MISAMIS UNIVERSITY

Ozamiz City 7200, Philippines

Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: [email protected]

CERTIFIED: ISO 9001:2015 Risk Management – Det Norske Veritas, The Netherlands
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation (PACUCOA)

HEALTH ASSESSMENT OF THE NERVOUS SYSTEM

A neurological assessment is an evaluation of a person's nervous system, which includes the brain, spinal
cord, and the nerves that connect these areas to other parts of the body.

The neurological exam can be organized into 5 areas: (1) Mental Status, (2) Cranial Nerves, (3) Motor
and Cerebellar system, (4) Sensory System, (5) Reflexes

Purpose:

1. To survey the functioning of nerves delivering sensory information to the brain and carrying motor
commands (peripheral nervous system) and impulses back to the brain for processing and coordinating
(central nervous system).
2. To assess for any abnormalities in the nervous system that can cause problems with daily functioning.
3. To determine the cause of impairment and help to localize the problem.

Equipment:

1. Examination gloves 7. Snellen chart

2. Cotton-tipped applicators 8. Sterile cotton ball
3. Newsprint to read 9. Substances to smell or taste such as soap,
4. Ophthalmoscope coffee, vanilla, salt, sugar, lemon juice
5. Paper clip 10. Tongue depressor
6. Penlight 11. Tuning fork

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

CRANIAL NERVES (CN)
Test CN I (OLFACTORY).

For all assessments of the cranial Client correctly identifies scent Inability to smell (neurogenic
nerves, have client sit in a presented to each nostril. anosmia) or identify the correct
comfortable position at your eye scent may indicate olfactory tract
level. Some older clients’ sense of lesion or tumor or lesion of the
Ask the client to clear the nose to smell may be decreased. frontal lobe. Loss of smell may also
remove any mucus then to close be congenital or due to other causes
eyes, occlude one nostril, and such as nasal disease, smoking, and
identify a scented object that you are use of cocaine.
holding such as soap, coffee, or
vanilla.
 MISAMIS UNIVERSITY
Ozamiz City 7200, Philippines
Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: [email protected]

CERTIFIED: ISO 9001:2015 Risk Management – Det Norske Veritas, The Netherlands
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation (PACUCOA)

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Repeat procedure for the other
nostril.

Test CN II (OPTIC).

Use a Snellen chart to assess vision Client has 20/20 vision OD Abnormal findings include
in each eye. (right eye) and OS (left eye). difficulty reading Snellen chart;
missing letters, and squinting.

Ask the client to read a newspaper Client reads print at 14 inches Client reads print by holding closer
or magazine paragraph to assess without difficulty. than 14 inches or holds print farther
near vision. away as in presbyopia, which occurs
with aging.

Assess visual fields of each eye by Full visual fields Loss of visual fields may be seen in
confrontation. retinal damage or detachment, with
lesions of the optic nerve, or with
lesions of the parietal cortex.

Use an ophthalmoscope to view the Round red reflex is present, Papilledema (swelling of the optic
retina and optic disc of each eye. optic disc is 1.5 mm, round or nerve) results in blurred optic disc
slightly oval, well-defined margins and dilated, pulsating veins.
margins, creamy pink with paler Papilledema occurs with increased
physiologic cup. Retina is pink intracranial pressure from
intracranial hemorrhage or a brain
tumor. Optic atrophy occurs with
brain tumors.

Assess CN III (OCULOMOTOR),

IV (TROCHLEAR), and VI
(ABDUCENS).

Inspect margins of the eyelids of Eyelid covers about 2 mm of the Ptosis (drooping of the eyelid) is
each eye. iris. seen with weak eye muscles such as
in myasthenia gravis.

Assess extraocular movements. If Eyes move in a smooth, Some abnormal eye movements and
nystagmus is noted, determine the coordinated motion in all possible causes follow:
direction of the fast and slow phases directions (the six cardinal 1. Nystagmus: rhythmic
of movement. fields). oscillation of the eyes),
cerebellar disorders.
 MISAMIS UNIVERSITY
Ozamiz City 7200, Philippines
Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: [email protected]

CERTIFIED: ISO 9001:2015 Risk Management – Det Norske Veritas, The Netherlands
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation (PACUCOA)

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

2. Limited eye movement through
the six cardinal fields of gaze,
increased intracranial pressure.
3. Paralytic strabismus, paralysis
of the oculomotor, trochlear, or
abducens nerves.

Assess pupillary response to light Bilateral illuminated pupils Some abnormalities and their
(direct and indirect) and constrict simultaneously. Pupil implications follow:
accommodation in both eyes. opposite the one illuminated 1. Dilated pupil (6 to 7 mm),
constricts simultaneously. oculomotor nerve paralysis.
2. Argyll Robertson pupils, CNS
syphilis, meningitis, brain
tumor, alcoholism.
3. Constricted, fixed pupils,
narcotics abuse or damage to
the pons.
4. Unilaterally dilated pupil
unresponsive to light or
accommodation, damage to
cranial nerve III (oculomotor).
5. Constricted pupil unresponsive
to light or accommodation,
lesions of the sympathetic
nervous system.
6. Bilateral muscle weakness is
seen with peripheral or central
nervous system dysfunction.
Unilateral weakness may
indicate a lesion of cranial
nerveV(trigeminal).

Assess CN V (TRIGEMINAL).

Test motor function.

Ask the client to clench the teeth Temporal and masseter muscles
while you palpate the temporal and contract bilaterally.
masseter muscles for contraction.

➤ Clinical Tip • This test may be

difficult to perform and evaluate in
the client without teeth.
 MISAMIS UNIVERSITY
Ozamiz City 7200, Philippines
Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: [email protected]

CERTIFIED: ISO 9001:2015 Risk Management – Det Norske Veritas, The Netherlands
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation (PACUCOA)

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Test sensory function.
Tell the client: “I am going to touch
your forehead, cheeks, and chin with The client correctly identifies Inability to feel and correctly
the sharp or dull side of this safety sharp and dull stimuli and light identify facial stimuli occurs with
pin or paper clip (a paper clip is less touch to the forehead, cheeks, lesions of the trigeminal nerve or
hazardous). and chin. lesions in the spinothalamic tract or
Please close your eyes and tell me if posterior columns.
you feel a sharp or dull sensation.
Also tell me where you feel it”. Vary
the sharp and dull stimulus in the
facial areas and compare sides.
Repeat test for light touch with a
wisp of cotton.

➤ Clinical Tip • To avoid

transmitting infection, use a new
object with each client. Avoid
“stabbing” the client with the
object’s sharp side.

Test corneal reflex.

Ask the client to look away and up
while you lightly touch the cornea Eyelids blink bilaterally. An absent corneal reflex may be
with a fine wisp of cotton. noted with lesions of the trigeminal
Repeat on the other side. ➤ Clinical Tip • This reflex may nerve or lesions of the motor part of
be absent or reduced in clients cranial nerve VII (facial).
who wear contact lenses.

Test CN VII (FACIAL).

Test motor function. Client smiles, frowns, wrinkles Inability to close eyes, wrinkle
Ask the client to forehead, shows teeth, puffs out forehead, or raise forehead along
• Smile cheeks, purses lips, raises with paralysis of the lower part of
• Frown and wrinkle forehead eyebrows, and closes eyes the face on the affected side is seen
• Show teeth against resistance. Movements with Bell’s palsy (a peripheral
• Puff out cheeks are symmetrical. injury to cranial nerve VII [facial]).
• Purse lips Paralysis of the lower part of the
• Raise eyebrows face on the opposite side affected
• Close eyes tightly against may be seen with a central lesion
resistance that affects the upper motor neurons
such as from CVA.
 MISAMIS UNIVERSITY
Ozamiz City 7200, Philippines
Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: [email protected]

CERTIFIED: ISO 9001:2015 Risk Management – Det Norske Veritas, The Netherlands
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation (PACUCOA)

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Test sensory function. Client identifies correct flavor. Inability to identify correct flavor on
Sensory function is not routinely anterior two-thirds of the tongue
tested. If it is, however, touch the In some older clients, the sense suggests impairment of cranial
anterior two-thirds of the tongue of taste may be decreased. nerve VII (facial).
with a moistened applicator dipped
in salt, sugar, or lemon juice and ask
the client to identify the flavor.
If the client is unsuccessful, repeat
the test using one of the other
solutions.
If needed, repeat the test using the
remaining solution.

➤ Clinical Tip • Make sure the

client leaves the tongue protruded to
identify the flavor. Otherwise the
substance may move to the posterior
third of the tongue (vagus nerve
innervation).
The posterior portion is tested
similarly to evaluate functioning of
cranial nerves IX and X. The client
should rinse the mouth with water
between each taste test.

Test CN VIII
(ACOUSTIC/VESTIBULOCOCHL
EAR).

Test the client’s hearing ability in Client hears whispered words Vibratory sound lateralizes to good
each ear and perform the Weber from 1 to 2 feet. ear in sensorineural loss.
and Rinne tests to assess the Air conduction is longer than bone
cochlear (auditory) component of Weber test: Vibration heard conduction but not twice as long, in
cranial nerve VIII. equally well in both ears. a sensorineural loss.

Note: The vestibular component, Rinne test: AC > BC (air

responsible for equilibrium, is not conduction is twice as long as
routinely tested. In comatose clients, bone conduction).
the test is used to determine integrity
of the vestibular system.
 MISAMIS UNIVERSITY
Ozamiz City 7200, Philippines
Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: [email protected]

CERTIFIED: ISO 9001:2015 Risk Management – Det Norske Veritas, The Netherlands
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation (PACUCOA)

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Test CN IX
(GLOSSOPHARYNGEAL) and
X (VAGUS).

Test motor function. Uvula and soft palate rise Soft palate does not rise with
Ask the client to open mouth wide bilaterally and symmetrically on bilateral lesions of cranial nerve X
and say “ah” while you use a tongue phonation. (vagus). Unilateral rising of the soft
depressor on the client’s tongue. palate and deviation of the uvula to
the normal side are seen with a
unilateral lesion of cranial nerve X
(vagus).

Test the gag reflex by touching the Gag reflex intact. Some normal An absent gag reflex may be seen
posterior pharynx with the tongue clients may have a reduced or with lesions of cranial nerve IX
depressor. Warn the client that you absent gag reflex. (glossopharyngeal) or X (vagus).
are going to do this and that the test
may feel a little uncomfortable.

Check the client’s ability to Client swallows without Dysphagia or hoarseness may
swallow by giving the client a drink difficulty. No hoarseness noted. indicate a lesion of cranial nerve IX
of water. Also note the client’s voice (glossopharyngeal) or X (vagus) or
quality. other neurologic disorder.

Test CN XI (SPINAL
ACCESSORY).

Ask the client to shrug the shoulders There is symmetric, strong Asymmetric muscle contraction or
against resistance to assess the contraction of the trapezius drooping of the shoulder may be
trapezius muscle. muscles. seen with paralysis or muscle
weakness due to neck injury or
torticollis.

Ask the client to turn the head There is strong contraction of Atrophy with fasciculations may be
against resistance, first to the right sternocleidomastoid muscle on seen with peripheral nerve disease.
then to the left, to assess the side opposite the turned face.
sternocleidomastoid muscle.
 MISAMIS UNIVERSITY
Ozamiz City 7200, Philippines
Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: [email protected]

CERTIFIED: ISO 9001:2015 Risk Management – Det Norske Veritas, The Netherlands
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation (PACUCOA)

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Test CN XII (HYPOGLOSSAL).

To assess strength and mobility of Tongue movement is symmetric Fasciculations and atrophy of the
the tongue, ask the client to protrude and smooth and bilateral tongue may be seen with peripheral
tongue, move it to each side against strength is apparent. nerve disease. Deviation to the
the resistance of a tongue depressor, affected side is seen with a
then put it back in the mouth. unilateral lesion.