commonly called involuntary nervous system,

NCM 122: Health Assessment

has two parts: the sympathetic and
NEUROLOGICAL ASSESSMENT parasympathetic, which typically bring about
opposite effects.
PHYSIOLOGY OF THE NERVOUS SYSTEM

1. Monitoring changes. Much like a sentry, it

uses its millions of sensory receptors to
monitor changes occurring both inside and
outside the body; these changes are called
stimuli, and the gathered information is called
sensory input.
2. Interpretation of sensory input. It processes
and interprets the sensory input and decides
what should be done at each moment, a
process called integration.
3. Effects responses. It then effects a response
by activating muscles or glands (effectors) via
motor output.
4. Mental activity. The brain is the center of
mental activity, including consciousness,
thinking, and memory.
5. Homeostasis. This function depends on the
ability of the nervous system to detect, BRAIN
interpret, and respond to changes in the
CEREBRAL HEMISPHERE
internal and external conditions. It can help
stimulate or inhibit the activities of other
systems to help maintain a constant internal
environment.

Cerebral cortex. Speech, memory, logical and

Somatic nervous system. The somatic
nervous system allows us to consciously,
or voluntarily, control our skeletal muscles.
Autonomic nervous system. The autonomic
nervous system regulates events that are
automatic, or involuntary; this subdivision,
emotional response, as well as consciousness,
interpretation of sensation, and voluntary
movement are all functions of neurons of the
cerebral cortex.
Pyramidal tract. The axons of these motor
neurons form the major voluntary motor tract-
the corticospinal or pyramidal tract, which
descends to the cord.
Broca’s area. A specialized cortical area that
is very involved in our ability to speak, Broca’s
area, is found at the base of the precentral
gyrus (the gyrus anterior to the central sulcus).
Speech area. The speech area is located at
the junction of the temporal, parietal, and
occipital lobes; the speech area allows one to
sound out words.
Cerebral white matter. The deeper cerebral
white matter is composed of fiber tracts
carrying impulses to, from, and within the
cortex.
DIENCEPHALON
Thalamus. The thalamus, which encloses the
shallow third ventricle of the brain, is a relay
station for sensory impulses passing upward to
the sensory cortex.
Hypothalamus. The hypothalamus makes up
the floor of the diencephalon; it is an important
autonomic nervous system center because it
plays a role in the regulation of body
temperature, water balance, and metabolism;
it is also the center for many drives and
emotions, and as such, it is an important part
of the so-called limbic system or “emotional-
visceral brain”; the hypothalamus also
regulates the pituitary gland and produces two
hormones of its own.
BRAIN STEM
Midbrain. The midbrain extends from the
mammillary bodies to the pons inferiorly; it is
composed of two bulging fiber tracts,
the cerebral peduncles, which convey
descending and ascending impulses.
Pons. The pons is a rounded structure that
protrudes just below the midbrain, and this
area of the brain stem is mostly fiber tracts;
however, it does have important nuclei
involved in the control of breathing.
Medulla oblongata. The medulla oblongata is
the most inferior part of the brain stem; it
contains nuclei that regulate vital visceral
activities; it contains centers that control heart
rate, blood pressure, breathing, swallowing,
and vomiting among others.
THE 4 LOBES
FRONTAL LOBE
The primary motor area, which allows us to
consciously move our skeletal muscles, is
anterior to the central sulcus in the front lobe.
Involved in personality characteristics,
decision-making and movement.
Recognition of smell
Broca’s area, which is associated with speech
ability.
Skeletal and muscular actions
IQ, emotions, behavior, personality, reasoning,
judgement
PARIETAL LOBE
The primary somatic sensory area is located
in the parietal lobe posterior to the central
sulcus; impulses traveling from the body’s
sensory receptors are localized and
interpreted in this area.
Processes your sense of touch and assembles
input from your other senses into a form you
can use
Tactile sensation: sharp, dull, rough, smooth
TEMPORAL LOBE
The auditory area is in the temporal lobe
bordering the lateral sulcus, and the olfactory
area is found deep inside the temporal lobe.
Processing auditory information and with the
encoding of memory.
Inferior side of the CNS
Auditory stimuli Wernicke’s, with the use of
your cerebral auditory pathway, the one you
are using for sense of hearing.
Receives and transmits the sound
OCCIPITAL LOBE
The visual area is located in the posterior part
of the occipital lobe.
Responsible for visual perception, including
color, form and motion.
Able to understand the rationale of each step,
since you are able to see it; comprehension.
HEALTH HISTORY
HEADACHE
Could be associated with increase intracranial
pressure of the brain.
Could be a manifestation for factors
associated cerebellum vascular or an accident
in the head.
 SEIZURES (GENERALIZED, FOCAL)
Epilepsy starts with an AURA
Grand Mal – Involves shaking involuntary
movement (systemic)
Petit Mal
Example: Patient who have a convulsive
epileptic state caused by a head injury
o Serotonin
o Gamma-aminobutyric acid
MEMORY LOSS
Early memory deficit – dementia (early case of
Alzheimer) alterations of the patient’s ADL.

DIZZINESS (MENIERE’S DISEASE , CAROTID

ARTERY DISEASE)

Responsible CN VIII
Disequilibrium problem associated with your
ear, which has the endolymph [is a
physiological fluid that fills the inner ear's
labyrinth and serves crucial sensory functions.
Vibrational waves transmitted following the
displacement of this fluid from outside stimuli
convey information about sound, position,
and balance to central sensory neural
structures.]

NUMBNESS AND TINGLING

(PARESTHESIA’S)

Example: patient with Diabetes Mellitus –

retinopathy and nephropathy main problem
[they somehow won’t feel any pain and puts
them at risk of injury because their blood
5 COMPONENTS OF THE NEUROLOGIC
becomes viscos (lapot), mahinay ang
TEST
transmission of nerve impulse to one another]
Mental Status Examination / Level of
SENSES (SMELL, HEARING, VISION) Consciousness
Cranial Nerves
Motor and Cerebellar Function
Sensory System
DIFFICULTY SPEAKING
Reflexes
Unable to understand the verbal language
IQ part of the brain – cerebral cortex MENTAL STATUS EXAMINATION
EQ part of the brain – amygdala and
Provide information about cerebral cortex
hypothalamus
function.
Cerebral abnormalities disturb the client’s
DIFFICULTY SWALLOWING (DYSPHAGIA)
intellectual ability, communication ability, or
Responsible for CN IX, X, XII emotional behaviors.

PAINFUL SWALLOWING (ODYNOPHAGIA)

Language
Orientation
LOSS OF MUSCLE CONTROL Memory
Attention Span and Calculation
Weakness – paralysis (score of hyporeflexia)
Tremors – abnormal involuntary gesture (pt’s LIFESTYLE AND HEALTH PRACTICE
with Parkinson’s disease)
4 major receptors (in the sympathetic Taking Prescribed Medications
response): Smoking (Nicotine)
o Dopamine (facial features) Diet – Peripheral Neuropathy
o Acetylcholine Stress
 Activities of Daily Living MEMORY

LANGUAGE
IMMEDIATE RECALL
Any defects in or loss of the power to express
Recall of information presented seconds
oneself by speech, writing, or signs, or to
previously.
comprehend spoken or written language due
to disease or injury of the cerebral cortex.
Difficulty in Speaking – Damaged to RECENT MEMORY
Cerebral Cortex Events or information from earlier in the day or
examination.

APHASIA REMOTE OR LONG – TERM MEMORY

Ability to convey and respond
Language disorder caused by damage in a
specific area of the brain that controls
language expression and comprehension.
WERNICKE’S APHASIA
Fast speech but lack of meaning
Knowledge recalled from months or years ago.
ATTENTION SPAN AND CALCULATION
Determines the client’s ability to focus on
mental task that is expected to be able to be
performed by individuals of normal
intelligence.

BROCA’S APHASIA LEVEL OF CONSCIOUSNESS

Slowed speech but understandable Alert And Awake with eye contact
The Glasgow Scale is 15

Types:
o Receptive / Sensory Aphasia
o Motor / Expressive Aphasia

RECEPTIVE / SENSORY APHASIA – WARS

Loss of the ability to comprehend written or

spoken words.

AUDITORY APHASIA
Loss the ability to understand the symbolic
content associated with sounds.

VISUAL APHASIA
Loss of the ability to understand printed or
written figures.

MOTOR / EXPRESSIVE APHASIA

Loss of the power to express oneself by Best Response: 15

writing, making signs, or speaking. Comatose: 8 or less
Totally Unresponsive: 3
ORIENTATION
4 TERMS
Determines the client’s ability to recognize
other people (person) awareness of when and LETHARGIC
where they presently are (time and place),
and who they, themselves, are (self). Drowsy but awaken
Lack of energy and motivation for physical and
mental tasks
Drowsy, bagong mata or not enough sleep
 Can only answer yes or no (close ended OLFACTORY (CN I)
questions)

OBTUNDED FUNCTION
Smell
Difficult to course
Dulled or reduced level of alertness
ASSESSMENT
STUPOR Ask client to close eyes and identify different
Arouses to rigorous and continuous moan mild aromas, such as coffee, vanilla, peanut
Sharp pain butter, orange / lemon, chocolate.
An excessively deep state of
unresponsiveness ABNORMAL

Neurogenic Anosmia
COMATOSE o Inability to smell or identify the correct
No response and does not make any verbal scent
response o May indicate olfactory tract lesion or
Lengthy deep state of unconsciousness tumor or lesion of the frontal lobe
Smoking and use of cocaine may also impair
CRANIAL NERVES one’s sense of smell.

Provides information regarding the OPTIC (CN II)

transmission of motor and sensory messages,
primarily to the head and neck.
FUNCTION
Sensory - Vision and Visual Fields

1. Olfactory
2. Optic ASSESSMENT
3. Oculomotor Ask the client to read Snellen-type chart;
4. Trochlear check visual fields by confrontation; and
5. Trigeminal conduct an ophthalmoscopic examination.
6. Abducens
7. Facial ABNORMAL
8. Auditory / Vestibulocochlear
9. Vagus Loss of Visual Fields
10. Accessory o May be seen in retinal damage or
11. Hypoglossal detachment, with lesions of the optic
nerve, or with lesions of the parietal
MEMORY TRICK: O ’S cortex.

Olfactory (CN 1) – 1 Nose

Optic (CN 2) – 2 Eyes
Oculomotor (CN 3) – Motor

MEMORY TRICK: T’S

Trochlear (CN IV) – Four

Trigeminal (CN V) – Five Presbyopia
o Client reads point by holding closer than
MEMORY TRICK: V’S 14 inches or holds print farther away as in
presbyopia.
Vestibulocochlear (CN VIII) – Ear / Equilibrium
= Eight
Vagus (CN X) – Thorax / Tummy = Ten
OCULOMOTOR (CN III), TROCHLEAR (CN Drooping of the Eyelid
IV), AND ABDUCENS (CN VI) o Seen with weak eye muscles such as in
myasthenia gravis.

FUNCTION
Extraocular eye movement (EOM) (III, IV, and
VI)
Eyelid elevation, pupillary construction, and
accommodation.

ASSESSMENT Nystagmus
Assess six ocular movements and pupil o Rhythmic Oscillation of the eyes
reaction.
Assess pupillary response to light (direct and
indirect) and accommodation in both eyes.

Paralytic Strabismus
o Paralysis of the oculomotor, and trochlear
and abducens nerves.

TRIGEMINAL–OPTHALMIC BRANCH (CN V)

HOW TO ASSESS EYES

Use penlight and determine the pupil’s size FUNCTION

2-4 mm in a Light Area
Sensory - Sensation of cornea, skin of face,
4-8 mm in a dark area and nasal mucosa.
9 mm abnormal dilation
Mydriasis is when the pupil is dilated and
doesn't respond to light ASSESSMENT
Anisocoria is unequal pupil size Elicit blink reflex.
Test light and deep sensation.
HOW TO ASSESS VERBAL
TRIGEMINAL–MAXILLARY BRANCH (CN V)
Orientation, more like an interview

HOW TO ASSESS MOTOR FUNCTION

Ask the patient to move, raise arm and any Sensory - Sensation of skin of face and
facial movement. anterior oral cavity (tongue and teeth).

ABNORMAL
 ASSESSMENT Sensory - Taste on posterior 1/3 of tongue the
gag reflex.
Assess skin sensation as for ophthalmic
Motor - Provides secretory fibers to the parotid
branch above.
axillary gland,

TRIGEMINAL–MANDIBULAR BRANCH (CN V)

ASSESSMENT
Ask the client to open mouth wide and say “ah”
FUNCTION
while you use a tongue depressor on the
Muscles of mastication; sensation of skin and client’s tongue.
face. Test the gag reflex by touching the posterior
pharynx with the tongue depressor.
ASSESSMENT
VAGUS (CN X)
Ask client to clench teeth.

FACIAL (CN VII) FUNCTION

Sensory - Carries sensation from the throat,
FUNCTION larynx, heart, lungs, bronchi, GI tract, and
abdominal viscera.
Motor - Facial Expression
Motor - Promotes swallowing, talking, and
Sensory - Taste (Anterior two thirds of tongue)
production of gastric juices.

ASSESSMENT
ASSESSMENT
Ask client to smile, raise eyebrows, frown, puff
Ask the client to open mouth wide and say “ah”
cheeks, close eyes tightly.
while you use a tongue depressor on the
Ask client to identify various tastes placed on
client’s tongue.
tip and sides of tongue: sugar (sweet), salt,
Test the gag reflex by touching the posterior
lemon juice (sour), and quinine (bitter); identify
pharynx with the tongue depressor.
areas of taste.
Check the client’s ability to swallow by giving
the client a drink of water.
ABNORMAL
Also note the client’s voice quality.
Bell’s Palsy
o A peripheral injury to Cranial Nerve VII ABNORMAL
o Inability to wrinkle brow
Absent Gag Reflex
o Drooping eyelid; inability to close eye.
o May be seen with lesions of Cranial
o Inability to puff cheek; asymmetrical smile
Nerve IX (Glossopharyngeal) or X
o Drooping corner of mouth; dry mouth
(Vagus).
AUDITORY – COCHLEAR BRANCH (CN VII)

FUNCTION
Hearing

ASSESSMENT
Assess client’s ability to hear spoken word and
vibrations of tuning fork. Dysphagia or Hoarseness
o May indicate a lesion of Cranial Nerve
ABNORMAL IX (Glossopharyngeal) or X (Vagus) or
Ringing in the Ear – Damage to CN VIII other neurological disorder.

GLOSSOPHARYNGEAL (CN IX)

FUNCTION
 ACCESSORY (CN XI) ABNORMAL

Muscle Atrophy
FUNCTION Loss of Proprioception
Head movement; shrugging of shoulders.
ASSESSMENT
ASSESSMENT Note any unusual involuntary movements.
Ask the client to shrug the shoulders against
the resistance to assess the trapezius muscle.
ABNORMAL
HYPOGLOSSAL (CN XII) Fasciculation – Rapid twitching of resting
muscle.
FUNCTION Tic – Twitch of the face, head, or shoulder
Tremors – Rhythmic, oscillating movements
Motor - Innervates tongue muscles that
promote the movement of food and talking.
ASSESSMENT

ASSESSMENT Evaluate gait and balance.

Ask the client to walk naturally across the
Ask the client to protrude tongue, move it to room.
each side against the resistance of a tongue Tandem Walking.
depressor, and then put it back in the mouth.

MOTOR AND CEREBELLAR SYSTEM

Provides information regarding the

transmission of motor and sensory messages,
primarily to the head and neck.
Are assessed to determine functioning of the
pyramidal and extrapyramidal tracts.
To determine the client’s level of balance and
coordination.
ASSESSMENT
PYRAMIDAL TRACTS
Romberg’s Test
Conscious control of muscles from the
cerebral cortex to the muscles of the body and
face.

EXTRAPYRAMIDAL

Originate in the brainstem

Unconscious, reflexive or responsive control of
musculature.
Examples
o Muscle Tone
o Balance
o Posture
o Locomotion
ABNORMAL
ASSESSMENT
Positive Romberg Test: Swaying and moving
Assess condition and movement of muscles. feet apart to prevent fall.
Assess the size and symmetry of all muscle Cerebellar Ataxia
groups.
 ASSESSMENT Analgesia – Absence of pain sensation
Hypoalgesia – Decreased sensitivity to pain
Assess Coordination
Hyperalgesia – Increased sensitivity to pain
o Finger-to-nose Test

ASSESSMENT
Sensitivity to position
Assess tactile discrimination (fine touch)
Point localization
Graphesthesia
Two-Point Discrimination

CEREBRAL VASCULAR ACCIDENT

The sudden death of some brain cells due to

lack of oxygen.
Assess Rapid Alternating Movements
The initial exam will establish baseline data
o Ask the client to touch each finger to
with which to compare subsequent
the thumb and to increase the speed
assessment findings.
as the client progresses.
A change in either is usually first clue to
o Ask the client to put the palms of both
deteriorating condition.
hands down on both legs, then turn
It helps to be familiar with treatment.
the palms up, then turn the palms
down again.
COMPLETE NEUROLOGIC EXAMINATION

SENSORY SYSTEM Mental

Cranial
Provides information regarding the integrity of
Motor
the spinothalamic tract, posterior columns of
Sensory
the spinal cord, and parietal lobes of the brain.

SPINOTHALAMIC TRACT ( STT)

Mental Status Examination
Is a sensory tact that carries nociceptive,
Cranial Nerve Evaluation
temperature, crude touch, and pressure from
our skin to the somatosensory area of the
MOOD, FEELINGS, AND EXPRESSION
thalamus.
Cooperative and has positive outlook
ASSESSMENT Negative, Gloomy, Eccentric Mood

Ass light touch, pain, and temperature

THOUGH PROCESS
sensations
Light touch sensation Free Flowing
Pain sensation Thought
Temperature Realistic
Vibration
TANGENTIAL THINKING
ABNORMAL FINDINGS
Someone moves from thought but never
Peripheral Neuropathies – Damage of seems to get main part.
nerves outside the spinal cord. No connection
Anomia – A deficit of expressive language
Amnesia – Loss of memory RESERVATION
Apraxia – Inability to perform
Repetition of words
Aphasia – Impairment of language.
o Borax’s Aphasia
COGNITIVE ABILITIES
o Wernicke’s Aphasia
Anesthesia – Absence of touch sensation Awake
Hypoesthesia – Decrease sensitivity to touch Hallucination
Hyperesthesia – Increased sensitivity to touch Concentration
 ABSTRACT REASONING ABNORMAL

Mental Retardation – Incomplete No response or an exaggerated response is

development of mind abnormal.
Delirium – Abrupt change in the brain that
causes mental confusion and emotional
disruption. Mostly with dehydration and High
temperature. BRACHIORADIALIS REFLEX (C5 AND C6)
Organic Brain Syndrome – State of diffuse
Radius: 2cm above the wrist; flat side
cerebral dysfunction

REFLEXES

Testing reflexes provides clues to the integrity

of deep and superficial reflexes.

DEEP REFLEXES
Depend on an intact sensory nerve, a
functional synapse in the spinal cord, an intact
motor nerve, a neuromuscular junction, and
competent muscles.

SUPERFICIAL REFLEXES
Depend on skin receptors rather than muscles. NORMAL

Flexion and Supination of the forearm.

SPINAL NERVES The fingers of the hand might also extend
Receive sensory information from the slightly.
periphery and pass them to the CNS.
Receive motor information from the CNS and ABNORMAL
pass them to the periphery. No response or an exaggerated response is
abnormal.

REFLEXES
BICEPS REFLEX (C5 AND C6) TRICEPS REFLEX (C6, C7, AND C8)
Thumb on biceps tendon; pointed side Tendon: 2-5cm above elbow; flat side

NORMAL NORMAL

Slight flexion of the elbow, and feel the bicep’s Elbow extends, triceps contracts.
contraction through your thumb. Range from 1+ to 3+
 ABNORMAL

No response or an exaggerated response.

PATELLAR REFLEX (L2, L3, AND L4)

Patellar tendon; flat side

NORMAL

Knee extends, quadriceps muscle contracts.

Ranges from 1+ to 3+

ABNORMAL

No response or exaggerated response.

BABINSKI REFLEX

ACHILLES (S1 AND S2)

Achilles Tendon; flat side

NORMAL

Negative Babinski Reflex – All five toes bend

downward

NORMAL ABNORMAL

Normal response s plantarflexion of the foot. Positive Babinski Reflex – The toes spread
Ranges from 1+ to 3+ outward and the big toe moves upward.

ABNORMAL

No response or an exaggerated response is

abnormal.
ASSESSING RESPONSE TO PAIN
SUPRAORBITAL PRESSURE
Using a finger or thumb, feel the orbital rim
under your patient’s eyebrow until you find a
small notch / groove.
With your thumb, push hard on the notch. This
should trigger intense local pain (like that of a
sinus headache).
Do not use if patient has facial fractures.
TRAPEZIUS SQUEEZE
The trapezius muscle is flat and triangular,
covering the shoulder like a scarf.
The muscle extends from the back of the neck
to the shoulder.
Tip: Using your thumb and two fingers, grab
the muscle and twist.
Do not use if patient has a clavicle fracture.
STERNAL RUB
Clench first, applying pressure with your
knuckles to patient’s sternum.
Tip: May need to apply stimuli for up to 30
seconds
DANGER!!!!
Do not use if patient has injury / surgery to
chest.
Avoid using every hour, may cause skin
breakdown.
GERIATRIC DEPRESSION SCALE (SELF
POSTURING
DIFFERENT POSTURING
POSTURE AND BODY MOVEMENTS
Normally during interview, the patient is
relaxed sitting.
Slumped or unnecessary/bizarre movements
is a psychological problem.
DRESS, GROOMING AND HYGIENE
Well Groomed
Meticulous grooming – obsessive compulsive
disorder
Poor hygiene
When the patient talks, there is the presence
of Halitosis (bad breath)
FACIAL EXPRESSION
Good Eye Contact
Apathy (Parkinson’s Disease Dopamine
Problem) - Presents as a lack of interest and
emotional expression.
Extreme / Exaggerated Facial Expression
SPEECH
Moderate, Clear, and without pace
Dysphonia – Horsiness of Voice (abnormal
voice) – Problem with CN X Vagus
Dysarthria – (slurred) difficulty speaking
caused by weak muscles paralyzed, damaged
speech
Cerebral Dysarthria – irregular/uncoordinated
speech.
REPORT)
Less than 10 has no depression
Above 11 – suffering depression
Perfect score 30
ABNORMAL FLEXION
Involves adduction of the arm, internal rotation
of the shoulder, flexion of the elbow, pronation
of the forearm and wrist flexion (known as
decorticate posturing).
Decorticate Posturing indicates that there
may be significant damage to areas including
the cerebral hemispheres, the internal capsule,
and the thalamus.
ABNORMAL EXTENSION
Also known as Decerebrate Posturing
The head is extended, with the arms and legs
also extended and internally rotated
The patient appears rigid with their teeth
clenched
The signs can be on just one side of the body
or on both sides (the signs may only be
present in the upper limbs)
Indicates brain stem damage. It is exhibited by
people with lesions or compression in the
midbrain and lesions in the cerebellum.
Progression from decorticate posturing to
decerebrate posturing is often indicative of
uncal (transtentorial) or tonsillar brain
herniation (often referred to as coning).