NEUROLOGIC

ASSESSMENT
Presented by: Ms. Jeceli Alviola Nobleza, BSN-RN
Learning Objectives:
After the presentation, we should be able to:
• Perform a physical assessment of the
neurologic system
• Document neurologic system findings
• Differentiate between normal and abnormal
findings
 INTRODUCTION
• The human nervous system is a unique system that
allows the body to interact with the environment as
well as to maintain the activities of internal organs.
• The nervous system acts as the main “circuit board” for
every body system. Because the nervous system works
so closely with every other system, a problem within
another system or within the nervous system itself can
cause the nervous system to “short-circuit.”
(Dillon,2007)
• A major goal of nursing is early detection to
prevent or slow the progression of disease.
• So it is important for nurses to accurately perform a
thorough neurologic assessment and to understand
the implications of subtle changes in assessment
findings. By doing so, we can initiate timely
interventions that can save lives.

(Dillon,2007)
 REVIEW OF THE
ANATOMY AND PHYSIOLOGY
OF THE

NEUROLOGIC SYSTEM
Cont. Review of Ana and Physio

General functions of the neurologic system include:

• Cognition, emotion, and memory.
• Sensation, perception, and the integration of
sensoryperceptual experience.
• Regulation of homeostasis, consciousness,
temperature, BP, and other bodily processes.
There are two types of nerve cells:
(1) neuroglia and
(2) neurons
 Neuroglia
• Functions:
a. act as supportive tissue, nourishing and protecting
the neurons
b. maintain homeostasis in the interstitial fluid around
the neurons and account for about 50 percent of the
central nervous system (CNS) volume
c. have the ability to regenerate and respond to injury
by filling spaces left by damaged neurons.
 Neurons
• Functions:
a. have the ability to produce action potentials or
impulses (excitability or irritability) and

b. to transmit impulses (conductivity).

Sensory (afferent) neuron Motor (efferent) neuron
dendrite
Nissl Nodes of
Cell body bodies Ranvier

Schwann
cell

nucleus

synapse

Synaptic
vesicles
Axon

Myelin

Presynaptic
terminal
Receptors Postsynaptic
Synaptic
in skin membrene
cleft

Neurotransmitter
Postsynaptic
substance
receptor

Neuromuscular
junction
Neurons band together into
- peripheral nerves,
- spinal nerves,
- spinal cord, and
- tissues of the brain.
• These structures make up the neurologic system,
which is divided into
- the CNS and
- the peripheral nervous system (PNS).
 CENTRAL NERVOUS SYSTEM
• consists of the brain and spinal cord.
 The Human Brain Central fissure
Lateral fissure
FRONTAL LOBE

ory
tex
PARIETAL LOBE

cort tosens
cor
Emotion

Motor
Behavior sensation

a
ex
Som
Intellect Wernicke’s area
Broca’s Area Speech
Motor
compensation
Speech Hearing
Smell
Taste OCCIPITAL LOBE
Memory Visual
perception
TEMPORAL LOBE Coordination
Equilibrium
Balance
Cerebellum
 The Spinal Cord
• The spinal cord descends through the foramen magnum (large
aperture) of the occipital bone of the skull, through the first
cervical vertebra (C1), and through the remainder of the
vertebral column to the first or second lumbar vertebra.
• conducts sensory information from the peripheral nervous
system (both somatic and autonomic) to the brain
• conducts motor information from the brain to our various
effectors
- skeletal muscles
- cardiac muscles
- smooth muscles
-glands
• serves as a minor reflex center
 Sensory Pathways
• Pathways,either ascending or afferent,allow sensory data, such as the feeling
of a burned hand, to become conscious perceptions.

Sensory Trunk, Arm,

cortex Hand, Fingers,
Leg
Knee Face, Lips,
Foot Tongue
toes

pons

medulla Posterior column

Fine touch, proprioception
Lateral spinothalamic tract
and vibration
Pain &temperature
Anterior spinothalamic tract
Crude touch & pressure Posterior root
of the spinal
cord

Spinal cord
 Motor Pathways

Motor Cortex
Trunk, Arm, Hand,
Leg Fingers, Face, Lips,
Knee Tongue
Foot
toes

Skeletal
muscles

Anterior corticospinal Lateral corticospinal

(uncroosed pyramidal tract (crossed pyramidal tract
 Spinal Reflexes
• Spinal reflexes do not depend on conscious perception
and interpretation of stimuli, nor on deliberate action;
in other words, they do not involve the brain.
• They occur involuntarily, with lightning speed, and
are identical in all healthy children and adults,
although they are less developed
• in infants.
Dorsal root ganglion
Sensory nerve

Motor nerve

Reflex arc
PERIPHERAL NERVOUS SYSTEM
• The peripheral nervous system consists of
- the cranial
- spinal nerves and the
- peripheral autonomic nervous system.
 Cranial Nerves
The 12 pairs of cranial nerves originate from the brain
and are called the peripheral nerves of the brain.
I-Olfactory nerve – Smell (S)
II-Optic nerve - Vision (S)
III-Oculomotor nerve (M)
- Eye movement; pupil constriction
IV-Trochlear nerve (M)
- Eye movement
V-Trigeminal nerve (B)
- Somatosensory information (touch, pain) from the
face and head; muscles for chewing.
VI-Abducens nerve - Eye movement (M)
VII-Facial nerve (B)
- Taste (anterior 2/3 of tongue); somatosensory
information from ear; controls muscles used in facial
expression.
VIII-Vestibulocochlear nerve/Auditory nerve (S)
- Hearing; balance
IX-Glossopharyngeal nerve (B)
- Taste(posterior 1/3 of tongue);
- Somatosensory information from tongue, tonsil,
pharynx;
- controls some muscles used in swallowing.
X-Vagus nerve (B)
- Sensory, motor and autonomic functions of
viscera (glands, digestion, heart rate)
XI-Accessory nerve/Spinal accessory nerve (M)
- Controls muscles used in head movement.
XII-Hypoglossal nerve (M)
- Controls muscles of tongue
 Spinal and Peripheral Nerves
• Branching from the spinal cord are 31 pairs of spinal
nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,
and 1 coccygeal
• The spinal nerves contain both ascending and
descending fibers, and although there is some
overlap,each is responsible for innervation of a
particular area of the body.
Dermatomes - are regions of the body innervated by the
cutaneous branch of a single spinal nerve.
 Components of
Neurologic Exam
• Mental Status
a. Appearance/ Hygiene/ Grooming/ Odor
b. Behavior
c. Speech/ Communication
d. Level of Consciousness
e. Memory
f. Cognitive function
• Cranial Nerve Function (12 cranial nerves)
• Sensory Function
a. Light touch b. Pain
c. Vibration d. Kinesthetics
e. Streognosis f. Graphesthesia
g. Two-point discrimination h. point localization
i. Sensory Extinction
• Reflex Function
a. Deep tendon reflexes
b. Superficial reflexes
Ensure proper hygiene before seeing a client
Ensure all equipment is properly cleaned
Equipment Needed:
- BP cuff - Tuning fork (128 or 256 Hz)
- Penlight - Nonsterile gloves
- Wisp of cotton - Tongue blade
- Reflex hammer
- Sharp object such as toothpick or sterile needle
- Objects to touch: coin, button, key or paperclip
- Something fragrant: rubbing alcohol or coffee
- Something to taste: such as lemon juice, sugar or salt
- Two taste tubes or other vials
- Ophthalmoscope
 Introduce self to the client.
 Assessing the Mental Status
1. APPEARANCE/ HYGIENE/ GROOMING/ ODOR

a. Begin the assessment as the patient approaches

you.
b. Observe the general appearance, hygiene,
grooming and the odor of the client.
Normal: Abnormal:
 good grooming, Poor hygiene
 dress in appropriate Unpleasant or offensive
to temperature & body odor
weather,
 no offensive or
unpleasant odor
 hair well kept or tied
2. BEHAVIOR

a. Assess the client’s mood and emotions

b. Observe body language and facial expression or
affect
c. Note his or her posture
Normal: Abnormal:
 Verbal expressions Lack of facial expression
match with the - Possible psychological
nonverbal behavior disorder (e.g., depression or
 Mood is appropriate schizophrenia) or neurologic
to the situation impairment affecting cranial
 Standing in upright nerves.
Masklike expression:
stance with parallel
- Parkinson’s disease.
alignment of hips
Slumped posture:
&shoulders
- Depression if
psychological in origin; or stroke
with hemiparesis if physiological
in origin.
3. SPEECH/ COMMUNICATION
a. Speech and Language
Listen to patient’s rate and ease of speech,
including enunciation.
Normal: Abnormal:
 Speech flows ■ Hesitancy, stuttering,
easily; patient stammering, unclear speech:
enunciates - Lack of familiarity with language,
deference or shyness, anxiety,
clearly.
neurologic disorder.
 Sophistication of
■ Dysphasia/aphasia:
speech matches - Neurologic problems such as stroke.
age, education, ■ Drugs and alcohol can also cause
and fluency. slurred speech.
b. Spontaneous Speech & Motor Speech
- Show patient a picture and have him or her
describe what he or she sees.
- Have patient repeat, “do, ray, me, fa, so, la, ti,
do.”
Normal: Abnormal:
 Spontaneous ■ Impaired spontaneous speech:
speech intact. - Cognitive impairment.
 Motor speech Impaired motor speech
intact. (dysarthria):
Problem with CN XII
c. Autonomic Speech
Have patient say something that is committed
to memory, such as days of week or months of
year.

Normal: Abnormal:
■ Automatic ■ Impaired automatic speech:
speech intact. Cognitive impairment or
memory problem.
4. LEVEL OF CONSCIOUSNESS
a. Test orientation to time, place, and person
Normal: Abnormal:
 Awake, alert, and Disorientation may be
oriented to time, physical in origin
place, and person Disorientation can also be
(AAO x 3) psychiatric in origin
(schizophrenia)
 Responds to
Lathargic or somnolent
external stimuli Obtunded
Stupor
Coma
 Glasgow Coma Scale
- A standardized objective assessment that defines the LOC by
giving it a numeric value.
- Most often after brain surgery
- Document as E_V_M_; for example, E4V5M6.
 GLASGOW COMA SCALE
Eyes open ■ Spontaneously . . . . . . . . 4 Findings
E ■ To command . . . . . . . . . . 3
■ To pain . . . . . . . . . . . . . . . 2
■ Unresponsive. .. . . . . . . . . 1
Best verbal response ■ Oriented . . . . . . . . . . . . . . . 5 Findings
V ■ Confused . . . . . . . . . . . . . . . 4
■ Inappropriate . . . . . . . . . . . . 3
■ Incomprehensible . . . . . . . . 2
■ Unresponsive. . . . . . . . . .. . . 1
Best motor response ■ Obeys commands . . . . . . . .. 6 Findings
M ■ Localizes pain. . . . . . . . . . . 5
■ Withdraws from pain. . . . …. 4
■ Abnormal flexion . . . . . . .. . . 3
■ Abnormal extension . . . . . . . 2
■ Unresponsive. . . . . . . . . . . . . 1
Total______

From Wijdicks, et al, 2005, with permission.

• The three numbers are added; the total score
reflects the brain functional level.
• A fully awake person = 15
• Coma = 7 or less

• The GCS assesses the functional state of the brain

as a whole, not of any particular site in the brain.
(Juarez and Lyon,1995)
 Four Score Coma Measurement Scale
EYE RESPONSE
4
3 Eyelids open or opened, tracking or blinking to command
2 Eyelids open but not tracking
1 Eyelids closed but open to loud voice
0 Eyelids closed but open to pain
Eyelids remain closed with pain

MOTOR
RESPONSE
4 Thumbs up, fist, or peace sign to command
3 Localizing to pain
2 Flexion response to pain
1 Extensor posturing
0 No response to pain or generalized myoclonus status epilepticus

BRAINSTEM
REFLEXES
4 Pupil and corneal reflexes present
3 One pupil wide and fixed
2 Pupil or corneal reflexes absent
1 Pupil and corneal reflexes absent
0 Absent pupil, corneal, and cough reflex

RESPIRATION
4 Not intubated, regular breathing pattern
3 Not intubated, Cheyne-Stokes breathing pattern
2 Not intubated, irregular breathing pattern
1 Breathes above ventilator rate
0 Breathes at ventilator rate or apnea
5. MEMORY
a. Test immediate recall:
Ask patient to repeat three numbers, such as “4, 9, 1.” If
patient can do so, ask her or him to repeat a series of five
digits.
b. Test recent memory:
Ask what patient had for breakfast.
c. Test long-term memory:
Ask patient to state his or her birthplace, recite his or her
Social Security number, or identify a culturally specific
person or event, such as the name of the previous president
of the United States or the location of a natural disaster.
Normal: Abnormal:
 Immediate, recent,  Memory problems can be
and remote benign or signal a more
memory intact. serious neurologic problem
- such as Alzheimer’s disease.
Forgetfulness - especially for
immediate and recent events
- often in older adults.
- With benign forgetfulness,
person can retrace or use memory
aids to help with recall.
Pathological memory loss
- as inAlzheimer’s disease
Cont.
Abnormal:
 Temporary memory loss
- may occur after head trauma.
 Retrograde amnesia
- for events just preceding illness or
injury.
 Postconcussion syndrome
- can occur 2 weeks to 2 months
after injury and may cause short- term
memory deficits.
 6. COGNITIVE FUNCTION
a. Mathematical and Calculative Ability
Ask patient to perform a simple calculation, such as
adding 4 x 4. If successful, proceed to more difficult
calculation, such as 11 9.

Normal: Abnormal:
 Mathematical/calculati  Inability to calculate at
ve ability intact and level appropriate to age,
appropriate for education, and language
patient’s age, ability requires evaluation
educational level, and for neurologic impairment.
language facility.
b. General Knowledge and Vocabulary
Ask how many days in a week and months in a year.

c. Thought Process
Ask patient to define familiar words such as “apple,”
“earthquake,” and “chastise.”
Begin with easy words and proceed to more difficult
ones.
Remember to consider the patient’s age, educational
level, and cultural background.
Normal: Abnormal:
 Thought  Incoherent speech
process  illogical or unrealistic ideas
intact repetition of words and phrases
repeatedly straying from topic
suddenly losing train of thought
(examples of altered thought processes that
indicate need for further evaluation)

Inability to define familiar words -

requires further evaluation
d. Abstract Thinking
Assess the client to think abstractly.
Quote a proverb and ask the client to explain it’s
meaning
Normal: Abnormal:
 Able to generalize from ■ Impaired ability to think
specific example and abstractly:
apply statement to - Dementia, delirium, mental
human behavior. retardation, psychoses.
 Children should be able
to distinguish like from
unlike as appropriate
for theirage and
language facility.
e. Judgment
Observe patient’s response to current situation.
Ask patient to respond to a situation or
hypothetical situation.
Normal: Abnormal:
 Judgment ■ Impaired judgment can be
appropriate and associated with dementia,
intact. psychosis, or drug and alcohol
abuse.
 Assessing the CRANIAL NERVES
1. CN I—Olfactory Nerve
a. Before testing nerve function, ensure patency of
each nostril by occluding in turn and asking patient
to sniff.
b. Once patency is established, ask patient to close
eyes.
c. Occlude one nostril and hold aromatic substance
such as coffee beneath nose.
d. Ask patient to identify
substance.
e. Repeat with other nostril.
Normal: Abnormal:
■ Patient is able to ■ Anosmia is loss of sense of
identify substance. smell.
-May be inherited and
(Bear in mind that nonpathological: chronic rhinitis,
some substances may be sinusitis, heavy smoking, zinc
unfamiliar, especially deficiency, or cocaine use.
to - It may also indicate cranial nerve
children.) damage from facial fractures or
head injuries, disorders of base of
frontal lobe such as a tumor, or
artherosclerotic changes.
- Persons with anosmia usually also
have taste problems.
2. CNs II, III, IV, and VI—Optic, Oculomotor,
Trochlear, and Abducens Nerves
a. Ask the client to read a printed material, observe the
distance between the printed material and the client’s eyes.
b. Use the snellen chart to check/ test:
- distant vision
- color
Client should be 20 feet distant from the chart
Use an object to occlude one eye
Evaluate the vision one eye at a time
c. Evaluate the Extra Ocular Movements of the Eyes
d. Convergens & Accomodation
e. Pupillary Light Reflex
- using direct and consensual pupillary reaction to light

Testing eye Testing pupil

movements accommodation
Normal: Abnormal:
■ Able to read without ■ CN II deficits
difficulty - can occur with stroke or brain
■ Visual acuity intact tumor.
20/20, both eyes ■ Changes in pupillary
 Hippus reactions
phenomenon: - Brisk - can signal CN III deficits.
constriction of pupils ■ Increased ICP causes
in reaction to light, changes in pupillary reaction.
followed by dilation As pressure increases,
and constriction response becomes more
- may be normal or sign sluggish until pupils finally
of early CN III become fixed and dilated.
compression.
3. CN V—Trigeminal Nerve
a. Testing motor function:
- Ask patient to move jaw from side to side against
resistance and then clench jaw as you palpate
contraction of temporal and masseter muscles, or
to bite down on a tongue blade.

Testing CN V –
motor function
b. Testing sensory function:
- Ask patient to close eyes
- Touch the face with the wisp of cotton
- Instruct to tell you when he or she feels
sensation on the face.
- Repeat the test using sharp and dull stimuli
(toothpick)
- Instruct to say “Sharp” or “Dull”
(Be random, don’t establish a pattern)
- Compare both bilaterally.

Testing CN V –
sensory function
c. Testing corneal reflex:
- Gently touch cornea with cotton wisp.
o Touching cornea can cause abrasions.
Alternative approach is to:
> puff air across cornea with a needless
syringe, or
> gently touch eyelash and look for blink reflex.

Testing corneal
reflex
Cont. CN V

Normal: Abnormal:
 Full range of Weak or absent contraction
motion (ROM) in unilaterally:
jaw and 15 - Lesion of nerve, cervical spine, or
brainstem.
strength.
Inability to perceive light touch
 Patient perceives
and superficial pain
light touch and - may indicate peripheral nerve
superficial pain damage.
bilaterally. ■ Tic douloureux:
- Neuralgic pain of CN V caused by
the pressure of degeneration of a
nerve.
■ Corneal reflex test used in
patients with decreased LOC
- to evaluate integrity of brainstem.
4. CN VII—Facial Nerve
a. Testing motor function:
- Ask patient to perform these movements: smile,
frown, raise eyebrows, show upper teeth, show
lower teeth, puff out cheeks, purse lips, close eyes
tightly while nurse tries to open them.

Testing CN VII – motor

function
b. Testing sensory function:
- Test taste on anterior two-thirds of tongue for
sweet, sour, salty.

Sweet:
Tip of the tongue
Sour:
Sides of back half of
tongue
Salty:
Anterior sides and tip of
tongue Testing taste sensation
Bitter: Back of tongue
Normal: Abnormal:
 Facial nerve intact; Asymmetrical or impaired
able to make faces. movement:
 Taste sensation on - Nerve damage, such as that
anterior tongue caused by Bell’s palsy or
intact. stroke.
■ Impaired taste/loss of taste:
(Taste decreased in - Damage to facial nerve,
older adults.) chemotherapy or radiation
therapy to head and neck.
5. CN VIII—Acoustic Nerve
a. Perform Weber and Rinne tests for hearing
b. Perform watch-tick test by holding watch close to
patient’s ear.
Watch tick test

c. Perform Romberg test for balance

- Nurse at the back or side of the pt.
- Instruct client to stand straight, feet together,
hands at the side and eyes closed.
(Evaluates the balancing function of the CN VIII)
Normal: Abnormal:
 Hearing intact. Hearing loss, nystagmus,
 Negative Romberg balance disturbance,
test. dizziness/vertigo:
- Acoustic nerve damage.
■ Nystagmus:
- CN VIII, brainstem, or
cerebellum problem or
phenytoin (Dilantin) toxicity.
6. CNs IX and X—Glossopharyngeal and Vagus
Nerves
a. Observe ability to cough, swallow, and talk.
b. Test motor function:
- Ask patient to open mouth and say “ah”
while you depress the tongue with a tongue
blade.
- Observe soft palate and uvula. Soft palate
and uvula should rise medially.

Testing CN IX and
X – motor function
c. Test sensory function of CN IX and motor function
of CN X by stimulating gag reflex.
- Tell patient that you are going to touch interior
throat
- then lightly touch tip of tongue blade to
posterior pharyngeal wall.
- Observe the pharyngeal movement.

- Ask the client to drink a small amount of water

Note the ease & difficulty of swallowing
Note quality of the voice or hoarseness
when speaking
Normal: Abnormal:
 Swallow and cough Unilateral movement:
reflex intact. - Contralateral nerve damage.
- Damage to CNs IX and X also impairs
 Speech clear. swallowing.
 Elevation and ■ Changes in voice quality (e.g.,
constriction of hoarseness): CN X damage.
pharyngeal - CN X damage may also affect vital
functions, causing arrhythmias because
musculature and
vagus nerve innervates most of viscera
tongue retraction through parasympathetic system.
indicate positive ■ Diminished/absent gag reflex:
gag reflex. Nerve damage.
- Evaluate further because patient is at
increased risk for aspiration.
■ Impaired taste on posterior portion
of tongue: Problem with CN IX.
7. CN XI—Accessory Nerve
a. Test motor function of shoulder and neck
muscles: - Ask patient to shrug shoulders
upward against your resistance. (Trapieze
muscle)
- Then ask her or him to turn head from side to
side against your resistance.
(Strenoclaidomastoid msucle)
- Observe for symmetry of contraction and
muscle strength.
Normal: Abnormal:
 Movement Asymmetrical
symmetrical, with Diminished
patient moving Absent movement
against resistance Pain
without pain. unilateral or bilateral
■ Full ROM of neck weakness:
with +5/5 strength. - Peripheral nerve CN XI
damage.
8. CN XII—Hypoglossal Nerve
a. Have patient say “d, l, n, t” or a phrase containing
these letters.
- The ability to say these letters requires use
of the tongue.
b. Ask the patient to protrude the tongue.
Observe any deviation from midline, tumors,
lesions, or atrophy.
Now ask the patient to move the tongue from
side to side.

Testing CN XII –
motor function
Normal: Abnormal:
 Can protrude Asymmetrical/diminished/
tongue medially. absent movement/deviation
 No atrophy, from midline/protruded tongue:
- Peripheral nerve CN
tumors, or
lesions. XII damage.
■ Tongue paralysis results in
dysarthria.
 Assessing Sensory Function
1. Light Touch
- Brush a light stimulus such as a cotton wisp over
patient’s skin in several locations, including torso
and extremities.
Normal: Abnormal:
Diminished/absent cutaneous
 Identifies areas
perception:
stimulated by light -Peripheral nerve damage or damage to
touch. posterior column of spinal cord.
- Peripheral neuropathies can also cause
sensory deficits.
■ Hypesthesia: Increased sensitivity.
■ Paresthesia: Numbness and tingling.
■ Anesthesia: Loss of sensation.
2. Pain
- Stimulate skin lightly with sharp and dull ends of
toothpick/ paper clip
-Apply stimuli randomly and ask patient to identify
whether sensation is sharp or dull.

-Touch patient’s skin with test tubes filled with hot or

cold water.
-Apply stimuli randomly, and ask patient to identify
whether sensation is hot or cold.
Normal: Abnormal:
Diminished or absent pain
 Identifies areas
perception:
stimulated and type
- Peripheral nerve damage or damage
of stimulation.
to lateral spinothalamic tract.
■ Hyperalgia:
Increased pain sensation.
■ Hypoalgesia:
Decreased pain sensation.
■ Analgesia: No pain sensation.
■ Diminished/absent temperature
perception:
- Peripheral nerve damage or damage
to lateral spinothalamic tract
3. Vibration
-Place a vibrating tuning fork over a finger joint, and
then over a toe joint.
-Ask patient to tell you when vibration is felt and
when it stops.
- If patient is unable to detect vibration, test proximal
areas as well.
Normal: Abnormal:
Diminished/absent vibration
 Vibratory
sense:
sensation intact
- Peripheral nerve damage caused
bilaterally in
by alcoholism, diabetes, or damage
upper and lower
to posterior column of spinal cord.
extremities.
4. Kinesthetics (Position Sense)
-Determine patient’s ability to perceive passive
movement of extremities.
- Hold fingers on sides and move up and down, and
have patient identify direction of movement.
-Flex and extend patient’s big toe, and ask patient to
describe movement as up or down.
• Avoid moving the patient’s
finger by placing your finger on
top of the patient’s because the
patient may sense the pressure of
your finger rather than a true
position change.
• If position sensation is intact
distally, it is intact
proximally.
Normal: Abnormal:
 Position sensation ■ Diminished or absent position
intact bilaterally in sense:
upper and lower - Peripheral nerve damage or damage
extremities. to posterior column of spinal cord.
5. Stereognosis
With patient’s eyes closed, place a familiar object,
such as a coin or a button, in patient’s hand, and ask
patient to identify it.
■ Test both hands using different objects.

Normal: Abnormal:
 Stereognosis ■ Abnormal findings suggest a
intact bilaterally. lesion or other disorder involving
sensory cortex or a disorder
affecting posterior
column.
6. Graphesthesia
- With patient’s eyes closed, use point of a closed
pen to trace a number on patient’s hand
- Ask patient to identify the number.
Normal: Abnormal:
 Graphesthesia ■ Abnormal findings suggest
intact bilaterally. lesion or other disorder involving
sensory cortex or disorder
affecting posterior
column.
7. Two-Point Discrimination
Ability to differentiate between two points of
simultaneous stimulation.
- Using ends of two toothpicks/ paper clip,
stimulate two points on fingertips simultaneously.
- Gradually move toothpicks together, and
assess
smallest distance at which patient can still
discriminate two points (minimal perceptible
distance).
- Document distance and location.
Normal: Abnormal:
 Discriminates ■ Abnormal findings suggest
between two lesion or other disorder involving
points on sensory cortex or disorder
fingertips no affecting posterior
more than 0.5 cm column.
apart and on hands
no more than 2 cm
apart.
8. Point Localization
■ Ability to sense and locate area being stimulated.
■ With patient’s eyes closed, touch an area; then
have
patient point to where he or she was touched.
■ Test both sides andAbnormal:
Normal: upper and lower extremities.
 Point localization Abnormal findings suggest lesion
intact. or other disorder involving sensory
cortex or disorder affecting
posterior column.
9. Sensory Extinction
■ Simultaneously touch both sides of patient’s body
at same point.
■ Ask patient to point to where she or he was
touched.
Normal: Abnormal:
 Extinction intact. Identification of stimulus on only
one side suggests lesion or other
disorder involving sensory cortical
region in opposite hemisphere.
 REFLEXES
Documenting Reflex Findings
• Use these grading scales to rate the strength of each
reflex in a deep tendon and superficial reflex assessment.
Deep tendon reflex grades
0 absent
+ present but diminished
+ + normal
+ + + increased but not necessarily pathologic
+ + + + hyperactive or clonic (involuntary contraction
and relaxation of skeletal muscle)

Superficial reflex grades

0 absent
+ present
• Documentation of reflex finding
 ASSESSING REFLEXES
1. Deep Tendon Reflexes
a. Biceps Reflex
■ Rest patient’s elbow in your nondominant hand,
with your thumb over biceps tendon.
■ Strike your thumbnail.

Normal:
■ Contraction of biceps with flexion of forearm.
■ +2
b. Triceps Reflex
■ Abduct patient’s arm and flex it at the elbow.
■ Support the arm with your nondominant hand.
■ Strike triceps tendon about 1 to 2 inches above
olecranon process, approaching it from directly
behind.

Normal:
■ Contraction of triceps with extension at elbow.
■ +2
c. Patellar Reflex
■ Have patient sit with legs dangling.
■ Strike tendon directly below patella..

Normal:
■ Contraction of quadriceps with extension of
knee.
■+2
d. Achilles Reflex
■ Have patient lie supine or sit with one knee
flexed.
■ Holding patient’s foot slightly dorsiflexed,
strike Achilles tendon.

Normal:
■ Plantar flexion of foot.
■+2
e. Test for Ankle Clonus
■ If you get 4 reflexes while supporting leg
and foot, quickly dorsiflex foot.

Normal:
■ No contraction
Abnormal:
■ Absent/diminished DTRs:
- Degenerative disease; damage to peripheral nerve
such as peripheral neuropathy; lower motor neuron
disorder, such as ALS and Guillain-Barré syndrome.
■ Hyperactive reflexes with clonus:
- Spinal cord injuries, upper motor neuron disease such
as MS.
■ Rhythmic contraction of leg muscles and foot is
positive sign of clonus
- indicates upper motor neuron disorder.
2. Superficial Reflexes
a. Abdominal Reflex
■ Stroke patient’s abdomen diagonally from upper
and lower quadrants toward umbilicus.
■ Contraction of rectus abdominis. Umbilicus
moves toward stimulus.
a. Abdominal Reflex
■ Gently stroke skin around anus with gloved
finger.

Normal:
■ Anus puckers.

b. Cremasteric Reflex
■ Gently stroke inner aspect of a male’s thigh.

Normal:
■ Testes rise.
c. Bulbocavernosus Reflex
■ Gently apply pressure over bulbocavernous
muscle on dorsal side of penis.

Normal:
■ Bulbocavernosus muscle contracts.

d. Plantar Reflex (Babinski’s Response)

■ Stroke sole of patient’s foot in an arc from
lateral heel to medial ball.

Normal:
■ Flexion of all toes.
 Assessing the Cerebellar Function
1. Balance tests
a. Gait
Observe as the person walks 10-20 feet, turns,
and returns to the starting point.
Normal: Abnormal:
 Person moves with a Stiff, immobile posture. Staggering
sense of freedom. or reeling. Wide base of support
 Gait is smooth, Lack of arm swing or rigid arms
rhythmic, and Unequal rhythm of steps. Slapping
effortless of foot. Scraping of toe of shoe
Ataxia – uncoordinated or unsteady
 Opposing arm swing
gait.
is coordinated
 The turns are smooth
Perform Tandem Walking
- ask the person to walk a straight line in a heel-
to-toe fashion.
This decreases the base of support and will
accentuate any problem with coordination.
Normal: Abnormal:
 Person can walk Crooked line walk
straight and stay Widens base to maintain balance
balanced Staggering, reeling, loss of
balance
An ataxia that did not appear
now. Inability to tandem walk is
sensitive for an upper motor
neuron lesion, such as multiple
sclerosis.
b. The Romberg Test
(discussed previously)

• Ask the person to perform a shallow knee bend or

hop in place, first on one leg, then the other.
- this demonstrates normal position sense, muscle
strength, and cerebellar function.
(some individuals cannot hop owing to aging or
obesity)
Normal: Abnormal:
 Negative Romberg Sways, falls, widens base of feet
test to avoid falling
Positive Romberg sign
-Loss of balance that occurs
when closing the eyes.
-Occurs with cerebellar ataxia
(multiple sclerosis, alcohol
intoxication)
-Loss of proprioception, and
loss of vestibular function
2. Coordination and Skilled Movements
a. Rapid Alternating Movements (RAM)
Ask the person to pat the knees with both hands,
lift up, turn hands over, and pat the knees with the
backs of the hands.
Then ask to do this faster.
Normal: Abnormal:
 done with equal Lack of coordination
Dysdiadochokinesia
turning and quick
rhythmic pace - Slow, clumsy, and sloppy
response
- occurs with cerebellar
disease
 b. Finger-to-Finger test
With the persons eyes open, ask that he or she use
index finger to touch your finger, then his or her
own nose.
After a few times move your finger to a different
spot.
Normal: Abnormal:
 Movement is  Dysmetria
smooth and accurate - clumsy movement with
overshooting the mark
- occurs with cerebellar
disorder
Past-pointing
- constant deviation to one side
 c. Finger-to-nose test
Ask the person to close the eyes and to stretch out
the arms.
Ask the person to touch the tip of his or her nose
with each index finger, alternating hands and
increasing speed.
Normal: Abnormal:

 Done with accurate Misses nose.
Worsening of coordination when
and smooth
movement the eyes are closed
- occurs with cerebellar disease
 sources
• Dillon, Patricia. Nursing Health Assessment. 2nd
Ed. F.A. Davis. 2007
• Jarvis, Carolyn. Physical Examination and Health
Assessment. 3rd ed. New York: W.B. Saunder
Company.2000
• Bickley. Lyn and Hoekenan, Robert. Bate’s Guide
to Physical Examination and History Taking. 7th
ed. New York: Lippincott Williams and Wilkins.
1999
• Estes, Mary Ellen Zator. Health Assessment &
Physical Examination. 3rd ed. Delmar Learning.
2006
THANK YOU!!!