neurological assessment

1. BY:
Ms. Malar

3. The neuro assessment is a key component in the
care of the neurological patient. It helps to:-
 Detect the presence of neurological disease or
injury and monitor its progression.
 Determine the type of care you'll provide , and
patient's response to your interventions.

4. The initial assessment should cover several
critical areas:
 level of consciousness
 cranial nerves
 Movement
 sensation
 cerebellar function
 and reflexes.
This initial exam will establish
baseline data with which to compare
subsequent assessment findings.

5. DEFINITION :-
 Neurological examination is a method of obtaining specific data in
relation to the function of a patient's nervous system.
INDICATIONS :-
Neurological observations are required :-
 to monitor and evaluate changes in the nervous system by indicating
trends.
 To aid in diagnosis and treatment which in turn may affect prognosis
and rehabilitation
 The frequency of neurological observations will depend on the
patient’s condition and the rapidity with which changes are occurring
or expected to occur.

6.  Evaluation of level of consciousness (LOC) are the
most important parts of the neuro exam. A change is
usually the first clue to a deteriorating condition.
 The following terms are commonly used :
 Full consciousness:- The patient is alert, attentive, and
follows commands. If asleep, she responds promptly to
external stimulation and, once awake, remains
attentive.
 Lethargy:- The patient is drowsy but awakens—
although not fully—to stimulation. She will answer
questions and follow commands, but will do so slowly
and inattentively.

7.  Obtundation:- The patient is difficult to arouse and
needs constant stimulation in order to follow a simple
command. She may respond verbally with one or two
words, but will drift back to sleep between stimulation.
 Stupor:- The patient arouses to vigorous and
continuous stimulation; typically, a painful stimulus is
required. She may moan briefly but does not follow
commands. Her only response may be an attempt to
withdraw from or remove the painful stimulus.
 Coma: - The patient does not respond to continuous or
painful stimulation. She does not move—except,
possibly, reflexively—and does not make any verbal
sounds.

8.  A fully conscious patient will respond to questions
quickly and is alert to events occurring around him.
 As his condition deteriorates he may display
irritability, lack of concentration and uncooperative
behavior.
 A comatose state is one in which the patient fails to
respond to verbal and painful stimuli. Fever and pain
commonly cause confusion, disorientation and
irritability.
 To prevent the patient from falling, stand by the side of
the patient during the test.
 The patient's cultural and educational background
influences his ability to answer test questions.

9.  1 Cotton applicator Assesses patient's response to light
touch.
 2. Needle Assesses patient's response to pain.
 3. Test tube containing hot & cold water Assesses temperature
sensation.
 4. Refex hammer
 5. Vials containing coffee or vanilla Assesses olfactory
nerve.
extract, sugar salt.
 6. Tongue blade
 7. Penlight
 8. Snellen’s chart
 9. Tuning fork
 10. Thermometer
 11. BP apparatus
 12. Stethoscope

11. ACTION
•Identify the patient.
•Explain the procedure to the patient
•Ensure patient's privacy.
•Wash and dry hands.
•Collect equipment.
•Place the patient in appropriate position.

13. ACTION
•Throughout the assessment process, note the patient's
mannerisms, actions and emotional response as well as the degree
of co-operation.
•Observe patient's speech pattern.
•Observe patient's appearance personal hygiene and
appropriateness of dress.

15. GLASGOW COMA SCALE
The Glasgow coma scale (GCS) is a numeric expression
of cognition, behavior and neurologic function to
measure level of consciousness.
The total score ranges from 3-15, with 3 being the most
severe and 15 being the normal.

16. ACTION RESPONSE SCORE
Eyes open Spontaneously
To speech
To pain
None
4
3
2
1
Verbal response Oriented
Confused
Inappropriate words
Incomprehensive sounds
5
4
3
2
Motor Response Obeys commands
Localized pain
Flexion withdrawal
Abnormal flexion (decorticate)
Abnormal extension (decerebrate)
Flaccid
6
5
4
3
2
1

17. I. EYE OPENING: (4)
•A patient who opens his eyes spontaneously, such
as an alert patient sitting in a chair, would be scored
a 4.
•If the patient is asleep or lying with eyes closed, but
opens them upon command, a 3 is awarded.
•If the patient only opens their eyes to painful
stimulus, such as running the tip of blunt scissors
along the bottom of the foot, or a pinch, the patient is
scored a 2.
• A patient who does not open their eyes no matter
what is given a 1.

18. II. VERBAL RESPONSE: (5)
•A patient who engages in normal, appropriate
conversation would be given a 5 on the GCS.
•A patient who makes appropriate conversation but is
confused, such as an Alzheimer's patient, would be
scored as a 4.
•The patient who makes inappropriate conversation, such
as answering a question on an entirely different subject,
would be given a 3.
• If the patient cannot make conversation, but instead has
very garbled speech or makes incomprehensible sounds,
they would be given a 2.
•The patient who is unable to speak or make any sounds
for any reason, such as being on a ventilator with a
breathing tube in their mouth, would be given a 1.

19. III MOTOR RESPONSE: (6)
•A patient who moves arms and legs either spontaneously or
on command is given a 6.
• If the patient displays purposeful movement with a painful
or unpleasant stimulus, such as trying to push it away, the
patient is given a 5.
•The patient who only withdraws away from pain with no
other response is given a 4.
•A score of 3 is given to the patient demonstrating decorticate
posturing, in which the patient's extremities are drawn
inward toward the center of the body.
•If the patient is in the decerebrate posture, the extremities
are turned away from the body, and the score is 2.
•The lack of any movement or posturing is given a 1.

20. ABNORMAL POSTURING

21.  Assess patient's immediate recall by asking the patient to
repeat a sequence of numbers.
 Assess patient's recent memory by asking him to give
details of the recent events like what he had in breakfast
etc.
 Assess patient's past memory by:
 Requesting him/her to re-call previous medical history, family
events e.g. birth days. instructions given earlier in the
assessment.
 Have the patient explain the meaning of a simple
proverb e.g. . “Nach na aaye angan tedha”. It determines
the higher level of intellectual functioning
 Ask patient to identify similarities or association between
terms or simple concepts e.g. similarity between mango
and an orange.

22. CRANIAL
NERVES
ASSESSMENT

23. I. OLFACTORY
NERVE (sensory)
Sensory Nerve:
Sense of smell.
Ask patient to
smell and then
identify different
non-irritating
aromas such as
coffee , vanilla,
toothpaste,
isopropyl alcohol

24. II. OPTIC NERVE
(sensory)
Sensory function
Assessment involves the following
steps:
•Inspect for foreign bodies, cataracts
or inflammation
•Test visual acuity by making the
client read a newspaper, a sign (from
a distance) or a Snellen’s chart
•Examine the eye fundus with an
ophthalmoscope which can provide
information about neurologic
disease.

25. III. OCULOMOTOR NERVE: (Motor)
 Responsible for elevation of the upper eyelid, pupil
constriction & dilation
 Assess direction of gaze.
 Measure pupil reaction to light reflex
 PERRLA: Pupils equal, round, reactive to light and
accommodation indicates that these functions are
normal
IV. TROCHLEAR NERVE: (Motor )
 Upward and downward movement of eyeball.
 Assess direction of gaze

26. V. TRIGEMINAL(mixed)
Sensory nerve to skin of face and motor nerve to
muscles of jaw (mastication)
SENSORY FUNCTION:
With the client’s eyes closed, test sensations of pain
(sharp point), touch (wisp of cotton), & temperature (hot
and cold meta objects) on both sides of the face from top
of the head to the chin.
Test corneal reflex by gently touching the cornea with a
sterile wisp of cotton
MOTOR FUNCTION:
Assess patient’s ability to clench teeth, open the mouth
against resistance, open the mouth widely & making
chewing movements.

27. VI. ABDUCENS NERVE: (MOTOR)
 Lateral movements of eye balls
 Assess directions of gaze
VII. FACIAL NERVE: (mixed)
 Motor division innervates muscles controlling facial
expression
 Ask patient to smile, frown, puff out cheeks, raise
and lower eyebrows
 For sensory function test each taste on each side of
the tongue with sweet, salty, acidic or sour (vinegar
or lemon) and bitter (coffee) substances

28. VIII. AUDITORY /ACOUSTIC
/VESTIBULOCOCHLEAR NERVE: (sensory)
i. Cochlear branch:
• Test auditory acuity by having the client to listen
to and report on a whispered voice,
• Test bone conduction (weber test)and air
conduction ( rinne test)with a tuning fork
• Audiometery may be used for precise
measurement

30. ii. Vestibular branch:
 Romberg’s test: Ask the client to stand with feet
together, arms by the sides, and eyes closed. Assess
the ability to maintain an upright posture. If the
client loses his balance, this is a positive Romberg
sign, suggesting vestibular ear problem or cerebellar
ataxia.
• Caloric test
• Electronystagmography

31. IX. GLOSSOPHARYNGEAL NERVE: (mixed)
•Ask the client to open his mouth widely and say “Ah”
•Place a tongue depressor on the tongue of the patient to visualize
uvula and palate
•Test the gag reflex gently
•Use a small amount of water to test the ability to swallow
•Test the posterior third of the tongue for taste
X. VAGUS NERVE: (mixed)
•Ask the client to cough & to speak.
•Damage to CN X causes an ineffective cough & a hoarse voice
XI. SPINAL ACCESSORY: (motor)
•Ask the client to: (1) elevate the shoulders (with & without
resistance), (2) turn the head to one side & then to other, (3) resist
attempts pull the chin back towards the midline and (4) push the
head forward against resistance

32. XII. HYPOGLOSSAL NERVE: (motor)
•Ask the client to open his mouth widely, stick out the tongue and
rapidly move the tongue from side to side & in and out
•Assess the strength by asking the client to push the tongue
against the inside of the cheek while applying external pressure

33.  Muscle size:
Inspect all major groups bilaterally for symmetry,
hypertrophy & atrophy
 Muscle Strength:
Assess the power in major muscle groups against resistance
on a 5 point scale in all four extremities, comparing one side
with the other
5/5= Normal full strength. Muscle moves actively through the
full range of motion against the effects of gravity & applied
resistance
4/5= Muscle moves actively through full range of motion
against the effect of gravity with weakness to applied
resistance
3/5=Muscle moves actively against the effects of gravity alone

34. 2/5= Muscle moves across a surface but cannot overcome
gravity
1/5= Muscle contraction is palpable & visible
0/5= Muscle contraction or movement is u8ndetectable
 Muscle Tone:
 Assess the muscle tone while moving each extremity
through its range of passive motion. When tone is
decreased, the muscles are soft, flabby or flaccid
 When tone is increased, the muscles are resistant to
movement, rigid, or spastic
 Muscle co-ordination:
 Ask client to touch each finger to the thumb quickly in
succession
 Ask the client to pat the thighs first with palms, then with
back of the hands & to repeat patting quickly

35. Gait & station:
•Ask the client to stand still, walk & walk with one foot in front
of the other on a straight line
•Ask the client to stand quietly with feet together

37. REFLEXES
Two types of reflexes are normally present:
1. Superficial or coetaneous reflexes
2. Deep Tendon reflex
1. Superficial Reflexes: Elicited by the stimulation of the skin or
mucous membranes. The stimulus is produced by stroking a
sensory zone with an object that will not cause damage
a. Abdominal Reflex: lightly stroking the skin on an abdominal
quadrant normally contracts the abdominal muscle, moving
the umbilicus towards the stimulated side.
b. Plantar Reflex: Scratching the foot’s outer aspect of the plantar
surface (outer sole) from the heel toward the toes normally
contracts or flexes the toes in clients older than 2 yrs of age.

38. c. Corneal reflex: Gently touching cornea with a wisp of cotton
causes reflex blinking
d. Pharyngeal (Gag) Reflex: Gentle stimulation with a tongue blade
at the back of the throat and pharynx normally produces gagging

39. 2. Deep tendon Reflex: Elicited by sharply striking a muscle’s
tendon’s point of insertion with a sudden, brief blow of a
reflex hammer
Reflex Assessment Technique Expected Response
Biceps Reflex A blow on the
examiner’s thumb
placed over the biceps
tendon
Flexion of elbow
Triceps Reflex Strike on triceps tendon
just above the olecranon
Extension of elbow
Patellar Reflex (knee
jerk)
Tap on patellar tendon Leg extends
Achilles Reflex (ankle
reflex)
Tap on achilles tendon Plantar flexion of foot

40. Note:-
 Deep tendon reflexes should be symmetric on
both sides of the body.
 Grading is conducted according to the scale.
0 = No response
1+ = Low normal or diminished
2+ = Normal
3+ = Brisker than normal. But may not indicate
disease
4+ = Hyperactive very brisk spinal cord
disorder

41.  Ask the patient to relax limbs to be tested.
 Position limb until slightly stretch muscles
being tested.
 Hold reflex hammer loosely between thumbs
and fingers.
 Tap tendon briskly.
 Compare symmetry of reflex from one side of
the body to the other.

42. Biceps Reflex :
•Flex patient’s arm at
the elbow with
palms down.
Place your thumb or
forefinger in the ante
-cubital fossa at base
of the biceps tendon.
Strike thumb with
the reflex hammer.
•Normal reflex :-
Flexion of arm at
elbow.

43. Triceps Reflex:
• Flex patient’s
elbow holding
upper arm
horizontally and
allow lower arm to
go limp.
•Strike the triceps
tendon just above
the elbow.
•Normal reflex :-
Extension at elbow.

44. Patellar Reflex: -
Have patient sit with
legs hanging freely
over side of the bed
or chair or have
patient lie supine and
support the knee in a
flexed position.
Briskly tap the
patellar tendon just
below the patella.
•Normal reflex :
Extension of lower
leg at knee.

45. Achilles Reflex:
1. Have the patient sit on a
table or bed so that his legs
dangle.
2. With your left hand,
grasp the patient's foot and
pull it in dorsiflexion
(upward)
3. Tap the tendon directly.
4. Normal response:
Plantar flexion of the foot.

46.  Leave patient comfortable.
 Clean and dispose off equipment.
 Wash and dry hands.
 Ensure that all procedures and observations
have been appropriately documented.

47.  Gerard j. tortora ; Bryan derrickson, principles
of anatomy and physiology, 11th edition, john
Wiley & sons, inc publication.
 www.google.co.in
 Merry C. Townsend, psychiatry mental health
nursing, 5th edition, jaypee publications.