assessment of central nervous system

1. UNIVERSITY OF EASTERN AFRICA, BARATON
SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF NURSSING
NEUROLOGICAL SYSTEM ASSESSMENT
ASSIGNMENT DONE IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE COURSE
NRSG212: HEALTH ASSESSMENT
PRESENTED BY:
GILLIAN JEPTOO
SGILJE2111
INSTRUCTOR:
MRS. EDINA AKURU
DATE DUE:
25TH OCTOBER, 2021

2. Anatomical review
The Central nervous system has 3 major motor pathways:
Corticospinal
It contains motor neuron fibers that originates from the motor cortex, travel to brainstem and
pass down spinal cord. Controls highly skilled voluntary movements.
Extrapyramidal tract
It includes all the motor nerve fibers outside the pyramidal tract. These fibers maintains muscle
tone and control automatic body movements.
Cerebellar system
Coordinate unconscious movements, maintain equilibrium and posture.
Reflex arc
In a simple reflex arc, sensory neurons carry the impulses from receptor through dorsal root and
into spinal cord where they synapse with the motor neurons. From ventral root motor neuron
carry impulse to the muscle which produce the desired reflex.
Motor system exam
If the client is well and has no significant history, perform screening neurological exam. If he
shows signs of neurologic dysfunction, perform a complete neurologic examination. Remember
that the incidence of stroke is two and a half times higher in blacks and whites and the incidence
of Multiple Sclerosis is higher among whites but both disorders affect the motor system.
Muscles
Inspect all muscle groups comparing one side with the other muscle groups. They should have
no atrophy, should be symmetrically bilateral, and within normal limits for the persons age.
Test the strength of the homologous muscles simultaneously. The person should be able to
overcome your resistance.
Test muscle tone. To do this, you should first persuade the person to relax completely, then,
move each extremities smoothly through a full range of motion, providing support at the elbow

3. or knee. Normally you will note a mild even resistance to movement. There should be no
involuntary movement. Ifpresent, note their location, frequency, rate, amplitude and their ability
to be controlled.
Cerebellar function
Begin by assessing the person's balance. To do this, observe his gait as he walk 10 to 20 feet, turn
and come back. Normal gait is smooth, rhythmic and effortless. Also, ask the person to walk a
straight linein aheel to toe fashion(tandem walking)this accentuate any coordination problems.
In normal conditions, the client can walk straight and stay balanced. An older adult gait may be
slower and more deliberate and may deviate from a midline path.
Perform the Romberg test. While standing close to the client, ask him to stand with his feet
together and his arms at his sides and then have him close his eyes and maintain this position for
20 seconds. A normal client can maintain his posture and balance but may sway slightly.
For the final balance test, ask client to do a shallow knee bend or hop in place. First on one leg
and then on the other. This demonstrates normal position sense, muscle strength and cerebellar
function. For further assessment of cerebellar function, evaluate coordination and skilled
movements.
Test rapid alternating movements by asking the person to tap his knees with both hands, lift up,
and turn hands over the back and then ask him to do it faster. The movement should be done
with equal turning and a quick rhythmic pace. Alternatively, ask the person to touch his thumb
to each finger on the same hand starting with the index finger and then reverse direction.
Normally, this can be done quickly and accurately.
Ask the person to perform the finger to finger test. With his eyes open, ask him to use his index
finger to touch your finger. After a few times. Move your fingers to a different spot. His
movement should be smooth and accurate. Ask him to do the finger to nose test. With his eyes
closed and arms outstretched, ask him to touch the tip of his nose with each index finger,
alternating hands and increasing speed. Normally this is done with accurate and smooth
movements.
With the person supine, do the heel to shin test. Ask him to place his heel on the apex of knee
and move it down the sheen from the knee to the ankle. Normally he can move his heel on a
straight-line down the shin.
Reflex examination
For the reflex examination, start by testing the deep tendon reflex in order to elicit and grade
reflexes proper, the following guidelines should be used:
Relax the limb

4. Stretch the muscle
Use hammers pointed end for small targets, and flat end for large targets.
Relax your hold on the hammer.
Strike a short, snappy blow
Do not rest hammer on tendon?
Compare the right and left sides. They should have equal responses.
If the reflex does not appear, encourage further relaxation, vary person’s position or increase the
strength of the blow. Try reinforcement by having the person performance isometric exercise
somewhat away from the one being tested.
Reflex grading
4 + very brisk, hyperactive with clonus.
2 + average or normal
1 + diminished or low-normal
0 no response
When grading reflex on the legs remember that an older adult normally may have decreased
reflexes and may have no Achilles reflex.
Begin reflex testing in the arm with the biceps reflex. Relax the person forearm by supporting it
on yours and then place your thumb on the bicep tendon and strike it. The normal result is
forearm flexion.
Check triceps reflex. Hold the person relaxed upper arm then strike the triceps tendon just above
the elbow. The normal responses is forearm extension.
Alternatively, hold the person's wrist across his chest to flex the arm, then tap the tendon.
Test the brachioradialis reflex. While holding the person arm to suspend and relax the fore arm
strike arm about two to three centimeters above the radiosterloid process. Normal response is
forearm flexion and supination.
Performing reflexes in the legs
Quadriceps reflex
With the lower legs dangling freely strike the tendon just below the patellar. This should elicit
lower leg extension and palpable quadriceps contraction. For a supine person, use your arm to
support the weight of one leg against the other leg and flex the knee. In this position you can
feel the quadriceps contraction.

5. If the clients reflex are hyperactive, perform the clonus test. Normally, clonus (rapid rhythmic
contractions in the foot) should be absent.
1. Superficial reflexes
Begin with abdominal reflex. With the person supine and knees slightly bent, use the handle of
reflex hammer to stroke the abdomen, towards the midline over the upper and lower quadrants.
In response the abdominal muscles should display ipsolateral contraction, and the umbilicus
pointing towards the stroke.
In men, test the cremasteric reflex by slightly stroking inner aspect of his thigh. This should cause
the elevation of the ipsolateral testicle.
2. Planter reflex
Test by stroking up the lateral side of the sole and a cross the ball of the foot. Should see planter
flexion of the toes and slight inversion.
In an infant, plantar reflex cause the toes to turn out. This should disappear at around age two.
Summary
Upon completingyourexaminationof the motorreflexes,answeranyquestionthatclientmayhave.
Teach himaboutrelatedhealthpromotionand self-care tohelpthemstayashealthyaspossible
NEUROLOGICALSYSTEM
The cranial nerves and sensory system monitor all the five senses.The senses of ;sight, hearing,
smell, taste, and touch, as well as the ability to speak and swallow, and perceive temperature
and other sensations.If they don't function properly, a personal can losethe ability to experience
and communicate with the world properly.
Anatomy review
Before examining the cranial nerve and sensory system, consider their anatomy.The nervous
system includes the central nervous system- which consists of the brain and spinal cord and the
peripheral nervous system,-which consists of 31 pairs of spinal nerves, and all their branches, as
well as 12 pairs of cranial nerve.
The cranial nerves enter and exit the brain and primarily innervate head and neck, allowing
sensation, movement and parasympathetic control.
The spinal nerves arise from the spinal cord and supply the rest of the body. These nerves, enter
and exit the cord through roots. Sensory afferent fibers through the posterior or dorsal root and
motor efferent fibers through the anterior or ventral root.
Pain, temperature and crude touch sensations follow of the spinothalamic track. They enter the
dorsal root, synapse and cross to the opposite side, and travel to the thalamus where they
synapse again and carry the sensation to sensory cortex for interpretation.

6. Position, vibration and fine touch sensations, follow the posterior columns. They entered the
dorsal root, move up the spinal cord to the brainstem, where they synapse and crossover, then
travel to the thalamus, synapse again, then travel to the sensory cortex.
During the health history be aware that the neurologic disorder, you're most likely to see is a
cerebrovascular accident or stroke.
While taking the person's history also perform a screening examination of the mental status.
Note level of conscious, orientation, memory, and thought process.
If there are signs of neurologic dysfunction, perform a neurologic examination.
When examining the sensory system follow these guidelines;
Make sure the person is alert cooperative, and comfortable.
Compare the sensations on symmetrical parts of the body.
Map any decrease in sensation by systematic testing in that area.
Keep the persons eyes closed when indicated.
Explain what will happen, and how he should respond.
Avoid asking leading questions.
Cranial nerve examination
If the person has abnormal mental status or suspected intracranial lesions, test cranial nerve I by
assessing his sense of smell.
First, check nostril patency by occluding one at a time and asking him to sniff.
With his eyes closed, occlude one nostril and present a familiar non-noxious aromatic substance
such as vanilla or coffee. Normally the sense of smell is intact and person can identify an odor on
each side of nose.
To test cranial nerve II- To assess visual acuity;
with a handheld vision card at the person’s reading distance about 35 centimeters from the eye
and hold an opaque card over one eye. Test each eye separately. Normally, a person can read
without hesitating or moving the card closer or farther away.
Perform a confrontation test to assess peripheral vision on each quadrant of the eye.
Use an ophthalmoscope to assess the ocular fundus which should display a normal optic disk
innervated by cranial nerve II and retinal vessel background and Macula.

7. Cranial nerves, III, IV and VI mediate eye movement and the oculomotor mediate pupillary
constriction. Use three technique to test these cranial nerves.
Inspect the palpebral fissures, which usually are nearly equal in width. No nystagmus,
Check the pupils, should appear round, regular and equal in size.
Assess extraocular movements by leading person’s eyes through 6 cardinal positions of gaze.
Note parallel tracking of your fingers with both eyes.
When testing extra ocular muscle function in a school aged child reasonable, have the parent
hold her head so that she tracks your movements with her eyes.
To assess motor function of cranial nerve V - Trigerminal nerve;
Assess the muscles of mastication
Palpate the temporalis and mastoid muscle as person clenches and relaxes his teeth. The muscles
should feel equally strong on both sides.
Test the sensory function of cranial nerve V;
With the person's eyes closed, ask himto say now, whenever he feels the touch of the whisk on
his face. Then lightly touch whisk on his forehead, cheek and chin to assess all three divisions of
the nerve.
If the person has abnormal facial sensations or movement.
Test the corneal reflex;
Bring a cotton waistband from the side while he looks forward, and lightly touches the cornea.
Normally, he will blink with both eyes
On testing cranial nerves seven, facial nerve. Begin with motor function.
Note mobility and facial symmetry as person smiles , frowns, shows his teeth, lift his eyebrows.
Test CN VIII by assessing hearing acuity during normal conversations;
Also perform voice test-The person should be able to repeat ‘Yeah’ the word whispered.
Weber test, which he should hear the tuning fork in both ears.
The Rinne test, he should hear the tuning fork sound longer near the ear by air conduction, then
to the mastoid process by bone conduction test the motor function of CN IX and CN X. depressed,
the tongue with the tongue blade, have the person say yaah .The uvula and soft palate should
rise in the midline.

8. Touching the posterior pharyngeal wall with tongue blade to elicit the gag reflex.
Also note that the voice should sound smooth and not strange.
To assess CN XI-examine the sternomastoid and trapezius muscles, they should be equal in size.
Muscle strength testing
Ask the person to turn his head against your resistance at the side of his chin, then ask him to
shrug his shoulders against your resistance. These movements should be equally strong on both
sides.
Finally, assess CN XII, inspect the tongue. It should have no wasting or tremors, then ask the
person to protrude his tongue, which should thrust forward in the midline.
Sensory system examination
To test the sensations mediated by the spinothalamic tract, start with the ability to perceive pain,
using a fractured tongue blade ask the person to close his eyes and say sharp or dull, depending
on the sensation he feels.
Then lightly touch the sharp point or dull end of the tongue blade randomly to his body.
The person should be able to identify each sensation correctly.
If the person's pain sensation is abnormal, test temperature sensation. Fill one test tube with
cold water, and one with hot water. Apply them randomly to his skin. He should be able to
identify the sensations correctly.
To test light touch, ask the person to say now, when you randomly apply a cotton swab to his
arms, forearms, hands, thighs and legs. He should feel light touch.
To test sensations mediated by posterior columns start by testing the ability to feel vibration
using a low pitch tuning fork.
After telling the person to indicate when the vibration starts and stops. Strike the tuning fork on
heel of your hand and hold in space on a bony surface such as the toe and finger he should sense
vibrations on these distal areas and remember that some older adults, normally lose vibration
sensation in the great toe and ankle.
Also test position sense. To prepare the person, have him watch a few trials as you move his
fingers or great toe up and down. Have him close his eyes and tell you which way you moved his
digits.
Normally a person can detect movements, performed tactile discrimination tests or test
scenarios. First, assess stereognosis; the ability to recognize objects by feeling. With a person's
eyes closed, place a familiar object such as a key or paperclip in his hand, and ask him to identify.

9. Graphesthesia ;the ability to read and number trace on the skin. With the person's eyes closed,
use a blunt instrument trace a single number or letter on a palm. Ask him to identify.
Testtwo isthe point discrimination- the ability to detect two simultaneous pricks on skin.
Apply two points of an Open paperclip lightlyto the skin in shorter distances.The person should
feel them normally eight millimeters on the finger body. To do this, ask the person to state how
many sensations he feels, and where he feels like. As you simultaneously touch both sides of his
body at the same point, normally feel both sensations.
Finally, test point location. Tell the person to touch the same spot you touched. Then touch his
skinand withdraw the stimulus promptly. Heshould be ableto point to the location accurately.
Review findings
Upon competing examination, review findings with the client. Teach him on how to maintain
good health of neurological system.