1. Neurological
Assessment

2. Nervous System
◦Central
◦Peripheral

3. Central Nervous System
◦ Brain
◦ Spinal cord

4. Brain
◦ Cerebral cortex
◦ Frontal
◦ Parietal
◦ Occipital
◦ Temporal
◦ Diencephalon
◦ Thalamus
◦ Hypothalamus
◦ Epithalamus

5. Brain
◦ Cerebellum
◦ Brain stem
◦ Midbrain
◦ Pons
◦ Medulla oblongata

6. Regions of the brain

7. Spinal Cord
◦Meninges
◦Cerebrospinal fluid
◦Vertebrae

8. Peripheral Nervous System
◦Cranial nerves
◦Spinal nerves

9. 12 Pairs of Cranial Nerves
◦ Originate in the brain
◦ Control many activities in the body
◦ Take impulses to and from the brain

10. Cranial nerves and their target regions. (Sensory nerves are shown in
blue; motor nerves, in red.)

11. Cranial Nerves

12. Spinal Cord
◦ 31 pairs of spinal nerves
◦ 8 pairs of cervical nerves
◦ 12 pairs of thoracic nerves
◦ 5 pairs of lumbar nerves
◦ 5 pairs of sacral nerves
◦ 1 pair of coccygeal nerves

13. Spinal nerves

14. NEUROLOGICAL
ASSESSMENT

15. Health History
◦ Common or concerning symptoms
◦ Headache
◦ Dizziness or vertigo
◦ Generalized, proximal or distal weakness
◦ Numbness, abnormal or lost sensations
◦ Loss of consciousness
◦ Seizures
◦ Tremors or involuntary movements

16. COMPONENTS OF NEUROLOGICAL
EXAMINATION
1. Mental Status
2. Cranial nerves
3. Motor Examination
4. Sensory Examination
5. Coordination
6. Reflexes
7. Gait

17. Neurologic History
◦ The neurologic history is the most important
component of neurologic diagnosis.
◦ The history is often the only way of diagnosing
neurologic illnesses that typically have normal or non-
focal findings on neurologic examination.

18. Points to consider when obtaining a
neurologic history:
◦ Carefully identify the chief complaint or major
problem.
◦ Listen carefully to the patient for as long as is
necessary.

19. ◦ Take a careful medical history, medication history,
psychiatric history, family history, and social and
occupational history.
◦ Summarize the history for the patient.

20. The Neurologic Review of Systems
◦ Mental Status
◦ Skull, Spine and Meninges
◦ Cranial Nerves
◦ Motor Function
◦ Sensory Function
◦ Coordination
◦ Gait and Station
◦ General Symptoms

21. MENTAL STATUS TESTING
◦ The mental status is an extremely important part of
the neurologic examination that is often overlooked. It
should be assessed first in all patients. Mental status
testing can be divided into five parts: level of
alertness; focal cortical functioning; cognition; mood
and affect; and thought content.

22. Level of Alertness
(Level of Consciousness)
◦ Level of alertness is defined as the best verbal or
motor response that can be elicited from the patient in
response to a specific stimulus.
◦ Many physicians label the level of alertness using
such non-specific terms as "awake”, “lethargic”,
“stuporous”, or “comatose".

23. Focal Cortical Functioning
◦ Aphasia
◦ Aphasia is an acquired disorder in the production or
understanding of language due to a lesion involving
the dominant cerebral hemisphere. In general,
aphasias are of two types, namely expressive or
receptive.
◦ An expressive aphasia (front, motor, non-fluent,
Broca) is usually seen following a lesion involving
Broca's area (lateral pre-motor cortex).
◦ A receptive aphasia (back, sensory, fluent,
Wernicke) is seen with a lesion involving the
supramarginal and angular gyri in the temporal lobe
(Wernicke's area).

24. Focal Cortical Functioning
◦ Aphasia Testing:
◦ Six language functions are routinely tested to evaluate the
patient for the presence of aphasia:
◦ • Fluency: The amount and ease of speech production.
◦ • Naming: The ability to name objects and parts of objects.
◦ • Comprehension: The ability to understand simple and complex
commands.
◦ • Repetition: The ability to repeat a spoken phrase, such as "no
ifs, ands or buts about it”.
◦ • Reading: The ability to read and understand a written sentence.
◦ • Writing: The ability to write to dictation.

25. ◦ Agnosia
◦ Agnosia is a defect in recognizing a complex sensory
stimulus. Normal primary sensory function is assumed.
Agnosias are due to lesions involving "association cortex",
primarily located in parietal and temporal lobes in either
the dominant or non-dominant hemispheres. Several
examples of agnosia include the following:
◦ • Anosognosia: Denial of illness.
◦ • Asomatagnosia: Denial of half of one's body.
◦ • Prosopagnosia: Inability to recognize faces.
◦ • Extinction to double simultaneous stimulation.
◦ • Geographic disorientation.

26. ◦ Apraxia
◦ Apraxia is a defect in the performance of a complex motor
task. Normal primary motor function is assumed. Apraxias
are also due to lesions involving "association cortex",
primarily in the 10 frontal lobes of the dominant or non-
dominant hemispheres. Several examples of apraxia
include the following:
◦ • Ideomotor Apraxia: Inability to perform motor tasks on
command ("Show me how you would salute", etc.).
◦ • Ideational Apraxia: Inability to plan a series of complex
tasks ("How would you set the table for dinner?")
◦ • Constructional Apraxia: Inability to copy complex figures.
◦ • Dressing Apraxia: Inability to dress oneself.

27. Cognition
◦ areas of cortex and subcortical white matter, and damage
to large areas of the cerebral hemispheres is required to
produce abnormalities in cognition. Five components of
cognition that can easily be tested include the following:
◦ • Orientation:
◦ • Memory:
◦ • Intellect:
◦ • Judgment:
◦ Mood and thought

28. SKULL, SPINE AND MENINGES
◦ The skull is palpated to the detect defects secondary to trauma or
surgery.
◦ Spine
◦ The spine is inspected for scoliosis, which may indicate an underlying
weakness of paraspinal muscles. Palpation of the spine is performed to
detect any tenderness.
◦ Straight Leg Raising Test (Sciatic Stretch Test)
◦ This test allows one to evaluate for lower lumbar or sacral nerve root
irritation, as can occur with herniated lumbar disks. To perform this test,
the patient lies supine and the thigh is flexed at the hip, with the leg
extended at the knee, and the patient is observed for the development of
lumbar pain that radiates down the involved leg in a dermatomal pattern
(sciatica).

30. Physical Assessment of the
Neurologic System
◦ Techniques
◦ Inspection
◦ Palpation
◦ Auscultation
◦ Sensory and motor function
◦ Reflexes

31. Cranial Nerves

32. Cranial Nerves
l. Olfactory: smell ll. Optic: vision
lll. Oculomotor: moves eye
constricts pupil, opens
eyelid
lV. Trochlear: moves eye in
and down

33. Cranial Nerves
V. Trigeminal: sensation to
face, scalp
cornea
Vl. Abducens: moves eye
laterally
Vll. Facial: moves face Vlll. Acoustic: hearing and
balance

34. Cranial Nerves
lX. Glossopharyngeal:
swallow &
speech
X. Vagus: voice quality
Xl. Spinal Accessory:
moves head &
shoulders
Xll. Hypoglossal: moves
tongue

35. Cranial Nerves
Assess together: lll, lV &
Vl
Assess together: lX, X &
Xll (swallow, gag & dysarthria)

37. THE MOTOR EXAMINATION
◦ When performing the motor examination on a patient presenting
with weakness, it is important to remember that weakness could
be a result of a lesion at any point in the neuraxis: cerebral
hemispheres, brain stem, spinal cord, anterior horn cell, nerve
root (myotome), peripheral nerve, neuromuscular junction, or
muscle.
◦ Another important distinction in the evaluation of weakness is
whether the weakness has a characteristic "upper motor neuron
pattern" or "lower motor neuron pattern".
◦ The motor examination consists of several parts: assessment of
muscle bulk, evaluation of muscle tone, observation for
spontaneous movements, and functional and formal muscle
strength testing.

38. Areas of the Neurologic System
Assessment
◦ Motor function
◦ Observation of gait and balance
◦ Administration of the Romberg test
◦ Administration of the finger-to-nose test
◦ Observation of rapid alternating action movements
◦ Administration of the heel-to-shin test

39. Evaluation of gait.

40. Heel-to-toe walk

41. Romberg’s test for balance

42. Finger-to-nose test

43. Alternative for pass point test

44. Testing rapid alternating movement, palms down.

45. Testing rapid alternating movement, palms up

46. ◦ Muscle Strength
◦ Muscle strength is assessed by both functional testing and formal
testing.
◦ Functional Testing
◦ Functional testing is a very reliable form of testing muscle strength that
is easily reproducible and reflects the ability of the patient to perform
certain tasks. Functional testing of the upper extremity includes the
following: ability to touch the chin to the chest when lying supine; ability
to raise the arms above one's head; ability to blanch the knuckles when
making a fist. Functional testing of the lower extremities includes the
following: ability to arise from a chair without using one's hands; ability
to arise from a squat; ability to step up on a chair with one leg; ability to
walk on one's toes or heels.

47. ◦ Formal Testing
◦ Formal muscle strength testing involves grading muscle strength for
individual muscle groups on a 0-5 scale by means of push/pull testing
by the examiner. Typically, a group of muscles is tested together.
Representative muscle groups that are often evaluated in a screening
examination are listed in table 8.

50. Testing coordination using the finger-to-finger test.

51. Heel-to-shin test.

52. Areas of the Neurologic System
Assessment
◦ Sensory function
◦ Observation of light touch identification
◦ Sharp, dull, temperature, and vibration
determination
◦ Stereognosis
◦ Graphesthesia
◦ Two-point discrimination
◦ Topognosis
◦ Position sense

53. Evaluation of light touch

54. Testing the client’s ability to identify sharp sensations

55. Testing the client’s ability to identify dull sensations

56. Testing the client’s ability to feel vibrations, the toe

57. Testing the client’s ability to feel vibrations, the knee

58. Position sense of joint movement

59. Areas of the Neurologic System
Assessment
◦ Reflexes
◦ Biceps
◦ Triceps
◦ Brachioradialsis
◦ Patellar
◦ Achilles
◦ Plantar
◦ Abdominal

60. Testing the biceps reflex

61. testing the triceps reflex

62. Testing the brachioradialis reflex.

63. Testing patellar reflex, client in a sitting position

64. Testing patellar reflex using a relaxation technique.

65. Testing the Achilles tendon reflex with client in a sitting position

66. Testing the Achilles tendon reflex with client in a supine position.

67. Testing the plantar reflex

68. Babinski response

69. Abdominal reflex testing pattern

70. Areas of the Neurologic System
Assessment
◦ Additional assessments
◦ Carotid auscultation
◦ Meningeal assessment
◦ Glasgow Coma Scale

71. Glasgow Coma Scale

72. Neurosurgery Considerations
◦ Assess for increased intracranial pressure (ICP)
◦ Level of consciousness (LOC)
◦ Motor function
◦ Pupillary response
◦ Vital signs
◦ Following an ICU stay of several days, client will
normally be confused about the date.

73. Pupils
Assess for size, shape
& reaction to light.

74. Pupils
◦ Controlled by:
◦ CN-III
◦ Brainstem
◦ Midbrain
◦ Pupillary Assessment
◦ Size N= 3-5mm
◦ Reaction
◦ Shape…
◦ N=Round
◦ Abn=oval –  ICP (15-20mmHg)
- post frontal / anterior
temporal lesions
- Contusion
Fixed Dilated=  ICP,
Prolonged diffuse
hypoxia, Atropine
Pinpoint pupil =
Narcotics (Morphine,
Demerol), Long Acting
analgesia (Fentanyl)

75. THANK YOU FOR
LISTENING !