ASSESSMENT TOOL ON NEUROLOGICAL SYSTEM

 BASELINE DATA:

Name:
Age:
Gender:
Religion:
Marital status:
Education:
Occupation:
Income:
Address:
Hospital No:
Ward:
Unit:
Bed No:
Diagnosis:
Source of referral:
Date of admission:
Date of discharge:

 CHIEF COMPLAINTS:

 HISTORY OF PRESENT ILL NESS:

1. Onset: sudden _________ Gradual ____________

Duration: Days _______Weeks _______ Months ______Years _______
Frequency: Intermittent _______ Continuous ___________
2. Pain:
Onset: Sudden _______ Continuous _______Intermittent __________
Type: Acute ________ Chronic _________
Intensity: None ___ Mild ___________ Discomforting _________
Distressing _________ Horrible _________ Excruciating____
Quality: Dull ______ Sharp _________ Both _____
 No response __________ Other ________
Radiation __________
Location ___________
Severity: Mild ___________ Moderate __________ Severe _________
Duration _________
Frequency: once a day ____ 1-3 times a day____________
4-6 times a day_______ +7 times a day_____________
Associated symptoms: __________
Aggravating factors: Walking ______Exercise _________
Running ________ Climbing stairs ____
Relieving factors: Rest _____Analgesics ____ Hot application_____
Cold application ______Others _____

3. Seizure:

Premonitory symptoms: _____________

Posture at onsets: __________
Transition to unconsciousness: ____________
Duration of unconsciousness: ___________________
Duration of tonic and clonic movements: _________
Frequency: _____________
Severity: __________
Aggravating factors: High fever: __________
Alcohol withdrawal: ___________
Drug withdrawal: ____ Hypoglycaemia: _____

4. Vertigo and dizziness:

Onset: Sudden: _________ Gradual: _________

Intensity: Mild: _______ Moderate: ________ Severe: ________
Pattern: Paroxysmal:__________ Constant: ________
Exacerbated by movements: Yes: ________ Variable: _________
Nystagmus: Horizontorotary: __________ Any: __________
Laterality of Nystagmus: Unilateral: ________ Bilateral: __________
Fatigability: Yes:___________ No: _________
Fixation: Yes:_______ No: ________
Habituation: Yes: __________ No: _________
Auditory Symptoms: Yes: _________ No: _______
CNS Symptoms: Absent: _____ Present: ________
If present: Spatial Disorientation: ____________
Light Headedness: ____________ Loss of equilibrium: _________
 Nausea and vomiting: _____________
5. Visual Disturbances:

Type: Double vision/Diplopia: ____________ Halos: ______ Pain:____

Partial blindness: ________ Total blindness: ___________
Colour Blindness: _________ Blurred Vision: __________
Duration: _________
Associated Factors: Headache: ______________
Aggravating factors: Stress____ TIredness__________ Flickering lights____
Glare________ Exercises ____Dehydration___
Alcohol_____ Excessive heat_________

6. Muscle Weakness:

Pattern: _______
Severity______
Associated symptoms: Localized pain_____
Shortness of breath________ Trembling_________
Muscle twitching _________Muscle cramps_________
SCALE:

POINTS SCALE REMARKS

0 No muscle contraction is seen

1 Flicker/trace contraction is seen

2 Active movement only with gravity eliminated

3 active movement against gravity but not

resistance

4 active movement against gravity with some

resistance

5 Active movement against gravity with full

resistance
7. Abnormal sensations:
Site________
Onset: Sudden____________ Gradual __________
Sensory symptoms: Tingling_____ Prickling_____
Numbness_____
Associated symptoms: Pain________ Weakness_______
Aggravating factors_________

 PAST MEDICAL HISTORY:

Previous health status:

Healthy: Yes __________No ____________
If no specify the reason________________

Previous hospitalization: Yes _________No_________

If yes specify the reason____________
Treatment: regular___ Irregular ________Outcome_________

History of trauma to head or spinal cord: Yes _______ No___

If yes specify the reason__________
Treatment taken________________

History of childhood illness: Yes_________ No______

If yes specify the illness___________ Duration______
Treatment ____________Outcome________________

History of surgeries: Yes __________No__________

If yes specify the type of surgery__________
Indication ____ Recovery ________ Followup ____________

Immunization: Immunized__________ Not immunized_______

History of adulthood diseases: Yes __________ No ___________

If yes specify____________ Treatment taken_______________

History of allergy: Present_____________ Absent ________

If present specify type of allergy__________
Dust_________ Pollen_________ Fur_____________
Occupational allergy_________
Treatment taken: Yes_____________ No ____________
Drugs________ Duration _______________
 MENSTRUAL HISTORY:

Age at menarche____________
Cycle: Regular____________ Irregular _______________
Frequency______________
Duration: 1-3 days________ 3-5 days__________
5-7 days __________More than 7 days_________________
Amount ________________

 FAMILY HISTORY:

Marital status: Married______ Unmarried_______________

Widow____________ Single_________ Divorced_______
Consanguineous marriage: Yes_____________ No __________
Type of family: Nuclear ________ Joint________
Position in the family___________
Number of adults_________
Number of children_____________
History of familial illness: Diabetes mellitus ____Hypertension_______
Heart diseases ___________Epilepsy____________
Asthma _____Any other illness_________
Any recent death occurred: Yes _______ No _____
If yes causes ______
FAMILY TREE:
 SOCIO ECONOMIC HISTORY:
Housing: Kutcha ______ Pucca __________ Semipucca _________
Lighting: Adequate _____________ Inadequate ____________
Ventilation: Adequate _________ Inadequate ____________
Drainage: Open _____________ Closed _________________

 OCCUPATIONAL HISTORY:
Type of Income: Daily Wage ____ Weekly Wage ________
Monthly Wage _________Yearly ___________
Type of Work: Sedentary ___________ Moderate ____________
Heavy Worker ____________Retired____________
 PERSONAL HISTORY:
Brushing: No of times __________ Type of dentifrice ___________
Bath: Daily _____ No of times / day __________
Bowel movements: Regular __________ Irregular ______
If irregular specify the cause ___________
Bladder function:
Micturition: Free _________ Strainful ___________ Stress __________
Incontinence ______Dribbling _____If retention specify ________
Sleep: Usual bedtime __________ Time of awakening _____________
Use of drugs: Yes ________ No ________
If yes specify the reason ______________
Activities of daily living: Dependent _________Independent __________
Dietary history: Vegetarian _________ Non vegetarian ________
Coffee: yes _______ no ____
If yes no of times/day_________ amount ____________
Smoking: Yes ___________ No _______
If yes no of cigarettes/day ______________
Frequency:Ooccasionally _____ Sometimes _______ Very often _____
Pan chewing: Yes _____ No ________
If yes no of packets/day
Frequency: Occasionally _____ Sometimes _______ Very often _____
Alcohol consumption: Yes _________ No _______
If yes type of alcohol ____________
Frequency: Daily_____Occasionally _____ Sometimes _______
Very often _____
 NEUROLOGICAL EXAMINATION

A. LEVELS OF CONSCIOUSNESS:

Alertness ___________ Lethargic ________ Stuporous _____________

Semi Comatose ______Comatose ____________

GLASGOWCOMA SCALE

RESPONSE SCORE REMARKS

1. Best eye opening Spontaneously 4
response To speech 3
Record “c” if eyes closed
To pain 2
by swelling
No response 1

2. Best motor response Obeys verbal 6

To painful stimulus command
Localizes pain 5

Flexion(withdrawal) 4

Flexion (abnormal ) 3

Extension (abnormal) 2

No response 1

3. Best verbal response Oriented to time, place 5

and person
Conversation confused 4

Speech inappropriate 3

Speech 2
Incomprehensive
No response 1

TOTAL SCORE 15

B.MENTAL SATUS EXAMINATION:

 GENERAL APPEARANCE AND BEHAVIOR:

Appearance: Looking ones age _______ Looks older ______________
Younger than age ____________Underweight ___________
Oveweight __________ Physical deformity _____________
 Facial expression: Anxious ___ Blunted _______ Pleasant _____Fearful_____
Level of grooming: Normal ____ Shabbily dressed _____
Overdressed ___________ Idiosyncratically dressed___
Level of consciousness: Fully conscious and alert ___ Drowsy ___
Stuporous _______Comatosed ____________
Mode of entry: Came willingly ___________ Persuaded ___________
Brought using physical force ______________
Behaviour: Normal_________Overfriendly __________
Pre occupied ______ Aggressive ____________
Cooperativenss : Normal ________ More than so ____ Less than so ___
eye to eye contact: Maintained ____ Difficult _____
Not maintained __________
Psychomotor activity: Normal _____ Increased _____Decreased ___________
Rapport: spontaneous ____Difficult _________ Not established___________
Gesturing: Normal _______ Exaggerated ____Odd ________
Posture: Normal posture _______Catatonic_____ Stooped ______
Stiff _______ Guarded _________
Other movements: Normal _________Stereotype _________Tremors _______
Extrapyramidal symptoms _____
Abnormal involuntary movements _____________
Other catatonic phenomena: Automatic obedience ____ Negativism ____
Excessive cooperation_____ Waxy flexibility _______
Echopraxia ___________ Echolalia ____________
Conversion and dissociative signs: pesudoseizures ________
Possession states _____ Any other _________
Compulsion acts: Rituals ________ Habits ______________
Hallucinatory behaviour: Smiling or Crying without reason___________
Muttering or Talking to self __________
Odd gesturing ________
 SPEECH:
Initiation: Spontaneous ___Speaks when spoken to _________
Minimal ________ Mute ____________
Reaction time: normal __________delayed ________
Shortened ______ difficult to assess _________
Productivity: Monosyllabic __________ Elaborate replies _____
Pressured ____
Rate: Normal _______ Slow _________ Rapid _______
Volume: normal ______ Increased ________Decreased _______
Tone: Normal variation ____ High pitch _________
Low pitch _______ Monotonous ________
Relevance: Fully relevant _______ Some times off target ______
Irrelevant ___________
 Stream: Normal __________ Circumstantial ______Tangential _________
Blocking _________ Verbigeration ___________
Stereotype verbal___ Flight of ideas _____ Clang associations’ ______
Coherence: Fully coherent ____________ Incoherent ____ Others _________

 MOOD AND EFFECT:

Predominant mood state: Irritable _____ Labile ______ Blunted ____________
Anxious ________ Fearful _______ Panic _______
Aggressive _______Cheerful __________
Depressed __________ Inappropriate ____Flat affect_____
 THOUGHT:

Stream: Normal _____ Racy thoughts ____Retarded thinking __________

Thought block __________Flight of ideas __________
Clang association _____________Thought insertion ______
Thought withdrawal ______Thought broadcasting ________
Form: Normal ________Not understandable __________
Circumstantiality _______Tangentiality __________
Neologism ___________ Word salad _________
Ambivalence _________ Perservation __________

 COGNITIVE FUNCTION:

Consciousness: Conscious ________Cloudy ________ Comatosed ____

Orientation:
Time: Appropriate time________ Day __________ Night _________
Date ____ Day _______ Month _________ Year ____________
Place: kind of place ________ Area __________ City _________
Person: self __________ Close associates _________ Hospital staff___
Attention: Normally aroused _________Aroused with difficulty _____
Concentration: Normally sustained _______ Sustained with difficulty__
Distractible _________
Memory:
Immediate: What is your name?________
Recent: what did you eat last night?___________
Remote: When is your birthday?__________________
Intelligence:
Arithmetic ability: add 2+ 5= _______
Abstraction: “Don’t sit like a clock work like a clock”.
Interpret the proverb____________________________
Similarities and dissimilarities between paired objects:
What are the similarities between apple and orange?__________
 What are the dissimilarities between bottle guard and bitter guard?________
Judgement:
Person(future plans):
What is your goal?_________________________
Intact _____________ Impaired ______________
Social (perception of the society)
Are interrelationships important in the society?
Intact ______________ Impaired __________
Test: (present a situation and ask their response to the situation)
While you are walking on the road,you have seen an accident,what you will do at
that situation?
Impact _____________ Impaired_____________
Insight:
SCALE SCORE RESPONSE
Complete denial of illness 1
Slight awareness of being sick 2
Awareness of being sick attributed to 3
external factor
Awareness of being sick due to 2
something unknown in himself
Intellectual insight 5
Emotional insight 6

C.SPECIAL CEREBRAL FUNCTION:

Agnosia: ______________ Apraxia: __________ Aphasia ____________

D. CRANIAL NERVE EXAMINATION:

1. Olfactory nerve:

Sense of smell: Present___________ Absent ____________

2. Optic nerve:

Inspection of eye:
Inflammation________ Cataract________ Foreign bodies ________
Any abnormalities_____________ No abnormalities__________
Visual acuity:
Normal vision:___Myopia ___________ Hyperopia __________
Presbyopia _________ Astigmatism ____________
 Visual field:
90 degree__________ 50 degree _________ 60 degree ___________
Ophthalmoscope examination:
Color vision: Present________ Absent___________

3.4,6. Occulomotor ,Trochlear and Abducent nerves:

Pupillary reaction to light:

Reacting__________ Not reacting _________
Pupillary size:
Equal _____________ Unequal _____________
Eye movements in 6 directions:
Normal _________ Abnormal ______________
nystagmus:
Present ____________ Absent _____________________
diplopia:
Present ____________ Absent ____________

5. Trigeminal nerve:

Corneal reflex: Present _________ Absent ____________

Facial sensory response: Present ___________Absent _____________
Mandibular strength: Adequate: ____________ Hypotonia ______________

7. Facial nerve:

Facial expressions: Normal _________Hypotonia ___________

Taste sensation: Present ______________ Absent _____________

8. Vestibule cochlear nerve or auditory nerve:

Auditory acuity test: _________________
Air conduction test_____________Bone conduction test_______________

9,10 Glossopharyngeal and Vagus nerve:

Gag reflex:
Present ______________ Absent __________________
swallowing reflex:
Present _________ Absent _____________________
position and movement of uvula and palate:
Normal position_________ Deviation ____________
sensation of taste:
Present _____________ Absent _____________
11.spinal accessory nerve:

Sterno cleido mastoid muscle strength:

Normal __________ Hypotonia _______________
Elevation of shoulders:
Adequate strength _______________ Weakness ____________
Turning of head:
Adequate ____________ Inadequate________

12. Hypoglossal nerve:

Tongue movement: Normal ___________ Abnormal ____________

E.MOTOR FUNCTION ASSESSMENT:

Muscle size:

Symmetry_____ Hypertrophy ___________ Atrophy __________

Muscle strength:

Scale Score Remarks

Full strength 5
Muscle actively moves through full ROM 4
Moves actively against gravity alone 3
Cannot overcome gravity 2
Muscle contraction is palpable 1
Undetectable muscle contraction 0

Muscle tone:

Hypotonicity_________ Hypertonicity___________

Muscle coordination:

Gait: _____________

Movement:

Range of motion: Possible ____Not possible _________Pain ________

Joint contractures ___________ Muscle resistance _________________
F. SENSORY FUNCTION ASSESSMENT:

Pain sensation:
Present__________ Absent ______________
Temperature sensation:
Present _________ Absent ____________
Touch sensation:
Present __________Absent ____________
Vibration sensation:
Present________________ Absent _____________

G.ASSESSMENT OF CEREBELLAR FUNCTION:

Finger to finger test: Normal _______________ Abnormal ___________

Finger to nose test: Normal _________________ Abnormal _____________
Tandem walking test: Normal ___________ Unable to perform ____________
Romberg test: Normal ________ Unable to perform _____________

H.ASSESSMENT OF REFLEXES:

REFLEXES ASSESSMENT EXPECTED PRESENT ABSENT

TECHNIQUE RESPONSE
SUPERFICIAL
REFLEXES

1.ABDOMINAL
Stroke skin
of Contraction of
REFLEX
upper, middle and abdominal
lower abdomen wall toward
toward umbilicus stimulus

2. PLANTAR Stroke sole of foot Flexion of toes

REFLEX
3.CORNEAL Light touch at the Closure of
REFLEX corneoscleral eyelids
junction

4.GAGGING REFLEX Gentle stimulation Produces

with a tongue gagging
blade at the back
of the throat and
pharynx
4. CREMASTERIC Stroke medial Elevation of
REFLEX surface of upper ipsilateral
thigh scrotum and
testicle
5. ANAL REFLEX Stroke perianal Contraction of
region external anal
sphincter
DEEP TENDON
REFLEXES: A blow on the Flexion of
1. BICEPS REFLEX examiners thumb elbow
placed over the
biceps tendon
2.BRACHIO Styloid process of Flexion of
RADIALIS REFLEX radius is tapped elbow,fingers
(SUPINATOR) while forearm is in and hand with
semiflexion and supination of
semipronation forearm
3.TRICEPS REFLEX Flex the patient Contraction of
arm at the triceps
elbow,hanging muscle and
freely at the extension of
sideplace.Blow the elbow
directly on the
triceps tendon
4. PATELLAR Strike the patellar Contractions
REFLEX tendon just below of the
the patella quadriceps
and knee
extension
6. ACHILLES Dorsiflex the foot Plantar flexion
REFLEX at the ankle and
strike Achilles
tendon with a
hammer

ABNORMAL
REFLEXES:

Normal:
1.BABINSKI’S Scrape the sole of Plantiflexion of
REFLEX the foot with a toes
blunt object from
midpoint of the Abnormal:
heel,outer border Dorsiflexion of
of the sole to the the great toe
ball of the foot and fanning of
the other toes
2.JAW REFLEX Tap gently on the Normal:
lower jaw belstow Jaw contracts
the mouth with and closes the
mouth slightly mouth
open
3.PALM CHIN Vigorous irritation chin muscles
REFLEX on the mound of pull up on the
the palm at the same side
thumbs base with
a blunt insrument
4. SNOUT REFLEX A brisk midline tap Pursing of the
above or below lips
the mouth
5.ROOTING REFLEX Stroke the side of Mouth opens
the face and head
turns towards
the stimulated
side
6.SUCKING REFLEX Touch the lips Movement of
with a blunt object the tongue,lips
and jaws
7.GLABELLAR Tap the forehead Sustained
REFLEX between the closure of the
eyebrows eyelids
8.GRASP REFLEX Place an object in Fingers curl
the palm of the around it
hand
9.CHEWING REFLEX A tongue blade Tight closing
placed between of the jaws
the teeth

PHYSICAL EXAMINATION
 GENERAL APPEARANCE:
Nourishment: Well nourished _______Undernourished_________
Body built: Moderate_______ Thin__________ obese_____
Activity: Active__________Dull _________Restless_______
Personal Hygiene: able to do self ____
Need assistance_____Dependant_________
 HEIGHT AND WEIGHT:
Height: ___________cm/feet
Weight : ________Kg/Pounds
HEAD TO FOOT EXAMINATION
 SKIN:
Colour: normal __________pallor___________icterus_________
Cyanosis__________erythema______________
Texture: Normal________ Dry______ Flaky___________ Wrinkled__________
Excessive moisture_______________
Temperature: Normal_________ Cold and Clammy___________ Febrile_________
Turgor: Normal_______________Tented_______________
Lesions:
Macules: Absent_______Present___________ If present description___________
Papules: Absent__________ Present________ If present description___________
Vesicles: Absent ___________ Present________If present description___________
Wounds: Absent___________Present_________If present description___________
Edema: Absent ______Present_________ If present description___________
Pitting_________Non Pitting______________
 HEAD:
Skull: Symmetry___________ Asymmetry_____________
Scalp: Clean____________ Dirty__________ Dandruff____________
Pediculi___________Nits_________
 HAIR:
Colour: Black____________ Brown____________ Grey_____________
Texture: Thick___________ Thin_______________ Silky__________
Brittle________________
Distribution: Even______________ Uneven___________ Alopecia___________
 FACE:
Shape: Symmetry___________ Asymmetry_________
Moonface______________ Puffiness_______________
Facial Hair: Absent___________ Present______________
Colour: Normal______________ Pallor___________Icterus___________
Cyanosis__________ Flushed_____________
 EYES:
Shape: Symmetry_______ Asymmetry___________
Eyebrows: Normal_________ Equal alignment_____________
Unequal alignment___________
Eyelashes: Normal__________ Turned inward_____________
Eyelids:normal __________Redness________ Swelling_____________
Discharge__________ Sty_________ Crusting_______
Closing symmetrically__________Asymmetrically___________
Conjunctiva: Normal___________Pale____________Red__________
Purulent________________
Sclera: normal _____ jaundiced ______
Pupils : reacting to light ___________ dilated ______________
constricted ________________
lens: normal __________ opaque ____________
vision: normal _____________ myopia __________________ hyperopia _________

 EARS:
External ear
Discharges: absent__________ present_________
Cerumen obstructing: absent____________present_________________
Tympanic membrane: normal ______________lesions______________
Hearing: normal _____________difficulty ____________
 NOSE:
Shape: symmetry ________ asymmetry_______
Lesions: none_____ yes ____________ if yes description___________
Polyps: none _________ yes ____________ if yes description_____________
Colour: normal _________pale______flaring___________cyanosed_______
Swelling:none______yes________if yes description_____________
Discharge:absent________exudates_________bleeding________
Septum: intact___________deviated_____Perforated________
Sinuses:
Frontal sinus: normal_______tender _________________
Transilluminates: yes __ no ___
Maxillary sinus:normal____________tender__________
Transilluminates: yes __________ no ____________

 MOUTH:
Lips and buccal mucosa : normal ______ pallor __________ cyanosed_____
Ulcerated_________cracked____________ Bleeding________
angular stomatitis_____ Moist_________ dry____________
Teeth: 32 adult teeth ____________missing teeth __________
discoloration________ dental caries ____________
 Gums: normal ____________ gingivitis________ gum bleeding _______
Tongue: normal _________ pale ___________ ulcerated____________ coated
______________ cyanosed _____________
Uvula: normal __________ discoloured ______________swollen_____________

 NECK:
Movement: normal _________ tremor___________ stiffness_______
Lymphnode: normal _____________enlarged____________
Thyroid gland: normal _____________ enlarged___________
Trachea: midline_________ deviated____________
 CHEST:
Size: symmetry___________asymmetry_____
Shape: normal__________barrel chest____pigeon chest________
Funnel chest________ kyphoscoliosiosis_____________
Breathing movement: normal _______ use of accessory muscle __________
Intercostal retractions________substernal retractions____

Position of comfort: supine_lateral _________orthopneic_________

Tripod___________paradoxical movement__
Respirations: eupnea___________ bradypnea________tachypnea_______
Hypernoea________ anea___- cheyne stokes___
Kussumauls_________- biots_____
Tendernes: none ___ yes______ if yes description______________
Masses: none____________yes________if yes description______
Breast: symmetry__-asymmetry_______
Tenderness_________ mass _________ discharge________
Gynecomastia_________
Respiratory excursion:
Anterior chest: symmetry___________asymmetry __________
If yes description______________
posterior chest: symmetry___________asymmetry __________
If yes description______________
Voice sounds:
Normal______ bronchophony___________egophony_____
Whispered pectoroiloquy______________
Heart sounds:
S1_____S2_____ murmers______gallop sounds _____________
 ABDOMEN:
Size: symmetry______________ asymmetry____________
Shape: normal _____________ distended____________
Colour: normal ____________ discolouration__________scars____
 Striae_________cullens sign_____________turner sign ___________
Bowel sounds: normal __ increased ____decreased____________
Absent_______________
Liver: normal _________enlarged__________tenderness______________
 EXTREMITIES:
Hands: symmetry_____________asymmetry__________
Deformity___________tenderness_____________swelling___________
Tremors____________contractures_______________
Nails:normal_______________spoon shaped_______paronychia________
Cyanosis___ early clubbing_____________late clubbing_____________
Capillary refilling time <3sec_______ >3sec_________
Legs: symmetry____asymmetry______
Bow legs___talipes equinovarus____________
Talipes equinovalgus_____________contractures____________
Hip disclocation___________ varicose veins______________
 RECTUM:
Lesions____________ Hemorrhoids ______________
Fistula_________________Rectal Bleeding____________________
 ANUS:
Anal Fissures _______ Bleeding____________Discharges_______________

DIAGNOSTIC EVALUATIONS
DATE TEST RESULT NORMAL VALUES REMARKS
NURSING DIAGNOSIS
 THEORY APPLICATION

Reason for theory application: