1.

GATHER THE EQUIPMENT

Clean gown, (sterile) gloves, tape measure,
tuning fork, paper clips, cotton balls, paper and
pen, coffee- to smell, sugar- to taste, warm and
cold water- to check the temperature, reflex
hammer, penlight, tongue depressor, and
cotton tip applicator
BEFORE PROCEDURE: As I go to my patient I
am already observing my patient, the manner of
how she dress and how she positions himself

2. EXPLAIN THE PROCEDURE TO THE

CLIENT
Jhaz: Hello sir, good morning. I am … your
nurse for today. May I know your name?
Patient:
Jhaz: I am here to assess your NEURLOGIC
SYSTEM. We will do NEUROLOGICAL
ASSESSMENT and there are certain
procedures I will ask you to do. I will be telling
you as we go along the way.
3. ASSIST THE PATIENT WITH GOWN

MENTAL STATUS
1. ASSESS LEVEL OF CONSCIOUSNESS
-- In the LEVEL OF CONSCIOUSNESS of my
patient, as I observe, when I asked him, she
looks at me—so there is an eye opening and
she answered me verbally and appropriately.
My patient is ALERT, AWAKE, & COHERENT
FINDINGS: There is a good response coming
from my patient and that is an indicator of a
GOOD NEUROLOGIC STATE
NOTE: When approaching the patient
 If the patient looks at you and drifts off to
sleep—it indicates LETARGY
 While patient that does not look at me and
still lying on the bed with eyes closed—and
 when I stimulate the by pressing onto the tip
of her nail and that’s only the time when the
patient awakes—that means that the client
only arose with a painful stimuli—that
indicates STUPOROSE
 Patient with NO RESPONSES—is maybe in
COMA

2. OBSERVE APPEARANCE AND

BEHAVIOR
FINDINGS:
-- As I can see before my patient wore his clean
gown, the patient dresses appropriately,
-- When I great him, he respond appropriately,
the behavior is correct, and as I can see, my
patient is in right body posture

3. OBSERVE THE MOOD, FEELINGS, AND

EXPRESSIONS
FINDINGS:
-- As I can see the mood of my patient is
appropriate, also with the feelings and
expression are appropriate
-- The eye contact and the affect are also good

ASK THE PATIENT:

Jhaz: Sir, how are you feeling today?
Jhaz: May I know what are your plans for
vacation?
FINDINGS: My patient respond properly and
answers my questions appropriately

4. OBSERVE THOUGHT PROCESS AND

PERCEPTIONS
Jhaz: Ma’am may I know your understanding
about feeding program
— So there, that’s the idea of my patient
regarding the feeding program
5. OBSERVE COGNITIVE ABILITIES
— Looking at my patient, I asked him a while
back to wear his gown, and he followed my
command
— She was able to follow directions without
difficulty

•Now I will test for the RECENT MEMORY of

my patient.
Jhaz: Sir May I know what did you eat this
morning?
— so there, you remembered accurately what
you ate this morning

•Now we will look for the REMOTE MEMORY of

the patient
Jhaz: Ma’am when is your birthday?
•I now check for the ABSTRACT REASONING
of my patient
Jhaz: May I know sir, what is the difference
between laptop and cellphone?
FINDINGS: My patient was able to differentiate
the two things

•I will also check for the JUDGMENT of the

patient
Jhaz: sir may I know what do you do if you are
in PAIN?
FINDINGS: He takes pain reliever and rest—
and that is an appropriate action if a person is
in pain and also to divert it

•I will now check for the VISUAL,

PERCEPTUAL, & CONSTRUCTIONAL
ABILITY
— by asking the patient to draw something
Jhaz: sir kindly draw a ball
Next… (Get paper with shapes)
Jhaz: Ma’am may I ask you to draw this
different figure?
FINDINGS:
— As I can see my patient was able to copy the
figure correctly and he was able to draw a ball.
— There is no problem in his VISUAL
PERCEPTUAL ability

NEUROLOGIC ASSESSMENT
1. TEST CRANIAL NERVE 1-Olfactory
— not usually tested unless the patient
complains disturbance of smell
Jhaz: may I ask you to occlude and sniff?
(Takpan ang isang butas ng ilong then sniff) no
blockage
— okayyyy
Jhaz: now sir, Kindly you to close your eyes
and I want you to smell this substances
1. COFEE
FINDINGS: my client was able to smell what I
asked him to smell, so there’s no disturbance in
the OLFACTORY NERVE

5. TEST CRANIAL NERVE 5 – Trigeminal

TRIGEMINAL NERVE— is a MIX NERVE with
SENSORY & MOTOR PORTION
— I will test first the MOTOR FUNCTION of my
patient’s TRIGEMINAL NERVE

•The MOTOR FUNCTION of Trigeminal nerve

is the MASSETER MUSCLE
— So I will now palpate over the masseter
muscle of my patient
(WEAR GLOVES)
1. TEMPORAL MUSCLE - first, there I can
palpate the temporal muscle of my patient
2. MASSETER MUSCLE
Jhaz: Is there a problem when you chew sir?
FINDINGS: That muscle is functioning very well

•Check for the SENSORY FUNCTION of the

Trigeminal nerve
(Using paper clip- touch the forehead)
Jhaz: sir kindly close your eyes, then tell me
where do you feel the stimulus
FINDINGS: My patient was able to tell correctly
where he felt the stimulus

7. TEST CRANIAL NERVE 7-Facial

— Facial nerve is also a mixed nerve

•MOTOR FUNCTION of Facial nerve—

movement of the face
Jhaz: sir can you smile for me? Kindly frown?
Kindly show your teeth? Kindly puff your
cheecks? Kindly purse your lips? And raise
your brows sir

Jhaz: Sir kindly close your eyes and resist my

hand. Don’t allow it to open your eyes
FINDINGS: My patient did it with resistance

•SENSORY PORTION of the Facial nerve

Jhaz: Sid kindly close your eyes again
— I’ll be asking you to describe what I’m going
to make you taste
1. SUGAR/ SALT
FINDINGS: My patient was able to identify the
substance very well

9. TEST CRANIAL NERVE 9 –

Glossopharyngeal - 10. TEST CRANIAL
NERVE 10 – Vagus
10- sip water
(TONGUE DEPRESSOR)-- these two are
partners do we will assess it together in one
time)
—— I’ll observe if the uvula rises when I ask my
patient to say AAA and I’m going to test the gag
reflex
Jhaz: open your mouth sir, say AAAHH

11. TEST CRANIAL NERVE 11 - Spinal

accessory (HANDS)
- this nerve innervates the trapezius muscle at
the back.
Jhaz: Sir kindly raise your shoulders?
Then I’m going to resist it
FINDINGS: So strong, my patient was able to
resist it

12. TEST CRANIAL NERVE 12 – Hypoglossal

(TONGUE DEPRESSOR)
— Test the hypoglossal nerve
Jhaz: kindly stick out your tongue sir and
protrude it: Then resist the tongue depressor
(Front, left, right) to this side sir?
FINDINGS: the hypoglossal nerve is stong and
it can resist the tongue depressor

MOTOR AND CEREBELLAR SYSTEMS

function
3. TEST BALACE, COORDINATION
• Jhaz: Sir kindly stand up and walk across the
room?
FINDINGS: As I observe, while my patient is
walking, he has a good balance and
coordination.
• Jhaz: Sir kindly walk again in a heel to heel?
• we also do the Romberg Test
— sir kindly bring your hands to the side, feet
together. Then close your eyes
(20 seconds)
FINDINGS: There is no swinging in my patient
• Jhaz: kindily stand on one foot, then hop on
one foot
— we do not do this in elder clients
Jhaz: Kindly sit sir and I’ll just ask you to follow
some command

•Jhaz: Sir kindly bring your finger to your nose

and do it alternately
(One hand to the nose and one outwards cross
wise)
DO IT AS FAT AS YOU CAN
—— REMOVE NOW THE GLOVES

•Jhaz: Using your thumb touch every finger.

Then do it fast. (Both hands)

•Jhaz: Sir put your palms on your lap, turn or

put them up and down alternately. Then you
have to increase the speed as you go along
•Jhaz: Sir put your heel into your sheen, then
put it up
FINDINGS: my patient was able to do the
commands correctly and properly. There is
balance and coordination. The gaits are also
normal

SENSORY SYSTEM
4. TEST TOUCH LIGHT, PAIN AND
TEMPERATURE SENSATION
•TEAT LIGHT TOUCH (USING COTTON)
Jhaz: Sir kindly close your eyes and I will
— If I touch you kindly say the word noun?
Jhaz: May I barrow your hand sir.
—— Point where I touch you sir
FINDINGS: My patient was able to feel and
point where I touch him

•PAIN SENSATION (TIP OF PAPER CLIP)

-using blunt and shart objects
Jhaz: Sir kindly identify wheter its sharp or
blunt. You say sharp if it’s sharp and blunt when
it’s blunt
FINDINGS: My patients was able to identify
sharp and blunt correctly

•TEMPERATURE SENSATION (WATER)

— with warm and cold water
Jhaz: Ma’am kindly close your eyes now. Tell
me what you feel
FINDINGS: He was able to identify the bottles
which contains warm and cold water

5. TEST VIBRATORY SENSATION (TUNING

FORK)
— strike the tuning fork and put it on the
knuckle)
Jhaz: Sir is there a vibration? Tell when the
vibration stops
(REPEATTTTT)
FINDINGS: My patient was able to feel
vibratory sensation

6. TEST POSITION SENSATIONS

Jhaz: Sir kindly close your eyes again
Tell me if I move your fingers up or down
OTHER SIDE…
FINDINGS: My client was able to determine
position sensation

7. TEST TACTILE DISCRIMINATION Tests

tactile discriminations (fine touch). (2 PAPER
CLIPS)
•Jhaz: Sir close your eyes
— I want you to hold something and identify it
using just your hands
FINDINGS: My patient was able to identify the
object I handed him

GRAPHISTICIA
•Jhaz: Sir I want you to identify the number
that I will write on your palm (using blunt
edge of a pen)
FINDINGS: My patient was able to identify the
numbers I draw on her palm

•TEST POINT LOCATION (PAPER CLIP)

— to identify the numbers of points felt
Jhaz: Sir kindly tell me if there are one point
or two points (on the arms)
(Two-two-two-one) (use two paper clip)
FINDINGS: with this distance my patient was
able to say that it is only one in 2cm distance

Jhaz: Sir on your fingers naman po (fingers)

REFLEXES
1. TEST DEEP TENDON REFLEX (biceps,
brachioralis, triceps, patellar, Achilles and ankle
clonus). – FOR LESIONS OR DAMAGE IN
NERVES
0 reflexia
2+ normal reflexia
4 hyper reflexia

•BICEPS (HAMMER PUKPOKIN)

Jhaz: sir kindly flex your hands
(Using thumb press the bicep tendon)
Jhaz: sir Relax lang po
(Galaw yung kamay parang nagulat)

•BRACHIORADIALIS
(2 INCHES BELOW THE WRIST WRIST)
•TRICEPS
(Likod ng biceps)—BUHATIN ANG KAMAY
Jhaz: sir relax mo lang ako ang magaangat

•PATELLAR
(On the knees)

•ACHILLES TENDON (HAMMEE BLUNT

EDGE)
(likod ng ankle)

•ANKLE CLONUS
(Ibend paataas yung paa)
FINDINGS: The grading of each reflexes is 2+
because it can react properly while I strike the
tendons. It is completely normal. THE TESTS
ARE NEGATIVE
2. TEST SUPERFICIAL REFLEX (plantar,
abdominal, cremasteric).
•PLANTAR
(baba ng paa)
— I’m going to draw an inverted letter J
FIDINGS: As we can see the patient gets tingle
so that’s a normal reaction

3. TEST FOR MENINGEAL IRRITATION/

INFLAMMATION

Jhaz: sir kindly flex your knees, then bring your

knees on your chest
—— I will put up your head (assist tapos
resist— sanggain mo yung knees at neck)
FINDINGS: My patient was able to tolerate it,
but for those people with meningeal irritation,
they cannot resist or tolerate it

•Brudzinski's and Kernig's signs

(Bend the knees, put up, bend inward)
Jhaz: Did you feel any pain sir?

ANALYSIS OF DATA
1. Formulates nursing diagnoses
(wellness, risk actual)
•The findings are all normal, the patient is alert
and reacts appropriately with the tests
•His neurology are functioning well
•I have not seen any abnormalities in my patient
related to any neurologic diseases.

2. Formulates collaborative problems.

For collaborative problems if there are
abnormalities seen such as gates
we are going to assist the client together with a
physician to properly check the patient
drugs: magnesium sulfate
3. Makes necessary referrals.
If you feel any pain, confusion, nausea, or any
disturbances please come back here and we
will do another assessment so that I can refer
you to a Physician or Neurologist if there are
abnormalities seen.