seizures occur with
Damage to midbrain legs - Experience? epilepsy, metabolic
2 – EXTENSION TO PAIN Mumbles incomprehensible - How often? disorders, head
(DECEREBRATE) sounds injuries, and high
Damage to the cortex fevers
1 – NO RESPONSE No response even after
(FLACCID) inflicting deep painful stimuli SEIZURES
Damage to the medulla ● An abnormal, sudden, excessive, uncontrolled
electrical discharge of neurons within the brain

CAUSES OF SEIZURES
C – Cerebrovascular vascular disease
H – Hypoxemia (vascular insufficiency)
A – Allergies
 Neurologic Assessment | Page 17 of 29
T – Tumor of the brain - Cerebral edema
C – CNS infections (meningitis, encephalitis) - Head trauma
H – Hypertension - Acute alcohol withdrawal
A – Alcohol and drug withdrawal - Antiepileptic drugs – sudden withdrawal
F – Fever - Infections – brain
H – Head injury (subdural hematomas, intracranial - Metabolic Disturbances – stroke, oxygen
hemorrhage) deprivation
M – Metabolic/toxic conditions (hypoglycemia,
renal failure, hyponatremia, pesticide
exposure)
● Absence seizures can happen at any time,
even while asleep.
● During the seizure, do not attempt to shake
the person awake or make loud noises at
them. This generally will increase the
length of the seizure and is unhealthy for
the person having it.
● After the seizure – will most likely not
remember the event and will resume what
he was doing.

NURSING ASSESSMENT (cont.)

HEADACHES
- Do you experience headaches?
- When do they occur?
- What do they feel like?

1. Generalized Seizure
Tonic Clonic Seizure (Grand Mal)
Signs and symptoms
- tongue or lip biting
- pupils dilate and eyes roll up and to one
side
- urinary or fecal incontinence on
awakening

2. Status Epilepticus (SE)

● Prolonged seizures 🡪 5 minutes or
repeated seizures over the course of 30
minutes.
● A potential complication of all types of
seizures
● Life-threatening condition particularly if
treatment is delayed
● Vigorous muscle contraction ⇨ heavy
metabolic demands ⇨ can result in
decreased oxygen supply and possible
cardiac arrest
Usual cause:
 Neurologic Assessment | Page 18 of 29
COMMON FOOD TRIGGERS FOR MIGRAINE
HEADACHES
● Aged Cheese
● Chocolate
● Alcohol – causes vasodilation
● Peanuts
● Breads with Fresh Yeast
● Citrus Fruits
● Preserved Meats such as Bologna,
Smoked Fish, Sausage, or Hot Dogs
● Yogurt
● Sour Cream

GUILLAIN-BARRE SYNDROME
● Autoimmune disorder with acute attack of
peripheral nerve myelin
● A disorder affecting the peripheral nervous
system Ascending paralysis, weakness
beginning in the feet and hands and migrating
towards the trunk, is the most typical symptom
(24 – 72 hours)
● Guillain-Barre syndrome is a serious disorder
that occurs when the body's defense (immune)
system mistakenly attacks part of the nervous
system. This leads to nerve inflammation that
causes muscle weakness.

ALZHEIMER’S DISEASE
● It is a progressive brain disorder that has a
gradual onset but causes an increasing decline
in functioning, including
- loss of speech
- loss of motor function
- profound personality
 Neurologic Assessment | Page 19 of 29
- behavioral changes such as paranoia,
delusions, hallucinations, inattention to
hygiene & belligerence
Main Pathology:
● Presence of senile plaques that destroys
neurons leading to decreased
acetylcholine

COMMON SIGNS & SYMPTOMS:

● Aphasia – inability to talk
● Anomia – inability to name objects
● Agnosia – inability to recognize objects
● Apraxia – inability to perform ADL
● Agraphia – inability to write down thoughts
● Alexia – inability to understand written
language
● Amnesia/Memory loss/Mnemonic disturbance
● Loss of neurons in the frontal lobe and
temporal lobes
- ATROPHY IN THESE AREAS - inability to
PROCESS AND INTEGRATE new
information and to retrieve memories
MOLLY DRUG/HAPPY DRUG/ECSTASY
● is a synthetic drug that has stimulant and
psychoactive properties. It is taken orally as a
capsule or tablet.
● Street Names: XTC, X, Adam, hug, beans,
love drug
● Short-term effects include feelings of mental
stimulation, emotional warmth, enhanced
sensory perception, and increase physical
energy
● Adverse health effects can include nausea,
chills, sweating, teeth clenching, muscle
cramping, and blurred vision.
LIFESTYLE AND HEALTH PRACTICES

PAST HEALTH HISTORY

FAMILY HISTORY

LIFESTYLE AND HEALTH PRACTICES


ASSESSMENT OF THE
NERVOUS SYSTEM
Equipment needed:
● In general, gloves, to protect the nurse
Mental Status Examination
✔ Annotated Mini Mental State Examination
(optional)
✔ Paper
✔ Pencil
Cranial Nerve Examination
✔ Paper clip
✔ Newsprint to read
✔ Snellen chart and others like...
✔ (Aromatic substances) Vanilla: to test first
cranial nerve (olfactory)
✔ Cotton balls: To assess system for light
touch
✔ Ophthalmoscope: a lighted instrument to
view the interior of the eye.
✔ Pen light: To determine the reactions of
the pupils
✔ Percussion Hammer: An instrument with
a rubber head to test reflexes.
✔ Clean toothpick: to assess pain sensory
system
✔ Tongue depressor: To depress the tongue
during the assessment of the mouth and
pharynx – gag reflex
✔ Tuning fork: A two-pronged metal;
Instrument used to test hearing acuity and
vibratory sense.
CRANIAL NERVES
CN 1 – OLFACTORY
Function: sense of smell
Normal Findings: able to detect various odors
(coffee, perfume) in each nostril
Abnormal Findings:
● Inability to smell (neurogenic anosmia) or
identify the correct scent (olfactory tract
lesions) or tumor (frontal lobe)
● Other causes smoking, cocaine use
Neurologic Assessment | Page 20 of 29
CN II – OPTIC
Function: visual acuity & visual field
– Snellen eye chart for far vision
– read newspaper for near vision
– Confrontation for visual fields
– Ophthalmoscopic exam
Normal Findings:
● Has 20/20 vision both eyes
● Can read print at 14 inches without
difficulty
● Full visual fields
● Round red reflex present, optic disc is 1.5
mm round
Abnormal Findings:
● Difficulty reading, missing letters, squinting
(Snellen chart)
● Reads print closer than 14 inches or
farther away (presbyopia – aging)
Eyes: Assess peripheral visual fields
Normal Findings:
● When looking straight ahead, client can
see objects in the periphery
Deviations From Normal:
● Visual fields smaller than normal (possible
glaucoma)
● One half vision in one or both eyes
(indicates nerve damage)
Kinetic Confrontation – client says “NOW” when
the fingers come to view.
Static Confrontation – present 1-4 fingers. Ask
the client to report the number of fingers, without
looking directly at them.
Retinal Detachment
Homonymous Hemianopia

LOSS OF PERIPHERAL VISION
Manifestation
● Difficulty seeing at night
● Unaware of objects or the borders of the
object
Nursing actions
● Place objects in center of the patient’s
intact visual field
● Encourage the use of a cane or other
objects to identify objects in the periphery
of the visual field.
● Driving ability will have to be evaluated
ASSESSMENT PROCEDURE
– Use an ophthalmoscope to view the retina
& optic disc of each eye
Normal Findings:
● Round red reflex present
● Optic disc is 1.5 mm, round or slightly oval,
well-defined margins, creamy pink with
paler physiologic cup
Abnormal Findings:
● Papilledema (swelling of the optic nerve)
results in blurred optic disc – increase ICP
CN III – OCULOMOTOR NERVE
Function: Pupil constriction, raising eyelids
ASSESSMENT PROCEDURE
– Inspect margin of the eyelids of each eye
Normal Findings: eyelid covers about 2mm of the
iris
Abnormal Findings: Ptosis (drooping of the
eyelid) is seen with weak eye muscles such as
myasthenia gravis
ASSESSMENT PROCEDURE
– Assess extra ocular movements
– Instruct client to look up, down, inward.
– Observe symmetry and eye opening
– Ask client to watch finger as you move it
toward his/her face
Neurologic Assessment | Page 21 of 29
Normal Findings: eyes move in a smooth,
coordinated motion in all directions (6 cardinal
fields)
Abnormal Findings:
● Nystagmus (cerebellar disorders)
● Limited eye movement – Increased ICP
ASSESSMENT PROCEDURE
– Assess pupillary response to light (indirect)
– Shine penlight into eye as client stares
straight ahead
Normal Findings:
● The reflection of light on the corneas
should appear on the same spot on each
eye which indicates parallel alignment.
Abnormal Findings:
● Asymmetric position of the light reflex
indicates deviated alignment of the eyes.
● Muscle weakness or paralysis
Normal Findings:
● the uncovered eye should remain fixed
straight ahead
● The covered eye should remain fixed
straight ahead after being uncovered
Abnormal Findings:
● Strabismus – constant misalignment of
the eyes
ASSESSMENT PROCEDURE
– Assess pupillary response to light (direct)
& accommodation in both eyes
– Darken the room & ask the patient to focus
on a distant object
– Shine light obliquely into one eye and
observe for the pupillary reaction
– Consensual response: same procedure –
observe pupillary reaction in the opposite
eye.
Normal Findings:
● Bilateral illuminated pupils constrict
simultaneously.
● Pupil opposite the one illuminated
constricts simultaneously
● Pupil: round with regular border, is
centered in the iris, equal in size (3-5 mm)
Abnormal Findings:
● Dilated pupil (6-7 mm) oculomotor nerve
paralysis
● Constricted pupils – narcotics abused,
lesions of the brain

TEST FOR ACCOMMODATION RESPONSE
– Hold your finger/pencil about 12-15 inches
from the client.
– Ask the client to focus on your finger/pencil
& to remain focused on it as you move it
closer in toward the eyes.
Normal:
● constriction of the pupils
● convergence of the eyes
PERRLA – Pupils Equally Responsive and
Reactive to Light and Accommodation
Neurologic Assessment | Page 22 of 29
– Ask him to close his eyes and he will tell
you if it is sharp or dull and where he feels
it
– Repeat test for light touch with wisp cotton,
– Direct the client to say ‘now’ every time
cotton is felt.
Normal Findings:
● Client correctly identifies sharp and dull
stimuli and light touch to the forehead,
cheeks, and chin.
Abnormal Findings:
● Inability to feel & correctly identify facial
stimuli occurs with lesion f the trigeminal
nerve.
ASSESSMENT PROCEDURE
Test for corneal reflex
– Ask the client to look away and up while
you lightly touch the cornea with a fine
wisp of cotton.
Normal Findings:
● Eyelids blink bilaterally. Note: reflex may
be absent or reduced in clients who wear
contact lenses

CN IV – TROCHLEAR Abnormal Findings:

Function: downward and inward movement in the ● An absent corneal reflex occurs with lesion
eyes of trigeminal nerve
ASSESSMENT PROCEDURE
– same as CN III
CN VI – ABDUCENS
Function: lateral movement of the eyes
Normal Response: able to move eyes downward
inward
ASSESSMENT PROCEDURE
– Same as CN III & IV
CN V – TRIGEMINAL NERVE
Normal Response: able to move eyes in all
Function:
direction
a. Motor – jaw movement
b. Sensory – sensation of the face and neck
CN VII – FACIAL NERVE
ASSESSMENT PROCEDURE Function:
a. Motor – facial muscle movement
Test Motor Function
b. Sensory – taste on the anterior 2/3 of the
– ask client to clench teeth while you palpate tongue
the temporal & masseter muscles for
contraction ASSESSMENT PROCEDURE
Normal Findings: Test Motor Function
● Temporal and masseter muscles contract – Ask client to smile, frown & wrinkle
bilaterally forehead, show teeth, puff out cheeks,
Abnormal Findings purse lips, raise eyebrows, close eyes
● Bilateral muscle weakness – CNS tightly against resistance
dysfunction Normal Findings:
● Unilateral weakness – trigeminal nerve ● Client can smile, frown & wrinkle forehead,
lesion show teeth, puff out cheeks, purse lips,
● Trigeminal neuralgia (Tic Douloureux) raise eyebrows, close eyes tightly against
Test Sensory Function resistance
– Tell patient that his forehead, cheeks & Abnormal Findings:
chin will be touched with the sharp or dull
side of the paper clip
 Neurologic Assessment | Page 23 of 29
● Client cannot smile, frown & wrinkle Abnormal
forehead, show teeth, puff out cheeks,
● Vibratory sound lateralizes to good ear in
purse lips, raise eyebrows, close eyes
sensorineural loss.
tightly against resistance
● AC > BC (AC is longer than BC but not 2x
BELL’S PALSY – Facial paralysis due to unilateral as long) in sensorineural loss.
inflammation of the 7th cranial nerve.
Test Sensory Function
– Touch the anterior 2/3 of the tongue with a
moistened applicator dipped in salt, sugar CN IX – GLOSSOPHARYNGEAL
or lemon juice and ask the client to identify NERVE
the flavor. Function:
Normal Findings a. Motor – pharyngeal movement and
● Client identifies correct flavor. swallowing
● Able to differentiate tastes among various b. Sensory – taste on posterior tongue
agents (sweet, sour, bitter and salty
substances on tongue) ASSESSMENT PROCEDURE
Test Motor Function
Abnormal Findings
– Ask client to open mouth wide and say
● Inability to identify correct flavor on anterior ‘ahh’’ while you use a tongue depressor on
2/3 of the tongue suggest impairment of the client’s tongue
cranial nerve VII
– Test the gag reflex

CN VIII – ACOUSTIC NERVE Normal Findings:

Function: sense of hearing and balance ● Gag reflex present
Abnormal Findings:
ASSESSMENT PROCEDURE ● Absence of gag reflex – lesion CN IX or X
– Perform the Whisper test, Watch tick test,
Weber and Rinne test ASSESSMENT PROCEDURE
– Test posture with the eyes closed – – Motor function: drink water
Balanced maintained while walking – Sensory function: place sour, sweet, bitter,
Ears: Assess client’s response to whispered voice and salty substances on tongue
– Whisper some nonconsecutive numbers Normal Findings
and have the client tell you what was ● Client swallows without difficulty
heard. Increase the loudness of the
● No hoarseness noted.
whisper until the client can identify at least
● Able to taste
50% of the numbers. Repeat with the
other ear. Abnormal Findings
Normal: Able to repeat nonconsecutive numbers ● Dysphagia or hoarseness – lesion CN IX
or X
Abnormal: Unable to repeat 50% of numbers
whispered CN X – VAGUS NERVE
Perform the watch tick test Function: swallowing and speaking
- Place ticking watch 2 to 3 cm (1-2 in) from ASSESMENT PROCEDURE
the unoccluded ear
– Ask client to open mouth wide and say
Normal Findings: Able to hear ticking in both ears “ahh” while you use a tongue depressor on
Deviations From Normal: Unable to hear ticking the client’s tongue.
in one or both ears – Note his voice quality
Normal Findings
Perform weber and Rinne’s test ● Client swallows without difficulty
Normal ● No hoarseness noted. Speak with a soft
● Clients hears whispered words from 1-2 voice.
feet. ● Uvula in the midline
● Weber test – Vibration heard equally well Abnormal Findings
in both ears
● Dysphagia or hoarseness – lesion CN IX
● Rinne test – AC > BC (AC is 2x as long as or X
BC)

CN XI – SPINAL ACCESSORY
NERVE
Function: flexion and rotation of the head
ASSESSMENT PROCEDURE
– Ask the client to shrug the shoulders
against resistance to assess the trapezius
muscle
– Ask the client to turn the head against
resistance, first to the right then to the left
to assess the sternocleidomastoid muscle.
Normal Findings:
● Symmetric, strong contractions of the
trapezius muscle.
● Strong contraction of sternocleidomastoid
muscle on side opposite the turned face.
Abnormal Findings
● Drooping of the shoulder – paralysis
● Atrophy with fasciculation – peripheral
nerve disease
CN XII – HYPOGLOSSAL NERVE
Function: motor and tongue movements
ASSESSMENT PROCEDURE
Test Tongue Movements
– Ask client to protrude and retract tongue.
– Ask client to protrude and move it to the
right and to the left
Test Tongue Strength
– Ask client to move tongue to each side
against resistance of a tongue depressor.
– Ask the client to push against the inside of
the cheek with the tip of the tongue.
– Provide resistance by pressing your 2
fingers against the client’s outer cheek.
– Repeat on the other side.
Normal Findings
● Tongue movement is symmetric and
smooth & bilateral strength is apparent.
Abnormal Findings
● Deviation to the other side – unilateral
lesion
PHYSICAL ASSESSMENT
Muscle Component
● Inspect for size and contour of muscles.
● Assess coordination of movement
● Palpate for muscle tone
● Estimate strength through cursory evaluation
(i.e., handshake) or scaled criteria (i.e., 0 = no
palpable contractions; 5 = normal ROM
against gravity with full resistance).
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● Measure girth to note increases due to
swelling or bleeding into muscle or decrease
due to atrophy (difference of 1 cm is
significant).
● Test muscle strength by asking the client to
move each extremity through its full ROM
against resistance.
- Apply some resistance against the part
being moved.
- Document muscle strength by using a
standard scale.
● Rate muscle strength in accord with the
strength table.
GRADING MUSCLE STRENGTH
TEST MUSCLE STRENGTH
● Sternocleidomastoid – Client turns the head
to one side against the resistance of your
hand. Repeat with the other side.
● Trapezius – Client shrugs the shoulder against
the resistance of your hands.
● Deltoid – Client holds arm up and resists while
you try to push it down. Compare strength –
both arms
– Patient extends and raises both arms
(carrying a pizza) and keep his arms in
place while he closes his eyes and count
to 10.
o PRONATOR DRIFT – the affected arm
will pronate and fall
● Biceps – Client fully extends each arm and
tries to flex it while you attempt to hold arm in
extension.
● Triceps – Client flexes each arm and then tries
to extend it against your attempt to keep it in
flexion.
● Wrist and finger muscles – Client spreads
the fingers and resist you attempt to push the
fingers together.
● Grip strength – Client grasps your index and
middle fingers while you try to pull it out.
● Hip muscles – Client is supine, both legs
extended; client raises one leg at a time while
you attempt to hold it down.
● Hip Adduction – Client is in same position as
for hip abduction. Place your hands between
 Neurologic Assessment | Page 25 of 29
the knee; client brings the legs together – Repeat this 3x
against your resistance. – Next ask the client to repeat these
● Hip Abduction – Client is supine, both legs movements with eyes closed.
extended. Place your hands on the lateral
surface of each knee; client spreads the legs Normal Findings:
apart against your resistance.
● Client touches finger to nose with smooth,
● Hamstrings – Client is supine, both knees accurate movements with little hesitation.
bent. Client resists while you attempt to
straighten the legs Abnormal Findings
● Quadriceps – Client is supine, knee partially ● Inability to touch the tip of the nose –
extended; client resists while you attempt to Cerebellar Disease
flex the knee. – KICK OUT
● Muscle of the ankles and feet – Client resists
while you try to dorsiflex the foot
● Ankle plantar flexion – press down on the
gas pedal
– Patient to move the large toe against the
examiner's resistance "up towards the Rapid Alternating Movements
patient's face"
– Have client sit down
MOTOR AND CEREBELLAR SYSTEMS – Ask the client to touch each finger to the
● Assess condition and movement of thumb and to increase the speed as the
muscles client progresses.
● Evaluate balance – Repeat with the other side.
● Romberg test
● Assess coordination

GAIT
– having the patient walk
– Next ask the patient to walk heel to toe
across the room, then on their toes only,
and finally on their heels only.

EVALUATE BALANCE
ASSESSMENT PROCEDURE (Tandem Balance)
– Ask the client to stand on one foot and to
bend the knee of the leg he or she is
standing on.
– Then ask the client to hop on that foot.
Repeat on the other floor
Heel To Shin Test
– Note: it is not usually done on the older
adult (RISK FOR FALL) Normal Findings:
● Client touches each finger to thumb
ROMBERG TEST – the patient stands with his
rapidly.
feet together and arms resting at the sides, first
with eyes open, then eyes closed (20 SECONDS) Abnormal Findings:
- If the patient loses his balance, swaying & ● Inability to perform rapid alternating
moving feet apart - the test is POSITIVE. movement – cerebellar disease
- May have sensory ataxia (lack of
coordination of the voluntary muscle)

ASSESS COORDINATION
Finger to nose test
To assess coordination:
– Ask the client to extend and hold arms out
to the side with eyes open.
– Next say “Touch the tip of your nose first SENSORY SYSTEM
with your right index finger, then with your
left index finger.”
 Neurologic Assessment | Page 26 of 29
Assess Light Touch, Pain & Temperature Abnormal – Inability to sense (peripheral
Sensations neuropathy - DM)
– For each test ask client to close both eyes
and tell you what he feels and where he
feels it.
– Scatter stimuli over the distal and proximal
parts of all extremities and the trunk to
cover most of the dermatomes.
– It is not necessary to cover the entire body
surface
Testing Light Touch Sensation To Test Sensitivity to Position
– Use a wisp of cotton to touch the client. – Ask the client to close both eyes.
Normal Findings: – Move the client’s toes/ finger up and down
● Client correctly identifies light touch – Ask the client to tell you the direction it is
moved.
Abnormal Finding:
– Repeat on the other side.
● Peripheral neuropathies (Diabetes
Mellitus)

To Test Pain Sensation

– Use the blunt and sharp ends of a safety
pin or paper clip.
– Able to differentiate between blunt and
sharp
Abnormal Findings: Assess Tactile Discrimination (fine touch)
● Analgesia (absence of pain) – Ask client to close his eyes.
● Hypoalgesia (decreased sensitivity to pain) – Place a familiar object such as a coin,
● Hyperalgesia (increased sensitivity to pain) paperclip, safety pin or a key in the client’s
hand and ask the client to identify it.
– Repeat with another object in the other
hand.
Normal – able to identify the object
Abnormal – Inability to correctly identify objects
(astereognosis)

To Test Temperature Sensation

– Use test tubes filled with hot and cold
water
Normal: able to distinguish between hot and cold
Test Point Localization
– Ask client to close his eyes.
– Briefly touch the client and ask the client to
identify the points touched
Normal – able to identify the areas touched
Abnormal – Inability to correctly identify areas
touched

To Test Vibratory Sensation Test Graphesthesia

– Strike a low-pitched tuning fork on the heel
of your hand and hold the base on a bony
surface of the fingers or the big toe.
– Ask the client what he feels.
– Repeat on the other side.
Normal – Correctly identifies sensation
- Ask client to close his eyes.
- Use a blunt instrument to write a number
Normal – able to identify the areas touched
Abnormal – Inability to correctly identify areas
touched

Test Two Point Discrimination
– Ask client to close his eyes.
– Ask the client to identify the number of
points felt when touched with the ends of 2
applicators at the same time.
– Touch him on the fingertips, forearm,
dorsal hands, back and thighs. Note the
distance between the 2 applicators.
Normal – able to identify two points on:
✔ fingertips at 2-5 mm apart
✔ forearm at 40 mm apart
✔ dorsal hands at 20-30 mm apart
✔ back at 40 mm apart
✔ thighs at 70 mm apart
Abnormal – Inability to discriminate between 2
points – lesion of the sensory cortex
Test Extinction
– Simultaneously touch the client in the
same area on both sides of the body at the
same point.
– Ask the client to identify the area touched.
Normal – able to identify the areas simultaneously
touched
Abnormal – Inability to identify the areas
simultaneously touched – lesion of the sensory
cortex
REFLEX TESTING
● The center for reflex act is the SPINAL CORD
− Deep Tendon Reflexes
− Superficial Reflexes
− Corneal reflex (blink)
− Gag reflex (back of the pharynx)
− Pathological Reflexes
− Babinski reflex
DEEP TENDON REFLEXES
✔ Comfortable sitting position
✔ Use of the reflex hammer to illicit reflex
NORMAL REFLEX SCORE
- 1+(present but not decreased)
- 2+(normal)
- 3+ (increased or brisk, but not pathologic)
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- 4+ (markedly hyperactive, clonus may be
present)
LEG REFLEXES
– ask the client to lock the fingers of both hands
and pull them against each other, them
immediately strike the tendon
– Compare the response of the right and left
sides.
BICEPS REFLEX
– Asked client to partially bend arm at elbow
with palm up.
– Place your thumb over the biceps tendon
and strike your thumb with the reflex
hammer
Normal – Elbow flexes and contraction of the
biceps muscle is seen or felt.
o Ranges from 1+ to 3+
Abnormal – No response or an exaggerated
response
BRACHIORADIALIS REFLEX
– Asked client to flex elbow with palm down
and hand resting on the abdomen or
lap.
– Tap the tendon at the radius about 2
inches above the wrist.
– Repeat on other side.
– Evaluates the function of C5 and C6
Normal – Forearm flexes and supinates.
TRICEPS REFLEX
– Asked client to hang his arm freely (limp)
while you support it with your nondominant
hand.
– With the elbow flexed tap the tendon
above the olecranon process.
– Repeat on other side.
– Evaluates the function of C6, C7 and C8
Normal – Elbow extends, triceps contracts extend.
PATELLAR REFLEX
– Asked client to let both legs hang freely of
the side of the examination table.
– Tap the patellar tendon which is located
just below the patella.
– Who cannot sit up – use supine position
– Repeat on other side.
– Evaluates the function of spinal nerves L2,
L3, and L4
Normal – Knee extends, quadriceps muscle
contracts.
ACHILLES REFLEXES
– Asked client to let both legs hang freely of
the side of the examination table.

– Dorsiflex the foot
– Tap the Achilles tendon with the reflex
hammer
– Repeat on other side.
– Who cannot sit up – use supine position
– Evaluates the function of spinal nerves S1
and S2.
Normal – Plantar flexion of the foot.
TEST FOR ANKLE CLONUS
– Done when the other reflexes tested have
been hyperactive.
– Dorsiflex the foot
– Tap the Achilles tendon with the reflex
hammer
– Repeat on other side.
– Who cannot sit up – use supine position
– Evaluates the function of spinal nerves S1
and S2.
Normal – Plantar flexion of the foot.
o Ranges from 1+ to 3+
BABINSKI’S TEST
– Running a sharp instrument along the
lateral border of the forefoot from the
calcaneus produces extension of the big
toe and fanning of the other toes. Extensor
plantar response (Babinski sign)
– Lesion of upper motor neurons, may be
caused by trauma to the brain
SUPERFICIAL REFLEXES
TEST ABDOMINAL REFLEX
– Lightly stroke the abdomen on each side,
above and below the umbilicus.
– Upper abdominal reflex - evaluates the
function of spinal levels T8, T9 & T10.
– Lower abdominal reflex – evaluates the
function of spinal levels T10, T11,and T12
Normal – Abdominal muscles contract, umbilicus
deviates toward the side being stimulated
Abnormal
– Superficial reflexes absent- upper or lower
motor neuron lesions.
CAUTION:
o The abdominal reflex may be concealed
because of obesity or muscular stretching
from pregnancies. This is not abnormality.
TEST CREMASTERIC REFLEX
– evaluates the presence of a pyramidal tract
lesion
Male Clients:
– Lightly stroke the inner aspect of the upper
thigh .
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– Evaluates the function of spinal levels
T12, L1 & L2.
Normal – Scrotum elevates on stimulated side.
Abnormal – Absence of reflex (motor neuron
disorder)
TEST FOR MENINGEAL IRRITATION OR
INFLAMMATION
ASSESSMENT OF NECK MOBILITY
– FIRST, make sure there is no injury to the
cervical vertebrae or cervical cord.
– Place client in supine position & with your
hands behind his head flex the neck
forward until the chin touches the chest if
possible.
Normal – neck is supple, can easily bend head
and neck forward.
Abnormal – neck pain, resistance to flexion may
be due to arthritis, neck injury or meningeal
inflammation
Meningitis – Inflammation of the membranes and
the fluid space surrounding the brain and spinal
cord
Clinical manifestations
● Irritated meninges (nuchal rigidity)
a) Stiff/sore neck – neck spasms
b) positive Kernig’s sign
c) positive Brudzinski’s sign
d) Photophobia (extreme sensitivity to
light)
Brudzinski’s Sign
✔ Flexion of neck causes neck pain and the
hip and knee to flex
Kernig’s Sign
✔ When the patient is lying with the thigh
flexed on the abdomen, the leg cannot be
completely extended.
SPINAL CORD INJURY
Level of injury – CERVICAL, THORACIC,
LUMBAR
● ACUTE SPINAL CORD INJURY
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- Quadriplegia – loss of movement and
sensation in all four limbs
- Paraplegia – loss of movement and
sensation in the lower half of the body

MECHANISMS OF INJURY
a. Hyperflexion
b. Hyperextension
c. Axial loading (force exerted straight up or
down spinal column as in diving accident)
d. Penetrating wounds

Complete Injury
● One cervical nerve root could recover in
80%
● Two nerve roots may recover in some
patients.