CORDILLERA CAREER DEVELOPMENT COLLEGE
Buyagan, Poblacion, La Trinidad, Benguet
College of Health Education – BS in Nursing
CCDC VISION CCDC MISSION
The center of quality education for culturally Deliver quality education and services through holistic,
diverse and global learners. accessible, and inclusive learning experiences
sustaining culturally sensitive and responsible global
citizens and leaders.
CHECKLIST: ASSESSMENT OF NEUROLOGIC SYSTEM
NAME: _________________________ _ Date: ___________ Score: ______________
INDICATORS 2 1 0 Remarks
1. Prepare Equipment: Percussion hammer, Wisp of cotton, Pins or
needles, tongue depressors, Substance to smell and taste (Sugar,
coffee, etc.)
2. Introduce self and verify the client. Explain the procedure and
gain consent
3. Perform hand hygiene and Provide privacy
4. Inquire if the client has any history of the following; presence of
pain in the head, back, or extremities, as well as onset and
aggravating and alleviating factors; disorientation to time, place, or
person; speech disorder; history of loss of consciousness, fainting,
convulsions, trauma, tingling or numbness, tremors or tics, limping,
paralysis, uncontrolled muscle movements, loss of memory, mood
swings, or problems with smell, vision, taste, touch, or hearing.
LEVEL OF CONSCIOUSNESS (Glasgow Coma Scale)
5. Assess difficulty of speech Language:
Point to common objects, and ask the client to name them.
Ask the client to read some words and to match the printed
and written words with pictures
6. Orientation: Determine the client’s orientation to time, place, and
person by tactful questioning. Ask the client the time of day, date,
day of the week, duration of illness, city and state of residence, and
names of family members
Memory
7. Assess immediate recall;
Ask the client to repeat a series of three digits, eg. 7-3-2,
spoken slowly.
Gradually increase the number of digits, e.g; 7-4-3-5, 7-4-3-
5-6, and 7-4-3-5-6-7-2, until the client fails to repeat the
series correctly
Start again with a series of three digits, but this time ask the
client to repeat them backward. The average person can
repeat a series of five to eight digits in sequence and four to
six digits in reverse order.
8. Assess recent memory;
Ask the client to recall information given early in the
interview, e.g. name of the doctor
9. To Assess Remote Memory
• Ask the client to describe a previous illness or surgery (e.g., 5
years ago) or a birthday or anniversary. Generally remote memory
will be intact until late in neurologic pathology. It is least useful in
assessing acute neurologic problems.
ATTENTION SPAN AND CALCULATION
10. Test the ability to concentrate or maintain attention span by
asking the client to recite the alphabet or to count backward from
100.
CRANIAL NERVES
11. Test Cranial nerves (recite the 12 cranial nerves)
REFLEXES
12. Biceps Reflex
“Ask the patient to partially bend the arm at the elbow with palm up.
Place your thumb over the biceps tendon and strike your thumb
with the pointed side of the reflex hammer. Repeat on the other
side”
13. Brachioradialis Reflex
“Ask the client to flex 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 the other side”
14. Triceps Reflex
“As the patient to hang the arm freely while you support it with your
non dominant hand. With the elbow flexed, use the flat side of the
reflex hammer to tap the tendon above the olecranon process.
Repeat on the other side”
15. Patellar Reflex
“Ask the patient to let both legs hang freely of the side of the
examination table. Tap the patellar tendon. Repeat on the other
side
16. Achilles Reflex
“With the patient’s leg hanging freely, dorsiflex the foot. Tap the
Achilles tendon with the reflex hammer. Repeat on the other side
17. Plantar Reflex or Babinski
GROSS MOTOR AND BALANCE TESTS
18. WALKING GAIT Ask the client to walk across the room and
back, and assess the client’s gait
19. ROMBERG TEST Ask the client to stand with feet together and
arms resting at the sides, first with eyes open, then closed. Stand
close during this test.
20. STANDING ON ONE FOOT WITH EYES CLOSED Ask the
client to close the eyes and stand on one foot. Repeat on the other
foot. Stand close to the client during this test.
21. HEEL-TOE WALKING Ask the client to walk a straight line,
placing the heel of one foot directly in front of the toes of the other
foot.
22. TOE OR HEEL WALKING Ask the client to walk several steps
on the toes and then on the heels.
FINE MOTOR TESTS FOR THE UPPER EXTREMITIES
23. FINGER-TO-NOSE TEST Ask the client to abduct and extend
the arms at shoulder height and then rapidly touch the nose
alternately with one index finger and then the other. The client
repeats the test with the eyes closed if the test is performed easily
24. FINGER-TO-NOSE AND TO THE NURSE’S FINGER Ask the
client to touch the nose and then your index finger, held at a
distance of about 45 cm (18 in.), at a rapid and increasing rate.
FINE MOTOR TESTS FOR THE LOWER EXTREMITIES
25. HEEL DOWN OPPOSITE SHIN Ask the client to place the heel
of one foot just below the opposite knee and run the heel down the
shin to the foot. Repeat with the other foot. The client may also use
a sitting position for this test
SENSATION
26. LIGHT-TOUCH SENSATION
Ask the client to close the eyes and to respond by saying
“yes” or “now” whenever the client feels the cotton wisp
touching the skin.
With a wisp of cotton, lightly touch one specific spot and
then the same spot on the other side of the body.
Test areas on the forehead, cheek, hand, lower arm,
abdomen, foot, and lower leg. Check a distal area of the
limb first (i.e., the hand before the arm and the foot before
the leg.
If areas of sensory dysfunction are found, determine the
boundaries of sensation by testing responses about every
2.5 cm (1 in.) in the area. Make a sketch of the sensory loss
area for recording purposes.
27. PAIN SENSATION
Ask the client to close the eyes and to say “sharp,” “dull,” or
“don’t know” when the sharp or dull end of a safety pin is
felt.
Alternately, use the sharp and dull end to lightly prick
designated anatomic areas at random (e.g., hand, forearm,
foot, lower leg, and abdomen). Note: The face is not tested
in this manner
Able to discriminate “sharp” and “dull” sensations
28. STEREOGNOSIS
Place familiar objects such as key, paper clip, coin in the patient’s
hand. Ask the patient to identify it.
29. GRAPHESTHESIA
Write a number or letter on the patient’s palm using a blunt
instrument. Ask the client to identify it.
30. Observe infection control. Perform handwashing.
31. Assist the patient to a comfortable position. Restate some
important finding to the patient
32. Document findings in the client record
TOTAL SCORE 64
STUDENTS SIGNATURE Clinical Instructor
Signature Over Printed Name
