1. SALALE UNIVERSITY COLLEGE OF MEDICAL AND
HEALTH SCIENCES DEPARTMENT OF ADULT OF
Seminar Presentation On Assessment Of Neurological
PRESENTED BY MESFIN ASSEFA ID NO 186-15
PRESENTED TO: MR. TADELE K ( BSC, MSC, ASS’T PROFESSOR)
: MR. BIKILA T (BSC, MSC ASS’T PROFESSOR )
2. Presentation out line
• Introduction of neurological system
• Anatomical and physiological overview
• Neurological assessment and techniques .
• The health History of neurological system.
At the end of this presentation the students will able to:
Perform detail physical examination of neurological system.
Describe the structure and function of the central and peripheral
Identify common types of physical examination .
Use nursing process as a frame work in provision of nursing care
for patients with neurologic disorders.
4. Introduction of neurological system
• Neurological system is the major controlling ,regulatory and
communicating system in the body.
• It is the center of all mental activity including thought, learning
and memory together with the endocrine system.
• The nervous system is responsible for regulating and maintaining
• It’s the organized network of nerve tissue in the body (Brain and
5. Anatomical and physiological overview of Neurological
• Central Nervous System (CNS)
– Brain and spinal cord
• Peripheral Nervous System
– Cranial nerves (12)
– Spinal nerves (31 pair)
– All branches of nerves
• Cerebrum composed of two hemispheres, the thalamus, the
hypothalamus, and the basal ganglia.
• Connections for the olfactory (CN I) and optic (CN II) nerves are
found in the cerebrum.
• Brain stem includes the midbrain, pons, medulla, and connections
for CN III and IV through XII.
• Cerebellum; located under the cerebrum and behind the brain stem
8. Parts of the cerebral cortex
• Personality, behavior,
• Primary center for
• Primary visual receptor
• Primary auditory receptor
9. The Spinal cord
Ascending tracts within the spinal cord carry sensory information
from the body, upwards to the brain, such as touch, skin
temperature, pain and joint position.
Descending tracts within the spinal cord carry information from
the brain downwards to initiate movement and control body
Protection: Bone , Meninges, CSF (cerebrospinal fluid)
3 meninges: -duramater (outer), arachnoid mater (middle)
10. Peripheral Nervous System
• Carries sensory messages to central nervous system (CNS)
• Carries motor function messages from CNS to muscles and glands
• Carries autonomic messages to internal organs and blood vessels
CNS Pathways Crossed representation:
Left cerebral cortex receives sensory information from and
controls motor function to right side of body
Right cerebral cortex receives sensory information from and
controls motor function to left side of body
11. Sensory Pathways
• Sensory receptors in skin, mucous membranes, muscles, tendons,
• Sensation travels through peripheral nerve to spinal canal and into
• Spinothalmic tract: pain, temperature, crude and light touch
• Posterior (dorsal) column: sensations of position, vibration, fine
• The third group of sensory neurons sends impulses from the
thalamus to the sensory cortex of the brain.
12. Motor Pathways
• Corticospinal (pyramidal) tract
– Mediates voluntary movement; skilled, discrete, purposeful
• Extrapyramidal tracts: all motor nerve fibers outside pyramidal tract
and Controls muscle tone, gross automatic movements
• Basic defense mechanism of nervous system; quick reaction to
potential pain/damage and Helps body maintain balance & muscle
13. Neurologic Assessment
Neurologic History includes details about
The onset, character, severity, location, duration, and
frequency of symptoms and signs;
Precipitating, aggravating, and relieving factors;
Progression, remission, and exacerbation;
And the presence or absence of similar symptoms among
14. Before starting neurological assessment
I= Introduce your self
P= permission and pain
E= Exposed the patient body
R= Reposition the patients
15. Neurological assessment
• generally starts immediately when assessment is started and
continues throughout the process.
• A detailed neurological examination includes the assessment of:
• mental status
• cranial nerves
• the motor system
• the sensory system
• the reflexes.
16. The health History
• Common or Concerning Symptoms
• Changes in mood, attention, or speech
• Changes in orientation, memory, insight, or judgment
• Delirium or dementia and Seizures
• Headache and Dizziness or vertigo
• Generalized, proximal, or distal weakness
• Numbness, abnormal or loss of sensations
• Loss of consciousness, syncope, or near-syncope
• Tremors or involuntary movements
17. Mental status examination
• Components of the mental status examination include:
• Appearance and behavior
• Speech and language
• Thoughts and perceptions
• Cognitive function, including memory, attention, information
and vocabulary, calculations, and abstract thinking and
Family story of memory loss
Spelling &/or numbers
Recognition of objects
18. I. Assessment of level of consciousness
Can be assessed in either of the following ways:
a. The Glasgow comma scale
b. using certain criteria to define the summary words:
• alert, lethargy, obtundation, stupor and coma
a. The Glasgow comma scale
• This method is based on the eye opening, best motor responses
and verbal responses of the patient to different stimuli.
• The values in this scale range from 3 (the deepest comma) to 15
(the full alertness).
• A score of seven of less is accepted as coma and requires the
appropriate nursing intervention for a comatose patient.
19. Eyes open Best motor responses Verbal responses
To speech =3
To pain =2
No response at all
Obeys command =6
Localizes pain =5
Withdraws to pain =4
Abnormal flexion to pain
Extends to pain =2
No response =1
Confused conversation =4
Inappropriate words =3
No response =1
Total score =3-15
20. b. Using certain criteria to define the summary words:
21. II.Assessment of the cranial nerves
Cranial nerve Method of assessment
Cranial nerve l (Olfactory nerve) Ask the patient to identify the aromas of
substances with his eyes closed
Cranial nerve II (Optic nerve) - Examine visual fields
- Examine ocular fundi
- Test visual acuity
Cranial nerve III (occulomotor nerve) - Test pupillary reactions
- The ability of the eyelid to stay opened
- Symmetry of lids at rest
22. Cranial nerves III, IV and VI
(Occulomoptor, trochlear, and abducens
Test for extra ocular movements of the
Cranial nerve V ( trigeminal nerve) - The corneal reflex test ( the blinking
- Test facial sensations
- Test jaw movements against resistance
Cranial nerve VII (facial nerve) - Test for facial movements such as
frowning, whistling, smiling
- Test for tasting ability of the anterior
2/3 or the tongue (sour and salt)
- The ability of the eyes to remain closed
against your resistance
23. Cranial nerve VIII (cochlear nerve, and
- Test for hearing, Romberg's test
Cranial nerve IX (glossopharyngeal) - Test for tasting ability of the tongue for
bitter taste ( posterior 1/3)
Cranial nerves IX and X ( glossopharyngeal
and vagus nerves)
- Test for swallowing
- Note the rise of the palate and uvula
- Test for gag reflex
- Test for uvular reflex
Cranial nerves V, VI, X and XII Examine voice and speech
Cranial nerve XI ( accessory nerve) - Test for movements of the shoulder and
Cranial nerve XII (hypoglossal nerve) - Inspect the tongue for symmetry and
24. III. Sensory assessment
• Assessment of pain sensation
• Assessment of temperature sensations
• Assessment of light touch sensations
• Discriminative sensations
• Compare the distal with the proximal areas of the extremities
• scatter the stimuli to sample most of the dermatomes and
major peripheral nerves
• Compare symmetrical areas
25. Assessment of Vibration Techniques
• Use a relatively low pitched vibrating tuning fork.
• Place it firmly over a distal interphalangeal joint of the patient’s
• Ask what the patient feels or ask the patient to tell you when the
vibration stops, and then touch the fork to stop it.
• If vibration sense is impaired, proceed to more proximal bony
• Vibration sense is often the first sensation to be lost in a
peripheral neuropathy and happen in posterior column disease.
26. Assessment of Position Techniques
Grasp the patient’s big toe, holding it by its sides between your
thumb and index finger.
• Demonstrate “up” and “down” as you move the patient’s toe
clearly upward and downward.
• Then, with the patient’s eyes closed, ask for a response of “up” or
“down” when moving the toe in a small arc.
• If position sense is impaired, move proximally to test the other
• Loss of position sense , like loss of vibration sense, suggests either
posterior column disease or a lesion of the peripheral nerve.
• Test big toe (position).MS, neurosyphilis, & pernicious
anemia may cause loss of lower extremity proprioception
27. Discriminative Sensations
• Because discriminative sensations are dependent on touch and
position sense, they are useful only when these sensations are
either intact or only slightly impaired.
• The patient’s eyes should be closed during all these tests.
• Stereo gnosis
• Number identification (graphesthesia)
• Two point discrimination
• Point localization
28. IV. Assessment of the motor system
focus on: Body Position
Observe the patient’s body position during movement and at rest
and can the patient:
assume up right position
Walk and turn with out difficulty
Assume normal sitting and lying positions?
Abnormal positions alert you to neurologic deficits such as
29. Involuntary Movements
• Watch for involuntary movements such as tremors, involuntary
movement, or fasciculation.
• Note their location, quality, rate, rhythm, and amplitude, and their
relation to posture, activity, fatigue, emotion, and other factors.
• Resting tremors can occur with Parkinson's disease
• Postural tremors occur with fatigue
• Intention tremors occur with loss of position sensation as
in case of cerebellar diseases
• Fasciculation can be seen upper motor neuron diseases
30. Involuntary Movements conti…
• To assess coordination, observe the patient’s performance in:
• Rapid alternating movements
• Point-to-point movements
• Gait and other related body movements
• Standing in specified ways
31. Rapid Alternating Movements
• Show the patient how to strike /rapid/ one hand on the thigh,
raise the hand, turn it over, and then strike the back of the hand
down on the same place.
• Ask the patient to repeat these alternating movements as rapidly
• Show the patient how to tap the distal joint of the thumb with the
tip of the index finger, again as rapidly as possible.
32. Rapid Alternating Movements cont. …..
• Ask the patient to tap your hand as quickly as possible with the ball
of each foot in turn.
• The feet normally perform less well than the hands.
• Observe the speed, rhythm, and smoothness of the movements.
Repeat with the other hand.
• In cerebellar disease, one movement cannot be followed quickly by
its opposite and movements are slow, irregular, and clumsy.
• Upper motor neuron weakness and basal ganglia disease may also
impair rapid alternating movements.
33. Point-To-Point Movements
• Ask the patient to touch your index finger and then his or her
nose alternately several times.
• Move your finger about so that the patient has to alter directions
and extend the arm fully to reach it.
• Observe the accuracy and smoothness of movements and watch
for any tremor.
• Normally the patient’s movements are smooth and accurate.
• Now hold your finger in one place so that the patient can touch it
with one arm and finger outstretched.
34. Point-To-Point Movements ….
Ask the patient to raise the arm overhead and lower it again to
touch your finger. After several repeats, ask the patient to close
both eyes and try several more times. Repeat on the other side.
Normally person can touch the examiner’s finger successfully with
eyes open or closed.
Cerebellar disease leads to loss of position sensation and causes
incoordination that get worse with eyes closed.
35. Point-To-Point Movements ….
• Ask the patient to place one heel on the opposite knee, and then run
it down the shin to the big toe.
• Note the smoothness and accuracy of the movements.
• Repeat the maneuver with the patient’s eyes closed to test position
• Repeat on the other side.
• In cerebellar disease, the heel may overshoot the knee and then oscillate from
side to side down the shin.
• When position sense is lost, the heel is lifted too high and the patient tries to
look and With eyes closed, performance is poor.
36. Gait and other movements
Ask the patient to:
• Walk across the room
• Walk heel-to-toe in a straight line /tandem walking/.
• Walk on the toes, then on the heels across the room
• Ataxia /uncoordinated movement / may be due to cerebellar
disease, loss of position sense, or intoxication.
Graded 0 - 5
0 - no movement
1 - flicker
2 - movement with gravity removed
3 - movement against gravity
4 - movement against resistance
5 - normal strength
stand close enough to the patient to prevent a fall.
• The Romberg test is a test of position sense.
• The patient should first stand with feet together and eyes open
and then close both eyes for 20 to 30 seconds without support.
• Note the patient’s ability to maintain an upright posture.
• In ataxia due to loss of position sense, vision compensates for the
• The patient stands fairly well with eyes open but loses balance when
they are closed, a positive Romberg sign.(In cerebellar ataxia).
39. Assessment of reflexes
• A reflex is defined as an immediate and involuntary response to a
• They occur due to the presence of intermediate neurons between
the sensory and motor nerve ends in the spinal cord.
• Reflexes are of two type
– Superficial /cutaneous/ reflexes
– Deep tendon reflexes
40. Biceps--deep tendon reflex
Have the patient's elbow at about a 90°
angle of flexion with the arm slightly
bent down .
Grasp the elbow with your left hand so
the fingers are behind the elbow and
your abductee thumb presses the
biceps brachial tendon .
Strike your thumb a series of blows with
the rubber hammer, varying your thumb
pressure with each blow until the most
satisfactory response is obtained .
Normal reflex is elbow flexion (bending(
41. Triceps--deep tendon reflex
Grasp the patient's wrist with your left
hand and pull his arm across his chest so
the elbow is flexed about 90° and the
forearm is partially bent down .
Tap the triceps brachial tendon directly
above the olecranon process. The normal
response is elbow extension .
Triceps jerk with arms folded
Triceps jerk with one arm flexed
42. Plantar (Babinski) reflex
• Lightly stimulate the outer margin of the sole
of the foot to get this reflex.
• Perform the reflex check in this manner:
• Grasp the ankle with your left hand .
• Use a blunt point and moderate pressure
and stroke the sole of the foot near its
• Stroke from the heel toward the ball of
the foot where the course should curve
across the ball of the foot to the medial
side, following the bases of the toes .
• A normal reflex is for the patient to have
plantar flexion of all his toes .
43. Patellar reflex (knee jerk).
Test the reflex in this manner
• Have the patient sit on a table or high bed to
allow his legs to swing freely .
• Tap the patellar tendon directly with a rubber
• Normally, the knee extends .
• Conduct the reflex check as shown in this figure
if the patient must be lying down. Put your
hand under the popliteal fossa and lift the
patient's knee from the table or bed. Tap the
patellar tendon directly.
44. Deep tendon reflexes should be graded on a scale of 0-4
• as follows:
0 absent despite reinforcement
1 present only with reinforcement
3 increased but normal
4 markedly hyperactive, with clonus
45. Abnormal posturing
• Legs and feet extended with planter flexion and
arms rotated and flexed on chest
• Occurs With damage to the diencephalon
decorticate posturing may be seen following
46. Assessment of meningeal irritation
• Meningeal irritation is the presence of sever pain as the layers of the
meninges rub to each other as in meningeal inflammation.
• Some of the causes for meningeal irritation may include: Meningitis,
carcinoma, cerebral abscess and encephalitis .
47. Assessment of meningeal irritation cont …
• Pain in the neck and resistance to flexion may suggest meningeal
irritation, arthritis or neck injury.
Kerning's Signs Positive Test suggesting Meningeal Irritation
• Resistance to knee extension
• Pain in hamstrings
Brudzinski's Sign :Positive Test suggesting Meningeal
• Involuntary hip flexion
• This history taking portion of the neurologic examination is
critical and, in many cases of neurologic disease, leads to an
• Examine the patients properly .
• Record what you evaluate and examine .
1. Barbara Bates (1995), a guide to physical examination and history
2. Bette A. Baker (1984), health assessment across the life spans.
3. Mary K. Dempsey (1981), health assessment for professional
4. Elizabeth Burns (1992), health assessment in nursing practice
5. Janet Weber (1997), nurses’ handbook of health assessment