NEUROLOGIC EXAMINATION NOTE!
The terms disorientation and confusion are often
Three major considerations determine the extent of used synonymously although there are differences.
a neurologic exam: It is always preferable to describe the client’s
1. the client’s chief complaints actions or statements rather than to label them.
2. the client’s physical condition (i.e., level of
consciousness and ability to ambulate) MEMORY
because many parts of the examination 1. Immediate Recall – information presented
require movement and coordination of the seconds previously.
extremities 2. Recent Memory – information from earlier
3. the client’s willingness to participate and in the day.
cooperate 3. Remote or long-term memory – knowledge
recalled from months or years ago.
MENTAL STATUS
● Assessment of intellectual (cognitive) as ATTENTION SPAN AND CALCULATION
well as emotional (affective) functions. ● Determines the client’s ability to focus on a
● Major areas of assessment include mental task that is expected to be able to
language, orientation, memory, and be performed by individuals of normal
attention span and calculation intelligence.
LANGUAGE LEVEL OF CONSCIOUSNESS
Aphasia – defects in or loss of the power to
express oneself by speech, writing, or signs, or to GLASGOW COMA SCALE
comprehend spoken or written language due to Faculty Response Score
disease or injury of the cerebral cortex. Measured
Eye Spontaneous 4
opening To verbal command 3
Categories: To pain 2
1. Sensory/receptive No response 1
2. Motor/expressive Motor To verbal command 6
response To localized pain 5
Flexes and withdraws 4
Sensory or receptive aphasia – loss of the ability
to comprehend written or spoken words. Flexes abnormally 3
1. Auditory aphasia - loss of the ability to (Decorticate)
understand the symbolic content associated Extends abnormally 2
with sounds. (Decerebrate)
2. Visual aphasia - loss of the ability to
understand printed or written figures. No response 1
Verbal Oriented, converses 5
response Disoriented, converses 4
Motor or expressive aphasia – loss of the ability Uses inappropriate words 3
to express oneself by writing, making signs, or Makes incomprehensible sounds 2
speaking. No response 1
● The lowest score is 3. Indicates that the patient has severe
neurological function or is brain dead.
ORIENTATION ● An assessment totaling 15 points indicates the client is alert
and completely oriented.
Assessment determines the client’s ability to: ● Comatose client scores 7-8 or less.
1. Recognize other people (person)
2. Awareness of when and where they
presently are (time and place)
3. Who they, themselves, are (self)
MOTOR FUNCTION
RICHMOND AGITATION-SEDATION SCALE Proprioceptors – are sensory nerve terminals that
4 Combative Overly combative, violent, occur chiefly in the muscles, tendons, joints, and
immediate danger to staff internal ear.
3 Very Pulls or removes tubes or catheters;
Agitated aggresive
● They give information about movements
2 Agitated Frequent non-purposeful and the position of the body
movements, fights ventilator
1 Restless Anxious, Apprehensive, but Cerebellum
movements are not aggressive or
● helps to control posture
vigorous
0 Alert and Calm ● acts with the cerebral cortex (found in the
-1 Drowsy Not fully alert but has sustained cerebra) to make body movements smooth
awakening to voice (eye opening and coordinated, and
and contact >10 seconds) ● controls skeletal muscles to maintain
-2 Light Briefly awakens to voice (eye
Sedation opening and contact <10 seconds) equilibrium.
-3 Moderate Movement or eye opening to voice
Sedation (but no eye contact) SENSORY FUNCTION
-4 Deep No response to voice, but has Abnormal responses to touch stimuli:
Sedation movement or eye opening to
1. Anesthesia – loss of sensation
physical stimulation
-5 Cannot be No response to voice or physical 2. Hyperesthesia – more than normal
aroused stimulation sensation
3. Hypoesthesia – less than normal sensation
CRANIAL NERVES 4. Paresthesia – electric shock, numbness,
● The nurse needs to be aware of specific tingling sensation
nerve functions and assessment methods
for each cranial nerve to detect Three types of tactile discrimination:
abnormalities. In some cases, each nerve 1. One and two-point discrimination – the
is assessed; in other cases only selected ability to sense whether one or two areas of
nerve functions are evaluated. the skin are being stimulated by pressure
2. Stereognosis – the act of recognizing
REFLEXES objects by touching and manipulating them
Reflex – is an automatic response of the body to a 3. Extinction – the failure to perceive touch on
stimulus one side of the body when two symmetric
areas of the body are touched
Deep tendon reflex (DTR) – is activated when a simultaneously.
tendon is stimulated (tapped) and its associated
muscle contracts.
NOTE!
The quality of a reflex response varies among
individuals and by age. As a client ages, reflex
responses may become less intense.
Babinski Reflex - plantar reflex, indicative of
possible spinal cord injury
Assessing the Neurologic System To assess Auditory Aphasia
● Ask the client to respond to simple verbal
PLANNING and written commands (e.g., “point to your
● If possible, determine whether a screening toes” or “raise your left arm”).
or full neurologic examination is indicated.
This impacts preparation of the client, ORIENTATION
equipment, and timing. Determine the client’s orientation to time, place,
and person by tactful questioning.
Equipments ● Ask the client the time of day, date, day of
(Depending on Components of Examination) the week, duration of illness, city and
● Percussion hammer state of residence, and names of family
● Wisps of cotton to assess light-touch members.
sensation ● Ask the client why he or she is seeing a
● Sterile safety pin for tactile discrimination healthcare provider.
IMPLEMENTATION Orientation is lost gradually, and early disorientation
Performance may be very subtle. “Why” questions may elicit a
1. Prior to performing the assessment, more accurate clinical picture of the client’s
introduce self and verify the client’s identity orientation status than questions directed to time,
using agency protocol. Explain to the client place, and person.
what you are going to do, why it is
necessary, and how to participate. Discuss To evaluate the response, you must know the
how the results will be used in planning correct answer. More direct questioning may be
further care or treatments. necessary for some people (e.g., “Where are you
2. Perform hand hygiene and observe other now?” “What day is it today?”).
appropriate infection prevention procedures.
3. Provide for client privacy. Most people readily accept these questions if
4. Inquire if the client has any history of the initially the nurse asks, “Do you get confused at
following: presence of pain in the head, times?” If the client cannot answer these questions
back, or extremities, as well as onset and accurately, also include assessment of the self by
aggravating and alleviating factors; asking the client to state his or her full name.
disorientation to time, place, or person;
speech disorder; loss of consciousness, MEMORY
fainting, convulsions, trauma, tingling or To Assess Immediate Recall
numbness, tremors or tics, limping, ● Ask the client to repeat a series of three
paralysis, uncontrolled muscle movements, digits (e.g., 7–4–3), spoken slowly.
loss of memory, mood swings; or problems ● Gradually increase the number of digits
with smell, vision, taste, touch, or hearing. (e.g., 7–4–3–5, 7–4–3–5–6, and
7–4–3–5–6–7–2) until the client fails to
LANGUAGE repeat the series correctly.
If the client displays difficulty speaking:
To assess Visual Aphasia To Assess Recent Memory
● Point to common objects, and ask the client ● Ask the client to recall the recent events of
to name them. the day, such as how the client got to the
clinic. This information must be validated,
To assess Motor Aphasia however.
● Ask the client to read some words and to ● Ask the client to recall information given
match the printed and written words with early in the interview (e.g., the name of a
pictures. doctor). • Provide the client with three facts
to recall (e.g., a color, an object, and an
address) or a three-digit number, and ask
the client to repeat all three.
To Assess Remote Memory
● Ask the client to describe a previous illness
or surgery (e.g., 5 years ago) or a birthday
or anniversary.
ATTENTION SPAN AND CALCULATION
To test the ability to concentrate or maintain
attention span
● Ask the client to recite the alphabet or to
count backward from 100.
To test the ability to calculate
● Ask the client to subtract 7 or 3
progressively from 100 (i.e., 100, 93, 86, 79,
or 100, 97, 94, 91),
● Normally, an adult can complete the serial
sevens test in about 90 seconds with three
or fewer errors.
LEVEL OF CONSCIOUSNESS
● An assessment totaling 15 points indicates
the client is alert and completely oriented. A
comatose client scores 7-8 or less.
CRANIAL NERVES
● Test each nerve not already evaluated in
another component of the health
assessment. A quick way to remember
which cranial nerves are assessed in the
face is shown.
Assessment Normal Findings Deviations from Normal
REFLEXES
Test reflexes using a percussion Normally, all five toes bend In an abnormal (positive) Babinski
hammer, comparing one side of the downward; this reaction is negative response, the toes spread outward
body with the other to evaluate the Babinski. and the big toe moves upward.
symmetry of response
0 No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximal activity (hyperactive)
To assess Plantar (Babinski) Reflex
● Using a moderately sharp
object, 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.
MOTOR FUNCTION
Gross Motor and Balance Tests
WALKING GAIT Has upright posture and steady gait Has poor posture and unsteady,
Ask the client to walk across the room with opposing arm swing; walks irregular, staggering gait with wide
and back, and assess the client’s gait. unaided, maintaining balance stance; bends legs only from hips;
has rigid or no arm movements
ROMBERG TEST Negative Romberg: may sway slightly Positive Romberg: cannot maintain
Ask the client to stand with feet but is able to maintain upright posture foot stance; moves the feet apart to
together and arms resting at the and foot stance maintain stance
sides, first with eyes open, then
closed. Stand close during this test. If client cannot maintain balance with
Rationale: This prevents the client the eyes shut, client may have
from falling. sensory ataxia (lack of coordination
of the voluntary muscles
If balance cannot be maintained
whether the eyes are open or shut,
client may have cerebellar ataxia
STANDING ON ONE FOOT WITH
EYES CLOSED Maintains stance for at least 5 Cannot maintain stance for 5 seconds
Ask the client to close the eyes and seconds
stand on one foot. Repeat on the
other foot. Stand close to the client
during this test
HEEL-TOE WALKING Maintains heel-toe walking along a Assumes a wider foot gait to stay
Ask the client to walk a straight line, straight line upright
placing the heel of one foot directly in
front of the toes of the other foot.
TOE OR HEEL WALKING Able to walk several steps on toes or Cannot maintain balance on toes and
Ask the client to walk several steps on heels heels
the toes and then on the heels.
Fine Motor Tests for the Upper
Extremities
FINGER-TO-NOSE TEST Repeatedly and rhythmically touches Misses the nose or gives slow
Ask the client to abduct and extend the nose response
the arms at shoulder height and then
rapidly touch the nose alternately with
one index finger and then the other
repeat the test with the eyes closed if
the test is performed easily.
ALTERNATING SUPINATION AND
PRONATION OF HANDS ON KNEES
Ask the client to pat both knees with Can alternately supinate and pronate Performs with slow, clumsy
the palms of both hands and then with hands at rapid pace movements and irregular timing; has
the backs of the hands alternately at difficulty alternating between
an ever-increasing rate. supination and pronation
FINGER-TO-NOSE AND TO THE
NURSE’S FINGER
Ask the client to touch the nose and Performs with coordination and Misses the finger and moves slowly
then your index finger, held at a rapidity
distance of about 45 cm (18 in.), at a
rapid and increasing rate
FINGERS-TO-FINGERS Performs with accuracy and rapidity
Ask the client to spread the arms
broadly at shoulder height and then Moves slowly and is unable to touch
bring the fingers together at the fingers consistently
midline, first with the eyes open and
then closed, first slowly and then
rapidly.
FINGERS-TO-THUMB (SAME
HAND)
Ask the client to touch each finger of Rapidly touches each finger to thumb Cannot coordinate this fine discrete
one hand to the thumb of the same with each hand movement with either one or both
hand as rapidly as possible hands
Fine Motor Tests for the Lower
Extremities
HEEL DOWN OPPOSITE SHIN
Ask the client to place the heel of one Demonstrates bilateral equal Has tremors or is awkward; heel
foot just below the opposite knee and coordination moves off shin
run the heel down the shin to the 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 FINGER
Ask the client to touch your finger with Moves smoothly, with coordination Misses your finger; cannot coordinate
the large toe of each foot. movement
LIGHT-TOUCH SENSATION
Compare the light-touch sensation of Light tickling or touch sensation Anesthesia,hyperesthesia,
symmetric areas of the body. hypoesthesia, or paresthesia
Rationale: Sensitivity to touch varies
among different skin areas.
● Ask the client to close the
eyes and to respond by
saying “yes” or “now”
whenever the client feels the
cotton wisp touching the skin.
● Test areas on the forehead,
cheek, hand, lower arm,
abdomen, foot, and lower leg.
Check a distal area of the
limb first (i.e., the hand before
the arm and the foot before
the leg). Rationale: The
sensory nerve may be
assumed to be intact if
sensation is felt at its most
distal part
● For areas with sensory
dysfunction make a sketch of
the sensory loss area for
recording purposes.
PAIN SENSATION
● Ask the client to close the Able to discriminate “sharp” and “dull” Areas of reduced, heightened, or
eyes and to say “sharp,” sensations absent sensation (map them out for
“dull,” or “don’t know” when recording purposes)
the sharp or dull end of a
safety pin is felt.
● Alternately, use the sharp and
dull end.
● Allow at least 2 seconds
between each test to prevent
summation effects of stimuli
POSITION OR KINESTHETIC
SENSATION
Commonly, the middle fingers and the
large toes are tested for the Unable to determine the position of
kinesthetic sensation one or more fingers or toes
● To test the fingers, support
the client’s arm and hand with
one hand. To test the toes,
place the client’s heels on the
examining table.
● Ask the client to close the
eyes.
● Grasp a middle finger or a big
toe firmly between your
thumb and index finger
● Move the finger or toe up,
down, or straight out, and ask
the client to identify the
position.
Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes
when appropriate. Describe any abnormal findings in objective terms, for example, “When asked to count backwards by
threes, client made seven errors and completed the task in 4 minutes.”
Cranial
Name Function Assessment Method
Nerve
I Olfactory Smell Ask client to close eyes and identify different mild
aromas, such as coffee, vanilla, peanut butter, orange,
lemon, chocolate
II Optic Vision and visual fields Ask client to read Snellen-type chart; check visual
fields by confrontation; and conduct an
ophthalmoscopic examination
III Oculomotor Extraocular eye movement Assess six ocular movements and pupil reaction
(EOM); movement of
sphincter of pupil; movement
of ciliary muscles of lens
IV Trochlear EOM; specifically, moves Assess six ocular movements
eyeball downward and
laterally
V Trigeminal
Ophthalmic Branch Sensation of cornea, skin of While client looks upward, lightly touch the lateral
face, and nasal mucosa sclera of the eye with sterile gauze to elicit blink reflex.
To test light sensation, have client close eyes, 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 same areas.
Maxillary branch Sensation of skin of face and Assess skin sensation as for ophthalmic branch above
anterior oral cavity (tongue
and teeth).
Mandibular branch Motor and sensory Muscles of Ask client to clench teeth
mastication; sensation of skin
of face
VI Abducens EOM; moves eyeball laterally Assess directions of gaze
VII Facial Facial expression; taste Ask client to smile, raise the eyebrows, frown, puff out
(anterior two thirds of tongue) cheeks, close eyes tightly.
Ask client to identify various tastes placed on tip and
sides of tongue: sugar (sweet), salt, lemon juice (sour),
and quinine (bitter); identify areas of taste
VIII Auditory
Vestibular branch Equilibrium Perform Romberg test
Cochlear branch Hearing Assess client’s ability to hear spoken word and
vibrations of tuning fork.
IX Glossopharyngeal Swallowing ability, tongue Apply tastes on posterior tongue for identification. Ask
movement, taste (posterior client to move tongue from side to side and up and
tongue) down
X Vagus Sensation of pharynx and Assessed with cranial nerve IX; assess client’s speech
larynx; swallowing; vocal cord for hoarseness.
movement
XI Accessory Head movement; shrugging Ask client to shrug shoulders against resistance from
of shoulders your hands and turn head to side against resistance
from your hand (repeat for other side).
XII Hypoglossal Protrusion of tongue; moves Ask client to protrude tongue at midline, then move it
tongue up and down and side side to side.
to side
