A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical history, but not deeper investigation such as neuroimaging.

1. NEUROLOGIC
EXAMINATION
PREPARED BY
MR. MATA DEEN
N U R S I N G T U TO R
C O L L E G E O F N U R S I N G , S G P G I M S

2. INTRODUCTION
• A neurological examination is the assessment of sensory neuron and
motor responses, especially reflexes, to determine whether the nervous
system is impaired.
• It typically includes a physical examination and a review of the
patient's medical history.

3. PURPOSES
• The basic purpose of the neurologic examination is to identify the
normal versus abnormal neurologic functions.
• The assessment is performed rapidly for patients with serious and life
threatening injury or illness, accompanied by the diagnostic studies for
the purpose of rapid and emergent treatment.
• In home setting, the assessment is performed to closely monitor the
recovery or responses of the patient.
• In OPD, the assessment is performed to assess the early signs of
complications that could result in hospitalization.

4. GOALS OF NEUROLOGIC ASSESSMENT
• Determine the diagnosis and triage.
• Determine the abnormal neurologic findings
• Establish and document the baseline for follow-up and serial
assessments
• Predict outcomes of the disease
• Develop a problem list of actual or potential problems using
appropriate nursing diagnosis

5. ARTICLES REQUIRED

6. A R T I C L E S
Article Purpose
Sterile needle To assess pain (sensory function)
Tuning fork To assess vibrations (auditory function)
Measuring tape To measure muscle strength
Test tubes For hot and cold water
Coffee, cloves To assess olfactory
Tongue depressor To assess the vagus nerve
Stethoscope To monitor vital signs

7. Article Purpose
Cotton swabs To assess the sensory function
Reflex hammer To examine the reflexes
Flash light/ torch To assess the cranial nerves
Snellen chart To assess the optic nerves
Gloves To prevent cross infection during
examination
Sugar and salt To assess glossopharyngeal nerve
Kidney tray and paper bag To collect waste

8. COMPONENTS
1. Patient’s History
2. Mental status
3. Cranial nerves
4. Motor function
5. Sensory function
6. Reflexes

9. HISTORY OF THE PATIENT
• The history can be obtained from the patient, if possible, or from
family or significant others.
• Remembering the mnemonics OLD CARTS helps to prompt
historical questions about the patient’s complaint in terms of the
following:
• Onset of the disease/ symptom
• Location of the symptom
• Duration of the symptom
• Characteristics of the symptom
• Associated factors/ aggravating factors
• Relieving factors
• Temporal factors
• Severity of symptoms

10. Neurologic History
 Signs and symptoms including date of onset, severity,
duration & frequency.
 Associated complaints, especially pain, headache, seizures,
changes in eating or sleeping pattern.
 Loss of sensation, difficulty in walking or coordination,
weakness on one or both sides of the body.
 Changes in vision or hearing.
 Difficulty with memory or ability to communicate or
understand or changes in speech

11. Neurologic History
 Changes in or loss of smell and/ or taste.
 Problems with loss of bladder/bowel control
 Loss of consciousness or feelings of
lightheadedness.
 Medical or metabolic disorders.
 Current treatment with prescription.

12. ASSESSMENT OF MENTAL STATUS
• The mental status examination (MSE) assesses the higher
cortical functions of thinking and reasoning.
• The goal to determine deviations from normal.

13. a) Orientation: Oriented to time, place and person
• What is the date today?
• Where are you?
• Who is the person sitting with you?
b) Memory :Deficit or No deficit
• Short term memory: Ask to repeat Rectangle, Raju, Blue,
after few minutes
• Recent memory: ask about the 24 hour diet recall.
• Remote memory: ask about past health, first job or
birthday.

14. c) Mood and Affect: Depressed/ euphoric
• How do you feel today?
d)Intellectual performance: good/poor
• Ask to calculate 7+3=--------
e) Judgement and Insight: good/poor
• What will you do when you see an addressed letter on the road?
f) Language (speech): good/poor
• Assess for articulation problem, ability to communicate, understanding,
quality of speech

15. LEVEL OF CONSCIOUSNESS
• The Level of consciousness (LOC) is the most important
component of the neurologic assessment.
• Consciousness is the state of awareness of self, the
environment, and responses to the environment; coma is the
opposite of consciousness, or the total absence of awareness
of the self and the environment.

16. COMPONENTS OF CONSCIOUSNESS
There are two major components of consciousness:
• Arousal, which includes the ability to respond to
stimuli, is the lowest LOC. Arousal is purely a function
of the brain stem. It does not have anything to do
with the thinking parts of the brain.
• Awareness is the orientation to person, place and
and implies interaction with and reaction to
environmental stimuli.

17. CATEGORIES OF CONSCIOUSNESS
Term Description
Alert
Confused
Delirious
Lethargic
Stuporous
Comatose
Patient responds immediately to minimal external stimuli.
Patient is disoriented to time or place but usually oriented to person,
with impaired judgement.
Patient is disoriented to time, place or person with loss of contact with
reality and often has auditory or visual hallucinations.
Patient displays a state of drowsiness or inaction in which a patient
needs an increased stimulus to be awakened.
Patient can be aroused only with vigorous and continuous external
stimuli. Motor response is often withdrawl.
Vigorous stimulation fails to produce any voluntary neural response.

18. GLASGOW COMA SCALE
• The most widely recognized LOC assessment tool is the Glasgow Coma
Scale (GCS).
• This score scale is based on evaluation of three categories:
• eye opening,
• verbal response and
• the motor response.
• The best possible score on the GCS is 15, and the lowest score is 3.
Generally, a GCS score of 8 or less indicates a coma.

19. CATEGORY RESPONSE SCORE
Eye opening Spontaneous 4
To loud voice 3
To pain 2
None 1
Verbal response Oriented 5
Confused, disoriented 4
Inappropriate word 3
Incomprehensible sounds 2
None 1
Motor response Obeys command 6
Localizes to pain 5
Withdraw(flexion) from a
pin
4
Abnormal flexion 3
Extension posturing 2

21. CRANIAL NERVES
• Cranial nerves are the nerves that emerge directly from
the brain (including the brainstem).
• Cranial nerves relay information between the brain and parts of the
body, primarily to and from regions of the head and neck.
• Humans are considered to have twelve pairs of cranial nerves (I–XII).

25. ASSESSING THE CRANIAL NERVES
I. Olfactory nerve: the main function is to detect sense of smell. Assess
the nerve with patient’s eyes closed, patient is asked to identify
familiar odours (coffee, tobacco). Each nostril is tested separately.
II. Optic nerve: visual acuity is tested in each eye separately. The patient
is asked to read progressively smaller lines on the near card or Snellen
chart.
III. Oculomotor nerve: test for eye movement toward the nose; inspect
for conjugate movement and nystagmus. Evaluate papillary and test
for pupillary reactivity to light, inspect ability to open eyelids.

26. IV. Trochlear nerve: test for upward eye movement; inspect for conjugate
movements and nystagmus (nystagmus is a back and forth oscillation of the
eyes).
V. Trigeminal nerve: Have patient close the eyes. Touch cotton to forehead,
cheeks, and jaw. Sensitivity to superficial pain is tested in these same three
areas by using the sharp and dull ends of a broken tongue blade. Alternate
between the sharp point and the dull end. Patient reports "sharp" or "dull"
with each movement. If responses are incorrect, test for temperature
sensation. Test tubes of cold and hot water are used alternately. While
patient looks up, lightly touch a wisp of cotton against the temporal surface
of each cornea. A blink and tearing are normal responses. Have patient
clench and move the jaw from side to side. Palpate the masseter and
temporal muscles, noting strength and equality.

27. VI. Abducens nerves: Test for lateral eye movement; inspect for conjugate
movement.
VII. Facial nerve: Observe for symmetry while patient performs facial
movements: smiles, whistles, elevates eyebrows, frowns, tightly closes
eyelids against resistance (examiner attempts to open them). Observe
face for flaccid paralysis (shallow nasolabial folds). Have patient
extend tongue. Test ability to discriminate between sugar and salt.

28. VIII.Acoustic (vestibulocochlear) nerve: Perform whisper or watch-tick test.
Test for lateralization (Weber test). Test for air and bone Conduction
(Rinne test). Assess standing balance with eyes closed (Romberg test).
IX. Glossopharyngeal nerve: Assess patient's ability to swallow and
discriminate between sugar and salt on posterior third of the tongue.
X. Vagus nerve: Depress a tongue blade on posterior tongue, or
stimulate posterior pharynx to elicit gag reflex. Note any hoarseness in
in voice. Check ability to swallow. Have patient say "ah." Observe for
symmetric rise of uvula and soft palate.

29. XI. Spinal accessory nerve: While patient shrugs shoulders against
resistance, palpate and note strength of trapezius muscles. As patient
turns head against opposing pressure of the examiner's hand, palpate
and note strength of each sternocleidomastoid muscle.
XII. Hypoglossal nerve: While patient protrudes the tongue, note any
deviation or tremors. Test the strength of the tongue by having
patient move the protruded tongue from side to side against a tongue
depressor.

30. ASSESSMENT OF MOTOR FUNCTION
• The successful performance of any motor function involves interaction
of the muscles, neuromuscular junction, peripheral nerves, central nerve
pathways, cerebellum and motor cortex of the frontal lobe

31. MUSCLE STRENGTH
Motor function level Grade % Normal Lovett scale
No-evidence of contractility
Slight contractility, no movement
Full range of motion, gravity
eliminated
Full range of motion with gravity
Full range of motion against gravity,
some resistance
Full range of motion against gravity,
full resistance
0
1
2
3
4
5
0
10
25
50
75
100
0 (zero)
T (trace)
P (poor)
F (fair)
G (good)
N (normal)

32. MOTOR ASSESSMENT
Assessment Normal findings Deviation from normal
Muscle size:
Inspect the muscles for size.
Compare the muscles on one
side of the body (e.g. of the
arm, thigh and calf) to the
same muscle on the other
side. For any discrepancies
measure the muscles with a
tape.
Equal size on both sides
of body
Atrophy (a decrease in size)
or hypertrophy (an increase
in size) asymmetry.
Muscle strength:
Compare the right side with
the left side, normal
movement against gravity and
against full resistance
Equal strength on each
body side
Abnormal 25% or less of
normal strength
100% of normal strength;
normal full movement
against gravity and against
full resistance.

33. Assessment Normal findings Deviation from normal
Muscle tone:
Tone is the normal degree of
tension (contraction) in
voluntarily relaxed muscles. It
shows as a mild resistance to
passive stretch.
To test muscle tone, move the
extremities through a passive
range of motion.
Mild, even resistance to
movement
Limited range of motion. Pain
with motion, Flaccidity-
decreased resistance, hypotonic.
Spasticity and rigidity
Involuntary Movements:
Note the location, frequency,
rate, and amplitude of
involuntary movement
No Involuntary Movements Tic, tremor, and fasciculation

34. BALANCE TESTS
• Gait: Observe as the person walks 10 to 20 feet, turns, and returns to the
starting point. The gait is smooth, rhythmic, and effortless; the opposing
arm swing is coordinated; the turns are smooth.
• Romberg’s test: ask the person to stand up with feet together and arms
at the sides. Once in a stable position, ask the person to close the eyes
and to hold the position. Wait about 20 seconds. Normally, a person can
maintain posture and balance.

35. COORDINATION TESTS
• Fingers-to Nose Test: Ask the client to abduct and extend the arms at
shoulder height and then rapidly touch the nose alternately with one
index finger and then the other. The client repeats the test with the eyes
closed if the test is performed easily.
• Finger-to-finger test: with the person’s eyes open, ask him to touch your
finger with his index finger, then the person’s own nose. After a few
times move your finger to a different spot. The person’s movement
should be smooth and accurate.

37. • Heel-to-shin Test: 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. Normally,
the person moves the heel in straight line down the shin.

39. THE SENSORY SYSTEM ASSESSMENT
• Pain: pain is tested by the person’s ability to perceive a pin prick. Using a
sterile needle, lightly apply the sharp point or the dull hub to the
person’s body in a ransom, unpredictable order. Ask the person to say
‘sharp’ or ‘dull’ depending on the sensation felt.
• Temperature: apply hot or cold element to the skin. Test temperature
sensation only when pain sensation is abnormal. Ask the person what
temperature is felt.

40. • Vibration: test the person’s ability to feel vibrations of the tuning fork
over bony prominences. Ask the person to indicate when the vibration
start and stops.
• Position (kinesthesia): test the person’s ability to perceive passive
movements of the extremities. Move a finger or the big toe up and
down, and ask the person to tell which way is it moving.

41. ASSESSMENT OF REFLEXES

42. DEEP TENDON REFLEXES- TECHNIQUE
• A reflex hammer is used to elicit a deep tendon reflex. The handle of the
hammer is held loosely between the thumb and index finger, allowing a
full swinging motion.
• The wrist motion is similar to that used during percussion. The extremity
is positioned so that the tendon is slightly stretched.
• This requires a sound knowledge of the location of muscles and their
tendon attachments. The tendon is then struck briskly, and the response
is compared with that on the opposite side of the body.

43. GRADING THE REFLEXES
• Deep tendon reflex responses are often graded on a scale of 0 to 4+,
with 2+ considered normal. The terms present, absent, and diminished
are used when describing reflexes.
• 0 No response
• 1+ Sluggish or diminished
• 2+ Active or expected response
• 3+ Slightly hyperactive
• 4+ Brisk, hyperactive

44. • Biceps Reflex (C5 – C6): Support the forearm on the examiners forearm.
Place your thumb on the bicep tendon (located in the front of the bend
of the elbow; midline to the anticubital fossa).

45. • Triceps Reflex (C7-C8): Have the individual bend their elbow while
pointing their arm downward at 90 degrees. Support the upper arm so
that the arm hangs loosely and “goes dead”. Tap on the triceps tendon
located just above the elbow bend (funny bone).

46. • Brachioradialis Reflex (C5-C6): Hold the person’s thumb so that the
forearm relaxes. Strike the forearm about 2-3 cm above the radial styloid
process (located along the thumb side of the wrist, about 2-3 cm above
the round bone at the bend of the wrist). Normally, the forearm with flex
and supinate.

47. • Patellar Reflex (Knee jerk) L2 – L4 : Allow the lower legs to dangle freely.
Place one hand on the quadriceps. Strike just below the knee cap. The
lower leg normally will extend and the quadriceps will contract.

48. • Achilles Reflex (ankle jerks) L5 – S2: Flex the knee and externally rotate
the hip. Dorsiflex the foot and strike the Achilles tendon of the heel. In
conscious patients, kneeling on a chair can help to relax the foot.

49. • Babinski Response (plantar reflex): The plantar reflex is a reflex elicited
when the sole of the foot is stimulated with a blunt
instrument. Dorsiflexion of the great toe with fanning of remaining toes
is a positive Babinski response. This indicates upper motor neuron
disease.

50. DOCUMENTATION
• Documentation of the abnormalities or deficit found in the neurologic
assessment is important.
• It helps to diagnose the client’s illness and in further management and
treatment of the illness.
• Record the findings in the client’s case sheet.

51. REFERENCES
• Brunner’s and suddarth’s. Textbook of Medical-Surgical Nursing 12th edition vol 2
p.1841-50
• Ellen Barker. Neuroscience Nursing. A spectrum of care. 2nd Edition p. 51-70
• Carolyn, Jarvis. A guide to physical and health assessment. 3rd Edition p.750-94
• Potter, Perry. Fundamentals of nursing.5th Edition, Vol-1. P.821-831
• www.wikipedia.com
• https://www.youtube.com/results?search_query=cranial+nerve+examination