Chapter 22: Assessing the Neurological
What You Will Learn
• Using inspection, auscultation, and palpation to assess the
Author: Key Terms
Nancy M. Birtley, APRN, BC,
Affect — The emotional reaction associated with an experience
Mental Health Clinical Nurse Hallucination — A false perception having no relation to reality and not
Specialist, Psychiatric Care and accounted for by any exterior stimuli
St. Louis, MO Delusion — False belief brought about without appropriate external
stimulation and inconsistent with the individual’s own knowledge and
Illusion — A misinterpretation of sensory impressions
Contracture — Permanent contraction of a muscle due to spasm or
Cogwheel Rigidity — Muscles responding with cogwheel-like jerks to the
use of force in bending the limb
Because the nervous system is the control center of the body, impair-
ment, injury, or illness affecting the nervous system has great impact on
all of the other body systems. Likewise, concerns in other systems of the
body can also affect the nervous system.
Chronic illnesses, such as heart When assessing the nervous system, it is important to review the resi-
disease, hypertension, diabetes, dent’s past history. Chronic illnesses can impact the function of the
cancer, and COPD, can impact the nervous system as can infections, surgeries, and prior injuries. Be aware
function of the nervous system. of medications that individually or in combination impact how the ner-
vous system functions. Sedatives, narcotics, and psychiatric drugs are
just a few classes of drugs affecting the nervous system. Over-the-
counter drugs (e.g., antihistamines) can have as much of a negative im-
pact on the nervous system as prescription drugs.
The following symptoms warrant further assessment of the nervous
• General behavior change
• Mood change
• Loss of consciousness
• Anxiety or nervousness
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• Speech problems
• Memory deficits
• Motor problems
• Sensory problems
The resident with a neurological
problem may be unaware of the The following reviews a neurological examination using observation (in-
condition or symptoms. Therefore, spection), listening (auscultation), and palpation as they relate to the ner-
it is helpful to elicit information vous system. The first section covers the mental status examination, which
from a significant other as to symp- provides important information about the resident’s overall functioning as
toms and changes in behavior. well as one’s ability to adapt to one’s environment.
Observation (Inspection): The Mental Status Examination
Begin by observing the person’s level of consciousness? Is the resident
alert and awake, or drowsy, lethargic, or unresponsive? Assess the person’s
appearance and grooming. For example, is she dressed appropriately for
the situation or weather/season? Are there layers of clothing or parts of
clothing missing? Is there any body odor? Pay special attention to make-
up, accessories, style of dress. Is she extravagantly dressed with excessive
makeup and accessories?
Note the person’s overall mood. For example, does he laugh or joke appro-
priately for the situation? Is he on the verge of tears or crying? Is he angry
or irritable? Ask questions which may elicit feelings. For example, “How
do you feel about being here?” or “Tell me about your family.” Observe
the person’s facial expression or affect. Is the affect congruent with the
topic of discussion? For example, if the person is speaking of his wife’s
death, you would expect the affect to be sad. Some individuals may have
a blunted or flat affect which shows no emotion. Neurological disorders
may result in an inability of the facial muscles to smile or frown, among
The term “mood” refers to what Watch the person walk. Note the posture and balance. Is the resident
the person is feeling and is sub- leaning, shuffling, or dragging a foot? Are there any involuntary move-
jective. The term “affect” refers ments, such as jerking, facial ticking, foot tapping, pelvic thrusting, rock-
to what the observer sees and is
ing, pill-rolling of the fingers, puffing of the cheeks, or tongue thrusting?
Describe any tremors or restlessness of the limbs. Does the speed of
movement appear normal, slow, or fast?
Assessing memory, intellect, insight, and judgment may also be included
in observation. Memory can be difficult to assess as many residents are
able to cover confusion in a superficial conversation. By asking questions
specific to orientation to time, place, and person, the nurse can get a
better idea of the person’s memory. Ask about the month, date, day, year,
season, city, state, facility, or address. Engage the person in a conversation
about current events that are well known and publicized, such as a presi-
dential election or a current war. The nurse can add to memory assess-
ment by asking for the names of the last three presidents.
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Short-term memory can be assessed by asking the person to remember
three, unrelated objects five minutes after they were introduced. For
example, tell the person you are going to ask them to remember three
things: dog, key, and banana. Ask the person to repeat the items. When
five minutes have passed, ask about the three items to remember. Short-
term memory can also be assessed by asking the person what they ate at
the last meal, provided the nurse is aware of what the resident actually ate.
Long-term memory involves distant past. For example, does the person
remember how many siblings he had or if his parents are still living?
Assessing long-term memory may require the assistance of a significant
other who can confirm or deny the answers.
Intellect can be observed by listening to the person’s vocabulary and
grammar. Asking about education and work experience may help to
quantify intellect. For example, ask the person if she is familiar with her
medical diagnoses and medications. Do her goals correlate with her physi-
cal and mental capabilities? Can she count backwards from 100 by 7 at
a time? Can she spell “world” forwards and backwards? Abstract think-
ing is another component of intellect. Is the resident able to interpret the
meaning of the proverbs, “A stitch in time saves nine,” or, “A rolling stone
gathers no moss”? The proverb, “A stitch in time saves nine,” means that if
a job needs to be done, it is best to do now because it will only get more
difficult later. The proverb, “A rolling stone gathers no moss,” means that
people who are always moving, with no roots in one place, tend to avoid
responsibilities and cares. If the resident explains the proverbs literally,
such as, “If you put in one stitch, you won’t need to do the rest of them,”
this answer indicates difficulty with abstract thinking.
In some settings, it may be helpful to ask the person’s significant other
about the resident’s ability to plan a meal, balance a checkbook, and pay
Hallucinations may be visual, audi- Thought content is another component of the mental status examina-
tory, olfactory, gustatory, or tactile. tion that can be observed. Note hallucinations, delusions and illusions.
Some residents may experience paranoid delusions that people are talking
about and against or trying to harm them. Grandiose delusions involve an
inflated sense of self importance. A resident who is experiencing grandi-
ose delusions may, for example, believe himself to be rich and influential.
Somatic delusions may result in believing one has a terrible illness. An
illusion is misinterpretation of a real stimulus. There is a difference be-
tween an illusion and hallucination. Looking at a white wall and seeing
roaches is hallucinating. Looking at a white wall with large black scuffs
and seeing those scuffs as roaches indicates that the resident is experi-
encing an illusion. Thought content may also involve obsessions, somatic
complaints, excessive guilt, blame, hyper-sexuality, and hyper-religiosity.
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We assess the nervous system through auscultation by listening to the
person’s voice quality and articulation. Some neurological disorders make
it difficult to speak loudly enough for others to hear. In addition, the abil-
ity to form words clearly can be compromised by a neurological disorder
because the nerves that control tongue and mouth movement are affected.
Is the speech mumbled, stuttered, or incoherent? Does the resident have
difficulty coming up with the correct term?
Listen to the resident’s flow of thought. For example, does he give exces-
sive, unnecessary details (circumstantiality)? Does he digress from the
topic (tangentiality)? Does his communication use complete sentences,
or is it full of meaningless, unrelated words (word salad)? Does he express
a series of thoughts that seem distantly or loosely related to one another
(loose association)? Is his speech a nearly continuous flow, jumping from
topic to topic (flight of ideas)?
Muscle tone and strength are greatly affected by the nervous system. It is
helpful to assess hand grips to determine if the grips are equal. Have the
person squeeze the first and second fingers of the nurse’s hands. Are the
hand grips equal? When the resident makes a muscle with the biceps, is
the nurse able to force the arm to straighten without difficulty? Does the
musculature appear symmetrical? Are the muscles in a particular joint
A contracture is a permanent contraction of a muscle due to spasm or
paralysis. In some situations, muscle rigidity may cause joint resistance.
The nurse can check for this resistance, called cogwheeling, by holding the
resident’s elbow in one hand and bending and straightening the arm with
the other hand. If there is cogwheeling, the nurse will feel a jerking resis-
tance while bending and straightening the arm. When muscles respond
with cogwheel-like jerks to the use of force in bending the limb, it is called
In addition to that listed above, further assessment of the neurological
system may reveal specific weaknesses requiring nursing intervention.
The main purpose of the neurological examination is to identify problems
and develop a plan to help residents cope effectively with self care deficits
during their activities of daily living. The nurse evaluates whether the per-
son can see, eat, speak, feel, move, and eliminate. Is the resident:
• Alert, oriented, and aware of the past and present?
• Emotionally stable and able to understand verbal and written in-
• Able to speak and write?
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• Demonstrating movements that are smooth and coordinated
• Able to smell familiar scents
• Hear sounds of various ranges and volume
• Taste salt, sour and sweet
• Feel sharp, soft, hot and cold
• Able to maintain bowel and bladder function
The human body is a wondrous result of delicate balance and interaction
A deficit in the nervous system between organ systems. While the nervous system is the control center
can change a person’s very exis- of our body, it affects and is affected by all other systems. It maintains
tence and devastate his quality of memories, experiences, and emotions and makes each person a unique
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Chapter 22 Review Questions
Define the following terms: Answer the following multiple-choice questions:
1. Affect — 12. Which of the following is a part of the Mental
2. Cogwheel Rigidity — a. Heart rate
b. Lung sounds
3. Contracture — c. Skin tone
d. Thought content
4. Delusion —
13. Which of the following is a type of
5. Hallucination —
6. Illusion — b. Catatonia
Circle “True” or “False” as appropriate for the d. Disorganized
Complete the following:
7. (True/False) — Past history is insignificant
when assessing the nervous system. 14. List four medications which can have a nega-
tive impact on the nervous system:
8. (True/False) — Chronic illnesses, such as a.
heart disease, hypertension, diabetes, cancer,
and COPD, can impact the function of the b.
nervous system. c.
9. (True/False) — The resident with a neuro-
logical problem may be unaware of the condi- 15. What are two types of memory assessed in
tion or symptoms. the Mental Status Examination?
10. (True/False) — The Mental Status Examina-
tion gives an indication of how the resident
is functioning as a whole and adapting to the 16. How might you assess the resident’s abstract
11. (True/False) — A deficit in the nervous sys-
tem can change a person’s very existence and
devastate quality of life.
17. Describe how to assess for cogwheel rigidity.
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