FORMAT FOR NEUROLOGICAL ASSESSMENT

I. Mental status examination

 Level of consciousness (LOC) by GCS
 Orientation to time, place & person
 Memory – immediate, recent & remote
 Speech & language – fluency, comprehension, repetition, naming / object
recognition
 Higher intellectual function – general knowledge, abstraction, judgment, insight,
reasoning

II. Cranial nerves

The nurse assesses the twelve cranial nerves. Some of these twelve cranial nerves are only
sensory or motor nerves, and others have both sensory and motor functions.
1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducens
7. Facial
8. Acoustic / vestibulocochlear
9. Glossopharyngeal
10. Vagus
11. Spinal accessory
12. Hypoglossal

Cranial Nerve I (Olfactory Nerve)

 The client is asked to close his eyes and occlude one nostril.
 The examiner places aromatic and easily distinguished items near the non-occluded
nostril (e.g. alcohol, vinegar, coffee).
 Ask the client to identify the odor.
 Each side is tested separately
 Repeat the process for the opposite side using different item

Cranial Nerve II (Optic Nerve)

The optic nerve is assessed by testing for visual acuity and peripheral vision.

Visual acuity
 The room used for this test should be well lighted.
 A person who wears corrective lenses should be tested with and without them
to check for the adequacy of correction.
 Only one eye should be tested at a time; the other eye should be covered by an
opaque card or eye cover, not with client’s finger.
 Make the client read the chart by pointing at a letter randomly at each line;
maybe started from largest to smallest or vice versa.
 A person who can read the largest letter on the chart (20/200) should be
 checked if they can perceive hand movement about 12 inches from their eyes,
or if they can perceive the light of the penlight directed to their yes.

Peripheral vision or visual fields

The performance of this test assumes that the examiner has normal visual
fields, since that client’s visual fields are to be compared with the examiners.
● The examiner and the client sit or stand opposite each other, with the eyes at
the same, horizontal level with the distance of 1.5 – 2 feet apart.
● The client covers the eye with opaque card, and the examiner covers the eye
that is opposite to the client covered eye.
● Instruct the client to stare directly at the examiner’s eye, while the examiner
stares at the client’s open eye. Neither looks out at the object approaching from
the periphery.
● Examiner brings the index finger into the field of vision from laterally & the
patient is asked to respond as soon as he sees the moving finger
● Movements should be tested in all directions upward, downward, to the right &
left.
● Normally the client should see the same time the examiners see it.
● The normal visual field is 180 degrees.

Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)

All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular
Movement (EOM) or the six cardinal position of gaze.
 Stand directly in front of the client and hold a finger or a penlight about 1 ft from
the client’s eyes.
 Instruct the client to follow the direction the object hold by the examiner by eye
movements only; that is without moving the neck.
 The nurse moves the object in a clockwise direction hexagonally.
 Instruct the client to fix his gaze momentarily on the extreme position in each of the
six cardinal gazes.
 The examiner should watch for any jerky movements of the eye (nystagmus).
 Normally the client can hold the position and there should be no nystagmus.

Cranial Nerve V (Trigeminal)

1. Sensory Function
● Ask the patient to close the eyes.
● Run cotton wisp over the fore head, check and jaw on both sides of the face.
● Ask the patient if he / she feel it, and where it is felt.
● Check for corneal reflex using cotton wisp.
● The normal response is blinking.
2. Motor function
● Ask the patient to chew or clench the jaw. Palpate the jaw and feel for movement.
● The patient should be able to clench or chew with strength and force.

Cranial Nerve VII (Facial)

 Sensory function (This nerve innervates the anterior 2/3 of the tongue).
1.
● Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
● Normally, the client can identify the taste.

2. Motor function
● Ask the patient to smile, frown, raise eye brow, close eye lids, whistle, or puff the
cheeks.

Cranial nerve VIII (Acoustic)

Acoustic nerve has 2 divisions: cochlear & vestibular
 The cochlear division is involved in hearing: Weber & Rinne test
 The vestibular division is involved in the sense of balance, which includes
equilibrium, coordination & orientation in space. First examine the patient’s ear
canal for obvious blockage or malformation

Cranial nerve IX & X (Glossopharyngeal, Vagus)

 The glossopharyngeal and vagus nerves are usually tested together.

 In the pharynx, CN IX is primarily sensory, and CN X is mostly motor.
 Observe the patient as he or she swallows a small amount of water. Ask if he or
she frequently chokes on food or has trouble swallowing. Dysphagia can often be
seen after neurosurgical procedures or CVA.
 Depress a tongue blade on posterior tongue, or stimulate posterior pharynx to elicit
gag reflex.
 Note any hoarseness in voice.
 Check ability to swallow.
 Have patient say "ah." Observe for symmetric rise of uvula and soft palate.

Cranial nerve XI (Spinal Accessory)

1. Trapezius

a. From behind patient, look for atrophy or asymmetry of trapezius.

b. Ask patient to shrug shoulders against resistance and note strength.

2. Sternocleidomastoid

a. Place hand on lower face and ask patient to turn head towards that side against
resistance.
b. Observe contraction of opposite sternocleidomastoid

Cranial nerve XII (Hypoglossal)

 The hypoglossal nerve is tested by asking the patient to open his or her mouth, stick
out his or her tongue, and wiggle it side to side.
 While patient protrudes the tongue, note any deviation or tremors. Test the strength
of the tongue by having patient move the protruded tongue from side to side against
a tongue depressor.
  The tongue should be midline. Observe for asymmetry, atrophy, or fasciculations.
 Carotid endarterectomy is a common cause of dysfunction of CN XII.

The summary table is given below:

Each of these twelve cranial nerves, their function and their classification as sensory, motor
or both sensory and motor are shown in the table below.

III. Sensory function

a) Tactile sensation

 Tactile sensation is assessed by lightly touching a cotton wisp or fingertip to

corresponding areas on each side of the body. The sensitivity of proximal parts of the
extremities is compared with that of distal parts, and the right and left sides are
compared.

b) Pain And Temperature Sensations

 Determining the patient's sensitivity to a sharp object can assess superficial pain
perception.
 The patient is asked to differentiate between the sharp and dull ends of a broken
wooden, cotton swab or tongue blade; using a safety pin is inadvisable because it
breaks the integrity of the skin. Both the sharp and dull sides of the object are applied
with equal intensity at all times, and the two sides are compared.
 Use the hot and cold object for skin to determine the hot and cold sensation.

c) Vibration

 Tested with a tuning fork of frequency of 128 Hz. Tuning fork of 128 Hz gives slow
quantitative stimulation because of the slow decaying of vibrations.
 Strike the tuning fork of 128 Hz with a knee hammer and keep it on the patient's
forehead.
 Patient should be able to appreciate the vibration and not the touch of the fork. Keep
the vibrating tuning fork, starting from the distal most bony prominence and proceed
proximally (including the spinous processes).
 Enquire the patient about the feeling of sensation of vibration.
 Early vibration sense loss:- Elderly and Diabetes Mellitus.

d) Joint sense

 Test the distal most joint (For the upper limb - distal inter phalangeal joint of the
finger & for the lower limb distal inter-phalangeal joint of toes).
 Clearly explain the procedure to the patient with the eyes open.
 Hold the joint to be tested on its lateral aspect (patient is closing his eyes).
 Neighboring toes or fingers should not be touched. Hold and stabilize the proximal
phalanx with the other hand.
 Move the joint up and down repeatedly and ask the patient about the position of the
joint.
 If there is impairment in the sensation of the distal joint proceed to the more proximal
joint.
 If the patient fails to recognize the joint position consistently, it is an indication of
posterior column disease.

e) Position Sense

 Ask the patient to close his eyes.

  Keep the limb in one particular position and ask the patient to keep his opposite limb
in the same position as the other limb. Patients with abnormal position sense on one
side will not be able to keep the opposite limb in the same position as the limb on the
diseased side.

f) Two point discrimination

 Touch two separate points on a part of the body simultaneously, first wide apart & then
as close distance as possible. (While closing the patient's eyes). Note the ability of the
patient to distinguish two separate points.

g) Sensory Inattention

 This is a test for parietal lobe dysfunction.

 Person should identify his right and left hand normally while testing for sensory
inattention.
 Touch two identical parts on each side of the patient's body simultaneously while patient
is closing his eyes.
 Patients with sensory inattention will identify only on normal side. (routine testing of
sensation is normal).
 Significance: Patients with sensory inattention on one side will have opposite parietal
lobe pathology.

h) Stereognosis

 Ability to recognize the dimension of an object is called stereognosis. Patient should be

able to recognize the familiar objects given to him by the feel of its size and shape while
closing his eyes. Inability to recognize the dimension is called Astereognosis.
 Cortical sensations will be impaired in parietal lobe dysfunction.

i) Graphesthesia

 Ability to recognize the numbers of letters which are drawn on any part of the body is
called Graphesthesia.
 Ask the patient to close the eyes. Write a number or a letter of sufficient size on
different parts of the body and compare it on two sides of the body.
 Normal person should be able to recognize the number written.

IV. Motor function

Motor Ability

 A thorough examination of the motor system includes an assessment of muscle size,

muscle tone, muscle strength.
 The patient is instructed to walk across the room, if possible, while the examiner
observes posture and gait.
 The muscles are inspected, and palpated, if necessary, for their size and symmetry. Any
evidence of atrophy or involuntary movements (tremors, tics) is noted.
 Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various
muscle groups at rest and during passive movement
  Resistance to these movements is assessed and documented. Abnormalities in tone
include spasticity (increased muscle tone), rigidity (resistance to passive stretch), and
flaccidity.
 Assessing the patient's ability to flex or extend the extremities against resistance tests
muscle strength. The quadriceps, for example, is a powerful muscle responsible for
straightening the leg.
 Once the leg is straightened, it is exceedingly difficult for the examiner to flex the knee.
If the knee is flexed and the patient is asked to straighten the leg against resistance,
weakness can be elicited.
 The evaluation of muscle strength compares the sides of the body to each other. For
example, the right upper extremity is compared to the left upper extremity.
 Subtle differences in strength may be evaluated by testing for drift. For example, both
arms are stretched out in front of the patient with palms up; drift is seen as pronation of
the palm, indicating a subtle weakness that may not have been detected on the resistance
examination.

Manual Muscle testing Scale

5: full power of contraction against gravity and resistance or normal muscle strength

4: fair but not full strength against gravity and a moderate amount of resistance or slight
weakness

3: just sufficient strength to overcome the force of gravity or moderate weakness

2: ability to move but not to overcome the force of gravity or severe weakness

1: muscle activation with flicker of movement. muscle contraction is palpable and

flicker movement is seen

0: no visible or palpable contraction / movement.

V. Cerebellar Function

1) Co-ordination

Cerebellar and basal ganglia influence on the motor system is reflected in balance
control and coordination.

a). Truncal stability

 Observe patient sitting on a chair or side of bed with hands in lap. (Make sure if
sitting on side of bed that bed is reclined flat.)
 Note any leaning towards one side or falling backwards.

b). Fine finger movements (finger tapping)

 Coordination in the hands and upper extremities is tested by having the patient
perform rapid, alternating movements and point-to point testing.
  First, the patient is instructed to pat his or her thigh as fast as possible with each
hand separately.
 Then the patient is instructed to alternately pronate and supinate the hand as
rapidly as possible.
 Last, the patient is asked to touch each of the fingers with the thumb in a
consecutive motion. Speed, symmetry, and degree of difficulty are noted.
 Point-to-point testing is accomplished by having the patient touch the examiner's
extended finger and then his or her own nose. This is repeated several times.
 Coordination in the lower extremities is tested by having the patient run the heel
down the anterior surface of the tibia of the other leg. Each leg is tested in turn.
 Ataxia is defined as incoordination of voluntary muscle action, particularly of the
muscle groups used in activities such as walking or reaching for objects.
 Tremors (rhythmic, involuntary movements) noted at rest or during movement
suggest a problem in the anatomic areas responsible for balance and coordination.

c). Finger-nose-finger test

 Have patient alternately touch your outstretched finger and own nose.
 Be sure your finger is far enough away that patient's arm must fully extend to
reach it.
 Observe speed, and precision of movements. Note any oscillation, especially one
that worsens as patient's finger nears the target. Note if patient consistently
passes (overshoots), fails to reach (undershoots), or is off to left or right of
target.
 Repeat on other side.

2) Balance / Romberg Test

 Ask the clients stand still with their heels together.

 Ask the clients to remain still and close their eyes.

Result: if the clients lose their balance after standing still with their eye closed. This is
positive Romberg.

3) Gait Testing

 To check ability to stand and walk:

 Ask the patient to walk across the room, turn, and come back towards you. Pay
particular attention to, difficult to walk and indicate upper extremities weakness.
 Difficulty getting up from a chair, Can the patient easily arise from a sitting position.
Problems with this activity might suggest proximal muscle weakness, a balance
problem, or difficulty initiating movements.
 Ask the clients to walk on heels is the most sensitive way to test foot dorsiflexion.

Pay attention to the following:

  Posture of body and extremities (e.g., leaning or pulling towards one side or backwards,
twisting or holding hack one arm).
 Length, speed, and rhythm of steps.
 Base of gait (how far apart are the legs).
 Arm swing (is it reduced unilaterally or bilaterally).
 Steadiness.
 Turning (steadiness of turns and number of steps required to complete the turn)

VI. Reflex Testing

The reflexes are deep tendon reflexes and superficial reflexes

1. Deep tendon reflexes

 Biceps reflex
 Triceps reflex
 Brachioradialis reflex
 Patellar reflex
 Achilles reflex

Grade Description

0: Absent reflex

1: Hypoactive reflex

2: Normal reflex

3: Brisk / hyperactive reflex

4: Markedly hyperactive with clonus and /or spreading

a). Biceps reflex testing

 This is most easily done with the client seated. The biceps reflex is elicited by striking
the biceps tendon over a slightly flexed elbow. The examiner supports the forearm with
one arm while placing the thumb against the tendon and striking the thumb with the
reflex hammer.
 The normal response is flexion at the elbow and contraction of the biceps.

b). Triceps Reflex Testing

 To elicit a triceps reflex, the patient's arm is flexed at the elbow and positioned in front
of the chest.
 The examiner supports the patient's arm and identifies the triceps tendon by palpating
2.5 to 5 cm (1 to 2 inches) above the elbow.
 A direct blow on the tendon normally produces contraction of the triceps muscle and
extension of the elbow.
c). Brachio radialis Reflex Testing

 With the patient's forearm resting on the lap or across the abdomen, the brachioradialis
reflex is assessed.
 A gentle strike of the hammer 2.5 to 5 cm (1 to 2 inches) above the wrist results in
flexion and supination of the forearm

d). Patellar Reflex Testing

 This is most easily done with the clients seated, feet dangling over the edge of the exam
table.
 The patellar reflex is elicited by striking the patellar tendon just below the patella.
 The patient may be in a sitting or a lying position. If the patient is supine, the examiner
supports the legs to facilitate relaxation of the muscles.
 Contractions of the quadriceps and knee extension are normal responses.

e). Achilles reflex

 To elicit an Achilles reflex, the foot is dorsiflexed at the ankle and the hammer strikes
the stretched Achilles tendon
 This reflex normally produces plantar flexion. If the examiner cannot elicit the ankle
reflex and suspects that the patient cannot relax, the patient is instructed to kneel on a
chair or similar elevated, flat surface.
 This position places the ankles in dorsiflexion and reduces any muscle tension in the
gastrocnemius.
 The Achilles tendons are struck in turn, and plantar flexion is usually demonstrated

2. Superficial Reflexes

a) The corneal reflex: Using a clean wisp of cotton and lightly touching the outer comer
of each eye on the sclera. The reflex is present if the action elicits a blink. A stroke or
brain injury might result in loss of this reflex, either unilaterally or bilaterally.

b) The gag reflex is elicited by gently touching the back of the pharynx with a cotton-
tipped applicator, first on one side of the uvula and then the other. Positive response is
an equal elevation of the uvula and "gag" with stimulation. Absent response on one or
both sides can be seen following a stroke.

c) The Plantar Reflex or Babinski Reflex: is elicited by stroking the sole of the foot with
a tongue blade or the handle of a reflex hammer. Stimulation normally causes toe
flexion.

 The clients may either sit or lies supine.

 Start at the lateral aspects of the foot, near the apply gentle, steady pressure with
the end of the hammer as you move medial, stroking across this area.
 A well-known pathologic reflex indicative of central nervous system disease
affecting the corticospinal tract

d) Abdominal reflex
  In the superficial abdominal reflexes, stroking the skin of the abdomen causes
the underlying abdominal wall muscle to contract, sometimes pulling the
umbilicus towards the stimulus

e) Cremasteric

 The cremasteric reflex is a superficial reflex found in human males that is

elicited when the inner part of the thigh is stroked. Stroking of the skin causes
the cremaster muscle to contract and pull up the ipsilateral testicle toward the
inguinal canal.

f) Pupillary reflex

 The pupillary light reflex is an autonomic reflex that constricts the pupil in
response to light, thereby adjusting the amount of light that reaches the retina.
Pupillary constriction occurs via innervation of the iris sphincter muscle, which
is controlled by the parasympathetic system.