The document discusses the assessment of the neurologic system through physical examination. It begins with an overview of the structure and function of the central and peripheral nervous systems. It then details the anatomy and physiology of the brain and spinal cord, as well as the cranial nerves and reflexes. Physical assessment techniques are provided to evaluate nervous system functioning, including tests for mental status, motor skills, sensation, and reflexes.

1. Assessment of
neurologic
function in nursing

2. Objectives
On the completion of this lecture student
will be able to
i. Describe the structure and function of
central and peripheral nervous system
ii. Enumerates the functioning of sympathetic
and Parasympathetic nervous system
iii.Discuss the significance of physical
assessment and examination in detecting
the dyfunctioning of nervous system
iv.Discuss the various diagnostic procedures
used to discuss the disfunctioning of
nervous system

3. INTRODUCTION
• The function of nervous system is to
control All motor ,cognitive
,autonomic and behavioral activities
happening in the human body,
disorders of nervous system can
occur during any point of life and a
nurse must be skilled in the
assessment and functioning of the
neurologic system

5. Anatomy of the nervous
system
Neurons are the structural and
functional unit of the nervous system
consisting of axon ,dendrite and cell
body

6. Anatomy of the nervous
system
Neurotransmitters:
They transmit message from one
neuron to the other neuron
Most of the neurological disorders
are due to the imbalance in the
transmission of neurotransmitters
Eg:low serotonin level in epilepsy,
decrease of dopamine in
Parkinson's disease.

7. Major neurotransmitters
NEUROTRANSMITTER SOURCE ACTION
Acetylcholine (major
transmitter of the
parasympathetic system)
Many areas of the brain;
autonomic nervous
System
Usually excitatory;
parasympathetic effects
Serotonin Brain stem, hypothalamus,
the spinal cord
Restraining, helps control
mood sleep, Inhibiting pain
pathways
Dopamine Substantia nigra and basal
ganglia
Usually restrains, affects
behavior (attention, emotions)
and fine movement
Norepinephrine (major
transmitter of the
sympathetic system)
Brain stem, hypothalamus,
sympathetic nervous
system
Usually excitatory; affects
mood and overall
activity
Gamma-aminobutyric acid
(GABA)
Spinal cord, cerebellum,,
some cortical areas
Excitatory amino acid
Enkephalin, endorphin Nerve terminals in the
spine, brain, pituitary
gland
Excitatory; pleasurable
sensation, inhibits
pain transmission

8. Central Nervous system: anatomy of the
Brain
2% of total body weight
1400gm in an average
adult.
The brain is divided in to 3
major areas
Forebrain: Cerebrum,
thalamus and
hypothalamus
Midbrain:tectum and
tegmentum
Hindbrain:Cerebellum,Pon
s and medulla

9. Anatomy of the brain: Forebrain
1.CEREBRUM consists of two
hemisphere that are incompletely
separated by fissure
Both hemispheres divided in to
Frontal Lobe: largest lobe of the brain
specialized in concentration, thought
formation and judgment
Parietal lobe: analyses sensory
information and gives orientation
Temporal lobe: contains the auditory
receptive areas
Occipital: posterior lobe responsible for
visual interpretation

11. Anatomy of the brain: forebrain
2.Thalamus- a large mass of gray
matter deeply situated in the
forebrain. primarily as a relay station
for all sensation except
smell. All memory, sensation, and
pain impulses through this section of
the brain
3. Hypothalamus: It controls
homeostasis, emotion, thirst, hunger,
circadian rhythms, autonomic nervous
system and pituitary gland

12. Anatomy of the brain: forebrain
4. Amygdala:located in the temporal
lobe; involved in memory, emotion,
and fear.
5. Hippocampus-. important for
learning and memory , for converting
short term memory to more
permanent memory, and for recalling
spatial relationships

13. Anatomy of the brain: Midbrain
Midbrain/ Mesencephalon- the rostral
part of the brain stem, which includes
the tectum and tegmentum. It is
involved in functions such as vision,
hearing, eyemovement, and body
movement.

14. Anatomy of the brain: Hindbrain
1.Cerebellum: The cerebellum
has both excitatory and inhibitory
actions and is largely responsible for
coordination of movement. It also
controls fine
movement, balance, position sense
(awareness of where each part of the
body is) and integration of sensory
input.

15. Anatomy of the brain: Hindbrain
2. Pons :It is a bridge between the
two halves of the cerebellum, and
between the medulla and the cerebrum. It
contains motor and sensory pathways.
Portions
of the pons also control the heart,
respiration, and blood pressure
3. Medulla Oblongata- this structure
between the pons and spinal cord. It is
responsible for maintaining vital body
functions, such as breathing and heart
rate

16. 

17. Anatomy of the brain: Structures protecting the brain
brain is protected from outside by rigid skull by 8
cranial bones.
Meninges :connective tissue which covers the
brain and spinal cord made up of
 Duramater: tough, thick and inelastic
outermost layer
 Arachanoid mater: delicate middle
membrane ,white in color with choroid plexus
which produce cerebrospinal fluid
 Piamater:thin innermost layer which
hugs the brain closely

19. Cerebrospinal fluid
CSF, a clear and colorless fluid with a
specific gravity of 1.007
It is produced from the ventricles and
is circulated through ventricular
system (right and left lateral, and the
third and fourth) to brain and spinal
cord
The composition of CSF is similar to
that of plasma
Normally CSF contains few white
blood cells but no red blood cells

20. Cerebrospinal fluid
• Circulation of CSF:

21. Cerebral circulation
 The cerebral circulation receives 15% of the
cardiac output, or 750 mL per minute.
 The brain does not store nutrients and requires
the high blood flow.
 The brain’s blood pathway is unique because it
flows against gravity
 Irreversible tissue damage will occur if blood
flow is occluded even for short span of time as
the brain lacks additional collateral blood flow
 Internal carotid artery and vertebral artery
branches provide blood supply to the brain
 blood brain barrier makes many substances In
the blood stream inaccessible to the central
Nervous system.

23. Spinal Cord
• The spinal cord and medulla form a
continuous structure about45 cm (18 in) long
and about the thickness of a finger
• Contrary to the brain spinal cord consists of
gray matter inside and white matter outside
and is protected by meninges
• The spinal cord is an H-shaped structure
• Lower portion of the H is anterior horn and
upper portion is called posterior horns both
serving reflex activity.
• The thoracic region of the spinal cord has a
projection at the crossbar of H and is called
the Lateral Horn
• The bones of the vertebral column made up of
33 bones

25. CRANIAL NERVES
There are 12 pairs of cranial nerves
CRANIAL NERVE TYPE FUNCTION
I (olfactory)
II (optic)
III (oculomotor)
IV (trochlear)
V (trigeminal)
VI (abducens)
VII (facial)
VIII (acoustic)
IX (glossopharyngeal)
X (vagus)
XI (spinal accessory)
XII (hypoglossal)
Sensory
Sensory
Motor
Motor
Mixed
Motor
Mixed
Sensory
Mixed
Mixed
Motor
Motor
 Sense of smell
 Visual acuity
 Muscles that move the eye and lid, lens
accommodation
 Muscles that move the eye
 Facial sensation, corneal reflex,
mastication
 Muscles that move the eye
 Facial expression ,salivation and tearing,
taste, sensation in the ear
 Hearing and equilibrium
 Taste, sensation in pharynx and tongue
and pharyngeal muscles
 Muscles of pharynx, larynx, and soft
palate; sensation in external ear,
parasympathetic innervations of thoracic
and abdominal organs
 Sternocleidomastoid and trapezius
muscles
 Movement of the tongue
12 pairs of cranial nerve (3 sensory,5 motor and 4 mixed)

26. Spinal nerves
• The spinal nerves are of 31 pairs
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal.
 Each spinal cord contains a dorsal root and a
ventral root
 The dorsal roots are sensory and transmit
sensory impulses from specific areas of the body
to dorsal ganglia of the spinal cord.
 The ventral roots are motor and transmit
impulses from the
spinal cord to the body.

27. Autonomic/involuntary
nervous system
Regulates the activities of internal organs and
plays a role in the maintenance of internal
homeostasis
PARASYMPATHETIC NERVOUS
SYSTEM
(controls visceral function)
Mainly functions in quiet and
stressful conditions
The neurotransmitter is
acetylcholine’
Response is cholinergic
Located in craniosacral division
SYMPATHETIC NERVOUS
SYSTEM
(fight and flight response)
Activates under stress condition
The neurotransmitter is
norepinephrine or adrenaline
The response is adrenergic
Located in thoracolumbar division

29. Somatic/voluntary nervous
system
Responsible for carrying motor and
sensory information to and from the
nervous system & all voluntary muscle
movements
Consists of
i.sensory neurons: carries
information from nerves to the central
nervous system
ii.Motor neurons: carries
information from central nervous system
to the nerves

30. Neurological Examination
• Health history :
 Details about the onset, character,
severity, location, duration, and
frequency of symptoms and signs;
precipitating, aggravating, and
relieving factors; progression,
remission, and exacerbation; any
family history of genetic diseases
 history of trauma or falls that may
have involved the head or spinal
cord.
 Use of alcohol, medications

31. Neurological Examination
• Clinical Manifestation:
Asses for major symptoms which may
point a neurological disturbance such
as pain, seizures, weakness, abnormal
sensation, parasthesias,visual
disturbance, vertigo and imbalance
• Physical examination:
Detailed and thorough physical
examination is needed to evaluate the
functioning of the nervous system.

32. Neurological Examination
• Assessing cerebral function: It includes
 Mental status: appearance, posture, manner of
speech, level of consciousness, orientation.
 Intelligent quotient
 Thought process
 Emotional status
 PERCEPTION: assess for agnosia which Is the
inability to interpret object which is seen through
special senses. (visual, auditory and tactile)
 Assessment of motor ability
 Language ability
• A deficiency in language function is called aphasia.

33. Neurological Examination: Assessment of Cranial
Nerves
I. Olfactory nerve: Assessment
of the olfactory nerve is done by
asked the person to smell
something very familiar with the
eyes closed.
II.Optic Nerve: Examination is
done by using the Snellen chart

34. Neurological Examination:
Assessment of Cranial Nerves
III,IV &VI Occulomotor,
trochlear and
Abduscens Nerve:
Ocular rotation, conjugate
movement, nystagmus ,
testing of puppillary
reflexes and checking for
ptosis is done to assess
the functioning of these
nerves

35. Neurological Examination:
Assessment of Cranial Nerves
• V.Trigeminal Nerve: the nerve has two
divisions:
a. Sensory:
 Touch one side of the patients face slightly
with a cotton ball and ask the patient to
identify if both sides of the face was
touched or not
 Touch the sides of face gently with a safety
pin and ask the patient to verbalize the
difference in the sensation of pain .Touch
the patients face sometimes with the sharp
point of the pin and at other times with the
dull guard. Ask the patient to describe the
sensation.
 Testing for the corneal reflex and the pain
sensation

36. Neurological Examination: Assessment of
Cranial Nerves
V.Trigeminal Nerve: Motor divisions
• Observe the skin over the temporal masseter
muscles. Concavity or asymmetry suggests
atrophy. The tip of the mandible should be in the
midline.
• Ask the patient to clench his or her jaws. Palpate
the masseter and temporal muscles for asymmetry
of volume and for tone.
• Observe for deviation of the tip of the mandible as
the jaws are opened.
• Ask the patient to move the jaw from side to side
against the resistance of your palm. The paralyzed
side will not move laterally.
• For the stretch reflex, demonstrate to the patient
what you are going to do. Have the jaws half open
and relaxed. Then place your index finger on the tip
of the mandible and tap your finger gently but
briskly with a reflex hammer.

37. Neurological Examination:
Assessment of Cranial Nerves
VII:Facial Nerve:
 The examiner should
observe for the symmetry of
the face when the patient
performs movement like
smiling, frowning, whistling
elevating eyebrows, closing
of the eyelid as the examiner
tries to open it
 Observing for flaccid face
 Ability to determine sugar
and salt.

38. Neurological Examination: Assessment of
Cranial Nerves
• VIII Acoustic Nerve (Vestibulocochlear)
• For Hearing:
Whisper test: Ask the patient to repeat the numbers which the
examiner whispers by standing behind the patient and masking the
other ear. Note for any asymmetry in the hearing.
• To differentiate conductive and sensorineural hearing loss:
Rinnes test: Place a tuning fork next to the mastoid process and
then behind the ear. Then ask the patient in which position sound
is heard louder
NORMAL RESPONSE: Sound should be heard louder in second
Weber’s test: Place the tuning fork in the centre of forehead and
ask in which ear sound is heard louder.
NORMAL RESPONSE: The sound is heard equally in both the ears.

39. Neurological Examination:
Assessment of Cranial Nerves
• IX, X: Glossopharyngeal,
Vagus
• Assess voice: Hoarse /Nasal
• Examine palate for uvular displacement .
• Observe for the symmetrical rise of uvula
and soft palate when patient says "Ah"
• Elicit Gag reflex
• Stimulate back of throat each side.
• Normal to gag each time.

40. Neurological Examination:
Assessment of Cranial Nerves
 . XI: Accessory
• Examine for any atrophy or asymmetry of
trapezius muscle from behind while
patient shrugs shoulders against
resistance
• Note for asymmetry of sternocledomastoid
muscle as the patient turn head against
resistance
 XII: Hypoglossal
• Ask the patient to protrude tongue to note
any unilateral deviation or tremors.
• Test the strength of the tongue by having
the patient move the tongue side to side
against a tongue depressor

41. Testing for reflexes
Technique: A Reflex hammer is used to elicit the reflex
.Testing of the reflexes should give symmetrically equivalent
result.
Observations:
 Absence of reflexes is important.
 Deep tendon reflexes are graded on a scale from 0 to 4+
 0-no response
 1+-diminished reflex
 2+-normal response
 3+-brisk /hyperactive response
 4+-clonus/repetitive response
Major deep tendon reflexes checked:
 Biceps reflex
 Triceps reflex
 Brachiordialis reflex
 Patellar reflex
 Ankle reflex/achilles reflex

42. Testing for superficial
reflexes
Reflex Method Response Interpretation
Corneal
reflex
Gag reflex
Plantar Reflex
Babinski reflex
Touch the sclera of
each eye on the outer
corner with clean wisp
of a cotton
Touch the posterior
potion of the pharynx
with a cotton tipped
applicator
Stroking the lateral
side of the tongue with
a tongue blade
Stroke the lateral
aspect of the sole of the
foot
Blink response is
expected
Equal elevation
of uvula and gag
response is
expected.
Flexion of the
toe is expected
Toes get
contracted and
draws together
•May be absent
in case of CVA
or coma
•Absent in
CVA ,paralysis
•Serious central
nervous system
dysfunction
•Toes fan out in
adults with
nervous system
disorders

43. Common diagnostic test
Computed tomography
It is noninvasive and painless
and has a high degree of
sensitivity for detecting lesions.
makes use of a narrow x-ray
beam to scan different areas of
the body .
Positron emission
tomography
PET is a computer-based
nuclear imaging technique that
produces images of actual organ
Functioning and produces a
series of two-dimensional views
at various levels
Nursing Interventions
 Teach the patient to lie quietly
throughout the procedure.
Sedation can be used for agitated
patients
Iodine or shell fish allergy should be
reported in case of CT with contrast
An intravenous line and a period of
fasting (usually 4 hours) are required
prior to the study.
Nursing Interventions
 Teach the patient to lie quietly
throughout the procedure.
Sedation can be used for agitated
patients
Iodine or shell fish allergy should be
reported in case of CT with contrast
An intravenous line and a period of
fasting (usually 4 hours) are required
prior to the study.
Nursing interventions
• Explaining the test and the
sensations (e.g., dizziness,
lightheadedness, and headache) that
may occur.
•Relaxation exercises may reduce
anxiety during the test.

44. Single photon emission
Computed tomography
SPECT is a three-dimensional imaging
technique that uses radio nuclides and
instruments to detect single photons. It
is a perfusion study that
captures a moment of cerebral blood
flow at the time of injection of a
radionuclide and helps to see the
contrast between normal and abnormal
tissue
Magnetic resonance imaging
MRI uses a strong magnetic field to
obtain the I mages of the body
Does not involve ionizing radiation
Will detect cerebral abnormalities
earlier than other test
Test takes up an hour to complete
Nursing interventions
patient preparation & monitoring
Teaching about what to expect
before the test
the woman who is breastfeeding
is instructed to stop
Monitor for allergic reactions
during and after the procedure
Nursing Interventions
Explain about the procedure and
what to expect
All metallic objects should be
removed
Clear history to know the presence
of any metallic objects in the body
No metallic patient care equipment
should be brought near the MRI
room
procedure is painless loud sound is
expected during the procedure

45. Cerebral angiography
It is an x-ray study of the cerebral
circulation with a contrast agent
injected into a selected artery.
It is a valuable tool to investigate
vascular disease, aneurysms, and
arteriovenous malformations
Myelography
It is an x-ray of the spinal
subarachnoid space taken after the
injection of a contrast agent into the
spinal subarachnoid space through a
lumbar puncture. It outlines the spinal
subarachnoid space and shows any
abnormality of the spinal cord
Less sensitive as compared to CT
and MRI
Nursing Interventions
•The patient should be well hydrated.
•The locations of the appropriate peripheral
pulses are marked
•The patient is instructed to remain
immobile during the process and is told to
expect a brief feeling of warmth a metallic
taste when the contrast agent is injected..
•Observe for signs and symptoms of
complications
•The color and temperature of the involved
extremity are assessed to detect possible
embolism.
Nursing Interventions:
Inform about to what to expect during
the procedure and position change
required during the same
Preparation for lumbar puncture
After the procedure patient should be
in fowlers position
The patient is encouraged to drink
water
Observe for signs of complication

46. Electroencephalogram (EEG)
It represents a record of the electrical activity
generated in the brain obtained through
electrodes applied on the scalp.
The EEG is a useful test for diagnosing and
evaluating seizure
disorders, coma, or organic brain syndrome.,
Tumors, brain abscesses, blood clots, and
infection and also used in determination of
brain death
the standard EEG takes 45 to 60 minutes, 12
hours for a sleep EEG
ELECTROMYOGRAPHY
An electromyogram (EMG) is obtained by
introducing needle electrodes into the skeletal
muscles to measure changes in the
electrical potential of the muscles and the
nerves leading to them.
The electrical potentials are shown on an
oscilloscope and amplified by a loudspeaker
so that both the sound and appearance of the
waves can be analyzed and compared
simultaneously.
An EMG is useful in determining the presence
of a neuromuscular disorder and myopathies.
Nursing Interventions
•Anti seizure agents, tranquilizers,
stimulants,
•and depressants should be withheld 24 to
48 hours before an EEG
• Coffee, tea, chocolate, and cola drinks
are omitted
•in the meal before the test because of
their stimulating effect.
•The meal is not omitted
• An EEG requires patient cooperation and
ability to lie quietly during the test.
Nursing Interventions
The procedure is explained and the
patient is warned to expect a
sensation similar to that of an
intramuscular injection as the needle
is inserted into the muscle. The
muscles examined may ache
for a short time after the procedure.

47. Lumbar puncture and
examination
It is a procedure by which CSF is withdrawn by
inserting a needle in to the subarachanoid
space
Indication
• To obtain CSF for examination
• To measure or reduce the pressure of CSF
• To detect subarachanoid block
• To administer medcine intrathecally
Preprocedure
• Obtain a written consent
• Explain the procedure to the patient and
tell what to expect
• Reassure the patient and provide support
• Instruct the patient to void before the
procedure
• Assist the patient to lateral recumbent
position with maximum flexion of the thighs

48. Procedure: (performed by physician)
 .The nurse assists the patient to maintain the position
to avoid sudden movement, which can produce a
trauma
 The patient is encouraged to relax and is instructed to
breathe normally
 Describe the procedure step by step as it proceeds
 The physician cleanses the puncture site with an
antiseptic solution and drapes the site.
 Local anesthetic is injected to numb the puncture site
 A spinal needle is inserted into the subarachnoid
space through the third and fourth or fourth and fifth
lumbar interspace.
 A specimen of CSF is removed and usually collected
in three test tubes, labeled in order of collection
 A small dressing is applied to the puncture site.
 The tubes of CSF are sent to the laboratory
immediately.

49. • Postprocedure
Instruct the patient to lie prone for 2 to
3 hours to separate the alignment of
the Dural and arachnoid needle
punctures in the meninges, to
reduce leakage of CSF.
• A post puncture head ache is
common after the procedure which
is usually relieved by positioning
,rest ,analgesic agents and hydration

50. Cerebrospinal Fluid Analysis
• The CSF should be clear and colorless.
• Pink, blood-tinged, or grossly bloody CSF may
indicate a cerebral contusion, laceration, or
subarachnoid hemorrhage.

51. References
• Suzanne c Smeltzer,Brinda BareBrunner &
Suddarth’s Textbook of Medical-Surgical
Nursing 10th edition,lippincott williams and
wilkins,pn 1820-1850
• Lewis Heitkamper,drisken,Medical and surgical
Nursing,aseessment and management of
clinical Problems, Mosby publications.Pn 1441-
1452
• Ignativicus and workman medical surgical
Nursing.Ptient centered collabritive care,pn-
1183-1215