Neurological Assessment
____________________
A Written Report Presented to
The Faculty of Nursing Department
Josephine B. Magno RN.,MN.
____________________
In Partial Fulfillment of
The Requirements NCM 212-RLE
Inflammatory & Immunologic Response,
Cancer Nursing Rotation
By:
Rhona Angel V. Payot
Clarissa S. Torres
BSN 3D Group 1
November 28, 2020
Definition: A neurological examination is a systematic method of assessing the inte
gration of brain function and motor response.A nursing assessment of the patient's n
eurological status incorporates monitoring of the patient's level of consciousness, cra
nial nerves, pupil reaction, motor and sensory function, and the reflexes.
Purpose:
● to detect neurological disease or injury
● monitor its progression to determine the type of care to provide
● gauge the patient's response to interventions
● to establish an understanding of each patient’s ‘best response’ baseline in ord
er to determine any subtle downward trends in function.
● to identify any subtle changes in neurological function of the patient that may
signify a potential deterioration
When do NVS need to be completed?
Neuro Vital Signs (NVS) will be assessed at minimum of once per shift for all i
npatients (to establish their baseline) or as per:
● Physician order
● Nursing Care Plans
● Nursing clinical judgment
● As required for a particular procedure or medication
NOTE: Nursing staff will perform a two nurse visual NVS assessment:
● at shift to shift handover if patient on every 2 hours or more frequent NVS ass
essment
● at shift to shift handover if patient on 1:1 or 2:1 nursing care
● if patient shows a change in GCS or other neurologic indicators that might indi
cate a potential deterioration
● if patient is difficult to assess due to age or other factors
● if patient requires a set of NVS done by a nurse other than the primary nurse
caring for the patient that shift
● when patient is transferred/admitted to another unit
Five Components
1. Cerebral function/Cognitive Status
2. Cranial Nerves
3. Motor System
4. Sensory System
5. Reflexes
1. Cognitive status
● Level of Consciousness (LOC)
It is a term used to describe a person's awareness and understanding of what
is happening in his or her surroundings. It is assessed through noting the presence o
f Arousal/Wakefulness,Alertness and Awareness, and Appropriate voluntary motor a
ctivity.
● Orientation
Orientation is used to evaluate cognitive functioning and screen for dementia.
It refers to a person's level of awareness of person, place, time, and situation. When
assessing for orientation, the nurse/ doctor typically asks for:
1. The patient’s name
2. Where he/she is
3. What is the date and time
4. What has happened to him/her
Orientation levels
The level—x1, x2, x3, or x4—is a way of expressing the extent of the patient's aware
ness.
X1: Oriented to Person- The patient knows his or her name and can recognize signifi
cant others.
x2: Oriented to Person and Place- In addition to knowing his or her name, the patient
knows where he or she is.
x3: Oriented to Person, Place, and Time- In addition to knowing his or her name and
location, the patient also knows the date, day of the week, and season.
x4: Oriented to Person, Place, Time, and Situation- In addition to knowing his or her
name, location, and time, the patient can explain the situation of why they are at the
healthcare facility.
● Memory and Concentration
Memory and concentration is used to assess for the Remote/Past memory, R
ecent/Present memory and Immediate/Short term memory.
Assessment: Ask questions such as:
(Remote or Past Memory): What color did you wear in your wedding? Or What year
did you first give birth?
(Recent or Present Memory): What food did you eat recently?
(Immediate or Short Term memory): Give 3-5 words and ask the patient to repeat the
words.
● Mood and Affect
Affect is the patient's immediate expression of emotion, It is inappropriate whe
n there is no consonance between what the patient is experiencing or describing and
the emotion he is showing at the same time (e.g,laughing when relating the recent d
eath of a loved one).; mood refers to the more sustained emotional makeup of the pa
tient's personality.
● Intellectual Performance
Assessment: Assessing for intellectual performance is done by using simple a
nd basic mathematical equations and having the patient answer it.
● Judgment and Insight
Insight is a patient's awareness of themselves and their condition.It is assesse
d by noting if the patient gives a direct or indirect answer on the question the tester a
sks. Judgment as used on the mental status exam refers most commonly to an asse
ssment of the patient's ability to avoid behavior that might be harmful to themselves
or others.
● Language and Communication
Assessment: Basic examination of language function should include an asse
ssment of spontaneous speech, comprehension of spoken commands, reading abilit
y, reading comprehension, writing, and repetition.
● Mini Mental State Exam (MMSE) for Elderly
The Mini-Mental State Exam (MMSE) is a widely used test of cognitive functio
n among the elderly; it includes tests of orientation, attention, memory, language and
visual-spatial skills.
Assessment: Give 5 letters to the patient and ask him/her to repeat the letters
in order.
Interpretation:
5/5 letters in order- no cognitive impairment
3/5 letters in order- mild/minimal/slight cognitive impairment
0/5letters - severe cognitive impairment
● Mini-Cognitive for the Elderly
It is a 3-minute instrument that can increase detection of cognitive impairment
in older adults. It can be used effectively after brief training in both healthcare and co
mmunity settings. It consists of two components, a 3-item recall test for memory and
a simply scored clock drawing test.
A. 3-Item Recall Test
The test starts with the nurse/doctor giving three unrelated words aloud, in a s
trong voice to ensure they’re clearly heard. Example words would be “shampoo, sun
rise, chair,” or “daughter,stars,monkey.” Then the test-taker is asked to draw a clock
(to be used in the Clock drawing test). After completing the drawing, the test-taker is
asked to repeat the three words that were spoken at the beginning of the test.
The three-item word recall is a means of testing short-term memory because
difficulty with short-term memory is one of the first signs of most kinds of dementia, i
ncluding Alzheimer’s disease. Asking for these words to be repeated after the distrac
tion of drawing the clock challenges memory.
B. Clock Drawing test
The subject is asked to draw a clock showing a specific time, usually “a quarte
r to 11” or “10 past 11.” This test is used to test an individual’s verbal understanding
by noting if he/she follows instructions when instructed to draw a clock,Visual memor
y when remembering what a clock even looks like, Planning and understanding since
it takes multiple steps to draw a clock and Abstract thinking.
5. Cranial Nerves
CN Function Method Of Assessment Indications of Dys
function
I Smell Ask client to close eyes and iden ● Anosmia
Olfactory n tify an aromatic, non irritating od
erve or such as coffee,vanilla and alc
ohol
II Central and Let the patient read the Snellen’ ● Amaurosis
Optic Nerv Peripheral s Chart ● Vision loss i
e Vision n 1or more d
irection
III,IV,VI EOM,Eyelid ● Have the patient look in al ● Nystagmus
Oculomoto elevation an l 6 directions (6 ocular mo ● Diplopia
r nerve d vement) without moving t ● Anisocuria
Pupillary Co heir head and ask them if ● Irregular sha
nstriction they experienced any dou ped pupils
ble vision.
● Note for Pupillary reaction
V Mastication ● Light touch is tested in ea ● Weakness,s
Trigeminal Sensation f ch of the three divisions o pasms of ma
nerve or entire fac f the trigeminal nerve and sseter or te
e,scalp,corn on each side of the face u mporal musc
ea and nas sing a cotton wisp or tissu les
al and oral c e paper. The ophthalmic ● Facial pain a
avities division is tested by touch nd paresthes
ing the forehead, the maxi ia
llary division is tested by t
ouching the cheeks, and t
he mandibular division is t
ested by touching the chi
n.
For pain and temperature,
repeat the same steps as
light touch but use a shar
p object and cold tuning f
ork respectively
● tested by asking the patie
nt to keep the mouth ope
n against resistance, and
move from side to side ag
ainst resistance.
VII Facial Expr ● Ask the patient to raise b ● Facial asym
Facial Nerv ession and oth eyebrows, Frown,Clos metry
e sensation e both eyes tightly. ● Facial paraly
● Test muscular strength b sis
y trying to open them,Sho ● Bell’s Palsy
w both upper and lower te
eth, Smile,Puff out both c
heeks
VIII Hearing and ● Hearing is tested by whis ● Diminished o
Vestibuloc balance pering numbers in one ea r loss of hear
ochlear Ne r as the patient covers the ing
rve other and by asking the p ● (+) Romber
atient to repeat the numb g’s test
ers. Alternatively, have th
e patient close their eyes
and say "left" or "right" de
pending on the side from
which they hear the soun
d. Vigorously rub fingers t
ogether in one ear at a ti
me to produce rustling so
und
● Rinne and Weber Test
IX & X Taste and ● Ask the patient to say “A ● Deviated uv
Glossophar Pharyngeal H” and note if the soft pal ula
yngeal and movement ate and pharynx rise sym ● No gag refle
vagus Nerv metrically, and if uvula is i x
e n midline ● Weak cough
● Assess taste in the back ● Loss of taste
of the tongue with sugar a
nd salt
XI Shoulder El Ask the patient to shrug shoulde ● Muscle atrop
Accessory evation and rs against resistance, turn head l hy and weak
Nerve Lateral Hea aterally against resistance shoulder shr
d Rotation ug
XII Tongue Mo Ask the patient to stick out his/h ● Deviation of
Hypogloss vement er tongue, move it side to side a tongue to we
al Nerve nd against each cheek and say ak side,atrop
“light,tight, dynamite” hy,fasciculati
ons, slurred
speech
6. Motor System
a. Reaction Level Scale
1 Alert
2 Drowsy, responds to light stimuli
3 Very drowsy, responds to strong stimuli
4 Unconscious, localizes
5 Unconscious, withdraws
6 Unconscious, decorticate
7 Unconscious, decerebrate
8 Comatose
b. Glasgow Coma Scale
The Glasgow Coma Scale provides an objective measure of the patient’s level
of consciousness. The GCS is scored between 3 and 15, 3 being the worst, and 15 t
he best. It is composed of three parameters: best eye response (E), best verbal resp
onse (V), and best motor response (M). The components of the GCS are recorded in
dividually; for example, E2V3M4 results in a GCS of 9.
Area Measured Response Score
Eye opening Spontaneous 4
To verbal command / to speech 3
To pain 2
None 1
Motor Response Obeying 6
Localizes 5
Withdraws 4
Decorticate 3
Decerebrate 2
None 1
Verbal Response Oriented 5
Confused 4
Inappropriate 3
Incomprehensible 2
No verbal response 1
Intubated I
c. Pupillary Assessment
PERRLA (Pupils equally round, reactive to light and accommodation) is an acr
onym used to document a common pupillary response test. This test is used to chec
k the appearance and function of the patient’s pupils. The information can help to dia
gnose several conditions, from glaucoma to neurological diseases.
Assessment Normal Response
Pupil Size The normal pupil size in adul
The examiner shines a handheld light obliquely ts varies from 2 to 4 mm in d
from below the nose for indirect illumination an iameter in bright light to 4 to
d a clear view of the pupils in both darkness an 8 mm in the dark. The pupils
d room light. are generally equal in size.
Light Reflex Test There should be a brisk, sim
To assess the integrity of the pupillary light refl ultaneous, equal response o
ex, the examiner must dim the ambient light an f both pupils in response to li
d ask the patient to fixate on a distant target. S ght shone in one or the other
hine on the right eye from the right side, and o eye
n the left eye from the left side.
Near Reflex Test There should be brisk constr
iction.
In a normally lit room, instruct the patient to loo
k at a distant target. Bring an object into the ne
ar point and observe the pupillary reflex when t
heir fixation shifts to the near target.
Swinging flashlight test Normally, each illuminated p
Compares direct and consensual responses of upil promptly becomes const
each eye. In a dim room light, the examiner not ricted. The opposite pupil als
es the size of the pupils. The patient is asked t o constricts consensually.
o gaze into the distance, and the examiner swi
ngs the beam of a penlight back and forth from
one pupil to the other, and observes the size of
pupils and reaction in the eye that is lit.
d. Balance and Coordination
Balance is the ability to maintain a position. Coordination is the capacity to mo
ve through a complex set of movements. Balance and coordination depend on the int
eraction of multiple body organs and systems including the eyes, ears, brain and ner
vous system, cardiovascular system, and muscles. Tests or examination of any or all
of these organs or systems may be necessary to determine the causes of loss of bal
ance, dizziness, or the inability to coordinate movement or activities.
1. Gross Motor and Balance Test
a. Walking gait - Gait is a person’s pattern of walking. Walking involves ba
lance and coordination of muscles so that the body is propelled forward
in a rhythm, called the stride. Gait is evaluated by having the patient wa
lk across the room under observation.
b. Romberg’s Test - The Romberg test is used for the clinical assessment
of patients with disequilibrium or ataxia from sensory and motor disorde
rs. In the Romberg test, the patient stands upright and asks to close his
eyes. A loss of balance is interpreted as a positive Romberg sign.
c. Standing with one foot with eyes closed - This is used to assess static
postural and balance control
d. Heel-toe Walking - or tandem gait means walking in a straight line with
the front foot placed such that its heel touches the toe of the standing f
oot. Normal gait is smooth, and has continuous rhythm
e. Toe or heel Walking - Walking on heels is the most sensitive way to tes
t for foot dorsiflexion weakness, while walking on toes is the best way t
o test early foot plantar flexion weakness.
2. Fine Motor Test for Upper Extremities
a. Finger to Nose Test - The Finger-to-Nose-Test measures smooth, coor
dinated upper-extremity movement by having the examinee touch the ti
p of his or her nose with his or her index finger.
b. Alternating Supination and pronation of hands on knees - It is consider
ed a Cerebellar Testing of Diadochokinesia (Rapid Alternating Moveme
nts)
c. Finger to Nose and to the Nurse’s finger - patient is asked to alternately
touch their nose and the examiner's finger as quickly as possible.
d. Fingers to Fingers - A test for coordination of the arms and hands in wh
ich an individual is asked to bring the index fingers together.
e. Fingers to thumb - This tests the cognitive function and coordination wh
ere the patient touches each finger of one hand to the thumb of the sa
me hand in an alternating pattern.
3. Fine Motor Test for the lower extremities
a. Heel Down Opposite Shin - The heel to shin test is a measure of coordi
nation and may be abnormal if there is loss of motor strength, proprioc
eption or a cerebellar lesion.
b. Toe or Ball of Foot to the Nurse’s finger - This also tests the coordinatio
n and cognitive function where the client is asked to touch the examine
r’s finger with his/her large toe.
4. Sensory System
a. Light touch Sensation - Light touch (thigmesthesia) is used as a screening tes
t for touch. With the use of a cotton wisp, a client is asked to close his/her eye
s and to respond whenever it touches his/her skin.
b. Pain sensation - Pain is one of the principle sensory modalities of the spinotha
lamic system. Pain provides a means to alert the body that tissue damage has
occurred, although pain can be elicited without tissue damage. This is assess
ed through the use of a broken tongue depressor, where a sharp and dull end
is utilized.
c. Temperature Sensation - Temperature, like pain provides a means to alert the
body to potential tissue damage. Temperature tests the individual’s ability to p
erceive the difference between hot and cold stimuli.
d. Position or Kinesthetic Sensation - is used to measure the ability of a subject t
o perceive limb position by moving a single joint on one side and matching its
exact position on the other.
e. Tactile Sensation - Tactile movement tests the patient's ability to detect the dir
ection of a 2-3 cm cutaneous stimulus.
➔ One- and-Two point Discrimination - measures the individual’s ability to
perceive two points of stimuli presented simultaneously. The health car
e practitioner is interested in the smallest distance between the points t
hat can still be perceived as two points by the individual being tested.
➔ Stereognosis - Stereognosis is the ability to identify the shape and form
of a three-dimensional object, and therefore its identity, with tactile man
ipulation of that object in the absence of visual and auditory stimuli.
➔ Extinction phenomenon - This tests if a client is able to attend to and id
entify a tactile stimulus that is applied to both sides of the body at the s
ame time.
5. Reflexes
A reflex is an involuntary and nearly instantaneous movement in response to
a stimulus. The reflex is an automatic response to a stimulus that does not receive or
need conscious thought as it occurs through a reflex arc. Reflex arcs act on an impul
se before that impulse reaches the brain.
a. Biceps Reflex - This is to test the spinal cord level C5-C6.
b. Triceps Reflex - This is to test the spinal cord level C7 and C8.
c. Brachioradialis reflex - This is to test the spinal cord level C3 and C6
d. Patellar Reflex - This is to test the spinal cord level L2, L3, L4.
e. Achilles Reflex - This tests that spinal cord level S1 and S2.
f. Plantar (Babinski’s) Reflex - The Babinski reflex occurs after the sole of the fo
ot has been firmly stroked. This disappears after age 1, thus, a negative Babin
ski sign is expected in adults, where the toes curl downward.
NEWBORN REFLEXES
a. Sucking Reflex - A feeding reflex that occurs when the infant’s lips are touche
d. The reflex persists throughout infancy
b. Rooting Reflex - A feeding reflex elicited by touching the baby’s cheek causin
g the baby’s head to turn to the side that was touched. This reflex usually disa
ppears after 4 months.
c. Moro Reflex - Aka startle reflex, is often assessed to estimate the maturity of t
he Central Nervous system (CNS). A loud noise, a sudden change in position,
an abrupt jarring of the crib elicits this reflex. The infant reacts by extending b
oth arms and legs outward with the fingers spread, then suddenly retracting th
e limbs. Often the infant cries at the same time. It disappears after 4 months.
d. Palmar Grasp Reflex - This occurs when a small object is placed against the p
alm of the hand, causing the fingers to curl around it. This reflex disappears af
ter 3 months.
e. Plantar Reflex - Similar to the palmar grasp reflex, an object placed just benea
th the toes causes them to curl around it. This disappears after 8 months
f. Fencing Reflex - or tonic neck reflex, is a postural reflex. When a baby who is
lying on its back turns its head to the right side, for example, the left side of th
e body shows a flexing of the left arm and the left leg. This reflex disappears a
fter 4 months.
g. Stepping Reflex - Aka walking or dancing reflex, can be elicited by holding the
baby upright so that the feet touch a flat surface. The legs then move up and
down as if the baby is walking. This disappears after 2 months
h. Babinski Reflex - When the sole of the foot is stroked, the big toe rises and th
e other toes fan out. A newborn baby has a positive Babinski. After age 1, the
infant exhibits a negative Babinski, that is, the toes curl downward. A positive
Babinski after age 1 indicates brain damage.
i. Blinking Reflex - This occurs in the presence of light or loud noise
j. Neck Righting - The baby’s head turned to one side.
k. Landau Reflex - Suspend horizontally against trunk and neck flexed, leg will fl
ex and be drawn up to the trunk
l. Parachute Reflex - Baby is held in prone and lowered quickly toward a surfac
e. Arms and legs will extend.
Equipment:
➔ Penlight
➔ Jotdown Notebook
➔ Ballpen
➔ Tongue depressor
➔ Tuning fork
➔ Snellen’s Chart
➔ Safety pin
➔ Paper Clip
➔ Coin
➔ Percussion/Reflex hammer
Procedure:
1. Wash hands in order to deter the spread of microorganisms.
2. Assemble the equipment to be used during the assessment.
3. Determine the client’s orientation to time, place and person by tactful question
ing.
4. Determine client’s Level of Consciousness (RLS/GCS). Make use of the Neur
o Assessment Graphic Sheet
5. Assess the client’s pupils
a. Compare the sizes of the pupils in the light and the dark.
b. Get the patient to fix their eyes on a distant point to begin with, then to
observe the pupils through a side illumination.
c. Assess direct and consensual light reflexes. Gently point the focal light
into one eye. Then, withdraw the light for a few seconds, followed by sti
mulating the same eye again but this time observe the indirect, or cons
ensual, PLR in the opposite eye.
6. Assess the Cranial Nerves
a. Cranial Nerve I - Olfactory
Ask the client to close eyes and identify different mild aromas, such as
coffee, alcohol, vanilla.
b. Cranial Nerve II - Optic
Ask the client to read Snellen’s chart and check visual fields by confron
tation.
c. Cranial Nerve III - Occulomotor
Assess six ocular movements and pupil reaction.
d. Cranial Nerve IV-Trochlear and VI - Abducens
Assess six ocular movements. CN 6 assess ability to gaze laterally.
e. Cranial Nerve V - Trigeminal
While the client looks upward, lightly touch the lateral sclera of the eye
to elicit a BLINK reflex. To test light sensation, have client close eyes, a
nd wipe a wisp of cotton over the client’s forehead and paranasal sinus
es. Use blunt and sharp ends of safety pins for deep sensation over the
same area.
f. Cranial Nerve VII - Facial
Ask the client to smile, raise the eyebrows, frown, puff out cheeks, clos
e eyes tightly (against attempts to open them).
g. Cranial Nerve VIII - Acoustic (Vestibulocochlear)
Assess client’s ability to hear spoken words, and vibrations from tuning
fork (Apply Weber and Rinne Test)
h. Cranial Nerve IX - Glossopharyngeal
Depress the tongue with a tongue blade, and note pharyngeal moveme
nt as the person says “ahh” or yawns. Touch the posterior pharyngeal
wall with the tongue blade and note the gag reflex. Apply tastes on post
erior tongue for identification.
i. Cranial Nerve X - Vagus
Assess with CN IX; assess client’s speech for hoarseness
j. Cranial Nerve XI - Spinal Accessory
Ask the client to shrug shoulders against resistance from your hands a
nd turn his head to side against resistance from your hand. Repeat for t
he other side.
k. Cranial Nerve XII - Hypoglossal
Ask the client to protrude his tongue at midline, then move it side to sid
e.
7. Reflexes
a. Biceps Reflex
Partially flex the client’s arm at the elbow; and rest the forearm over the
thighs, placing the palm of the hand down. Place the thumb of your non
dominant hand horizontally over the biceps tendon.
Deliver a blow (slight downward thrust) with the percussion hammer to
your thumb. Observe the normal slight flexion of the elbow, and feel the
bicep’s contraction through your thumb.
b. Triceps Reflex
Flex the client’s arm at the elbow level, and support it in the palm of yo
ur nondominant hand. Palpate the triceps tendon about 2-5cm (1-2 in)
above the elbow.
Deliver a blow with the percussion hammer directly to the tendon. Obse
rve for the normal slight extension of the elbow.
c. Brachioradialis Reflex
Rest the client’s arm in a relaxed position on your forearm or on the cli
ent's own leg.
Deliver a blow with the percussion hammer directly on the radius 2-5 c
m (1-2 in) above the bony prominence on the thumb side of the wrist. O
bserve the normal flexion and supination of the forearm. The fingers of
the hand may also extend slightly.
d. Patellar Reflex
Ask the client to sit on the edge of the examining table so that his legs
hand freely.
Locate the patellar tendon directly below the patella.
Deliver a blow with the percussion hammer directly to the tendon. Obse
rve the normal extension or kicking out of the leg as the quadriceps mu
scle contracts.
e. Achilles Reflex
With the client in the same position as for the patellar reflex, slightly dor
siflex the client’s ankle by supporting the foot lightly in the hand.
Deliver a blow with the percussion hammer directly to the Achilles tend
on just above the heel. Observe and feel the normal plantar flexion (do
wnward jerk) of the foot.
f. Plantar (Babinski’s) Reflex
Use a moderately sharp object, such as the handle of a percussion ha
mmer.
Stroke the lateral border of the sole of the client’s foot, starting at the h
eel, continuing to the ball of the foot, and then proceeding across the b
all of the foot toward the big toe. Observe for the response. Normally, i
n adults all five toes bend downward.
8. Motor Function
8.1 Gross Motor and Balance Test
a. Walking Gait
Ask the client to walk across the room and back, and assess the client’
s gait
b. Romberg’s Test
Ask the client to stand with feet together and arms resting at the sides,
first with eyes open, then closed for 20 to 30 seconds without support.
c. Standing with one foot with eyes closed
Ask the client to close his/her eyes and stand on one foot, then the oth
er. Stand close to the client during the test.
d. Heel-Toe Walking
Ask the client to walk a straight line, placing the heel of one foot directly
in front of the toes and then on the heels.
e. Toe or heel walking
Ask the client to walk several steps on the toes and then on the heels.
8.2 Fine Motor Test for Upper Extremities
a. Finger to Nose Test
Ask the client to abduct and extend the arms at shoulder height and ra
pidly touch the nose alternately with one index finger and then the othe
r. Have the client repeat the test with the eyes closed if the test is perfo
rmed easily.
b. Alternating Supination and Pronation of hands on knees
Ask the client to pat both knees with the palms of both hands and then
with the back of the hands alternately at an ever-increasing rate.
c. Finger to Nose and to the Nurse’s finger
Ask the client to touch the nose and then your index finger is held at a
distance of about 45cm (18 in) at a rapid and increasing rate.
d. Fingers to Fingers
Ask the client to spread the arms broadly at shoulder height and then b
ring the fingers together at the midline, first with the eyes open and the
n closed, first slowly and then rapidly.
e. Fingers to thumb
Ask the client to touch each finger of one hand to the thumb of the sam
e hand as rapidly as possible.
8.3 Fine motor test for the lower extremities
Ask the client to lie supine and to perform these tests:
a. Heel down Opposite Shin
Ask the client to place the heel of one foot just below the opposite knee
and run the heel down the shin to the foot. Repeat with the other foot. T
he client may also use a sitting position for this test.
b. Toe or Ball of foot to the Nurse’s finger
Ask the client to touch your finger with the large toe of each foot.
8.4 Light-touch sensation
a. Compare the light touch sensation of symmetric areas of the body.
b. Ask the client to close the eyes and to respond by saying “yes” or “no
w” whenever the client feels the cotton wisp touches his skin.
c. With a wisp of cotton, lightly touch specific spot and then the same spot
on the other side of the body
d. Test areas on the forehead, cheek, hand, lower arm, abdomen, foot, an
d lower leg. Check a specific area of the limb first.
e. Ask the client to point to the spot where the touch was felt.
f. If areas of sensory dysfunction are found, determine the boundaries of
sensation by testing responses about every 2.5 cm (1 in) in the area. M
ake a sketch of the sensory loss area for recording purposes.
8.5 Pain Sensation
a. Ask the client to close his/her eyes and to say “sharp” , “dull”, “don’t kn
ow” when the sharp or dull end of the broken tongue depressor is felt.
b. Alternately, use the sharp and dull end of the sterile pin or needle to lig
htly prick designated anatomic areas at random. The face is not tested
in this manner. Allow at least 2 seconds between each test.
8.6 Temperature Sensation
a. Touch skin areas with the test tubes filled with hot or cold water
b. Have the client respond saying “hot” , “cold” or “don’t know”
8.7 Position or Kinesthetic Sensation
a. Commonly, the middle fingers and the large toes are tested for the kine
sthetic sensation.
b. To test the fingers, support the client’s arm with one hand and hold the
client’s palm in the other. To test the toes, place the client’s heels on th
e examining table.
c. Ask the client to close his/her eyes.
d. Grasp a middle finger or a big toe firmly between your thumb and index
finger and exert the same pressure on both sides of the finger or toes
while moving it.
e. Use a series of brisk up-and-down movements before bringing the fing
er or toe suddenly to rest in one of the three positions.
f. Move the finger of toe until it is up, down, or straight out, and ask the cli
ent to identify the position.
8.8 Tactile Sensation
For the entire test, the client’s eyes need to be closed.
a. One- and two- point Discrimination
Alternatively stimulate the skin with two pins simultaneously and then w
ith one pin. Ask whether the client feels one of two pinpricks.
b. Stereognosis
Place familiar objects - such as a key, paper clip, or coin - in the client’s
hand, and ask the client to identify them.
If the client has a motor impairment of the hand and is unable to manip
ulate an object, write a number or letter on the client’s palm, using a blu
nt instrument, and ask the client to identify it.
c. Extinction Phenomenon
Simultaneously stimulate two symmetric areas of the body, such as the
thighs, the cheeks, or the hands.
9.Wash hands
10. Document findings in the client’s chart.
REFERENCES
Belliveau, A., et al (2020). Pupillary Light Reflex. Retrieved: November 26, 2020
from: https://www.ncbi.nlm.nih.gov/books/NBK537180/
Child Health BC (2015). Child Health BC Pediatric Early Warning System (PEWS)
Neuro Vital Sign (NVS) Assessment Edu-quick. Retrieved: November 26,
2020 from: https://www.clwk.ca/wp-content/uploads/buddyshared/CHBC-PEW
S-edu-quick-Neurovital-Signs_Dec-16-2015.pdf
EBM Consult (n.d.). Tandem Gait (Heel-to-Toe): Physical Exam. Retrieved:
November 26, 2020 from:
https://www.ebmconsult.com/articles/tandem-gait-heel-to-toe
Physiopedia (n.d.). Romberg Test. Retrieved: November 26, 2020 from:
https://www.physio-pedia.com/Romberg_Test
Salmon, N. (2016). Neuro Assessment Made Easy. Retrieved: November 26, 2020
from: https://www.rn.com/nursing-news/neuro-assessment-made-easy/
