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NEUROLOGIC ASSESSMENT
Members:
Tumulak, Anne Corraine
Ubas, Ma. Marithel
Ueno, Liza
Yray, Aireen Mae
Ycong, Dixie
Objectives: After 5 hours of varied classroom activities, the Level 1 students will be able to:
2. briefly discuss the anatomy and physiology of the Nervous System with emphasis on
the following concepts:
2.1 classification of the Nervous System
● Central Nervous System
● Peripheral Nervous System
2.2 major Structures of the Brain
2.3 Major types and functions of the 12 Cranial Nerves
2.4 Cross-Section of the Spinal Cord
3. state the purpose of neurologic assessment.
4. enumerate the indications of neurologic assessment.
5. discuss the following:
5.1 Mental Status Assessment
5.2 Glasgow Coma Score
5.3 Cranial Nerve Assessment
5.4 Sensory Nerve Assessment
● Test for light touch sensation, pain sensation, temperature sensation
● Test for vibratory sensation, sensitivity to position
● Assessing tactile discrimination (stereognosis, graphesthesia)
● Two point discrimination, extinction and etc.
1.2 Glossopharyngeal
- It is also known as the Cranial Nerve #9. For its sensory impulse, it contains
sensory fibers for taste on the posterior third of the tongue and sensory fibers of
the pharynx that result in the gag reflex when stimulated. For its motor impulse, it
provides secretory fibers to the parotid salivary glands and promotes swallowing
movements.
1.3 Olfactory
- It is also known as the Cranial Nerve #1. It has a sensory impulse; it is the
nerve that carries smell impulses from the nasal mucous membrane to the brain.
1.4 Facial
- It is also known as the Cranial Nerve #7. For its sensory impulse, it contains
sensory fibers for taste on anterior two thirds of tongue, and stimulates secretions
from salivary glands (submaxillary and sublingual) and tears from lacrimal
glands. For its motor impulse, it supplies the facial muscles and affects facial
expressions (smiling, frowning, closing eyes).
1.5 Hypoglossal
- It is the Cranial Nerve #12. It has a motor impulse; it innervates tongue
muscles that promote the movement of food and talking.
1.6 Acoustic/Vestibulocochlear
- It is the Cranial Nerve #8 which contains sensory fibers that are concerned
with hearing, balance, and head position. It branches into two parts, acoustic
nerve is for transmitting sound reception for hearing and vestibulocochlear is for
hearing, balance, and head position.
1.7 Optic
- It is also known as the Cranial Nerve #2. It has a sensory impulse; it is the
nerve that carries visual impulses from the eye to the brain.
1.8 Vagus
- It is also known as the Cranial Nerve #10. It has a sensory motor impulse that
carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal
tract, and abdominal viscera. It also promotes swallowing, talking, and production
of digestive juices. It is the longest nerve of the autonomic nervous system in the
human body.
1.9 Abducens
- It is also known as the Cranial Nerve #6. It has a motor impulse that controls
the lateral eye movements, responsible for outward gaze. It is a somatic efferent
nerve.
1.10 Oculomotor
- It is the Cranial Nerve #3. It has a motor impulse that contracts eye muscles to
control eye movements (interior lateral, medial, and superior), constricts pupils,
and elevates eyelids. Paralysis of the oculomotor nerve results in a drooping
eyelid (ptosis), deviation of the eyeball outward (and therefore double vision),
and a dilated (wide-open) pupil.
1.11 Trigeminal
- It is the Cranial Nerve #5. It has a sensory motor impulse that is responsible
for carrying sensory impulses of pain, touch, and temperature from the face to the
brain. It influences clenching and lateral jaw movements (biting, chewing).
1.12 Trochlear
- It is the Cranial Nerve #4. It has a motor impulse that contracts one eye muscle
(extraocular muscles) to control the superior oblique muscle of the eye. Paralysis
of the trochlear nerve results in rotation of the eyeball upward and outward (and,
therefore, in double vision). The trochlear nerve is the only cranial nerve that
arises from the back of the brain stem. It follows the longest course within the
skull of any of the cranial nerves.
1.14 Hypothalamus
- The hypothalamus is a small region of the brain. It is located at the base of the
brain, near the pituitary gland.
- While it’s very small, the hypothalamus is responsible for regulation many
body functions, including water balance, appetite, vital signs (temperature, blood
pressure, pulse, and respiratory rate), sleep cycles, pain perception, and emotional
status.
2. Briefly discuss the anatomy and physiology of the Nervous System with emphasis on the
following aspects:
● 8 cervical (C1-C8) nerves emerge from the cervical spine; cervical means of the neck
(there are 8 cervical nerves, but only 7 cervical vertebra).
● 12 thoracic (T1-T12) nerves emerge from the thoracic spine; thoracic means of the
chest.
● 5 lumbar (L1-L5) nerves emerge from the lumbar spine; lumbar means from the lower
back region.
● 5 sacral (S1-S5) nerves emerge from the sacral bone; sacral means of the sacrum, the
bony plate at the base of the vertebral column.
● 1 coccygeal nerve emerge from the coccygeal bone; coccygeal means of the coccyx,
the tailbone.
Loss of orientation to person (ie, not knowing one’s own name) occurs only when
obtundation, delirium, or dementia is severe; when it occurs as an isolated symptom, it
suggests malingering.
Insight into illness and fund of knowledge in relation to educational level are assessed, as are
affect and mood. Vocabulary usually correlates with educational level.
● Follow a complex command that involves 3 body parts and discriminates between
right and left (eg, “Put your right thumb in your left ear, and stick out your tongue”)
● Name simple objects and parts of those objects (eg, glasses and lens, belt and belt
buckle)
● Name body parts and read, write, and repeat simple phrases (if deficits are noted,
other tests of aphasia are needed)
Spatial perception can be assessed by asking the patient to imitate simple and complex finger
constructions and to draw a clock, cube, house, or interlocking pentagons; the effort expended
is often as informative as the final product. This test may identify impersistence,
perseveration, micrographia, and hemispatial neglect.
Praxis (cognitive ability to do complex motor movements) can be assessed by asking the
patient to use a toothbrush or comb, light a match, or snap the fingers.
Every brain injury is different, but generally, brain injury is classified as:
● Severe: GCS 8 or less
● Moderate: GCS 9-12
● Mild: GCS 13-15
Mild brain injuries can result in temporary or permanent neurological symptoms and
neuroimaging tests such as CT scan or MRI may or may not show evidence of any damage.
Moderate and severe brain injuries often result in long-term impairments in cognition
(thinking skills), physical skills, and/or emotional/behavioral functioning.
To pain +2
None +1
Confused +4
Inappropriate words +3
Incomprehensible sounds +2
None +1
Localized pain +5
Flexion withdrawal +4
Abnormal Flexion +3
(decorticate)
Abnormal extension +2
(decerebrate)
Flaccid or No response +1
An example of this is when a patient scored 2(to pain) in the action of eyes opening, a score
of 4(confused) in the verbal response and a score of 6(obeys commands) in the motor
response, this can be documented as E2 V4 M6 that when added together equals to 12 (e.g.
E2V4M6 = 12). It can also be documented as GCS 12 = E2 V4 M6. As for the patient, he
scored 12 which means that the patient has a moderate brain injury.
5.3 Cranial Nerve Assessment
The nurse may assess all 12 cranial nerves or test a single nerve or related group of
nerves. A test of the oculomotor nerve measures pupillary response. Assessment of the
glossopharyngeal and Vagus nerves reveals integrity of the gag reflex. Measurements used to
assess the integrity of organs within the head and neck also assess cranial nerve function. The
function of the ninth and tenth nerves can be assessed during examination of the pharynx. A
dysfunction in any nerve reflects an alteration at some point along the cranial nerve’s
distribution.
Test CN I (olfactory)
Ask the client to clear the nose to Client correctly identifies Inability to smell (neurologic
remove any mucus, then close scent presented to each anosmia) or identify the correct
eyes, occlude one nostril, and nostril. scent may indicate olfactory tract
identify a scented object that you Some older clients sense of lesion or tumor or lesion of the
are holding such as soap, coffee smell may be decreased. frontal lobe.
or vanilla.
Test CN II (optic)
Use a snellen chart to assess the Client has 20/20 vision OD Abnormal findings include
vision in each eye. (right eye) and OS (left eye). difficulty reading snellen chart,
missing letters, and squinting.
Test CN III (oculomotor), IV
(trochlear), and VI (abducens).
Inspect margins of the eyelids of Eyelids cover about 2 mm of Ptosis (drooping of the eyelid) is
each eye. the iris. seen with weak eye muscles such
as in myasthenia gravis.
Test CN V (trigeminal)
Test motor function. Ask the Temporal and masseter Decreased contraction in one of the
client to clench the teeth while muscles contract bilaterally. both sides. Asymmetric strength in
you palpate the temporal and moving the jaw may be seen with
masseter muscles. lesion or injury of the 5th cranial
nerve.
Test CN VIII
(acoustic/vestibulocochlear)
Test the client’s hearing ability in Client hears whispered words Vibratory sound lateralizes to good
each ear and perform the Weber from 1 to 2 ft. Weber test: ear in sensorineural loss. Air
and Rinne tests to assess the vibration heard equally well conduction is longer than bone
cochlear (auditory) component of in both ears. Rinne test: AC > conduction, but not as twice as
cranial nerve VIII. BC (air conduction is twice as long, in a sensorineural loss.
long as bone conduction).
Test CN IX (glossopharyngeal)
and X (vagus)
Test motor function. Ask the Uvula and palate rise Soft palate does not rise with
client to open mouth wide and bilaterally and symmetrically bilateral lesions of cranial nerve X
say “ah” while you use a tongue on phonation. (vagus). Unilateral rising of the soft
depressor on the client’s tongue. palate and deviation of the uvula to
the normal side are seen with a
unilateral lesion of the cranial
nerve X (vagus).
To test light touch sensation, use a Client correctly identifies light Client reports:
wisp of cotton to touch the client. touch. In some older clients, ● Anesthesia (absence of touch
light touch may be decreased. sensation)
● Hypesthesia (decreased
sensitivity to touch)
● Hyperesthesia (increased
sensitivity to touch)
● Analgesia (absence of pain
sensation)
● Hypalgesia (decreased
sensitivity to pain)
● Hyperalgesia (increased
Client correctly differentiates sensitivity to pain)
To test pain sensation, use the blunt
between dull and sharp
and sharp ends of a safety pin or
sensations.
paper clip.
Client correctly differentiates
To test temperature sensation, use hot and cold temperatures over
test tubes filled with hot and cold various body parts.
water.
To test point localization, briefly Client correctly identifies area Same as above
touch the client and ask the client to touched.
identify the points touched.
Assess coordination.
Demonstrate the finger-to-nose test Client touches finger to nose Uncoordinated, jerky movements
to assess accuracy of movements, with smooth, accurate and inability to touch the nose
then ask the client to extend and hold movements, with little may be seen with cerebellar
arms out to the side with eyes open. hesitation. disease.
Next, say “touch the tip of your nose
first with your right index finger,
then with your left index finger.
Repeat this three times”
Assess rapid alternating
movements.
Have the client sit down. First, ask Client touches each finger to the Inability to perform rapid
the client to touch each finger to the thumb rapidly alternating movements may be
thumb and to increase the speed as seen with cerebellar disease,
the client progresses. Repeat with upper motor neuron weakness, or
the other side. extrapyramidal disease.
6. Present the steps, normal and abnormal assessment findings in neurologic assessment
Physical Assessment
Prior to the examination, review these key points:
1. Understand what is meant by mental status and the level of consciousness.
2. Know how to correctly apply and interpret mental status examinations and the Glasgow
Coma Scale (GCS).
3. Identify the 12 cranial nerves and their sensory and motor functions.
4. Thoroughly assess movement, balance, coordination, sensation, and reflexes during
physical examination.
5. Know how to use a reflex hammer.
Coordinate patient education- particularly in regard to risks related to stroke- with the health
CRANIAL NERVES
Test CN 1 (Olfactory)
1. For all assessments of the Client correctly identifies Inability to smell (neurogenic
cranial nerves, have client sit scent presented to each anosmia) or identify the correct scent
in a comfortable position at nostril. may indicate olfactory tract lesion or
your eye level., occlude one tumor or lesion of the frontal lobe.
nostril, and identify a
scented object that you are
holding such as soap, coffee,
or vanilla.
Test CN II (Optic)
1. Use a Snellen chart to assess Client has 20/20 vision OD Abnormal findings include difficulty
vision in each eye. (right eye) and OS (left reading Snellen chart; missing letters,
eye). squinting.
2. Ask the client to read a Client reads print at 14 Client reads print by holding closer
newspaper or magazine paragraph inches without difficulty. than 14 inches or holds print farther
to assess near vision. away as in presbyopia, which occurs
with aging.
3. Assess visual fields of each eye Full visual fields. Loss of visual fields may be seen in
by confrontation. retinal damage or detachment with
lesions of the optic nerve or parietal
cortex.
4. Use an ophthalmoscope to view Round red reflex is present, Papilledema (swelling of the optic
the retina and optic disc of each optic disc is 1.5 mm, round nerve) results in blurred optic disc
eye. or slightly oval, well- margins and dilated, pulsating veins.
defined margins, creamy
pink with paler physiologic
cup. Retina is pink.
2. Assess extr aocular movements. Eyes move in a smooth, Some abnormal eye movements and
If nystagmus is noted, determine coordinated motion in all possible causes follow:
the direction of the fast and slow direction ( the six cardinal Nystagmus: rhythmic,
phases of movement. fields). oscillation of the eyes,
cerebellar disorders.
Limited eye movement
through the six cardinal fields
of gaze
Bilateral illuminated pupils Some abnormalities and their
3. Assess pupillary response to
constrict simultaneously. implications follow:
light (direct and indirect) and
Pupil opposite the one Dilated pupil (6-7 mm):
accomodation in both eyes.
illuminated constricts oculomotor nerve paralysis.
simultaneously. Argyll Robertson pupils:
CNS syphilis, meningitis,
brain tumor, alcoholism..
Assess CN V (Trigeminal)
1. Test motor function. Ask the Temporal and masseter Decreased contraction in one of both
client to clench the teeth while you muscles contract sides. Asymmetric strength in moving
palpate the temporal and masseter bilaterally. the jaw may be seen with lesion or
muscles for contraction. injury of the fifth cranial nerve.
Clinical Tip:
Test may be difficult to
perform and evaluate in
the client without teeth.
2. Test on sensory function. Tell The client correctly Inability to feel and correctly identify
the client: “I am going to touch identifies sharp and dull facial stimuli occurs with lesions of
your forehead, cheeks, and chill stimuli and light touch to the trigeminal nerve or lesions in the
with the sharp or dull side of this the forehead, cheeks, and spinothalamic tract or posterior
safety pin or paper clip (a paper chin. columns.
clip is less hazardous). Please close
your eyes and tell me if you feel a
sharp or dull sensation. Vary the
sharp and dull stimulus in the facial
areas and compare sides. Repeat
test for light touch with a wisp of
cotton.
Safety tip:
To avoid transmitting infection,
use a new object with each client.
Avoid “stabbing” the client with
the object’s sharp side.
3. Test corneal reflex. Ask client to Eyelids blink bilaterally Absent corneal reflex may be noted
look away and up while you lightly with lesions of the trigeminal nerve or
touch the cornea with a fine wisp of lesions of the motor part of cranial
cotton. Repeat on the other side. nerve VII (facial).
Clinical tip:
This reflex may be absent or
reduced in clients who wear
contact lenses.
Test CN VII (facial)
1. Test motor function. Ask the Client smiles, wrinkles Inability to close eyes, wrinkle
client to: forehead, shows teeth, forehead, or raise forehead along with
● Smile puffs out cheeks, purses paralysis of the lower part of the face
● Frown and wrinkle forehead lips, raises eyebrows, and on the affected side is seen with
● Show teeth closes eyes against Bell’s palsy lower part of the face on
● Puff out cheeks resistance. Movements are the opposite side affected may be
● Purse lips symmetrical. seen with a central lesion that affects
● Raise eyebrows ● Client identifies the upper motor neurons such as from
● Close eyes tightly against correct flavor. stroke.
resistance
Sensory function is not routinely OLDER ADULT
tested. If it is, however, touch the CLIENT
anterior two-thirds of the tongue CONSIDERATIONS
with a moistened applicator dipped In some older clients, the
in salt, sugar, or lemon juice and sense of taste may be
ask the client to identify the flavor. decreased.
If the client is unsuccessful, repeat
the test using one of the other
solutions. If needed, repeat the test
using the remaining solution.
Clinical tip:
Make sure the client leaves the
tongue protruded to identify the
flavor. Otherwise the substance
may move to the posterior third
of the tongue (vagus nerve
innervation). The posterior
portion is tested similarly to
evaluate functioning of cranial
nerves IX and X. The client
should rinse the mouth with
water between each taste test.
Test CN VIII (acoustic/
vestibulocochlear).
1. Test the client’s hearing ability in Client hears whispered Vibratory sound lateralizes to good
each ear and perform the Weber words from 1 to 2 feet. ear in sensorineural loss. Air
and Rinne tests to assess the Weber test: Vibration heard conduction is longer than bone
cochlear (auditory) component of equally well in both ears. conduction but not twice as long, in a
cranial nerve VIII. Rinne test: AC>BC (air sensorineural loss.
conduction is twice as long
Clinical tip:
as bone conduction).
The vestibular component,
responsible for equilibrium, is not
routinely tested. In comatose
clients, the test is used to
determine integrity of the
vestibular system.
Test CN IX (glossopharyngeal)
and X (vagus).
1. Test motor function. Ask the Uvula and soft palate rise Soft palate does not rise with bilateral
client to open mouth wide and say bilaterally and lesions of cranial nerve X (vagus).
“ah” while you use a tongue symmetrically on Unilateral rising of the soft palate and
depressor on the client’s tongue. phonation. deviation of the uvula to the normal
side are seen with a unilateral lesion
of cranial nerve X.
2. Test the gag reflex by touching Gag reflex intact. Some An absent gag reflex may be seen
the posterior pharynx with the normal clients may have a with lesions of cranial nerve IX
tongue depressor. reduced or absent gag (glossopharyngeal) or X (vagus)
Clinical tip: reflex.
Warn the client that you are
going to do this and that the test
may feel a little uncomfortable.
3. Check the client’s ability to Client swallows without Dysphagia or hoarseness may
swallow by giving the client a drink difficulty. No hoarseness indicate a lesion of cranial nerve IX
of water. Also note the client’s noted. (glossopharyngeal) or X (vagus) or
voice quality. other neurologic disorder.
2. Ask the client to turn the head There is strong contraction Atrophy with fasciculations may be
against resistance, first to the right of sternocleidomastoid seen with peripheral nerve disease.
then to the left, to assess the muscle on side opposite the
sternocleidomastoid muscle. turned face.
Test CN XII (hypoglossal).
1. To assess strength and mobility Tongue movement is Fasciculations and atrophy of the
of the tongue, ask the client to symmetric and smooth and tongue may be seen with peripheral
protrude tongue, move it to each bilateral strength is nerve disease. Deviation to the
side against the resistance of a apparent. affected side is seen with a unilateral
tongue depressor, then put it back in lesion.
the mouth.
ASSESSMENT
NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
2. Assess the strength and Relaxed muscles contract Soft, limp, flaccid muscles are seen with
tone of all muscle voluntarily and show mild, lower motor neuron involvement. Spastic
groups smooth resistance to passive muscle tone is noted with involvement of
movement. All muscle the corticospinal motor tract. Rigid muscles
groups equally strong that resist passive movement are seen with
against resistance, without abnormalities of the extrapyramidal tract.
flaccidity, spasticity, or
rigidity.
OLDER ADULT
CONSIDERATIONS
This test is often impossible
for the older adult to perform
because of decreased
flexibility and strength.
Moreover, it is not usual to
perform this test with the
older adult because it puts
the client at risk.
Assess coordination.
1. Demonstrate the finger- Client touches finger to nose Loss of positional sense and inability to
to-nose test to assess with smooth, accurate touch tip of nose are seen with cerebellar
accuracy of movements movements with little disease.
the ask the client to hesitation.
extend and hold arms out
to the side with eyes Clinical tip:
open. Next say “Touch When assessing
the tip of your nose first coordination of
with your right index movements, bear in mind
finger, then with your that normally the client’s
left index finger. Repeat dominant side may be
this three times”. Next more coordinated than the
ask the client to repeat nondominant side.
these movements with
eyes closed.
2. Next ask the client to put Client rapidly turns palm up Uncoordinated movements or tremors are
the palms of both hand and down. abnormal findings. They are seen with
down on both legs, then cerebellar disease (dysdiadochokinesia).
turn the palms down
again. Ask the client to
increase the speed.
3. Perform the heel-to-shin Client is able to run each Deviation of heel to one side or the other
test. Ask the client to lie heel smoothly down each may be seen in cerebellar disease.
down (supine position) shin.
and to slide the heel of
the right foot down the
left shin. Repeat with the
other heel and shin.
SENSORY SYSTEMS
ASSESSMENT
NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Clinical tip:
If vibratory sensation is
intact distally, then it is
intact proximally.
Assess tactile
discrimination (fine touch).
1. Remember that the
Client correctly identifies Inability to correctly identify objects, area
client should have her
object. touched, number written in hand,
eyes closed. To rest
discriminate between two points, or
stereognosis, place a
identify areas simultaneously touched may
familiar object such as a
be seen in lesions of the sensory cortex.
quarter, paper clip, or
key in the client’s hand
and ask the client to
identify it. Repeat with
another object in the
other hand.
ASSESSMENT
NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Assess brachioradialis
reflex.
1. Ask the client to flex
Flexion and supination of No response or an exaggerated response is
elbow with palm down
forearm. abnormal.
and hand resting on the
abdomen or lap. Tap the
tendon at the radius
about 2 inches above the
wrist. Repeat on the
other side. (This
evaluates the function of
spinal levels C5 and C6.)
Clinical tip:
Use the handle end of the
reflex hammer to elicit
superficial reflexes, whose
receptors are in the skin
rather than the muscles.
is no injury to the cervical easily bend head and neck can arise from meningeal inflammation,
Cerebrovascular accident (CVA) is the medical term for a stroke. A stroke is when blood
flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel.
There are important signs and symptoms of a stroke that you should be aware of and watch
out for these are the following:
● Sudden numbness or weakness in the face, arm, or leg, especially on one side of the
body
● Sudden confusion, trouble speaking, or difficulty understanding speech
● Sudden trouble seeing in one or both eyes
● Sudden trouble walking, dizziness, loss of balance, or lack of coordination
● Sudden severe headache with no known cause
Seek medical attention immediately if you think that you or someone around you might be
having a stroke. The more quickly you receive treatment, the better the prognosis, as a stroke
left untreated for too long can result in permanent brain damage.
Risk Factors
● Hypertension
● Smoking
● Chronic alcohol intake (more than three drinks per day)
● History of cardiovascular disease such as coronary artery disease, heart failure,
rhythm abnormalities (especially atrial fibrillation), mitral valve prolapsed
● Overweight
A number of disorders result from damage or death to brain cells of the cerebral cortex.
Apraxia is a group of disorders that are characterized by the inability to perform certain
motor tasks, although there is no damage to motor or sensory nerve function.
Oculomotor nerve palsy or third nerve palsy is an eye condition resulting from damage to the
third cranial nerve or a branch thereof. As the name suggests, the oculomotor nerve supplies
the majority of the muscles controlling eye movements. Thus, damage to this nerve will result
in the affected individual being unable to move his or her eye normally.
Risk Factors
● diabetes mellitus
● hypertension
● hyperlipidemia
● heart disease
● smoking
Peripheral neuropathy refers to the conditions that result when nerves that carry messages to
and from the brain and spinal cord from and to the rest of the body are damaged or diseased.
Damage to these nerves interrupts communication between the brain and other parts of the
body and can impair muscle movement, prevent normal sensation in the arms and legs, and
cause pain.
Risk factors
● Diabetes mellitus, especially if your sugar levels are poorly controlled
● Alcohol abuse
● Vitamin deficiencies, particularly B vitamins
● Infections, such as Lyme disease, shingles, Epstein-Barr virus, hepatitis C and
HIV
● Autoimmune diseases, such as rheumatoid arthritis and lupus, in which your
immune system attacks your own tissues
8. Identify the different materials needed and its uses in neurologic assessment
For complete examination, the following special equipment will be needed:
● Snellen eye chart- used to assess visual acuity and tests functionality of optic nerve.
● Penlight- used to diagnose and discern the severity of a concussion and is often used
with patients that are passed out to check reflex and brain function.
● Two test tubes, one filled with hot water and the other with cold water- to evaluate
thermal sensitivity on the injured skin of leprosy patients.
● Sterile cotton balls or cotton-tipped applicators- to examine ability to feel fine touch
with a monofilament. These are called small fiber sensations.
● Tuning fork- used to test a patient’s hearing. The physician strikes the prongs causing
them to vibrate and produce a humming sound.
● Percussion or reflex hammer- used to test neurologic reflexes. The head of the
instrument is used to test reflexes by striking the tendons of the ankle, knee, wrist and
elbow.
● Paper clip- Testing between areas for diminished/altered sensation. May be usual in
patients with central sensation.
● Substances to smell, such as coffee, vanilla, and perfume- to assess cranial nerve
number 2
● Objects to touch/feel, such as quarter or key- to assess nerves for sensations.
● Substances to taste, such as salt, lemon, and sugar- to assess cranial nerve number 7.
9. State the nursing responsibilities before, during and after neurologic assessment
Before:
● Check physician’s order.
● Gather the necessary equipment.
● Wash hands and observe appropriate infection control procedures.
● Make a brief survey to determine the client’s ability to participate.
● Ensure that the room is warm and free of drafts, with full lighting.
● Explain all procedures to the client. Identify client.
During:
● Ensure client privacy and safety.
● Vary your approach according to the physical condition of the client.
● When possible, perform the nonthreatening, easily performed tasks first.
● Use standard precautions throughout the neurologic assessment.
● Work in an organized manner, taking a head-to-toe and distal-to-proximal approach.
● Assess mental status, cranial nerves, motor function, sensory function, and reflexes.
After:
● Record or document findings from physical assessment.
● Review and validate all findings before assisting the client with dressing, if necessary,
to recheck any information or gather additional data.
● Do after care.
BIBLIOGRAPHY
What Is the Glasgow Coma Scale? (2018, July 25). Retrieved from
https://www.brainline.org/article/what-glasgow-coma-scale
Potter, P. A., & Perry, A. (2005). Virtual clinical excursions--medical-surgical for Potter &
Perry: Fundamentals of nursing, 6th edition (6th ed.). St. Louis, MO: Elsevier Mosby.
Sims, L., D’Amico, D., Stiesmeyer, J., & Webster, J. (1995). Health Assessment in Nursing.
Redwood City, California: Addison-Wesley Publishing Company.