Name: Date of Lecture Demo:

Assessing the Neurological System

Basic Concept: It is an examination of the neurologic system which comprises the assessment of
the mental status including the level of consciousness, the cranial nerves, reflexes, motor and
sensory functions. Some parts of the neurologic assessment are performed throughout the health
assessment like mental status assessment, observing the appearance and cranial nerve functions
(Berman, et.al. 2015).

Objectives:
1. To obtain an accurate nursing history of the client’s neurologic system.
2. To determine any deviations or abnormal findings of the client’s nervous system
functioning.
3. To formulate valid nursing diagnoses; collaborative problems and / or referrals.

Preparation:

1. Assemble equipment:
Sugar, salt, lemon juice, quinine flavors
Percussion hammer
Tongue depressors (one broken diagonally, for testing pain sensation)
Wisps of cotton, to assess light touch sensation
Test tubes of hot and cold water, for skin temperature assessment (optional)
Pins or needles for tactile discrimination
2. Introduce yourself, and verify the client’s identity. Explain to the client what you are
going to do, why it is necessary, and how the client can cooperate.
3. Perform hand hygiene, and observe other appropriate infection control procedures.
4. Provide for client privacy.

PROCEDURE RATIONALE
1. Inquire if the client has any history of 1. Verifying the client’s history will
the following: provide valuable information to ensure
Presence of pain in the head, back or proper care.
extremities, as well as onset and
aggravating and alleviating factors.
Disorientation to time, place, or person
Speech disorders
Any history of loss consciousness,
fainting, convulsions, trauma, tingling
or numbness, tremors or tics, limping,
paralysis, uncontrolled muscle
movements, loss of memory, or mood
swings
Problems with smell, vision, taste,
touch, or hearing

Language
2. If the client displays difficulty 2. To determine if the client is
speaking: experiencing aphasia.
-Point to common objects and ask the
client to name them.
-Ask the client to read some words and
to match the printed and written words
with pictures.
-Ask the client to respond to simple
verbal and written commands-e.g.
 “Point to your toes,” or “Raise your
left arm”.
Orientation
3. Determine the client’s orientation to 3. To determine the client’s level of awareness
time, place, and person by tactful of self, place, time, and situation.
questioning.
-Ask the client the city and state of
residence, time of day, date, day of the
week, duration of illness, and names of
family members.
-More direct questioning might be
necessary for some people-e.g.,
“Where are you now?” What day is it
today?”

Memory
4. Listen for lapses in memory. 4. To assess the client’s recall of information
- Ask the client about difficulty with or events presented seconds previously,
from earlier in the day or examination, and
memory. knowledge recalled from months or years
- If problems are apparent, three ago.
categories of memory are tested:
immediate recall, recent memory, and
remote memory.
To assess immediate recall:
- Ask the client to repeat a series of
three digits-e.g., 7-4-3-spoken slowly.
- Gradually increase the number of
digits-e.g., 7-4-3-5,7-4-3-5-6, and 7-4-
3-5-6-7-2-until the client fails to repeat
the series correctly.
- Start again with a series of three
digits, but this time, then ask the client
to repeat them backward.

To assess recent memory:

- Ask the client to recall the recent
events of the day, such as how he got
to the clinic. This information must be
validated.
- Ask the client to recall information
given early in the interview-e.g., the
name of a doctor.
- Provide the client with three facts to
recall-e.g., a color, an object, an
address, or a three-digit number-and
ask the client to repeat all three. Later
in the interview, ask the client to recall
all three items.

To assess remote memory:

- Ask the client to describe a previous
illness or surgery.
Attention Span and Calculation
5. a. Test the ability to concentrate or 5. To determine the client’s ability to focus on
attention span by asking the client to a mental task that is expected to be able to
recite the alphabet or to count be performed by individuals of normal
backward from 100. intelligence.
 b. Test the ability to calculate by
asking the client to subtract 7 or 3
progressively from 100-i.e., 100, 93,
86, 79, or 100, 97, 94.

Level of Consciousness
6. Apply the Glasgow Coma Scale: 6. To determine if the client is alert and
Eye response, motor response, and completely oriented by applying the
verbal response Glasgow Coma Scale

Cranial Nerves
7. Test the cranial nerves. 7. To detect abnormalities for each cranial
Cranial Nerve I-Olfactory nerve
- Ask client to close eyes and identify
different mild aromas such as coffee
and vanilla.

Cranial Nerve II-Optic

- Ask the client to read Snellen’s
chart; check visual fields by
confrontation, and conduct an
ophthalmoscopic examination.
Cranial Nerve III-Oculomotor
- Assess six ocular movements and
pupil reaction.

Cranial Nerve IV-Trochlear

- Assess six ocular movements.

Cranial Nerve V-Trigeminal

- While client looks upward, lightly
touch the lateral sclera of the eye to
elicit the blink reflex.
- To test light sensation, have the
client close eyes, and wipe a wisp of
cotton over client’s forehead and
paranasal sinuses.
- To test deep sensation, use
alternating blunt and sharp ends of a
safety pin over the same area.

Cranial Nerve VI-Abducens

- Assess directions of gaze.

Cranial Nerve VII-Facial

- Ask the client to smile, raise the
eyebrows, frown, puff out cheeks, and
close eyes tightly.
- Ask the client to identify various
tastes placed on the tip and sides of
tongue-sugar, salt-and to identify
areas of taste.

Cranial Nerve VIII-Auditory

- Assess the client’s ability to hear the
spoken word and the vibrations of a
tuning fork.
 Cranial Nerve IX-Glossopharyngeal
Apply tastes on the posterior tongue
for identification. Ask the client to
move tongue from side to side and up
and down.

Cranial Nerve X-Vagus

- Assess with CN IX.
- Assess the client’s speech for
hoarseness.

Cranial Nerve XI-Accessory

- Ask the client to shrug shoulders
against resistance from your hands
and to turn head to the side against
resistance from your hand. Repeat for
the other side.

Cranial Nerve XII-Hypoglossal

- Ask the client to protrude tongue at
midline, then, move it side to side.

Reflexes
8. Test reflexes using a percussion 8. To assess each of the deep tendon reflexes
hammer, comparing one side of the of the client.
body with the other to evaluate the
symmetry of response.
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.

Triceps Reflex
- Flex the client’s arm at the elbow,
and support it in the palm of your non-
dominant hand.
- Palpate the triceps tendon about 2-
5cm (1-2 inches) above the elbow.
- Deliver a blow with the percussion
hammer directly to the tendon.
- Observe for the normal slight
extension of the elbow.

Brachioradialis Reflex
 - Rest the client’s arm in a relaxed
position on your forearm or on the
client’s own leg.
- Deliver a blow with the percussion
hammer directly on the radius 2-5 cm
(1-2 inches) above the wrist or the
styloid process, the bony prominence
on the thumb side of the wrist.
- Observe the normal flexion and
supination of the forearm. The fingers
of the hand might also extend slightly.

Patellar Reflex
- Ask the client to sit on the edge of
the examining table so that the legs
hang freely.
- Locate the patellar tendon directly
below the patella.
- Deliver a blow with the percussion
hammer directly to the tendon.
- Observe the normal extension or
kicking out of the leg as the
quadriceps muscle contracts.
- If no response occurs, and you
suspect the client is not relaxed, ask
the client to interlock fingers and pull.

Achilles Reflex
- With the client in the same position
as for the patellar reflex test, slightly
dorsiflex the client’s ankle by
supporting the foot lightly in your
hand.
- Deliver a blow with the percussion
hammer directly to the tendon.
- Observe and feel the normal plantar
flexion (downward jerk) of the foot.

Plantar (Babinki’s) Reflex

- Use a moderately sharp object such
as the handle of the percussion
hammer, a key, or the dull end of a pin
or applicator stick.
- Stroke the lateral border of the sole
of the client’s foot, starting at the heel,
continuing to the ball of the foot, and
then proceeding across the ball of the
foot toward the big toe.
- Observe the response.

Motor Function
9. To assess for the movements and the
9. Gross Motor and Balance Tests position of the client’s body
Walking Gait
- Ask the client to walk across the
room and back, and assess the client’s
gait.
 Romberg’s Test 9.1 To determine if the client is able to
- Ask the client to stand with feet maintain upright posture and foot stance
together and arms resting at the sides,
first with eyes open, then, closed.

Standing On One Foot With Eyes 9.2 To determine if the client is able to
Closed maintain stance for at least 5 seconds
- Ask the client to close eyes and stand
on one foot, then the other.
- Stand close to the client during this
test.

Heel-Toe Walking 9.3 To determine if the client is able to walk

- Ask the client to walk a straight line, along a straight line
placing the heel of one foot directly in
front of the toes of the other foot.

Toe or Heel Walking 9.4 To determine if the client is able to walk

- Ask the client to walk several steps several steps on toes or heels
on the toes and then on the heels.
10. Fine Motor Tests for the Upper 10. To determine if the client can repeatedly
Extremities and rhythmically touches his/her nose
Finger-to-Nose Test
- Ask the client to abduct and extend
arms at shoulder height and rapidly
touch nose alternately with one index
finger and then the other.
- Have the client repeat the test with
eyes closed if the test is performed
easily.

Alternating Supination and 10.1 To determine if the client can

Pronation of Hands on Knees alternately supinate and pronate hands at
- Ask the client to pat both knees with rapid pace
the palms of both hands and then with
the backs of hands, alternately, at an
ever-increasing rate.

Finger to Nose and to the Nurse’s 10.2 To determine if the clients

Finger performs with coordination and rapidity
- Ask the client to touch nose and then
your index finger, held at a distance at
about 45cm (18 inches), at a rapid and
increasing rate.

Fingers to Fingers 10.3 To determine if the clients

- Ask the client to spread arms broadly performs with accuracy and rapidity
at shoulder height and then bring
fingers together at the midline, first
with eyes open and then closed, first
slowly and then rapidly.

Fingers to Thumb (Same Hand) 10.4 To determine if the client can

Ask the client to touch each finger of rapidly touches each finger to thumb
one hand to the thumb of the same with each hand
hand as rapidly as possible.
 11. To determine if the client has tremors
11. Fine Motor Tests for the Lower
Extremities
- Ask the client to lie supine and to
perform these tests:
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 foot.
- Repeat with the other foot.
- The client may also use a sitting
position for this test.

Toe or Ball of Foot to the Nurse’s 11.1 To determine if the client can move
Finger smoothly with coordination
- Ask the client to touch your finger
with the large toe of each foot.

12. Light-Touch Sensation 12. Sensitivity to touch varies among different

- Compare the light-touch sensation of skin areas
symmetric areas of the body.
- Ask the client to close eyes and to
respond by saying, “yes” or “now”
whenever the client feels the cotton
wisp touching the skin.
- With a wisp of cotton, lightly touch
one specific spot and then the same
spot on the other side of the body.
- Test areas on the forehead, cheek,
hand, lower arm, abdomen, foot, and
lower leg. Check a distal area of the
limb first.
Ask the client to point to the spot
where the touch was felt.
If areas of sensory dysfunction are
found, determine the boundaries of
sensation by testing responses
approximately every 2.5cm (1 inch) in
the area.
- Make a sketch of the sensory loss
area for recording purposes.

13. Pain Sensation 13. To determine if the client is able to

Assess pain sensation as follows: discriminate “sharp” and “dull” sensations.
- Ask the client to close his/her eyes
and to say, “sharp”, “dull”, or “don’t
know” when the sharp or dull end of
the broken tongue depressor it felt.
- Alternately, use the sharp and dull
end of the sterile pin or needle to
lightly prick designated anatomic areas
at random.
- The face is not tested in this manner.
- Allow at least two seconds between
each test.
 14. Temperature Sensation 14. To determine if the client is able to
- Touch skin areas with test tubes discriminate “hot” and “cold” sensations
filled with hot or cold water.
- Have the client respond say saying,
“hot”, “cold,” or don’t know”.

15. Position or Kinesthetic Sensation 15. To determine if the client can readily
- Commonly, the middle fingers and determine the position of fingers and toes
the large toes are tested for the
kinesthetic sensation.
- 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 the examining table.
- Ask the client to close his/her eyes.
- 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 toe while
moving it.
- Move the finger or toe until it is up,
down, or straight out, and ask the
client to identify the positions.

16. Tactile Discrimination 16. To determine whether the client feels one
For all the tests, the client’s eyes need or two pinpricks
to be closed:
One-and Two-Point Discrimination
- Alternately stimulate the skin with
two pins simultaneously and then with
one pin.
- Ask whether the client feels one or
two pinpricks.

Stereognosis 16.1 To determine if the client is able to

- Place familiar objects such as a key, identify small objects placed on the hand
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 manipulate
an object, write a number or letter on
the client’s palm, using a blunt
instrument, and ask the client to
identify it.

Extinction Phenomenon
16.2 To determine if the client is able to
- Simultaneously stimulate two
identify two touches when touched in two
symmetric areas of the body, such as different areas of the body.
the thighs, the cheeks, or the hands.
17. Document findings in the client record
Adopted from Kozier and Erb’s Fundamentals of Nursing (2015).
Berman, Audrey, et.al. (2015). Kozier and Erb’s Fundamentals of Nursing: Concept, Process and
Practice, 10th ed.Weber, Janet R., et.al. (2014). Health Assessment in Nursing, 5th ed.
Lynn, P.(2008). Taylor’s Clinical Nursing Skills, 2nd ed.