1. Neurological Assessment
NURS 347 Towson University

2. Nervous System Brain Spinal Cord 12 pair of cranial nerves
Central Nervous System (CNS)
Peripheral Nervous System (PNS)
Brain
Spinal Cord
12 pair of cranial nerves
31 pair of spinal nerves
Nerve branches

3. Central Nervous System
Cerebral Cortex: Outer layer of cerebrum
Gray Matter
Area of highest functioning: through, memory, reasoning, sensation, and voluntary movement
Cerebrum: Right and Left hemispheres
Left dominant in 95% of people: Right handed
Four lobes per hemisphere:
frontal parietal
temporal occipital

4. Assessing the Cerebral Cortex
Begin with subjective data and history.

5. Neurological System Subjective Data Questions to ask the patient:
Orientation: Person, Place, Time, Situation
Headache
Head Injury
Dizziness/Vertigo
Seizures
Tremors
Weakness
Incoordination
Numbness or tingling
Difficulty swallowing (Dysphagia)
Difficulty speaking (Dysphasia)
Significant Past History
Environmental or occupational hazards
Review medications: anticonvulsants, antitremors, antivertigos, and pain medications
Neurological System
Subjective Data

6. Level of Consciousness (LOC)
Alert: Easily awakened with minimal stimulation
Lethargic: Drowsy, vigorous stimulation necessary for brief, but appropriate response
Stupor: Sluggish response to aggressive verbal, visual, or painful stimuli
Comatose: Response of reflex motor activity only to painful stimuli
Sternal Rub: Painful Stimuli used with a stuporous or comatose patient

7. Glasgow Coma Scale (GCS)
The Glasgow Coma Scale (GCS) minimizes the ambiguity of level of consciousness assessments,
The GCS is a quantitative tool that standardizes patient’s responses with a numerical value

8. Peripheral Nervous System Function
Carries sensory messages TO the central nervous system’s sensory receptors
Transmits messages FROM the CNS to the muscles and glands throughout the body

9. Cranial Nerves

10. Neurological Assessment
Inspection:
Symmetry of skull (normocephalic)
Symmetry of face
observe palpebral fissures, nasolabial folds
Scalp: Mobility
Neck: Range of Motion (ROM)
Palpation:
Scalp: Lesions
Neck: Tenderness
Neurological Assessment
Objective Data:
Head & Neck

11. CN I: Olfactory Nerve Do not test routinely
Test among those who report loss of smell or had experienced head trauma
Step I: Occlude one nostril at a time and ask the patient to sniff
Establishes baseline and patency
Step II: With patient’s eyes closed, present an aromatic substance that is easily identified beneath one nostril
Step III: Repeat on opposite side

12. CNV: Trigeminal Nerve Motor: Sensation:
Both a sensory and motor nerve!
Motor:
Symmetrical jaw movement
Mastication (chewing)
Assess:
Palpate temporal and masseter muscles bilaterally as patient clenches teeth.
Attempt to push down on chin to separate jaws.
Sensation:
Three nerve divisions:
1) Opthalmic, 2) Maxillary, 3) Mandibular
Assess: Touch cotton wisp to bilateral areas of forehead, cheek, and chin and request patient to state when sensation is felt.

13. CN VII: Facial Nerve Mixed Motor and Sensory Nerve
MOTOR Assessed by observing bilateral movement when a patient:
Smiles!
Frowns
Closes eyes tightly
Lifts eyebrows
Shows teeth
Puffs cheeks
When you press puffed cheeks in, assess for equal bilateral, evacuation of air

14. CN VII: Facial Nerve SENSORY nerve:
Assessed when facial nerve injury is suspected
Apply a cotton applicator that has been covered with a solution of sugar, salt, or lemon juice to patient’s tongue- ask patient to identify taste.

15. CN IX & X: Glossopharyngeal & Vagus
Assess the nerves’ motor function by:
Depress tongue with a tongue blade: watch for pharyngeal movement as the patient says “ahh” or yawns:
Uvula and soft-palate should rise midline
Tonsillar pillars should move medially
Touch the posterior pharyngeal walls with tongue blade:
Note positive gag reflex
Voice clear, no evidence of straining
Assess sensory motor:
Posterior third of tongue: bitter taste

16. CN XI: Spinal Accessory
Spinal accessory motor nerve transmits communication between the PNS and CNS.
Prior to testing nerve, assess sternomastoid and trapezius muscles for equal, bilateral size
1. Ask patient to forcibly rotate head against resistance applied at chin, repeated on both sides.
2. Ask patient to shrug shoulders against bilateral resistance
An intact CN XI should provide motor responses of equal, bilateral strength.

17. CN XII: Hypoglossal
Inspect the tongue: should be free from tremors or wasting
Forward thrust of tongue should remain midline
Listen for clear l, t, d sounds with speech of “light, tight, dynamite”

18. The Eye: Subjective Assessment
Vision difficulty (blurring, blind spots, decreased acuity)
Pain
Strabismus, diplopia
Redness, swelling
Watering, discharge
History of ocular problems
Glaucoma
Use of glasses or contact lenses
Self-Care Behaviors
Surgeries
The Eye: Subjective Assessment

19. The Eye: Objective Assessment
Prior to testing neurological reflexes, inspect anatomy of the eye for:
Symmetry, position, discharge
External Structures:
Lid, lashes, and brow
Color
Conjunctive
Sclera
Anterior Structures:
Cornea and Lens
Iris and Pupils
The Eye: Objective Assessment

20. Inspecting the Ocular Fundus
In a darkened room using an opthalmoscope:
Elicit Red Reflex
Assess retinal vessels for
Nicking
Hemorrhages
Exudates
Visualize the optic disc for:
Color
Size
Shape

21. CN II: The Optic Nerve Snellen Acuity Test (Distant)
Confrontation Test Visual Fields

22. Visual Acuity “Near Sighted” “Far Sighted” Peripheral Vision
Decreased visual acuity at a distance
Assessed via Snellen Chart
“Far Sighted”
Decreased visual acuity in a close range.
Assessed via Jaeger card
Peripheral Vision
Assessed via Confrontation Test

23. CN III, IV & VI: Oculomotor, Trochlear & Abducens
CN III: Responsible for the eye’s up and down movement, movement of the pupil
CV IV: Superior and oblique eye movement
CN VI: Outward eye movement
Assess for:
Strabismus: Deviated gaze or limited movement
Nystagmus: Involuntary back and forth or cyclical movement

24. Corneal Light Reflex: Hirschberg Test
Click on video to play, from YouTube

25. Cover/Uncover Test

26. PERRLA Assessment of the CN III, IV and VI via the PUPILS Pupils Equal
Round
React to
Light and
Accommodation

27. The Ear: Subjective Assessment
Earaches
Infections
Discharge
Hearing loss
Environmental Noise
Tinnitus
Vertigo
Self-Care Behaviors
The Ear: Subjective Assessment

28. The External Ear: Objective Assessment
INSPECTION
Size and Shape: Equal size bilaterally, free from swelling or thickness
Skin color of ears matches facial skin color, skin intact, free from lumps or lesions
External auditory meatus: Note opening size, any swelling, redness, or discharge
PALPATION
Mastoid process
Move pinna and push on tragus
Palpation should reveal firm structures that move without producing pain
The External Ear: Objective Assessment

29. Inspection of the Tympanic Membrane

30. Otoscope
Otoscope size depends on the diameter of the auditory meatus: choose the largest speculum that will fit comfortably in the ear canal
Have the patient tilt head away from you and towards opposite shoulder
With the adult patient, pull pinna up and back
Infant or child under 3 years old, pull pinna down
Holding the otoscope in a position that seems upside down helps you balance the otoscope during the exam, decreasing risk of injury to the tympanic membrane.

31. CN VIII: Vestibulocochlear Assessment
Begins with subjective assessment: How well does the patient hear conversational speech?
Voice Test
Tuning Fork Test
Weber Test
Rinne Test

32. Voice Test
Test one ear at a time by muffling sound in one ear by placing finger over tragus and rapidly pushing it in and out of auditory meatus
Stand behind patient so lip-reading cannot occur
In the other ear, with your hear 2-3” from patient’s ear, slowly whisper two-syllable words and have patient repeat words; repeat on opposite ear
Ex. Tuesday, armchair, baseball, and fourteen

33. Tuning Fork Tests: Weber & Rinne

34. Hearing Loss
Conductive: Mechanical dysfunction of the external or inner ear resulting in partial hearing loss. May be caused by impacted cerumen, foreign bodies, or a perforated tympanic membrane; inner ear pus or serum, and otosclerosis.
Sensorineural: Pathology associated with inner ear, CNVIII, or cerebral cortex ; gradual nerve degeneration (presbycusis) caused by aging; ototoxic medications (Lasix) that affect cochlear hair cells.
Mixed: Combination of both conductive and sensorineural hearing loss in the same ear.

35. CN VIII: Romberg Test CN VIII is also a nerve with a “special sense.”
The inner ear provides information regarding your body’s position in space (proprioception).
If the inner ear is inflamed, incorrect information is transmitted (via the PNS) to the brain (CNS), causing the sensation of vertigo and an unsteady gait.
Equilibrium and vertigo can be assessed via the Romberg Test.

36. Romberg Test

37. Cerebellar Functioning Assessment
BALANCE:
The Romberg Test (CN VIII) assesses balance, an extension of the CNS and the functionality of the cerebellum.
Gait: Have the patient walk feet, turn and walk back. Gait should be smooth, rhythmic, and effortless with coordinated swing in the opposing arm and 15” from heel to heel.
Tandem Walking: Walk in a straight line in a heel-to-toe fashion. If intact, the person will walk straight and maintain balance, even with a decreased support base.

38. Cerebellar Functioning
Coordination and Skilled Movements:
Rapid Altering Movements (RAM)
Finger-to-Finger Test
Finger-to-Nose Test
Heel-to-Shin Test

39. Finger-to-Finger Test & Rapid Alternating Movement

40. Heel-to-Shin Test

41. Sensation: Superficial Pain
Use a tongue blade with both a sharp and dull point, lightly apply the sharp and dull points to the patient’s body in random, unpredictable manner.
Provide a 2-second break between application to prevent summation, when a frequent but separate stimuli are perceived as one, strong stimulus.

42. Sensation: Light Touch
Apply a wisp of cotton to the skin and brush it over the patient’s body in a random order at irregular intervals. Asl the patient to report when the touch is felt by stating “now” or “yes.”
Compare symmetric points bilaterally.

43. Sensation: Vibration
Use a low-pitch tuning fork and strike against the heel of your hand.
Apply the base of the tuning fork to a body surface of the fingers or great toe.
Ask patient to report when the vibration starts and stops.
If no vibration is felt in those locations, move proximally, testing the ulnar processes, ankles, patellae, and iliac crests.
Compare findings bilaterally.

44. Motor Strength
Assess via inspection the muscle groups for symmetry and size; if asymmetric, measure each in centimeters and compare difference. Measurements greater than 1 centimeter is significant.
Assess strength by assessing bilaterally muscle groups in the extremities, neck, and trunk, continuing to compare bilateral findings in each group.
Tone is the normal degree of contraction at rest. Assessment involves inspection and observation. Watch for resistance of the muscles during passive range of motion, assess bilaterally and compare.

45. Deep Tendon Reflexes (DTR)
Use the reflex hammer and use a short, snapping flow to the muscle’s insertion tendon.
Do not rest the hammer on the tendon.
Use the pointed end for smaller targets; the flat end on wider targets or to prevent pain
Compare bilateral responses
Grading 4+ Very brisk, hyperactive with clonus. Indicates presence of disease process 3+ Brisker than average; may indicate need for further work-up 2+ Average, normal 1+ Diminished, low-normal 0 No response

46. Upper Extremity DTR
Biceps
Triceps
Brachioradialis

47. Abdominal Reflexes

48. Lower Extremity DTR
Patellar
Achilles
Ankle Clonus

49. Babinski Sign: Normal only in infants
Plantar Assessment
Plantar Reflex
Babinski Sign: Normal only in infants

50. For Fun…