The document discusses a neurological assessment which includes examining the central nervous system, peripheral nervous system, cranial nerves, and various tests to evaluate motor and sensory function. A complete assessment consists of checking level of consciousness, mental status, cranial nerves, motor skills, sensation, coordination, and gait. Specific tests described include visual acuity, hearing tests, reflexes, and tests of coordination, balance, touch, and pain sensation. The nurse's role is to prepare the patient and environment, assist with the examination, record findings, and monitor the patient's condition.

2. CENTRAL NERVOUS SYSTEM

3. Neurological assessment helps to:
• Identify which component of the neurological
system are affected
• If possible, determine the precise location of the
problem.
• Screening for the presence of discrete abnormalities
in patients at risk for the development of
neurological disorders

4. REVIEW
The Central Nervous System
• Brain
• Spinal cord
The peripheral nervous system
• The 12 pairs of cranial nerves
• 31 pairs of spinal nerves and all their
branches.
4

5. A complete neurologic assessment
consists of :
Level of consciousness
Mental status examination
Cranial nerve assessment & peripheral nerve
assessment ( power, reflex ,co-ordination,
sensation )
Motor system assessment
Sensory system assessment
Coordination
 Gait
(Always consider left to right symmetry and vital
signs )

6. Assessment of level of consciousness
• It includes following categories
Alertness : patient is awake ,responds
immediately and appropriately to verbal
stimuli
Lethargic : patient is drowsy and inattentive
but arouse easily, frequently off to sleep
Stuporous : he arouses with great difficulty
and cooperates minimally when stimulated

7. CONT..
• Semi-comatose :The patient has lost his
ability to respond to verbal stimuli. There is
some response to painful stimuli. little motor
function is seen
• Comatose : when the patient is stimulated
there is no response to verbal or painful
stimuli .no motor activity is seen
• GCS is widely used to measure the level of
consciousness

8. Areas of the Neurologic System
Assessment-Additional assessments

9. Mental status examination (MSE)
• Intellect: (Memory, Orientation,
Attention, Calculations)
• Insight and
Judgment

10. Central nervous system
• Cranial nerves I an II extends from the
cerebrum
• CN III to XII extends from the lower
diencephalon and brain stem.
• Peripheral nerves: 31 pairs arise from
the length of the spinal cord and support
the rest of the body.
• 8 cervical, 12 thoracic, 5 lumber, 5
sacral, 1 coccygeal.
10

11. CENTRAL NERVOUS SYSTEM

12. POINTSTOREMEMBER
• olfactory nerve -It is the smallest nerve in terms of the
number of axons it contains.
• Vagus nerve. The vagus nerve is one of 12 cranial
nerves. It is the longest of the cranial nerves, extending
from the brainstem to the abdomen by way of multiple
organs including the heart, esophagus, and lungs.
• Trigeminal is the thickest /largest cranial nerves in
human body

13. Peripheral nervous system
Reflexes: They are the basic defense mechanism of
the Nervous system. They are involuntary
Deep tendon reflexes: basic defense mechanis of the
nervous system (pateller and knee jerk)
Superficial reflexes: by stimulating the skin:
abdominal, corneal
Visceral (organic): papillary response to light and
accommodation
Pathologic: (abnormal)
13

14. Equipments needed
A tray containing
• Penlight
• Pen
• Stethescope
• News paper
• Test tube with hot or cold water
• Tongue blade
• Cotton swab
• Cotton ball
• Tuning fork
• Percussion hammer
• Aromatic substances (pepperminst, coffee, vanilla) 14

16. l. Olfactory: smell
Purely sensory nerve
Instruction : check that the nasal passages are
clear .
• Client both eyes and one naris are closed
The examiner places aromatic ,non irritant,
easily distinguish substance and ask the person
to identify the odor
Each side is tested separately ,ideally with two
different substances

17. • ABNORMALITIES…
• ANOSMIA : inability to smell
• AGNOSIA :inability to process sensory
information. Often there is a loss of ability
to recognize objects , persons, sounds ,
shapes , or smell

19. ll. Optic: vision
 Visual acuity and peripheral vision
-Distance/Central vision: Snellen eye chart
-Near vision (hand-held card)
 Visual field
 Examine the Optic Fundi by using the Ophthalmoscope

21. Snellen chart –the chart has a standardized number
at the end of each line of letter ,these Numbers
indicates the degree of visual acuity when
measured at a distance of 20 feet/6mtrs
The numerator 20 /6 is the distance in the feet
between the chart and client .the denominator 20
is the distance from which the normal eye can
read the lettering ,which correspond to number at
the end of each letter line, therefore the largest
the denominator the poorer the vision
Eyes – Techniques of Examination

22. Eyes – Techniques of Examination
• Visual acuity
– Near vision: use (Jaeger or
Rosenbaum chart (hand-
held card)
– can also use to test visual
acuity at the bedside
– hold 14 inches (about 30
cm) from patient’s eyes
Rosenbaum chartJaeger chart

24. • Peripheral vision or visual fields :The performance
of this test assumes that examiner has normal visual
field,
• Sit in front of the patient at 1 m distance.
• To test the right eye ; ask the patient to close the
right eye with right hand simultaneously the
examiner close the left eye with left hand.
• Instruct the patient to look at the examiners eye
[ steadily fixing the gaze ]
• Hold the examiner hand to side at an arms length in
a plane midway between patient and you
• Ask the patient whether she/he sees the movements
make sure that the same time the patient is steadily
fixing the gaze at your eye

28. PUPIL SIZE

30. • Accommodation- the eye able to focus on both
near and far object.
An object held about 10 cm from the client’s nose
Eyes – Techniques of Examination

32. • PERRLA –Pupil equally round reacting to light
and accomodation

33. lll. Oculomotor
lV. Trochlear
Vl. Abducens
• All the 3 cranial nerves are tested at same
time by assessing the extra ocular
movements (EOM) or the six cardinal
position of gaze
• Accommodation

38. Vll. Facial
Sensory function (this nerve innervate the anterior 2/3 of the
tongue )
Place the sweet, salty, sour or bitter items near the tip of
tongue .normally the client can identify the taste (Between
each solution the mouth needs to be rinsed with water)
• Motor function :Ask patient to raise eyebrows, show teeth,
grimace, smile, puff both cheeks (Assess face for
asymmetry, abnormal movements).
Normal findings
Shape may be oval or round , Face is symmetrical
No involuntary muscle movements

41. Vlll. Acoustic
Turning fork test: Weber Test
(by using a tuning fork).
Rinne test: to compares air and
bone conduction
Romberg test: Ask the patient
to remain still and close their
eyes (for about 10-20 seconds).

44. WEBER TEST

45. CONTD…
• The defective ear is the one marked with a red
'X' and the normal ear marked with
green 'tick' mark. In Webers test, the tuning
fork is held against the forhead in the place of
'W'. Weber's is lateralised to defective ear in
conductive deafness and Sound ear
in Sensorineural deafness. You can remember
the picture using mnemonic 'X CoWS S'.

47. Weber’s test
Assesses bone conduction ,this is test of sound
lateralization .vibrating tuning fork is placed on the
middle of the forehead or top of the skull. normally
hear sounds equally in both ears (no lateralization of
sound )

48. Ears – Hearing acuity
– Rinne
o Compare time of air vs. bone
conduction
o Place the base of the tuning fork on the
client’s mastoid process- and note the
number of seconds.
o Then move the fork in front the external
auditory meatus (1-2 cm)
Air and bone conduction (AC and BC)

49. Romberg’s test for balance.
Ask the patient to remain still and close their eyes (for
about 20 seconds).

51. LX. GLOSSOPHARYNGEAL
X. VAGUS
oAsk the client to open the mouth, depress the
client’s tongue with the tongue blade, ask the client
to say ”ah” . Usually, the soft palate raises and the
uvula remains in the midline. Observe the
individual swallowing.
oTest gag reflex,

52. • Sensory part :test the taste sensation in the
posterior 1/3rd of the tongue . Touch the tonsil or
pharynx .
• Touch the gag reflex

55. Xl. Spinal Accessory
 Test the Trapezius muscle: have
the client shrug the shoulders
while you resist with your hands
 Turn the head to one side and then
other
 Push the head forward against the
resistance

57. Xll. Hypoglossal
• Ask patient to protrude tongue and move it
side to side. Assess for symmetry, atrophy.

58. Summary of Cranial Nerves
58

59. 2) Peripheral Nerve Examination
• Power
• Reflexes
• Co-ordination
• Sensation

61. Power
• Know grades
• Compare side to side
• Muscle groups

70. REFLEXES

74. reflexes
• Reflexes includes (Stimulus-response
activities of the body(.
–Biceps
–Triceps
--Patellar (knee)
–Achilles
–Plantar (Babinski)

75. Testing the biceps reflex.
The patient's arm should be partially flexed at the elbow
with the palm down.
-Place your thumb or finger firmly on the biceps tendon.
-Strike your finger with the reflex hammer.
-look for contraction of the biceps muscle and slight
flexion of the forearm.

76. Testing the triceps reflex.
Support the upper arm and let the patient's forearm hang free.
-Strike the triceps tendon above the elbow with the broad side of
the hammer.
-observe contraction of the triceps muscle with extension of the
lower arm.

77. Testing patellar (knee) reflex, client
in a sitting position.
-Have the patient sit with the knee flexed.
-Strike the patellar tendon just below the patella.
-Note contraction of the quadriceps muscle and
extension of the knee.

78. Testing the Achilles tendon reflex
with client in a sitting position.
-Dorsiflex the foot at the ankle.
-Strike the Achilles tendon.
-Watch and feel for plantar flexion at the ankle.

79. Testing the plantar reflex (Babinski).
-Stroke the lateral aspect of the sole of each foot
with the end of a reflex hammer or key.
-Observe for planter flexion of the foot .

82. REFLEXES: SCALE FOR GRADING
Reflexes are usually graded on a 0 to 4+ scale
4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between
flexion and extension)
3+ Brisker than average; possibly but not necessarily indicative of
disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response

83. Areas of the Neurologic System
Assessment
• Motor function
Observation of gait (tandem walk)and
balance
Co-ordination (Administration of the
Romberg test &Administration of the
finger-to-nose test)
Observation of rapid alternating action
movements

85. Observation of gait and balance
Ask the client to walk across the room and
return

86. Romberg’s test for balance.
Ask the patient to remain still and close their eyes (for
about 20 seconds).

87. Finger-to-nose test.
Ask the client to extend both arms from the sides of the body
-ask the client to keep booth eyes open
-ask the client to touch the tip of the nose with right index
finger, and then return the right arm to an extended position.
-ask the client to touch the tip of the nose with left index
finger, and then return the left arm to an extended position.
-Repeat the procedure several times.
-Ask the client to close both eyes and repeat the alternating
movements

88. SENSORY FUNCTION
–Observation of light touch identification
–Sharp, dull determination
–Stereognosis
–Graphesthesia (Number identification)

91. -Evaluation of light touch.
-Use wisp of cotton to touch the skin lightly on both sides
simultaneously.
-Test several areas on both the upper and lower
extremities.
-Ask the patient to tell you if there is difference from side
to side or other "strange" sensations.

92. Testing the client’s ability to identify sharp sensations.
-Ask the client to say “sharp” or “dull” when something
sharp or dull is felt on the skin.
-Touch the client using random locations.
Testing the client’s ability to identify dull sensations Testing the client’s ability to identify sharp sensations

93. -Testing stereognosis using a coin
-Use as an alternative to graphesthesia.
-Place a familiar object in the patient's hand (coin, paper,
pencil, etc.).
-Ask the patient to tell you what it is.

94. -Testing graphesthesia (Number
identification)
-With the blunt end of a pen or pencil, draw a large
number in the patient's palm.
-Ask the patient to identify the number.

96. What are the role of a nurse???????

97. NURSES ROLE IN
NEUROLOGICAL EXAMINATION
Provide calm ,suitable environment
Collect the personal data with patient and family
members
Set the equipment's needed for neurological
examination
Assess the current level of conciousness, monitor
vital parameters – temperature, pulse, respiration
,blood pressure, pupillary reactions whether
decerebrating or decorticating

98. CONT…
• Thorough mental status examination should
be done and record it properly
• Assessment of cranial nerves should be done
and record it properly
• During the time of examination should
maintain good support with patient and
family members

99. Cont…
• He/she should instruct the procedure correctly
& then they should be asked to do it
• Should be informed to the concern doctor if
there is any change