3. PURPOSES
To determine the nervous system dysfunction
To diagnose diseases of the nervous system
To locate disease with in the nervous system
Provides data base of critical information of
neurological functions
Review areas of special considerations
Potential nursing diagnoses may be suggested by
the dysfunction identified
6. APPROACH
Preceded by
General physical examination and
History
Conducted in a systematic, hierarchial,
stepwise approach from the highest level of
functions to the lowest and from general
integrated functions to very specific functions
7. History
Chief complaints:
Onset and frequency,
Precipitating or exacerbating factors,
Associated symptoms
( head ache, dizziness or faintness,
confusion or impaired mental status, balance and gait
disturbances, LOC changes)
8. History……
Current health history:
Haedache, dizziness, numbness, tingling,
seizures,tremors, weakness or paralysis
Evaluate speech, comprehension, reading or
writing skills
Identify interferences with ADLs
Detects impairment of memory and concentration
9. History……
Past health history
Previous major illnesses, recurrent major illness,
accidents or injuries, surgical procedures and
allergies
Health and dietary habits and drug use
12. GENERAL
OBSERVATIONS
The appropriateness of appearance and behavior
in relation to the settings.
Predominant attitude, mood and facial
expressions
Flow of speech
Thought processes, content and perceptions
13. TESTING COGNITIVE
FUNCTIONS
Orientations to time, place, and person
Attention and concentration
Memory
Retention and immediate recall
Calculations
Abstract reasoning
Similarities
Judgment
14. SPECIAL CEREBRAL
FUNCTIONS
Recognition- Agnosia.
Ability to recognise familiar objects, sight, sound or
feeling.
Visual agnosia, auditory agnosia, tactile agnosia.
Autopagnosia is the inability to identify body parts or
understanding the relationships of body parts
15. Anosognosia is lack of awareness of
or a denial of a deficit in physical function
( seen in left hemispheric lesions)
16. Neurological exam…….
Cortical motor integration- apraxia
Performing a skilled motor act.
Communication- Aphasia
Inability to communicate
( expressive or broca’s aphasia, reactive or
Wernicke’s global aphasia),
dysphasia, facial muscle paralysis, dysarthria,
dysphonia
18. Olfactory nerve (I)
Sense of smell is tested
Anosmia- inability to smell
Suspected ant. fossa tumor
Foster kennedy syndrome- caused by a tumor or
abscess at the base of the frontal lobe, s/s include
ipsilateral blindness, anosmia, ipsilateral atrophy of
olfactory and optic nerve and contra lateral
papilledema
19. Optic nerve ( II)
Visual acuity
Snellen chart
Visual field
normally extends 60 degrees to the nasal side,
100 degrees on the temporal side and 130 degrees
vertically ( deficit seen in lesions along the visual
path way)
Ophthalmoscopic examination
20. Optic nerve…….
Visual field defects
Blindness of right eye
Bitemporal hemianopsia or loss of half the visual
field
Left homonymous hemianopsia
Left homonymous hemianopsia superior quadrant
21. Optic nerve………
Common visual defects
Scotomas- abnormal blind spots on visual fields
Amblyopia- dim vision
Amaurosis- complete blindness in an eye
Photophobia- sensitivity of the eyes to light
Diplopia- double vision
23. Occulomotor (III), Trochlear(IV) and
Abducent nerves (VI)
Position of eye ball with in the head
Eye movements
Ophthalmoplegia
Dolls eye movement, oculovestibular reflex
Nystagmus – involuntary movement of the eyes
Ptosis
25. Pupilary examination
For assessing occulomotor nerve
Check pupil size, pupil shape and pupillary
response to light
Pupil size may be affected by increased ICP, optic
or oculomotor nerve damage or anisocoria
26. Trigeminal nerve (V)
Sensory component
Comparing each side with respect to sensation( light
and sharp touch) of the patient’s fore head, cheek and
jaw
Motor component
Evaluating the strength of masseter and temporal
muscles by palpating them when jaws are tightly
clamped
Reflexes
Corneal reflex and jaw reflex
27. Trigeminal nerve (V)…..
Abnormal findings
Loss of sensation in forehead, cheek or jaw
Peripheral nerve damage
Severe piercing or stabbing pain one or more facial
dermatomes
Trigeminal neuralgia
Impaired sensory and motor function
Spinal cord lesion
Absent corneal reflex
Peripheral nerve or brain stem damage
28. Facial nerve (VII)
Sensory component
Testing sense of taste on the ant. Two thirds of the
tongue
Motor component
Observing the symmetry of face and facial
movements
30. Acoustic nerve (VIII)
Testing hearing ( Acoustic portion)
Weber test
Rinne test
Nystagmus and disturbed balance(Vestibular
portion)
31. Acoustic nerve (VIII)………….
Abnormal findings
Total hearing loss in sensoryneural hearing loss
Nystagmus and vertigo in disturbances of vestibular
centers
32. Glossopharyngeal(IX) and Vagus
nerves(X)
Assessing voice and gag reflex
The patient is asked to open his or her mouth and
say ‘ ah.’
The palate should elevate when the patient say ah…
The uvula should be checked to see if it deviates to
one side or the other
33. Glossopharyngeal and Vagus…….
Abnormal findings
Impaired swallowing, paroxysmal pain or loss of gag
reflex in glossopharyngeal neuralgia
Vagal damage affect involuntary vital functions
34. Spinal accessory
nerve(XI) Tests patient’s ability to overcome resistance applied to
shoulders
Tests patient’s ability to overcome resistance applied to
his neck while his head is turned
Abnormal findings
Unilateral weakness, atrophy or paralysis of muscles
in peripheral nerve leision
35. Hypoglossal nerve (XII)
Patient’s tongue is elevated to check lateral
deviation, atrophy, fasciculations or spasticity
Assessing the strength of tongue by tongue blade
36. Hypoglossal nerve……………..
Abnormal findings
Unilateral flaccid paralysis of tongue, atrophy of affected
side and deviation in peripheral nerve lesion
Unilateral spastic paralysis produces dysarthria
38. Assessing
Muscle size - wasting. atrophy
Muscle tone – palpating while on rest and on
movement, check for spasticity, rigidity, flacidity,
decortication, decerebration
Muscle strength- upper and lower extremity
39. Motor examination…
Involuntary movement- tremors, tics, spasms,
choreiform movements
Gait – walk back and forth , obseve posture,
movements of body parts, and types of steps
40. Motor exam……..
Abnormal findings
Uncontrollable tics, involuntary tremors, muscle
fasciculations
Hemiparetic, ataxic or steppage gait- indicates
disorders of cerebellum, posterior columns, cortico
spinal tract, basal ganglia and lower motor neurons
42. Superficial sensation
Touch, pain, sensitivity to hot and cold
Deep sensation
Sensitivity to vibration, deep pressure pain, proprioception
Discriminative sensation
Two-point discrimination, point discrimination, recognition of
shape and form. Texture discrimination, graphesthesia,
extension phenomenon
43. Sensory system……
Abnormal findings
Reduced sensory acquity
Sensory deficit
Tingling or dysesthesia
Loss of sense of light touch, vibration or position
Impaired pain or temperature sensation
Peripheral neuropathy
Impaired discriminative sensation
Impaired point localization
44. Cerebellar function
Evaluate patient’s balance and co-ordination
Assess accuracy of action, a staggering gait,
uncordinated movements, tremors
Cerebellar dysfunction produces a wide based,
unsteady gait
45. Cerebellar function…..
Romberg’s test
Observe patient’s balance as he stands with his
eyes open, feet together, and arms at his sides. Then ask
him to close his eyes.
Hold your arms out on either side of him to
protect him if he sways. If he falls to one side the result of
Romberg’s test is positive
46. Cerebellar function…..
Nose to finger test
Test extremity coordination by asking the patient to
touch his nose and then touch your overstretched
finger as you move it. Have him do this faster. His
movements should be accurate and smooth
48. Reflexes
Involves testing deep tendon and superficial
reflexes
Deep tendon reflexes
Biceps reflex ; contraction of biceps
muscle & flexion of forearm
Triceps reflex; contraction of triceps and
extension of fore arm
Brachioradialis reflex: supination of hand
and flexion of forearm at elbow
49. Deep tendon reflexes…
Patellar reflex: contraction of quadriceps
muscle in the thigh with extension of the
leg
Achillis reflex: plantar flexion of foot at
the ankle
53. Babinski’s reflex
Stroking lateral side of patient’s sole from heel to
great toe
The normal response is plantar flexion of the toes
Upward movement of the great toe and fanning of
the little toes – called babinski’s reflex- is
abnormal
