11 (A) - Neurological Assessment

Neurological Assessment
Presented By:
Noor Ul Haq
Clinical Nursing Instructor
RCN
Objective
By the end of the unit, learners will be able to
 Perform mental status examination of a client.
 Assess cranial nerve, sensory, sense of proprioception
and cerebellar functions and deep tendon reflexes.
 Document findings.
 List the changes in the nervous system that are
characteristics of the aging process
8/26/20 (Neurological Assessment || By : NooR 2

Structure and Function
Neurological system (CNS) Consists of two structures
1. Central Nervous system
2. Peripheral Nervous system

Central Nervous System
 CNS encompasses the brain and spinal cord
 Covered by meninges
 Three layers of connective tissues for protection and
nourishment
 Subarachnoid space surrounds the brain and spinal cord (
cerebrospinal fluid)
 The fluid filled space cushions the brain and spinal cord

Brain
Located in the cranial cavity and has 3 major divisions
1. Fore Brain (Cerebrum & Diencephalon)
2. Mid brain
3. Hind Brain (Cerebellum, Medulla oblongata and Pons)
OR
1) Cerebrum
2) Diencephalon
3) Brain stem
4) Cerebellum

1: Cerebrum
 Cerebrum divided into the right and left cerebral
hemisphere ( joined by the corpus callosum).
 Each hemisphere sends and receives impulses from the

opposite sides of the body.
 Each hemisphere consists of four lobes ( frontal, parietal,

temporal, and occipital).

Lobes of the Cerebral Hemisphere and
their Function
 Frontal
Direct skeletal actions, communication, emotions,

intellect, reasoning ability, judgment, and behavior.
Contains Broca’s area (speech)

 Parietal
Interprets tactile sensation including, touch, pain,

temperature, shapes and two point discrimination.

Cont.
 Occipital
Influences the ability to read and understand and is the

primary visual receptor center
 Temporal
Responsible for interpreting an auditory stimuli

(auditory center)

2: Diencephalon
 The diencephalon lies beneath the cerebral hemispheres and
consists of the thalamus and hypothalamus.
 Thalamus : Responsible for screening and directing the

impulses to specific areas in the cerebral cortex.
 Hypothalamus: Responsible for water balance, appetite,

vital sign, sleep cycles, pain perception , and emotion status.

3: Brain Stem
 Located between the cerebrum and the spinal cord.
 Consists of 03 parts (midbrain, pons, and medulla
oblongata)
Midbrain: Relay center for eyes and ear reflexes
Pons: Links the cerebellum to the cerebrum and the midbrain

to the medulla
Medulla oblongata : it control and regulate respiratory

function, heart rate and blood pressure

4: Cerebellum
The cerebellum located behind the brain stem and under
the cerebrum
 Coordination and smoothing of voluntary movement
 Maintenance of equilibrium

Spinal cord
 The spinal cord is located in the vertebral canal and extends
from the medulla oblongata to the first/second lumbar vertebra.
 The spinal cord conducts sensory impulses up, ascending tracts
to the brain.
 Conducts motor impulses down, descending tracts to neurons
that stimuli glands and muscles throughout the body
 Simple reflex activity:
Sensory neurons (afferent)
Motor neurons (efferent)

Peripheral Nervous System
 Carrying information to and from the CNS

 Consists of 12 pairs of cranial nerves and 31 pairs of spinal
nerves
 These nerves are categorized as 02 kinds of fibers
1. (Somatic) Carry CNS impulses to voluntary skeletal

muscles
2. (Autonomic) Carry CNS impulses to smooth involuntary

muscles ( in the heart and glands)
Spinal Nerves
Comprising 31 pairs of spinal nerves
◦ 08 cervical,
◦ 12 thoracic,
◦ 5 lumber,
◦ 5 sacral and
◦ 1 coccygeal nerves.

Autonomic Nervous System
 The autonomic nervous system maintains the internal
homeostatic of the body, consist of sympathetic and
parasympathetic nervous system.
 The sympathetic nervous system is activated during stress
and produce responses such as decreased increased pulse rate,
and pupil dilation.
 The parasympathetic nervous system functions to restore
and maintain normal body functions.

Indications of Neurological Assessment
 If the person has any of the following complaints:
◦ Headaches & Blurry vision
◦ Change in behavior
◦ Fatigue & Weakness
◦ Change in balance or coordination
◦ Numbness, tingling or Decrease movement in the

extremities
◦ Injury to the head, neck, or back
◦ Seizures/Tremors.
Cont.…
 Patient suffering under disease such as:
◦ Meningitis
◦ Brain tumor
◦ Unconscious patient
◦ Tetanus
◦ Coma
Ali M Clinical methods in medicine 2015

Neurological Assessment
History:
Present health concern
Do you experience
1. Numbness, tingling, or loss of feeling
2. Difficulty with speaking, vision, or hearing
3. Any physical disability
4. Problems with coordination and balance
5. Change in ability to remember
6. Shakiness or tremors of the hands or legs
7. Presence of anxiety or depression
8. Seizures
9. Difficulty with swallowing

Past Health History
Have you ever had
1. Head Injury
2. Loss of consciousness
3. Auto accident
4. Physical or mental changes
5. Seizures
6. Fainting
7. Headaches
Family history
Do you have family history of
1. High blood pressure
2. Stroke
3. Epilepsy
4. Brain cancer

Equipments
1. Gloves 1. Tongue depressor

2. Pencil paper 2. Tuning fork
3. Snellen chart and
Newsprint
4. Ophthalmoscope
5. Paper clip
6. Penlight
7. Cotton balls

Components of Mental Status
Examination
 Consciousness & Orientation

 Language
 Mood and Affect

 Memory
 Thought Process & Perceptions
Ali M Clinical methods in medicine 2015.

Consciousness & Orientation
 Level of Consciousness:
◦ Alert
◦ Lethargic
◦ Obtunded
◦ Stupor
◦ Coma
 Orientation:
◦ Time, place, person

Glasgow Coma Scale
 Created in 1974 by Jennett & Teasdale consciousness
 Made up of 3 components
 Eye opening
 Motor response
 Verbal response to assess a patient’s level of
 A score of 15 denotes 8 denotes a coma a fully conscious
patient,
 Lowest score possible is 3.
 For a more accurate hand over, score should be
communicated in three components.E, V, M
(Ellen B, (1994)Neurological Assessment 13

Speech and Language
 Quantity/Quality
 Rate
 Loudness/Volume
 Articulation of Words(dysarthria, aphasia)

 Fluency(hesitancies, stammering, circumlocutions , Par
aphasias,)
Mood
 Mood(euphoria, angry, tense, irritable)
 Affect
Thoughts and Perceptions
 Thought Processes(Logic , relevance, organization , Speech
progressing towards a logical goal, Flight of Ideas,
Neologisms, Echolalia)
 Cognitive Function
◦ Memory
◦ Information
◦ Vocabulary
◦ Orientation(time, place, person )
◦ Attention
Cranial Nerves Assessment

Cranial Nerves
CN Name Type Function
I Olfactory Sensory Sense of smell

Carries smell impulses from nasal mucosa to brain
II Optic Sensory Visual acuity

Carries visual impulses from eye to brain
III Oculomotor Motor Eye movement.

Pupil constriction and dilation.
Contracts eye muscles to control eye movement, constricts pupils
IV Trochlear Motor Upward and

downward movement
of eyeball
V Trigeminal Sensory carries sensory impulses of pain, touch and temperature from the face
and to brain
motor Influences clenching and lateral jaw movements ( biting and chewing)
VI Abducens Motor Controls lateral movement of

eyeballs.
34 (Neurological Assessment || By : NooR

Cranial Nerve (contd..)
CN Name Type Function
VII Facial Sensory Facial expression and Taste

and contains sensory fibers for taste and stimulates secretions
motor from salivary glands
Supplies the facial muscles and affects facial expressions
(smiling, frowning)
VIII Auditory Sensory Hearing

(Acoustic) Contains sensory fibers for hearing and balance
IX Glassopharyngeal Sensory Taste , Ability to swallow

and Contains sensory fibers for taste and sensory fibers of the
moto pharynx that result in the gag reflex when stimulate
r Promotes swallowing movements
X Vagus Sensory Carries sensations from the throat
and Promotes swallowing, talking
motor
XI Spinal Motor promote movements of the shoulders and head rotation

accessory
XII Hypoglossal Motor Innervates tongue muscles that promote the movement of
tongue
(Neurological
35 Assessment || By : NooR
Cranial Nerves
1 Olfactory OH Sensory Some
2 Optic OH Sensory Say
3 Oculomotor OH Motor Marry
4 Trochlear Try Motor Money
5 Trigeminal To Both But
6 Abducens Administer Motor My
7 Facial Full Both Brother
8 vestibulocochlear Very Sensory Says
9 Glossopharyngeal good Both Bad
10 Vagus Vaccine Both Boys
11 accessory at Motor Marry
12 Hypoglossal Hip Motor Money

(Neurological
36 Assessment || By : NooR
Cranial Nerve I -Olfactory Nerve
 Before testing nerve function, ensure patency of each
nostril by occluding in turn and asking patient to sniff
 Once patency is established, ask patient to close eyes
 Occlude one nostril and hold aromatic substance
(coffee) beneath nose
 Ask patient to identify substance
 Repeat with other nostril
 Normal:
 Patient is able to identify substance
 Abnormal:
 Anosmia-loss of sense of smell.

Cranial Nerve II -Optic Nerve
 To assess Optic nerve we assess the following:
 Visual field –confrontation test
 Visual acuity
◦ -Use the Snellen chart for distance vision
◦ -Rosenbumcard for near vision

Cranial Nerves III, IV and VI
 (Occulamotor , Trochlear, Abducens )
 Assess these nerves together using the corneal light
reflex test using direct & consensual pupillary reaction
to light
 Six cardinal positions of gaze.

CN- V -Trigeminal Nerve
 A . Testing Motor Function:
 Ask patient to move jaw from side to side against
resistance and then clench jawas you palpate contraction
of temporal and masseter muscles.

B. Testing sensory function:
 -Ask patient to close eyes
 -Touch the face with the wisp of cotton
 -Instruct to tell you when he or she feels sensation on
the face.
 -Repeat the test using sharp and dull stimuli (tooth pick
or tongue blade)
 -Instruct to say “Sharp” or “Dull”

C. Testing Corneal Reflex:
 Gently touch cornea with cotton wisp.
 Touching cornea can cause irritation .
 Alternative approach is to: puff air across
 Cornea with a needless syringe, or gently touch eyelash
and look for blink reflex

Cranial Nerve VII -Facial Nerve
 A . Testing Motor Function:

 Ask patient to perform these movements:
◦ smile, frown, raise eyebrows, show upper teeth, show lower
teeth, puff out cheeks, purse lips, close eyes tightly while nurse
tries to open them.

B. Testing Sensory Function:
 Test taste on anterior two-thirds of tongue for sweet,
sour, salty.
 Sweet: Tip of the tongue
 Sour: Sides of back half of tongue
 Salty: Anterior sides and tip of tongue
 Bitter: Back of tongue.

Cranial Nerve VIII-Acoustic
Nerve
 a. Perform Weber and Rinne tests
 b. Perform watch-tick test
 c. Perform Romberg test for balance.

Cranial Nerves IX and X
Glossopharyngeal & Vagus Nerves
• A .Observe ability to cough, swallow, and talk.
B .Test motor function:
 Ask patient to open mouth and say “ah” while you
depress the tongue with a tongue blade.
 Observe soft palate and uvula. Soft palate and uvula
should rise medially.

C .Test sensory function of CN IX and motor
function of CN X by stimulating gag reflex.
 Tell patient that you are going to touch interior throat

 Then lightly touch tip of tongue blade to posterior
pharyngeal wall.
 Observe the pharyngeal movement.
 Ask the client to drink a small amount of water
 *Note the ease & difficulty of swallowing
 *Note quality of the voice or hoarseness.

CN XI -Spinal Accessory Nerve
 Test motor function of shoulder and neck muscles:
 Ask patient to shrug shoulders upward against your
resistance. (Trapeze muscle)
 Then ask her or him to turn head from side to side
against your resistance. (Streno-claiodo-mastoid muscle)
 Observe for symmetry of contraction and muscle
strength.

CN XII –Hypoglossal Nerve
 Have patient say “d, l, n, t” or a phrase
containing these letters.

 The ability to say these letters requires use of the tongue.
 Ask the patient to protrude the tongue.
 Observe any deviation from midline, tumors, lesions, or
atrophy.
 Now ask the patient to move the Tongue from side to side.

Cont.………..

11 (A) - Neurological Assessment

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Neurological Assessment

8/26/20 (Neurological Assessment || By : NooR 2

1. Central Nervous system

2. Peripheral Nervous system

8/26/20 (Neurological Assessment || By : NooR 4

8/26/20 (Neurological Assessment || By : NooR 5

3. Hind Brain (Cerebellum, Medulla oblongata and Pons)

8/26/20 (Neurological Assessment || By : NooR 6

 Each hemisphere sends and receives impulses from the

 Each hemisphere consists of four lobes ( frontal, parietal,

8/26/20 (Neurological Assessment || By : NooR 8

Direct skeletal actions, communication, emotions,

Contains Broca’s area (speech)

Interprets tactile sensation including, touch, pain,

8/26/20 (Neurological Assessment || By : NooR 9

Influences the ability to read and understand and is the

Responsible for interpreting an auditory stimuli

8/26/20 (Neurological Assessment || By : NooR 10

 Thalamus : Responsible for screening and directing the

 Hypothalamus: Responsible for water balance, appetite,

8/26/20 (Neurological Assessment || By : NooR 11

Midbrain: Relay center for eyes and ear reflexes

Pons: Links the cerebellum to the cerebrum and the midbrain

Medulla oblongata : it control and regulate respiratory

8/26/20 (Neurological Assessment || By : NooR 12

8/26/20 (Neurological Assessment || By : NooR 13

Motor neurons (efferent)

 Carrying information to and from the CNS

1. (Somatic) Carry CNS impulses to voluntary skeletal

2. (Autonomic) Carry CNS impulses to smooth involuntary

8/26/20 (Neurological Assessment || By : NooR 17

8/26/20 (Neurological Assessment || By : NooR 18

 If the person has any of the following complaints:

◦ Headaches & Blurry vision

◦ Fatigue & Weakness

◦ Change in balance or coordination

◦ Numbness, tingling or Decrease movement in the

◦ Injury to the head, neck, or back

Ali M Clinical methods in medicine 2015

8/26/20 (Neurological Assessment || By : NooR 20

8/26/20 (Neurological Assessment || By : NooR 21

Have you ever had

4. Physical or mental changes

Do you have family history of

1. High blood pressure

8/26/20 (Neurological Assessment || By : NooR 23

1. Gloves 1. Tongue depressor

8/26/20 (Neurological Assessment || By : NooR 24

 Consciousness & Orientation

 Mood and Affect

 Thought Process & Perceptions

Ali M Clinical methods in medicine 2015.

8/26/20 (Neurological Assessment || By : NooR 26

◦ Time, place, person

8/26/20 (Neurological Assessment || By : NooR 27

(Ellen B, (1994)Neurological Assessment 13

 Articulation of Words(dysarthria, aphasia)

◦ Orientation(time, place, person )

8/26/20 (Neurological Assessment || By : NooR 33

I Olfactory Sensory Sense of smell

II Optic Sensory Visual acuity

III Oculomotor Motor Eye movement.