Purpose & Objectives _____________________________________________________________________ 3
Introduction _____________________________________________________________________________ 4
Focused Neurological History _______________________________________________________________ 5
Adult Patient___________________________________________________________________________ 5
Infant, Pediatric, and Aging Considerations _________________________________________________ 6
The Complete Neurologic Exam _____________________________________________________________ 7
Mental Status __________________________________________________________________________ 7
12 Cranial Nerves _______________________________________________________________________ 8
Inspect and Palpate the Motor System_____________________________________________________ 11
Check Cerebellar Function ______________________________________________________________ 12
Assess the Sensory System_______________________________________________________________ 13
Assess the Spinothalmic Tract ___________________________________________________________ 13
Assess Posterior Column Tract___________________________________________________________ 14
Check the Reflexes _____________________________________________________________________ 14
The Neurological Recheck or Abbreviated Neuro Exam ________________________________________ 17
Motor Function________________________________________________________________________ 17
Pupillary Response_____________________________________________________________________ 17
Glasgow Coma Scale ___________________________________________________________________ 18
References ______________________________________________________________________________ 20
Post Test Viewing Instructions _____________________________________________________________ 21
RN.com acknowledges the valuable contributions of…
… Lori Constantine MSN, RN, C-FNP, a nurse of nine years with a broad range of clinical experience. She has
worked as a staff nurse, charge nurse and nurse preceptor on many different medical surgical units including
vascular, neurology, neurosurgery, urology, gynecology, ENT, general medicine, geriatrics, oncology and blood
and marrow transplantation. She received her Bachelors in Nursing in 1994 and a Masters in Nursing in 1998,
both from West Virginia University. Additionally, in 1998, she was certified as a Family Nurse Practitioner.
She has worked in staff development as a Nurse Clinician and Education Specialist since 1999 at West Virginia
University Hospitals, Morgantown, WV.
PURPOSE & OBJECTIVES
The fundamental processes of the brain and nervous system are key to understanding why nurses perform a
focused neurological assessment. If there is a disruption to any of these processes, the whole body suffers. This
course will discuss specific neurological history questions and exam techniques for your adult patient. Physical
exam techniques such as inspection, palpation, percussion, and auscultation will be highlighted. Additionally,
throughout the course, you will learn how alterations in your neurological assessment findings could indicate
potential nervous system abnormalities.
After successful completion of this course, the participant will be able to:
1. Outline a systematic approach to neurological assessment.
2. Discuss history questions which will help you focus your neurological assessment.
3. Describe abnormal neurological assessment findings associated with inspection, auscultation,
percussion, and palpation.
The neurological history and exam allows the examiner to pinpoint various areas of the brain or nervous system
that may be dysfunctional. Specific signs and symptoms manifested by your patient are associated with specific
areas of the brain. Nurses observe for signs and symptoms that may be abnormal and link them to general areas
of the nervous system that may be causing the disturbance. You must also recognize when further neurological
injury is manifesting, intervene appropriately, and notify the physician for a change in plans for the patient.
Integrate the steps of the neurological history with the steps taken during the complete physical examination. It
may not be necessary to perform the entire neurological exam on a patient with no suspicion of neurological
disorders. You should perform a complete, baseline neurological examination on any patient that has verbalized
neurological concerns in their history. Recheck the neuro exam at periodic intervals with any patient that has a
neurological deficit (Agone, et al., 1997; Jarvis, 1996).
The exam and history should be in an orderly, symmetrical
fashion. This way, you will be certain that all areas are
assessed. Each side of the body should be compared with the
other side to detect any abnormalities. When reporting off, it Most healthcare providers
is wise to perform a brief exam with the oncoming nurse at the shorten the term neurologic or
bedside. This ensures the subjectiveness of your exam is not neurological to “neuro”. We
misinterpreted by the next examiner. It allows for baseline will do the same in this course.
neurological status to be ascertained at the beginning of each
shift. Also, when a change in neurological function is
experienced by the patient it is more easily identified.
FOCUSED NEUROLOGICAL HISTORY
When your patient is conscious, you can ask the patient the following history questions. If they are not
conscious, sometimes a family member or friend can provide some of this information. Their past medical
records may also provide some answers to the following questions as well.
When assessing the nervous system with your adult patient, ASK the following:
Any past history of head injury? (location, loss of consciousness) This
question may give you clues to underlying neurological damage that may
change your patient’s baseline.
Do you have frequent or severe headaches? (when, where, how often)
Pain is a neurologic phenomenon. Most patients do not complain of
pain in the neurological history. Their complaints of pain are mentioned
more in association with an extremity, back, or head assessment.
Any dizziness or vertigo? (frequency, precipitating factors, gradual or
sudden) Syncope is a sudden lack of strength, a sudden loss of
consciousness usually due to a lack of cerebral blood flow. It is also
known as fainting. Vertigo is experienced as a rotational spinning. It is
usually due to neurological disorder or an inner ear disturbance.
Ever had/or do you have seizures? (when did they start, frequency, course and duration, motor activity
associated with, associated signs, post-ictal phase, precipitating factors, medications, coping strategies) Seizures
typically occur in disorders such as epilepsy. Often, the patient will describe an aura; an auditory, visual, or
motor warning of the impending seizure.
Any difficulty swallowing? (solids or liquids, excessive saliva) Difficult swallowing may clue you in to a
possible abnormality with cranial nerves IX and X.
Any difficulty speaking? (forming words or actually saying what you intended) If the patient answers yes to this
question, then ask when it was first noticed and how long did it last. These questions may clue you in to
potential transischemic attacks (TIA’s), which may be a warning signal for impending stroke.
Do you have any coordination problems? (describe) Muscle tone and strength may be affected by both
peripheral and central abnormalities.
Do you have any numbness or tingling? (describe) Any abnormal sensations such as numbness or tingling may
be referred to as parasthesias.
Any significant past neurologic history? (CVA, spinal cord injuries, neurologic infections, congenital disorders)
Specific neurological infections include meningitis and encephalitis.
Environmental or occupational hazards? (If so, explain type, length, and nature of exposure) Exposure to
insecticides, lead, organic solvents, drugs, and alcohol may all manifest in neurological symptoms.
Infant, Pediatric, and Aging Considerations
Additional history questions you may wish to ask regarding your infant, pediatric, or aging patients are listed in
the table below:
Additional History for Infants Additional History for Additional History for Elderly
Did the mother have any health Does the child have any balance Any problems with dizziness? If
problems during pregnancy? problems? Any unexplained so when does it occur?
falling? Muscle weakness?
Difficulty getting up and down
Tell me about the baby’s birth? Does the child have any seizures? Any decrease in memory or
Premature or term? Birth Describe the circumstances change in mental functioning?
weight? Apnea? APGAR around which they occurred.
Any congenital defects? Did motor and development Any tremors in your hands or
milestones occur during the face?
appropriate age range?
Are sucking and swallowing Has your child had any Any sudden vision changes or
coordinated? environmental exposure to lead? sudden blindness?
Does baby turn his head toward Any learning problems in school? Any sudden weakness on one
touch? side of the body and not the
Does baby startle with a loud Any family history of Ever experience loss of
noise? neurological disorders? consciousness?
THE COMPLETE NEUROLOGIC EXAM
Integrate the steps of the neurological history with the steps taken during the complete examination. It may not
be necessary to perform the entire neuro exam on a patient with no suspicion of neuro disorders. You should
perform a complete baseline neurological examination on any patient that has verbalized neuro concerns in their
history. Recheck the neuro exam at periodic intervals with any patient that has a neuro deficit (Agone, et al.,
1997; Jarvis, 1996).
When performing the complete neuro exam, EXAMINE the following:
The mental status portion of the examination is a series of detailed but
simple questions designed to test cognitive ability including: the
patient's awareness and responsiveness to the environment and the
senses, appearance and general behavior, mood, content of thought, and
orientation with reference to time, place, and person.
Most nurses will not perform a detailed mental status exam. Therefore, assessing key parts of the
aforementioned will be sufficient for most nurses to ascertain accurate mental status in their patients.
Specifically nurses should establish if their patient is oriented to person, place, and time. Additionally,
determine if your patient is alert. If not, what does it take to get them alert - calling their name, light touch,
vigorous touch, pain? Verbal response to your questions should also be noted.
Nurses should know that many neurological diseases, such as dementia, cause changes in intellectual status or
emotional responsiveness, and specific personality features. If other parts of the neurological exam are normal,
and you still feel the patient’s neurological status is impaired, a neurological consult to complete a full mental
status exam may be warranted.
12 Cranial Nerves
The cranial nerves arise directly from the central nervous system. Most often, a neurological problem is
detected through the assessment of these nerves. The cranial nerves are composed of twelve pairs of nerves that
stem from the nervous tissue of the brain. Some nerves have only a sensory component, some only a motor
component, and some both. The motor components of cranial nerves transmit nerve impulses from the brain to
target tissue outside of the brain. Sensory components transmit nerve impulses from sensory organs to the brain.
A summary of the functions of the cranial nerves is listed in the table below.
Cranial Nerve Major Functions
Cranial Nerve I: Olfactory Sensory Smell
Cranial Nerve II: Optic Sensory Vision
Cranial Nerve III: Oculomotor Sensory and Motor – Eyelid and eyeball movement
Cranial Nerve IV: Trochlear Sensory and Motor – Innervates superior oblique
Primarily Motor eye muscle
Turns eye downward and
Cranial Nerve V: Trigeminal Sensory and Motor Chewing
Face and mouth touch and
Cranial Nerve VI: Abducens Sensory and Motor – Turns eye laterally
Primarily Motor Proprioception (sensory
awareness of part of the body)
Cranial Nerve VII: Facial Sensory and Motor Controls most facial
Secretion of tears and saliva
Cranial Nerve VIII: Vestibulocochlear Sensory Hearing
(auditory) Equilibrium sensation
Cranial Nerve IX: Glossopharyngeal Sensory and Motor Taste
Senses carotid blood pressure
Muscle sense –
awareness of the body
Cranial Nerve X: Vagus Sensory and Motor Senses aortic blood pressure
Slows heart rate
Stimulates digestive organs
Cranial Nerve XI: Spinal Accessory Sensory and Motor – Controls trapezius and
Primarily Motor sternocleidomastoid
Muscle sense - proprioception
Cranial Nerve XII: Hypoglossal Sensory and Motor – Controls tongue movements
Primarily Motor Muscle sense - proprioception
When testing the cranial nerves, follow the following guidelines for each cranial nerve.
Cranial Nerve I: Olfactory
Evaluate the patency of the nasal passages bilaterally by asking the patient to breathe in through their nose while
the examiner occludes one nostril at a time. Once patency is established, ask the patient to close their eyes.
Occlude one nostril, and place a small bar of soap or other familiar smell near the patent nostril and ask the
patient to smell the object and report what it is. Making certain the patient's eyes remain closed. Switch nostrils
and repeat. Furthermore, ask the patient to compare the strength of the smell in each nostril. Very little
localizing information can be obtained from testing the sense of smell. This part of the exam is often omitted,
unless there is a reported history suggesting head trauma or toxic inhalation.
Cranial Nerve II: Optic
First test visual acuity by using a pocket visual acuity chart. Perform this part of the examination in a well lit
room and make certain that if the patient wears glasses, they are wearing them during the exam. Hold the chart
14 inches from the patient's face, and ask the patient to cover one of their eyes completely with their hand and
read the lowest line on the chart possible. Have them repeat the test covering the opposite eye. If the patient has
difficulty reading a selected line, ask them to read the one above. Note the visual acuity for each eye.
Next evaluate the visual fields via confrontation. Face the patient about one foot away, at eye level. Tell the
patient to cover their right eye with their right hand and look the examiner in the eyes. Instruct the patient to
remain looking you in the eyes and have the patient indicate when the examiner's fingers enter from out of sight,
into their peripheral vision. Then, extend your arm and first two fingers out to the side as far as possible.
Beginning with your hand and arm fully extended, slowly bring your outstretched fingers centrally, and notice
when your fingers enter your field of vision. The patient should indicate seeing your fingers at the same time
you see your fingers. Repeat this maneuver a total of eight times per eye, once for every 45 degrees out of the
360 degrees of peripheral vision. Repeat the same maneuver with the other eye.
If you are an advanced practice nurse, you may want to use an ophthalmoscope, observe the optic disc,
physiological cup, retinal vessels, and fovea. Note the pulsations of the optic vessels, check for a blurring of the
optic disc margin and a change in the optic disc's color from its normal yellowish orange.
Cranial Nerves II & III:
Ask the patient to focus on any object in the distance.
Observe the diameter of the pupils in a dimly lit room.
Note the symmetry between the pupils. Next, shine the Direct Light Response:
penlight or ophthalmoscope light into one eye at a time
When a light shines into one eye the
and check both the direct and consensual light responses
in each pupil. Note the rate of these reflexes. If they are
sluggish or absent, test for pupillary constriction via
Consensual Light Response:
accommodation by asking the patient to focus on the
light pen itself while the examiner moves it closer and When a light shines into one eye the
closer to their nose. Normally, as the eyes other eye’s pupil will also constrict.
accommodate to the near object the pupils will constrict.
The test for accommodation should also be completed in
a dimly lit room.
Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, and Abducens
Instruct the patient to follow the penlight or ophthalmoscope with their eyes without moving their head. Move
the penlight slowly at eye level, first to the left and then to the right. Then repeat this horizontal sweep with the
penlight at the level of the patient's forehead and then chin. Note extra-ocular muscle palsies and horizontal or
vertical nystagmus, which would be abnormal. Eye movements should be coordinated and smooth.
Cranial Nerve V: Trigeminal
First, palpate the masseter muscles (muscles of chewing or Palsy:
of the jaw) while you instruct the patient to bite down Uncontrolable tremor or quivering
hard. Note via observation if there is any masseter muscle
wasting. Next, ask the patient to open their mouth against Nystagmus:
resistance applied by the instructor at the base of the Rapid oscillation (movement) of the
patient's chin. eye in any direction, but generally in
a back-and-forth manner.
Next, test gross sensation of Cranial Nerve V. Tell the
patient to close their eyes and say "sharp" or "dull" when
they feel an object touch their face. Using a semi-sharp
object and a dull object, randomly touch the patient's face
with either object. Touch the patient above each temple, next to the nose and on each side of the chin, all
bilaterally. Ask the patient to also compare the strength of the sensation of both sides. If the patient has
difficulty distinguishing pinprick and light touch, then proceed to check temperature and vibration.
Finally, test the corneal reflex using a large Q-tip with the cotton extended into a wisp. Ask the patient to look
at a distant object and then approaching laterally, touch the cornea (not the sclera) and look for the eye to blink.
Repeat this on the other eye. Often, the patient will blink before the object touches the cornea. This is also
Cranial Nerve VII: Facial Nerve
Inspect the face during conversation and rest noting any facial asymmetry including drooping, sagging or
smoothing of normal facial creases. Ask the patient to raise their eyebrows, smile showing their teeth, frown
and puff out both cheeks. Note asymmetry and difficulty performing these tasks. Ask the patient to close their
eyes strongly and not let the examiner pull them open. When the patient closes their eyes, simultaneously
attempt to pull them open with your fingertips. Normally the patient's eyes cannot be opened by the examiner.
Once again, note asymmetry and weakness.
Cranial Nerve VIII: Acoustic
Assess hearing by instructing the patient to close their eyes and Lateralization:
to say "left" or "right" when a sound is heard in the respective
Localization of a function or
ear. Vigorously rub your fingers together very near to, yet not
activity to one side of the
touching, each ear and wait for the patient to respond. After this
test, ask the patient if the sound was the same in both ears, or
louder in a specific ear. If lateralization or hearing
abnormalities exist, and you are a nurse practitioner, perform
the Rinne and Weber tests. These will not be described in this
Cranial Nerve IX & X: Glossopharyngeal and Vagus
Ask the patient if they have difficulty swallowing and then ask them to swallow and note any difficulty doing
so. Next, note the quality and sound of the patient's voice. Is it hoarse or nasal? Ask the patient to open their
mouth wide, protrude their tongue, and say "AHH". While the patient is performing this task, flash your
penlight into the patient's mouth and observe the soft palate, uvula and pharynx. The soft palate should rise
symmetrically, the uvula should remain midline and the pharynx should constrict medially like a curtain. Often
the palate is not visualized well during this task. One may also try telling the patient to yawn, which often
provides a greater view of the elevated palate. Also at this time, use a tongue depressor and the butt of a long Q-
tip to test the gag reflex. Perform this test by touching the pharynx with the instrument on both the left and then
on the right side, observing the normal gag or cough.
Cranial Nerve XI: Spinal Accessory
Inspect for wasting of the trapezius muscles by observing the patient from behind. Ask the patient to shrug their
shoulders as strong as they can while the examiner resists this motion by pressing down on the patient's
shoulders with their hands. Next, ask the patient to turn their head to the side as strongly as they possibly can
while the examiner once again resists with their hand. Repeat this test on the opposite side. The patient should
normally overcome the resistance. Note asymmetry.
Cranial Nerve XII: Hypoglossal
Have your patient "stick out their tongue" and move it side to side. Normally, the tongue will be protruded from
the mouth and remain midline. Have the patient say “light, tight, dynamite” and note the clarity of each distinct
word in pronunciation. Note deviations of the tongue from midline, a complete lack of ability to protrude the
tongue, tongue atrophy and fasciculation (muscle twitches) on the tongue.
Inspect and Palpate the Motor System
Does your patient have appropriate size muscles for body type, age, and gender?
Atrophy is abnormally small muscles with a wasted appearance. This can occur
with disuse, injury, motor neuron diseases, and muscle diseases. Hypertrophy
occurs with athletes and body builders. It is characterized by increased size and
strength of muscles.
Test muscle strength against resistance using a 0 – 5 scale, with 0 = no movement and 5 = strong muscle
strength. Muscle strength should be equal bilaterally.
When testing muscle strength in the arms ask your patient to do the following against resistance:
Lift arms away from side Lift wrist up; push wrist down
Push arms towards side Squeeze examiners finger
Pull forearm towards upper arm Pull fingers apart
Push forearm away from upper arm Squeeze fingers together
When testing muscle strength in the legs ask your patient to do the following against resistance:
Lift legs up Pull lower leg towards upper leg
Push legs down Push lower leg away from upper leg
Pull legs apart Push feet away from legs
Push legs together Pull feet towards legs
Abnormal findings can include: limited range of motion, pain on motion, flaccidity, decreased resistance,
spasticity, or rigidity.
Tics, tremors, and fasciculations (involuntary contraction of a muscle) are all examples of abnormal involuntary
movements you may note on exam.
Check Cerebellar Function
Checking cerebellar functioning includes testing balance, coordination, and skilled movements.
Have the patient walk heel to toe in a straight line - forwards and backwards. Assess
for abnormalities such as stiff posture, staggering, wide base of support, lack of arm
swing, unequal steps, dragging or slapping of foot, and presence of ataxia.
With eyes closed, have the patient stand with feet together and arms extended to the
front, palms up. Your patient should be able to maintain their balance. Stay next to
the patient when they are performing this test in particular, so if they begin to fall,
you can catch them. Balance should be maintained.
Rapid Alternating Movements
Have your patient rapidly slap one hand on the palm of the other, alternating palm up and then palm down - test
both sides. Abnormal findings might be lack of coordination, or slow, clumsy movements.
Finger to Finger Test
Have your patient touch your index finger with their index finger, as you move your index finger in the space
around them. Patients should be able to do this without missing the mark.
Finger to Nose Test
Have your patient touch their nose with their index finger of each hand with eyes shut. Patients should be able
to do this without missing the mark.
Heel to Shin Test
While standing, have your patient touch the heel of one foot to the knee of the opposite leg. While maintaining
this contact, have the patient run the heel down the shin to the ankle. Test each leg. If your patient misses the
mark, lower extremity coordination may be impaired.
Assess the Sensory System
Testing the sensory system checks the intactness of peripheral nerves, sensory tracts, and higher cortical
discrimination. Have your patient close his eyes while checking sensory perception. Check the following
Light Touch Can your patient feel light touch equally on both sides of the body?
Sharp/Dull Can your patient distinguish between a sharp or dull object on both sides
of the body?
Hot/Cold Can your patient distinguish between a hot or cold object on both sides of
Assess the Spinothalmic Tract
Checking the spinothalmic tract tests your patient’s ability to sense pain, temperature, and light touch.
Presence of Pain
Pain can be tested by a simple pin prick with the patient’s eyes closed. Abnormal sensation
findings would include hypalgesia, hyperalgesia, and analgesia.
Temperature should be tested only if pain test is normal. Hot and cold objects
may be placed on the patient’s skin at various locations bilaterally to test for temperature sensation.
With a cotton ball or soft side of a Q-tip, touch the patient’s body bilaterally with “-esthesia” =
their eyes closed. Ask them to indicate when you have touched them. Abnormal sensitivity
responses include hypesthesia, anesthesia, and hyperesthesia.
Assess Posterior Column Tract
Assessing the posterior column tract may identify lesions of the sensory cortex or vertebral column.
Test the patient’s ability to feel vibrations by placing a tuning fork over various boney
locations on the patient’s toes and feet. If these areas are normal, then you may assume the
proximal areas are also normal.
Position or kinesthesia is tested by having the patient close their eyes and move their big toe
up and down. The patient should be able to tell you which way there toes are moving.
Tactile discrimination tests the discrimination ability of the sensory cortex. Stereognosis tests the patient’s
ability to recognize objects by feeling them. You can place car keys, a spoon, a pencil, or other common object
in your patient’s hand. They should be able to identify that object by feel only. Graphesthesia is the ability to
“read” a number “written” in your palm.
Two point discrimination
Two point discrimination tests the brain’s ability to detect two distinct pin
pricks on the skin. An increase in the distance it normally takes to identify two
distinct pricks occurs with sensory cortex lesions (Jarvis, 1998; Shaw, 1998).
Check the Reflexes
Reflexes are involuntary actions in response to a stimulus sent to the central nervous system. Alterations in
reflexes are often the first sign of neurological dysfunction such as upper motor neuron disease, diseases of the
pyramidal tract, or spinal cord injuries.
Stretch or Deep Tendon Reflexes
Deep tendon reflexes, also known as muscle stretch reflexes, are reflexes elicited in response to stimuli to
tendons. Normally, when a specific area of the muscle tendon is tapped with a soft rubber hammer, the muscle
fibers contract. Abnormal responses may indicate injury to the nervous system pathways that produce the deep
tendon reflex. Deep tendon reflexes can be influenced by age, metabolic factors such as thyroid dysfunction or
electrolyte abnormalities, and anxiety level of the patient. The main spinal nerve roots involved in testing the
deep tendon reflexes are summarized in the following table:
Reflex Main Spinal Nerve Roots Involved
Biceps C5, C6
Achilles Tendon S1
Check the deep tendon reflexes with a reflex hammer to stretch the muscle and tendon. The limbs should be in a
relaxed and symmetric position. Strike the reflex hammer across the selected tendon with a moderate tap. If
you cannot elicit a reflex, you can sometimes bring it out by certain reinforcement procedures. For example,
have the patient grit their teeth then try to elicit the reflex again. Or you may have them clench their fists
together when checking lower extremity reflexes. When reflexes are very brisk, clonus is sometimes seen. This
is a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch.
Deep tendon reflexes are often rated according to the following scale:
Rating Reflex Response
0 absent reflex
1+ trace, or seen only with
4+ Non-sustained clonus (i.e.,
repetitive vibratory movements)
5+ sustained clonus
Deep tendon reflexes are considered normal if they are 1+, 2+, or 3+. Reflexes that are asymmetric, or there is a
large difference between the arms and legs, or are rated as 0, 4+, or 5+ abnormal (Jarvis, 1998).
The following reflexes are considered normal in adults.
Can you define Ipsilateral?
Upper Abdominal: Ipsilateral contraction of abdominal
muscles on the stroked side. It means on the same side or
Lower Abdominal: Ipsilateral contraction of abdominal affecting the same side
muscles on the stroked side.
Cremasteric: Stroke inner thigh, elicits elevation of testes.
The following reflexes are considered ABNORMAL in adults. Absence of superficial reflexes or unilateral
suppression of superficial reflexes often results from upper motor lesions subsequent to a stroke. Presence of
primitive reflexes in adults is often a sign of frontal lobe lesions.
Reflex Name Method to Elicit
Babinski Sign Stroking the bottom of the foot elicits fanning (eversion) of big toe.
When the external malleolar skin area is irritated, extension of the great toe
occurs in cases of organic disease of the corticospinal reflex paths.
Scratching the inner side of leg elicits extension of toes. Sign of cerebral
Squeeze the calf muscles and note the response of the great toe. Fanning or
extension is considered abnormal.
Flexion of the terminal phalanx of the thumb and of the second and third
Hoffman's Sign phalanges of one or more of the fingers when the palmar surface of the
terminal phalanx of the fingers is flicked.
Gently tapping or rubbing the upper lip elicits a reflexive sucking or
Grasp Reflex Stroking the patient's palm, causing him to grasp your fingers. A positive test
occurs when the patient does not let go of your fingers.
Palmomental Sign Rub the thenar eminence (area of palm just below the thumb) ------> elicit
reflexive contraction of the muscles of the chin.
(Agone, et al., 1997; Jarvis, 1996)
THE NEUROLOGICAL RECHECK OR ABBREVIATED
Perform the neurological recheck exam at periodic intervals with any patient that has a neuro deficit. This exam
is also useful for your inpatient with a head injury or systemic disease process that may be manifesting as a
neuro symptom. When performing this abbreviated exam, EXAMINE the following, in addition to any
previously identified neurological deficits noted from the complete exam:
Level of Consciousness (Monitors for signs of increasing intracranial pressure)
Is your patient oriented to person, place, and time?
Is your patient alert? If not, what does it take to get them alert - calling their name, light touch,
vigorous touch, pain?
Ask your patient to squeeze your fingers with their hands and
let go (tests for strength and symmetry of strength in the
Ask your patient to push and pull their arms toward and
away from you when their elbows are bent. Provide some
resistance. (tests for strength and symmetry of strength in
Ask your patient to dorsiflex and plantarflex their feet, while
providing some resistance (tests for strength and symmetry of
strength in lower extremities)
Ask your patient to perform straight leg raises with and
without resistance (tests for strength and symmetry of
strength in lower extremities)
Size, shape, and symmetry of both pupils should be the
Each pupil should constrict briskly when a light is shined
into the eyes
Each pupil should have consensual light reflex
Glasgow Coma Scale
The Glasgow Coma Scale assesses how the brain functions as whole and not as individual parts (Teasdale,
1975). The scale assesses three major brain functions: eye opening, motor response, and verbal response. A
completely normal person will score 15 on the scale overall. Scores of less than 7 reflect coma. Using the scale
consistently in the healthcare setting allows healthcare providers to share a common language and monitor for
trends across time (Jarvis, 1996).
Glasgow Coma Scale
Best Eye Opening 1 = No response
Response 2 = To pain
3 = To speech
4 = Spontaneously
Best Motor Response 1 = No response
2 = Extension – abnormal
3 = Flexion - abnormal
4 = Flexion – withdrawal
5 = Localizes pain
6 = Obeys verbal commands
Best Verbal Response 1 = No response
2 = Sounds - incomprehensible
3 = Speech - inappropriate
4 = Conversation - confused
5 = Oriented X 3
Integrating the neurological health history and physical exam takes practice. It is not enough to simply ask the
right questions and perform the physical exam. As the patient’s nurse, you must critically analyze all of the data
you are obtaining, synthesize the data into relevant problem areas, and identify a plan of care for your patient
based upon this synthesis. As the plan of care is being carried out, reassessments must occur on a periodic basis.
How often these reassessments occur is unique to each patient and is based upon their physical disorder.
Knowing when and how often to reassess is based on the specific patient, evidence presented, and facility
policies, standards, and protocols.
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