Assessment of Neurological

System
By: Elie Salameh, DNP
 Nervous System
It is composed of two parts:
Central nervous system (Brain & Spinal cord).
Peripheral nervous system (12 pairs of cranial nerves, 31 pairs of
spinal nerves).
 Nervous System (Con’t)
Anatomy of the brain:
Composed of 4 lobes: Frontal, Parietal, Temporal, & Occipital.
Brain stem include: Pones, Medulla (autonomic functions),
Cerebellum (motor control).
 Subjective Data Collection
History of present health concern (COLDSPA): Character,
Onset, Location, Duration, Severity, Pattern and Associated
Factors.

Past health history.

Family health history.

Lifestyle & health practices.

 Objective Data Collection
Physical examination: Inspection only! No palpation,
percussion, or auscultation.

Preparing the client: Have the client remove all clothing &
apply gown.

Explain procedure.

Equipment:
 Reflex hammer.
 Examination gown.
 Gloves.
 Neurological Assessment Approach
It is divided into 5 categories:

1. Mental status.

2. Cranial nerves.

3. Motor system.

4. Sensory system.

5. Reflexes.
 Mental Status Assessment
Assess state of awareness & level of consciousness.

Assess orientation to time, place, & person.

Assess thought process, perceptions, & cognitive abilities.

Assess mood & manners.

Assess facial expression & speech.

Assess dress, grooming, & personal hygiene.

Perform the Mini-Mental State Examination.

 Mental Status Assessment (Con’t)
Mini-Mental State Examination:
 Cranial Nerves Assessment
Olfactory: (CN-I)
Be sure that both nasal passages are patent.
Ask the client to close his/her eyes.
Test each nostril separately by occluding the opposite side.
Ask the client to identify odors (Alcohol, Acetone, etc…).
Normally, client should smell equally in both nostrils.
 Cranial Nerves Assessment (Con’t)
Optic: (CN-II)
Test visual acuity: Ask the client to read Snellen’s chart each eye
separately. Normal vision should be 20/20 in both eyes.
Assess visual fields: Check each eye separately. Normally, both
eyes should have equal visual fields.
 Cranial Nerves Assessment (Con’t)
Oculomotor: (CN-III)
Check for pupillary response (constriction) to light {direct &
indirect (consentual)}. Normally, both pupils should react equally.
Opening the eyes & most extraocular movements.
 Cranial Nerves Assessment (Con’t)
Trochlear: (CN-IV)
Downward, inward movement of the eyes with head in fixed
position. Normally, both eyes should move equally.

Abducens: (CN-VI)
Lateral deviation of the eyes with head in fixed position. Normally,
both eyes should move equally.
 Cranial Nerves Assessment (Con’t)
Trigeminal: (CN-V)
Motor: Facial movements, including those of facial expressions,
closing the eyes, & closing the mouth. Ask the client to clench the
teeth while you palpate the temporal & masseter muscles for
contraction. Normally, both muscles should contract equally.
 Cranial Nerves Assessment (Con’t)
Trigeminal: (CN-V) (Con’t)
Sensory: Ask the client to close his/her eyes, then touch the client’s
forehead, cheeks & chin with sharp & dull (soft) sides of the safety
pin or of any object. Normally, the client should correctly identify
the stimuli.
Sensory: Test for corneal reflex: Ask the client to look away &
upwards, then touch the cornea with a soft cotton. Normally, the
eyes will blink bilaterally.
 Cranial Nerves Assessment (Con’t)
Facial: (CN-VII)
Motor: It supplies the facial muscles & affects facial expressions.
Ask the client to smile, frown, show teeth, puff cheeks, rise
eyebrows, & close eyes against resistance. Normally, movements
should be symmetrical.
Sensory: Contains sensory fibers for taste on anterior two-thirds of
the tongue. Ask client to taste salty, sweet, sour, & bitter substances
on the anterior two-thirds of the tongue. Normally, the client should
identify flavors correctly.
 Cranial Nerves Assessment (Con’t)
Acoustic / Vestibulocochlear: (CN-VIII)
Hearing (Cochlear part): Test the client’s hearing ability in each
ear, & perform the Weber & Rinne tests to assess the cochlear
component. Normally, whispers should be heard from 1-2 feet.
Balance (Vestibular part): Test client’s equilibrium.
 Cranial Nerves Assessment (Con’t)
Acoustic / Vestibulocochlear: (CN-VIII) (Con’t)
Weber test: The vibrating tuning fork base is placed in the
forehead. It assesses sound conducted via bone. Normally,
vibrations should be heard equally well in both ears. If vibrations
felt on one side, then it can be conductive (middle ear) hearing loss
or sensorineural (inner ear) hearing loss.
 Cranial Nerves Assessment (Con’t)
Acoustic / Vestibulocochlear: (CN-VIII) (Con’t)
Rinne test: The vibrating tuning fork base is placed first on the
mastoid process after which the prongs are moved to the front of
the external auditory canal. Normally, air conduction (AC) is twice
as long as bone conduction (BC): AC>BC.
With conductive (middle ear) hearing loss, bone conduction sound
is heard longer than or equally to air conduction sound.
 Cranial Nerves Assessment (Con’t)
Glossopharyngeal: (CN-IX)
Ask the client to open mouth & say “AH” or to yawn. Using the
tongue depressor, observe the upward motion of the soft palate &
uvula, & the inward “curtain” movement of the posterior pharynx.
Normally, the rise should be bilateral & symmetrical.
Check client’s ability to swallow by giving the client a drink of
water. Normally, client should swallow without any difficulty.
 Cranial Nerves Assessment (Con’t)
Vagus: (CN-X)
Touch the posterior (back) part of the throat with a tongue
depressor. Note the gag reflex & hoarseness of the voice.
Check client’s ability to swallow by giving the client a drink of
water. Normally, client should swallow without any difficulty.
 Cranial Nerves Assessment (Con’t)
Spinal Accessory: (CN-XI)
Ask the client to shrug his/her shoulders upwards against your
hands. Note the strength & contraction of the Trapezius muscles.
Normally, there should be symmetrical & strong contraction of the
Trapezius muscle.
Ask the client to turn his/her head to each side against your hand.
Observe the contraction of the opposite sternocleidomastoid
muscle, & note the force of the movement against your hands.
 Cranial Nerves Assessment (Con’t)
Hypoglossal: (CN-XII)
Inspect the client’s tongue as it lies in the mouth floor. Note any
lesions or masses.
Ask the client to stick out his/her tongue, & move it to each side
against resistance. Note any asymmetry, deviations, or atrophy.
Normally, tongue movement & strength should be symmetrical &
strong.
Cranial Nerves Summary
 Motor & Cerebellar System Assessment
Assess condition, strength, & movement of muscles:
Normally, muscles strength & size should be symmetrical.
Evaluate balance: Ask the client to walk across the room,
heel-to-toe walk (tandem walk) in a straight line. Observe
client posture, balance, swinging of arms, & movement of
legs.
Motor & Cerebellar System Assessment (Con’t)
Romberg test: Ask the client to stand with their feet
together (touching each other). Then ask the client to close
his/her eyes. Stay close to the client in case the patient
begins to sway or fall. Normally, the client should stay erect
with minimal swaying with eyes open & closed.
Repeat the same process with client standing on one foot, &
then hop on that foot. Repeat the same on the other foot.
Motor & Cerebellar System Assessment (Con’t)
Assess coordination: Finger-to-nose test with eyes closed,
rapid alternating movements of palms, & heel-to-shin test.
 Sensory System Assessment
Assess light touch, pain, and temperature sensations: Keep
eyes closed. Normally, client should identify sensations
correctly.

Test vibratory sensation: Normally, client should feel

vibratory sensation equally on bony surfaces.
 Sensory System Assessment (Con’t)
Test sensitivity to position: Move client’s fingers & toes
upwards & downwards with eyes closed. Normally, the
client should identify correctly the directions of movement.
 Sensory System Assessment (Con’t)
Assess tactile discrimination (Fine touch):
Graphesthesia: Write a number with a blunt object on the client’s
palm & ask him/her to identify with eyes closed. Normally, the
client should identify the number correctly.

Stereognosis: Place a familiar object in the client’s hand & ask

him/her to identify with eyes closed. Normally, the client should
identify objects correctly.
 Sensory System Assessment (Con’t)
Assess tactile discrimination: (Con’t)
Two points discrimination: Ask the client to identify the number of
points felt when touched with the end of 2 applicators at the same
time, with eyes closed. Normally, the client should correctly
identify points touched.
 Reflexes
Two types of reflexes:

Deep tendon reflexes: Biceps, Triceps, Bracioradialis, Patellar

(Knee), & Achilles (Ankle) reflexes.

Superficial reflexes: Plantar (Babinski), Abdominal, & Cremasteric

reflexes.
 Assessment of Reflexes
The Biceps reflex (C5 & C6):
Ask client to partially bend arm at the elbow with palms up.
Place your thumb firmly on the biceps tendon, then strike your
thumb with the reflex hammer.
Observe flexion at the elbow and watch for & feel the contraction
of the biceps muscle.
 Assessment of Reflexes (Con’t)
The Triceps reflex (C6, C7, & C8):
Ask the client to hang his/her arm freely while you support the arm.
With the elbow flexed, strike directly the triceps tendon above the
elbow with the reflex hammer.
Watch for contracting of the triceps muscle & extension at the
elbow.
 Assessment of Reflexes (Con’t)
The Brachioradialis reflex (C5 & C6):
Ask the client to flex elbow with palm down & hand resting on the
abdomen or lap.
Strike directly the tendon at the radius about 2 inches above the
wrist with the reflex hammer.
Observe flexion & supination of the forearm.
 Assessment of Reflexes (Con’t)
The Patellar (Knee) reflex (L2, L3, & L4):
Ask the client to be either sitting with legs hanging freely or lying
down while you support his knees in somewhat flexed position.
Tap the patellar tendon directly just below the patella with the
reflex hammer.
Note contraction of the quadriceps with extension of the knee.
 Assessment of Reflexes (Con’t)
The Achilles (Ankle) reflex (S1 & S2):
With the leg somewhat flexed at the knee, dorsiflex the foot.
Strike directly at the Achilles tendon with the reflex hammer.
Watch for plantar flexion of the foot.
 Assessment of Reflexes (Con’t)
The Planter (Babinski) reflex (L4, L5, S1, & S2):
With the end of the reflex hammer, stroke the lateral aspect of the
sole from the heel to the ball of the foot, curving medially across
the ball.
Note movement of the toes, normally flexion of the toes. This is
called: Negative Babinski response.
If fanning of the toes occur, this is abnormal & is called: positive
Babinski response.
 Assessment of Reflexes (Con’t)
The Abdominal reflex (T8 – T11):
With client laying down, lightly stroke the abdomen on each side
above & below the umbilicus.
Note the contraction of the abdominal muscles, & the umbilicus
deviates towards the side being stimulated.

The Cremasteric reflex (T12, L1, & L2):

It is done in male clients only.
Lightly stroke the inner aspect of the upper thigh.
Note the scrotum elevates on the stimulated side.
Assessment of Reflexes (Con’t)