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P r o c e d u r e 4 . 1 0 Assessing the Neurologic System 105

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to normal
● Pursue more specific tests and assessment regarding abnormal
findings if warranted

KEY POINTS FOR REPORTING AND RECORDING

● If patient has abdominal or lower back pain, record the pain
in detail (location, onset, frequency, severity, precipitating fac-
tors, aggravating factors).
● Assess normal bowel habits and any history of changes.
● Determine if patient has had abdominal surgery or trauma to
the abdomen in the past.
● Assess for difficulty swallowing, heartburn, black or tarry
stools, diarrhea, or constipation.
● Determine if patient is pregnant, and note last menstrual
period.
● Ask patient about history of alcohol or aspirin intake.

PROCEDURE 4.10
Assessing the Neurologic System
OVERVIEW
● To determine alteration in neurologic functions such as initiation
and coordination of movement, reception and perception of sensory
stimuli, organization of thought processes, control of speech, and
storage of memory.
● To determine a cause for level of consciousness (LOC), mental/emo-

tional status, and to determine if there are any alterations in central

or peripheral nervous system. Identification of specific patterns may
aid in the diagnosis of a pathologic condition.

P R E PA R AT I O N
● Neurologic assessment can be time consuming, and the examiner
must not rush through the assessment process.
● An efficient nurse can integrate neurologic measurements with

other parts of a physical examination. Example: While taking the his-

tory, the nurse can note the patient’s mental and emotional status.
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106 C h a p t e r 4 Physical Assessment

Special Considerations
• A patient’s level of consciousness influences the ability to follow
directions.
• General physical well-being may influence tolerance to assessment.
• Chief complaint helps determine the need for a more thorough
examination.
• Complaint of headache or recent loss of function in an extremity
may warrant a complete neurologic examination.

R E L E VA N T N U R S I N G D I A G N O S E S
● Confusion related to fluid volume deficit
● Self-care deficit due to immobility

EXPECTED OUTCOMES
● Assessment completed while maintaining the patient’s privacy and
comfort
● Awareness of patient’s cultural and traditional health practices

EQUIPMENT/SUPPLIES
Reading materials
Safety pin
Penlight
Tongue blade
Hot and cold water
Cotton balls
Tuning fork
Reflex hammer

I M P L E M E N TAT I O N
Mental and Emotional Status
➧ Mental and emotional status.
An observation made by the nurse to assess the appropriateness of emotions
and mental status.
Levels of Consciousness
➧ Level of consciousness.
Assess whether the patient will be able to follow with you during the exami-
nation. If a patient is not fully awake and alert, the neurologic assessment
may be difficult.
● Note LOC from fully awake, alertness, and cooperation to unrespon-
siveness to any form of stimuli.
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● Note if patient is oriented to person, time, and place.

A fully conscious patient responds to questions spontaneously. As patient’s
LOC lowers, you may see irritability, shorter attention span, and uncoopera-
tiveness.
● Exert pressure on supraorbital ridge of nailbed.
Normally, patient will try to stop or pull away from painful stimuli.
● Pinch Achilles tendon.
If not responding properly, the patient may assume
Decorticate posturing— (legs extended; feet extended with plantar flexion;
arms internally rotated and flexed on chest) may be due to lesion of corti-
cospinal tract near cerebral hemisphere.

A. Decorticate posturing
Wrists and fingers flexed

Feet plantar flexed Legs internally rotated Elbows flexed Arms adducted

B. Decerebrate posturing

Feet plantar flexed Wrists and fingers flexed Arms adducted

Forearms pronated Elbows extended

FIGURE 4.10 Decorticate (A) and decerebrate (B) posturing.

Decerebrate posturing— (arms stiffly extended and hands turned outward

and flexed; legs extended with plantar flexion) may be due to lesion in dien-
cephalons, pons, or midbrain.
Flaccid posturing— (no motor response) may be due to extreme brain
injury to motor area of brain.
Abnormal involuntary movements
Choreiform—(jerky and quick).
Athetoid—(twisting and slow) present in cerebral palsy.
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108 C h a p t e r 4 Physical Assessment

Tremors—hyperthyroidism, cerebellar ataxia, parkinsonism.

Spasms—cord injury.
Seizures—brain injury, heat stroke, electrolyte imbalance.
Asterixis—metabolic encephalopathy due to liver or kidney failure.
Behavior and Appearance
➧ Behavior and appearance.
Patient’s behavior and appearance initially show how they view themselves.
This will often alert the nurse to a more thorough examination.
● Note the patient’s behavior, mood, hygiene, and choice of dress.
Appearance reflects how one feels about oneself. An unkempt appearance
can mean a variety of things, such as:
Poor self-image.
Inability to keep clothes clean.
Inability to perform grooming.
Language
➧ Language.
When communication is altered, the assessment may be difficult, but also
may indicate a pathologic diagnosis.

➧ Assess language when communication with the patient is

ineffective.
● Have the patient name an object you point to.

● Have the patient follow simple written commands like “sit down.”

● Have the patient read simple sentences aloud.

If the patient is unable to understand spoken words or written words and to

express the self through writing or gestures, there may be an injury to the
cerebral cortex, which is called aphasia:
Receptive—cannot understand written or verbal speech.
Motor—can understand written and verbal speech but cannot return
communication.
Global—unable to understand speech or express the self.

Intellectual Function
➧ Intellectual function.
Alerts the nurse of possible pathologic diagnosis.
Memory
➧ Memory.
Many conditions can alter a patient’s memory.
● Test for memory by assessing immediate recall and recent remote
memory.
● Have patient repeat a series of numbers.
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● Have patient recall events occurring during the same day.

● Have patient recall medical history or family history or ask about
birthdays or anniversaries.
Sudden confusion may be caused by acute conditions such as dehydration,
infection, drug toxicity, or hypoglycemia.
In elderly, confusion and forgetfulness are common, but gradual, progressive
deterioration in mental function may indicate Alzheimer’s disease.
Abstract Thinking
➧ Abstract thinking.
Any type of altered mentation may prevent the patient from explaining an
abstract idea.

➧ Test by asking the patient to explain “a stitch in time saves nine.”

If the explanations are relevant and concrete, altered mentation is not sus-
pected.
A patient with altered mentation may interpret the phrase literally or just
repeat the phrase.

Pupil Assessment
➧ Pupil assessment.
When a beam of light is shone through the pupil and onto the retina, the
third cranial nerve is stimulated and innervates the muscles of the iris to
contract. Any abnormality along the nerve pathway from the retina to
the iris alters the ability of the pupil to react to light.

➧ Size of pupil (holding eyelids open).

Shape of pupil.
Unilateral dilation—third cranial nerve involvement.
Bilateral dilation—upper brainstem damage.
Unilateral and nonreactive—increased ICP or CNIII compression.
Fixed and dilated—midbrain involvement.
Pinpoint and fixed—a sign of pontine involvement or opiate effects.

➧ Equality of pupil.
Unequal denotes that parasympathetic and sympathetic nervous systems
are not synchronized.

➧ Reaction to light—In darkened room, open eyelid being tested

(cover opposite eye) and move penlight toward patient’s eye from
side position.
Sluggish reaction is an early warning of deteriorating condition.
If pupil does not constrict, the connection between the brainstem and pupil
is not intact.
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110 C h a p t e r 4 Physical Assessment

➧ Light reflex—hold both eyes open and shine light into one eye while
observing the reaction of the opposite pupil.
Note— light reflex is the most important sign differentiating structural (cra-
nial involvement) from metabolic coma due to extracranial cause (diabetic
coma), which does not alter light reflex.

Motor Function
➧ Motor function.
An assessment of motor function includes the same measurements made
during the musculoskeletal examination. In addition, cerebellar function is
assessed.
Muscle Strength
➧ Have patient squeeze your fingers bilaterally.
Test arm strength by having patient close eyes and hold arms out in
front with palm side up.
Lack of or diminished muscle function on one side may be a sign of:
Hemiplegia (paralysis on one side of the body).
Hemiparesis (weakness on one side of the body).
Paraplegia (paralysis of the legs or lower body) .
Tetraplegia or quadriplegia (paralysis of arms and legs).
Flexion and Extension
➧ Stand in front of patient and ask patient to push your hands away.
Have patient pull upward after placing your hand on patient’s
forearm.
Place patient’s knee in flexed position and ask patient to keep foot
down while you extend the leg.
Have patient straighten leg as you apply resistant force to knee and
ankle with each hand.
1. Increased resistance is a sign of increased muscle rigidity or spasticity, and
decreased resistance to leg extension and arm flexion may be assign of
cerebrovascular accident (CVA).
2. Weakness may indicate cerebellar lesion.
Muscle Tone
➧ Flex and extend patient’s upper extremities to assess how well
patient resists your movements.
Flex and extend patient’s lower extremities to assess resistance.
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Coordination
➧ Coordination.
The nurse must observe the smoothness and balance of movements.
Uncoordinated movements may be from cerebellar involvement or basal
ganglia involvement.
Hand
➧ Hand.
● While patient is seated, have the patient pat both thighs as rapidly
as possible.
● Have the patient turn hands over in rapid succession.

● Ask the patient to touch thumb with each finger in rapid

succession—repeat with other hand.

Foot
➧ Foot.
●Place your hands close to patient’s feet and ask the patient to tap
your hands alternately with the balls of the feet.
Hand Positioning
➧ Hand positioning.
● Ask the patient to alternately touch his own nose and your index
finger of one hand.
● Repeat test with patient’s eyes closed.

Inability to perform task with eyes closed: may be due to loss of positioning
sense.
Leg Positioning
➧ Leg positioning.
● Have patient run the heel of one foot down the shin or tibia of the
other leg.
Reflexes
➧ Reflexes.
Eliciting reflex reactions allows the nurse to assess the integrity of sensory
and motor pathways of the reflex arc and specific spinal cord segments.
Blink
➧ Blink.
● Have patient look up and away from you, as you approach from the
side. Lightly touch the cornea with a cotton wisp.
Absence of a blink response may indicate fifth or seventh cranial nerve
involvement.
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112 C h a p t e r 4 Physical Assessment

Gag and Swallow

➧ Gag and swallow.
● Open patient’s mouth and hold tongue down with tongue blade.
● Touch back of pharynx on each side with cotton applicator stick.
Absence of gag and swallow may indicate ninth or tenth cranial nerve
involvement.
Plantar Response
➧ Plantar response.
● Run a pointed object on the lateral side of foot, from heel to ball,
then curve medially across the ball of the foot.
Babinski response—great toe dorsiflexes; others fan on foot of paralyzed
side (CVA), and bilaterally in spinal cord injury (SCI).
Deep Tendon
➧ Deep tendon.
● Patient must be relaxed. Position the limb with slight tension on
the tendon to be tapped. Briskly tap tendon.
• Biceps—flex at elbow and contract bicep
• Triceps—extend at elbow and contract triceps
• Knee—extend knee and contract quadriceps
Absent or diminished bicep reflex—C5 or C6 involvement.
Absent, diminished triceps—C7 or C8 involvement.
Absent or diminished knee—L2–3 or L3–4 involvement.

Sensory Function
➧ Sensory function.
The sensory pathways of the central nervous system conduct sensations
of pain, temperature, touch, and position.
Pain
➧ Pain.
● Stroke or touch skin with safety pin, alternate dull and sharp
end—ask patient to distinguish the two.
Alteration in pain or temperature sensations may indicate a lesion in poste-
rior horn or spinal cord.
Analgesia ⫽ absence of sense of pain.
Hypoalgesia ⫽ decrease pain sensation.
Hyperalgesia ⫽ exaggerated sensitivity to pain.
Temperature
➧ Temperature.
● With patient’s eyes closed, have patient distinguish between a hot
and cold item.
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Touch
➧ Touch.
● Have patient close eyes. Touch skin lightly and have patient point
or tell you the area when sensation is felt.
Anesthesia ⫽ loss of light touch.
Positioning
➧ Positioning.
● Have patient close eyes; grasp finger with your thumb and index
finger.
● Move patient’s finger up and down.

● Have patient identify direction of movement.

Inability to identify correct direction of movement may indicate injury to

posterior column or peripheral nerve disease.

Vital Signs
Respirations
➧ Respirations.
● Assess rate and pattern of breathing.
● If respiratory imbalance noted, monitor arterial blood gases.
Cheyne-Stokes—rhythmic increase in depth of breathing followed by
a period of apnea may indicate a cerebellar lesion or condition altering
cerebral profusion.
Hyperventilation—upper brain stem involvement.
Ataxic—irregular, unpredictable breathing due to lower brain stem involve-
ment.
Alterations in pH and Pco2 values indicate respiratory imbalance.
Normal: pH: 7.35–7.45.
Pco2: 35–45 mm Hg.
HCO3: 22–26 mEq/L.
pH ⬍7.35 and Pco2⬎ 45 ⫽ Respiratory acidosis (hypoventilation).
pH ⬎7.45 and Pco2 ⬍35 ⫽ Respiratory alkalosis (hyperventilation).
HCO3 ⬎26 indicates metabolic compensation for chronic respiratory acidosis
(hypoventilation).
Apical and Radial Pulse
➧ Apical and radial pulse.
● Note character of pulses.
● Count heart rate.
● Count radial pulse rate.

Fast heart rate—decreased blood volume, arrhythmia, heart failure.

Irregular rhythm with premature beats—hypoxia, cardiac irritability,
or electrolyte imbalance.
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Temperature
➧ Temperature.
● Take rectal or tympanic temperature if patient is semiresponsive.
Inability to maintain normal temperature may indicate damage to hypo-
thalamus.
Blood Pressure
➧ Blood pressure.
● Position neurologic patients in low to semi-Fowler’s position.
Systolic pressure rise without a rise in diastolic (widening pulse pressure)
may indicate increased ICP.
B/P ⬎140/90 mm Hg ⫽ hypertension.
B/P ⬍95/60 mm Hg ⫽ hypotension.

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to normal
● Pursue more specific tests and assessment regarding abnormal find-
ings if warranted

KEY POINTS FOR REPORTING AND RECORDING

● Mental and emotional status.
● Intellectual function.
● Pupil size and reaction.
● Motor coordination.
● Reflexes.
• Use grading scale:
4⫹ Hyperactive or exaggerated
3⫹ More brisk than usual but not indicative of disease state
2⫹ Average or normal
1⫹ Slightly diminished, low normal
0 No response
● Sensory.
● Vital signs.