NEUROLOGIC

ASSESSMENT
Presented by: Ms. Jeceli Alviola Nobleza, BSN-RN

Learning Objectives:
After the presentation, we should be able to:
Perform a physical assessment of the
neurologic system
Document neurologic system findings
Differentiate between normal and abnormal
findings

INTRODUCTION
The human nervous system is a unique system that
allows the body to interact with the environment as
well as to maintain the activities of internal organs.
The nervous system acts as the main circuit board
for every body system. Because the nervous system
works so closely with every other system, a
problem within another system or within the
nervous system itself can cause the nervous system
to short-circuit.
(Dillon,2007)

 A major goal of nursing is early detection to

prevent or slow the progression of disease.
So it is important for nurses to accurately perform a
thorough neurologic assessment and to understand
the implications of subtle changes in assessment
findings. By doing so, we can initiate timely
interventions that can save lives.

(Dillon,2007)

REVIEW OF THE
ANATOMY AND PHYSIOLOGY
OF THE

NEUROLOGIC SYSTEM

Cont. Review of Ana and Physio

General functions of the neurologic system include:

Cognition, emotion, and memory.
Sensation, perception, and the integration of
sensoryperceptual experience.
Regulation of homeostasis, consciousness,
temperature, BP, and other bodily processes.

There are two types of nerve cells:

(1) neuroglia and
(2) neurons

Neuroglia
Functions:
a. act as supportive tissue, nourishing and protecting
the neurons
b. maintain homeostasis in the interstitial fluid around
the neurons and account for about 50 percent of the
central nervous system (CNS) volume
c. have the ability to regenerate and respond to injury
by filling spaces left by damaged neurons.

Neurons
Functions:
a. have the ability to produce action potentials or
impulses (excitability or irritability) and
b. to transmit impulses (conductivity).

Sensory (afferent) neuron

Motor (efferent) neuron

Nissl
bodies

Cell body

dendrite

Nodes of
Ranvier

Schwann
cell

nucleus

synapse

Synaptic
vesicles
Axon
Myelin

Receptors
in skin

Presynaptic
terminal

Postsynaptic
membrene

Synaptic
cleft

Neurotransmitter
substance

Postsynaptic
receptor

Neuromuscular
junction

Neurons band together into

- peripheral nerves,
- spinal nerves,
- spinal cord, and
- tissues of the brain.
These structures make up the neurologic system,
which is divided into
- the CNS and
- the peripheral nervous system (PNS).

CENTRAL NERVOUS SYSTEM

consists of the brain and spinal cord.

The Human Brain

Central fissure

cortex

FRONTAL LOBE

TEMPORAL LOBE

Motor
Speech

Motor

Emotion
Behavior
Intellect

Brocas Area

Som
a
cort tosens
ory
ex

Lateral fissure

Hearing
Smell
Taste
Memory

PARIETAL LOBE
sensation

Wernickes area

Speech
compensation

OCCIPITAL LOBE
Visual
perception
Coordination
Equilibrium
Balance

Cerebellum

The Spinal Cord

The spinal cord descends through the foramen magnum
(large aperture) of the occipital bone of the skull, through
the first cervical vertebra (C1), and through the remainder
of the vertebral column to the first or second lumbar
vertebra.
conducts sensory information from the peripheral nervous
system (both somatic and autonomic) to the brain
conducts motor information from the brain to our various
effectors
- skeletal muscles
- cardiac muscles
- smooth muscles
-glands
serves as a minor reflex center

Sensory Pathways
Pathways,either ascending or afferent,allow sensory
data, such as the feeling of a burned hand, to become
conscious perceptions.
Sensory
cortex

Leg
Knee
Foot
toes

Trunk, Arm,
Hand, Fingers,
Face, Lips,
Tongue

pons
medulla
Lateral spinothalamic tract
Pain &temperature
Anterior spinothalamic tract
Crude touch & pressure

Spinal cord

Posterior column
Fine touch, proprioception
and vibration

Posterior root
of the spinal
cord

Motor Pathways

Motor pathways (descending or efferent) transmit

impulses from the brain to the muscles
Motor Cortex
Trunk, Arm, Hand,
Leg Fingers, Face, Lips,
Tongue
Knee
Foot
toes

Skeletal
muscles

Anterior corticospinal
(uncroosed pyramidal tract

Lateral corticospinal
(crossed pyramidal tract

Spinal Reflexes
Spinal reflexes do not depend on conscious
perception and interpretation of stimuli, nor on
deliberate action; in other words, they do not
involve the brain.
They occur involuntarily, with lightning speed, and
are identical in all healthy children and adults,
although they are less developed
Dorsal root ganglion
in infants.
Sensory nerve
Motor nerve

Reflex arc

PERIPHERAL NERVOUS SYSTEM

The peripheral nervous system consists of
- the cranial
- spinal nerves and the
- peripheral autonomic nervous system.

Cranial Nerves
The 12 pairs of cranial nerves originate from the brain
and are called the peripheral nerves of the brain.

I-Olfactory nerve Smell (S)

II-Optic nerve - Vision (S)
III-Oculomotor nerve (M)
- Eye movement; pupil constriction
IV-Trochlear nerve (M)
- Eye movement
V-Trigeminal nerve (B)
- Somatosensory information (touch, pain)
from the face and head; muscles for chewing.
VI-Abducens nerve - Eye movement (M)
VII-Facial nerve (B)
- Taste (anterior 2/3 of tongue); somatosensory
information from ear; controls muscles used
facial expression.

in

VIII-Vestibulocochlear nerve/Auditory nerve (S)

- Hearing; balance
IX-Glossopharyngeal nerve (B)
- Taste(posterior 1/3 of tongue);
- Somatosensory information from tongue, tonsil,
pharynx;
- controls some muscles used in swallowing.
X-Vagus nerve (B)
- Sensory, motor and autonomic functions of
viscera (glands, digestion, heart rate)
XI-Accessory nerve/Spinal accessory nerve (M)
- Controls muscles used in head movement.
XII-Hypoglossal nerve (M)
- Controls muscles of tongue

Spinal and Peripheral Nerves

Branching from the spinal cord are 31 pairs of spinal
nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,
and 1 coccygeal
The spinal nerves contain both ascending and
descending fibers, and although there is some
overlap,each is responsible for innervation of a
particular area of the body.

Dermatomes - are regions of the body innervated by the

cutaneous branch of a single spinal nerve.

Components of
Neurologic Exam

 Mental Status
a. Appearance/ Hygiene/ Grooming/ Odor
b. Behavior
c. Speech/ Communication
d. Level of Consciousness
e. Memory
f. Cognitive function

Cranial Nerve Function

Sensory Function
a. Light touch
c. Vibration
e. Streognosis
g. Two-point discrimination
i. Sensory Extinction

Reflex Function
a. Deep tendon reflexes
b. Superficial reflexes

(12 cranial nerves)

b. Pain
d. Kinesthetics
f. Graphesthesia
h. point localization

Ensure proper hygiene before seeing a client

Ensure all equipment is properly cleaned
Equipment Needed:
- BP cuff - Tuning fork (128 or 256 Hz)
- Penlight - Nonsterile gloves
- Wisp of cotton - Tongue blade
- Reflex hammer
- Sharp object such as toothpick or sterile needle
- Objects to touch: coin, button, key or paperclip
- Something fragrant: rubbing alcohol or coffee
- Something to taste: such as lemon juice, sugar or salt
- Two taste tubes or other vials
- Ophthalmoscope

Introduce self to the client.

Assessing the Mental Status

1. APPEARANCE/ HYGIENE/ GROOMING/ ODOR

a. Begin the assessment as the patient approaches

you.
b. Observe the general appearance, hygiene,
grooming and the odor of the client.

Normal:
good grooming,
dress in appropriate
to temperature &
weather,
no offensive or
unpleasant odor
hair well kept or tied

Abnormal:
Poor hygiene
Unpleasant or offensive
body odor

2. BEHAVIOR
a. Assess the clients mood and emotions
b. Observe body language and facial expression or
affect
c. Note his or her posture

Normal:
Verbal expressions
match with the
nonverbal behavior
Mood is appropriate
to the situation
Standing in upright
stance with parallel
alignment of hips
&shoulders

Abnormal:
Lack of facial expression
- Possible psychological
disorder (e.g., depression or
schizophrenia) or neurologic
impairment affecting cranial
nerves.

Masklike expression:
- Parkinsons disease.

Slumped posture:
- Depression if
psychological in origin; or stroke
with hemiparesis if physiological
in origin.

3. SPEECH/ COMMUNICATION
a. Speech and Language
Listen to patients rate and ease of speech,
including enunciation.
Abnormal:
Normal:
Speech flows Hesitancy, stuttering,
easily; patient stammering, unclear speech:
Lack
of
familiarity
with
language,
enunciates
deference or shyness, anxiety,
clearly.
neurologic disorder.
Sophistication of
Dysphasia/aphasia:
speech matches - Neurologic problems such as stroke.
age, education, Drugs and alcohol can also cause
and fluency.
slurred speech.

b. Spontaneous Speech & Motor Speech

- Show patient a picture and have him or her
describe what he or she sees.
- Have patient repeat, do, ray, me, fa, so, la, ti,
do.
Normal:
Spontaneous
speech intact.
Motor speech
intact.

Abnormal:

Impaired spontaneous speech:

- Cognitive impairment.
Impaired motor speech
(dysarthria):
Problem with CN XII

c. Autonomic Speech
Have patient say something that is committed
to memory, such as days of week
or months of
year.
Normal:
Automatic
speech intact.

Abnormal:

Impaired automatic speech:

Cognitive impairment or
memory problem.

4. LEVEL OF CONSCIOUSNESS
a. Test orientation to time, place, and person
Normal:
Awake, alert, and
oriented to time,
place, and person
(AAO x 3)
Responds to
external stimuli

Abnormal:
Disorientation may be
physical in origin
Disorientation can also be
psychiatric in origin
(schizophrenia)

Lathargic or somnolent
Obtunded
Stupor
Coma

Glasgow Coma Scale

- A standardized objective assessment that defines
the LOC by giving it a numeric value.
- Most often after brain surgery
- Document as E_V_M_; for example, E4V5M6.

GLASGOW COMA SCALE

Eyes open
E

Spontaneously . . . . . . . . 4
To command . . . . . . . . . . 3
To pain . . . . . . . . . . . . . . . 2
Unresponsive. .. . . . . . . . . 1

Findings

Best verbal response

V

Oriented . . . . . . . . . . . . . . . 5
Confused . . . . . . . . . . . . . . . 4
Inappropriate . . . . . . . . . . . . 3
Incomprehensible . . . . . . . . 2
Unresponsive. . . . . . . . . .. . . 1

Findings

Best motor response

M

Obeys commands . . . . . . . .. 6
Localizes pain. . . . . . . . . . . 5
Withdraws from pain. . . . . 4
Abnormal flexion . . . . . . .. . . 3
Abnormal extension . . . . . . . 2
Unresponsive. . . . . . . . . . . . . 1

Findings

Total______

From Wijdicks, et al, 2005, with permission.

 The three numbers are added; the total score

reflects the brain functional level.
A fully awake person = 15
Coma = 7 or less
The GCS assesses the functional state of the brain
as a whole, not of any particular site in the brain.
(Juarez and Lyon,1995)

Four Score Coma Measurement Scale

EYE
RESPONSE
4
3
2
1
0

Eyelids open or opened, tracking or blinking to command

Eyelids open but not tracking
Eyelids closed but open to loud voice
Eyelids closed but open to pain
Eyelids remain closed with pain

MOTOR
RESPONSE
4
3
2
1
0

Thumbs up, fist, or peace sign to command

Localizing to pain
Flexion response to pain
Extensor posturing
No response to pain or generalized myoclonus status epilepticus

BRAINSTEM
REFLEXES
4
3
2
1
0
RESPIRATION
4
3
2
1
0

Pupil and corneal reflexes present

One pupil wide and fixed
Pupil or corneal reflexes absent
Pupil and corneal reflexes absent
Absent pupil, corneal, and cough reflex
Not intubated, regular breathing pattern
Not intubated, Cheyne-Stokes breathing pattern
Not intubated, irregular breathing pattern
Breathes above ventilator rate
Breathes at ventilator rate or apnea

5. MEMORY
a. Test immediate recall:
Ask patient to repeat three numbers, such as 4, 9, 1. If
patient can do so, ask her or him to repeat a series of five
digits.

b. Test recent memory:

Ask what patient had for breakfast.

c. Test long-term memory:

Ask patient to state his or her birthplace, recite his or her
Social Security number, or identify a culturally specific
person or event, such as the name of the previous president
of the United States or the location of a natural disaster.

Normal:
Immediate, recent,
and remote
memory intact.

Abnormal:
Memory problems can be
benign or signal a more
serious neurologic problem
- such as Alzheimers disease.

Forgetfulness - especially for

immediate and recent events
- often in older adults.
- With benign forgetfulness,
person can retrace or use memory
aids to help with recall.

Pathological memory loss

- as inAlzheimers disease

Cont.

Abnormal:
Temporary memory loss
- may occur after head trauma.

Retrograde amnesia
- for events just preceding illness
injury.

Postconcussion syndrome
- can occur 2 weeks to 2 months
after injury and may cause short- term
memory deficits.

or

6. COGNITIVE FUNCTION

a. Mathematical and Calculative Ability

Ask patient to perform a simple calculation, such
adding 4 x 4. If successful, proceed to more
difficult
calculation, such as 11 9.

as

Normal:
Abnormal:
Mathematical/calculati Inability to calculate at
ve ability intact and level appropriate to age,
appropriate for
education, and language
patients age,
ability requires evaluation
educational level, and for neurologic impairment.
language facility.

b. General Knowledge and Vocabulary

Ask how many days in a week and months in a year.

c. Thought Process
Ask patient to define familiar words such as apple,
earthquake, and chastise.
Begin with easy words and proceed to more difficult
ones.
Remember to consider the patients age, educational
level, and cultural background.

Normal:
Thought
process
intact

Abnormal:
Incoherent speech
illogical or unrealistic ideas
repetition of words and phrases
repeatedly straying from topic
suddenly losing train of thought
(examples of altered thought processes that
indicate need for further evaluation)

Inability to define familiar words

requires further evaluation

d. Abstract Thinking
Assess the client to think abstractly.
Quote a proverb and ask the client to explain its
meaning

Normal:

Abnormal:
Able to generalize from Impaired ability to think
specific example and abstractly:

apply statement to
- Dementia, delirium, mental
human behavior.
retardation, psychoses.
Children should be able
to distinguish like from
unlike as appropriate
for theirage and
language facility.

e. Judgment
Observe patients response to current situation.
Ask patient to respond to a situation or
hypothetical situation.
Normal:
Abnormal:
Impaired judgment can be
Judgment
appropriate and associated with dementia,
psychosis, or drug and alcohol
intact.
abuse.

Assessing the CRANIAL NERVES

1. CN IOlfactory Nerve
a. Before testing nerve function, ensure patency of
each nostril by occluding in turn and asking patient
to sniff.
b. Once patency is established, ask patient to close
eyes.
c. Occlude one nostril and hold aromatic substance
such as coffee beneath nose.
d. Ask patient to identify
substance.
e. Repeat with other nostril.

Normal:
Abnormal:
Patient is able to
Anosmia is loss of sense of
identify substance. smell.
-May be inherited and
nonpathological: chronic rhinitis,
(Bear in mind that
some substances may be sinusitis, heavy smoking, zinc
unfamiliar, especially deficiency, or cocaine use.
- It may also indicate cranial nerve
to
damage from facial fractures or
children.)
head injuries, disorders of base of
frontal lobe such as a tumor, or
artherosclerotic changes.
- Persons with anosmia usually also
have taste problems.

2. CNs II, III, IV, and VIOptic, Oculomotor,

Trochlear, and Abducens Nerves
a. Ask the client to read a printed material, observe the
distance between the printed material and the clients eyes.
b. Use the snellen chart to check/ test:
- distant vision
- color
Client should be 20 feet distant from the chart
Use an object to occlude one eye
Evaluate the vision one eye at a time

c. Evaluate the Extra Ocular Movements of the Eyes

d. Convergens & Accomodation
e. Pupillary Light Reflex
- using direct and consensual pupillary reaction to light

Testing eye
movements

Testing pupil
accommodation

Normal:
Able to read without
difficulty
Visual acuity intact
20/20, both eyes

Hippus
phenomenon: - Brisk
constriction of pupils
in reaction to light,
followed by dilation
and constriction
- may be normal or sign
of early CN III
compression.

Abnormal:
CN II deficits
- can occur with stroke or brain
tumor.

Changes in pupillary
reactions
- can signal CN III deficits.

Increased ICP causes

changes in pupillary reaction.
As pressure increases,
response becomes more
sluggish until pupils
finally
become fixed and dilated.

3. CN VTrigeminal Nerve
a. Testing motor function:
- Ask patient to move jaw from side to side against
resistance and then clench jaw as you palpate
contraction of temporal and masseter muscles, or
to bite down on a tongue blade.

Testing CN V
motor function

b. Testing sensory function:

- Ask patient to close eyes
- Touch the face with the wisp of cotton
- Instruct to tell you when he or she feels
sensation on the face.
- Repeat the test using sharp and dull stimuli
(toothpick)
- Instruct to say Sharp or Dull
(Be random, dont establish a pattern)
- Compare both bilaterally.
Testing CN V
sensory function

c. Testing corneal reflex:

- Gently touch cornea with cotton wisp.
o Touching cornea can cause abrasions.
Alternative approach is to:
> puff air across cornea with a needless
syringe, or
> gently touch eyelash and look for blink reflex.

Testing corneal
reflex

Cont. CN V

Normal:
Full range of
motion (ROM) in
jaw and 15
strength.
Patient perceives
light touch and
superficial pain
bilaterally.

Abnormal:
Weak or absent contraction
unilaterally:
- Lesion of nerve, cervical spine, or
brainstem.

Inability to perceive light touch

and superficial pain
- may indicate peripheral nerve
damage.

Tic douloureux:
- Neuralgic pain of CN V caused by
the pressure of degeneration of a
nerve.

Corneal reflex test used in

patients with decreased LOC
- to evaluate integrity of brainstem.

4. CN VIIFacial Nerve
a. Testing motor function:
- Ask patient to perform these movements: smile,
frown, raise eyebrows, show upper teeth, show
lower teeth, puff out cheeks, purse lips, close eyes
tightly while nurse tries to open them.

Testing CN VII motor

function

b. Testing sensory function:

- Test taste on anterior two-thirds of tongue for
sweet, sour, salty.
Sweet:
Tip of the tongue
Sour:
Sides of back half of
tongue
Salty:
Anterior sides and tip of
tongue
Bitter: Back of tongue

Testing taste sensation

Normal:
Facial nerve intact;
able to make faces.
Taste sensation on
anterior tongue
intact.
(Taste decreased in
older adults.)

Abnormal:
Asymmetrical or impaired
movement:
- Nerve damage, such as that
caused by Bells palsy or
stroke.
Impaired taste/loss of taste:
- Damage to facial nerve,
chemotherapy or radiation
therapy to head and neck.

5. CN VIIIAcoustic Nerve
a. Perform Weber and Rinne tests for hearing
b. Perform watch-tick test by holding watch close to
patients ear.
Watch tick test

c. Perform Romberg test for balance

- Nurse at the back or side of the pt.
- Instruct client to stand straight, feet together,
hands at the side and eyes closed.
(Evaluates the balancing function of the CN VIII)

Normal:
Hearing intact.
Negative Romberg
test.

Abnormal:
Hearing loss, nystagmus,
balance disturbance,
dizziness/vertigo:
- Acoustic nerve damage.
Nystagmus:
- CN VIII, brainstem, or
cerebellum problem or
phenytoin (Dilantin) toxicity.

6. CNs IX and XGlossopharyngeal and Vagus

Nerves
a. Observe ability to cough, swallow, and talk.
b. Test motor function:
- Ask patient to open mouth and say ah
while you depress the tongue with a tongue
blade.
- Observe soft palate and uvula. Soft palate
and uvula should rise medially.
Testing CN IX and
X motor function

c. Test sensory function of CN IX and motor function

of CN X by stimulating gag reflex.
- Tell patient that you are going to touch interior
throat
- then lightly touch tip of tongue blade to
posterior pharyngeal wall.
- Observe the pharyngeal movement.
- Ask the client to drink a small amount of water
Note the ease & difficulty of swallowing
Note quality of the voice or hoarseness
when speaking

Normal:

Abnormal:

Swallow and cough

reflex intact.
Speech clear.
Elevation and
constriction of
pharyngeal
musculature and
tongue retraction
indicate positive
gag reflex.

Unilateral movement:
- Contralateral nerve damage.
- Damage to CNs IX and X also impairs
swallowing.

Changes in voice quality (e.g.,

hoarseness): CN X damage.
- CN X damage may also affect vital
functions, causing arrhythmias because
vagus nerve innervates most of viscera
through parasympathetic system.

Diminished/absent gag reflex:

Nerve damage.
- Evaluate further because patient is at
increased risk for aspiration.

Impaired taste on posterior portion

of tongue: Problem with CN IX.

7. CN XIAccessory Nerve
a. Test motor function of shoulder and neck
muscles: - Ask patient to shrug shoulders
upward against
your resistance. (Trapieze
muscle)
- Then ask her or him to turn head from side to
side against your resistance.
(Strenoclaidomastoid msucle)
- Observe for symmetry of contraction and
muscle strength.

Normal:
Movement
symmetrical, with
patient moving
against resistance
without pain.
Full ROM of neck
with +5/5 strength.

Abnormal:
Asymmetrical
Diminished
Absent movement
Pain
unilateral or bilateral
weakness:
- Peripheral nerve CN XI
damage.

8. CN XIIHypoglossal Nerve
a. Have patient say d, l, n, t or a phrase containing
these letters.
- The ability to say these letters requires use
of the tongue.
b. Ask the patient to protrude the tongue.
Observe any deviation from midline, tumors,
lesions, or atrophy.
Now ask the patient to move the tongue from
side to side.
Testing CN XII
motor function

Normal:
Can protrude
tongue medially.
No atrophy,
tumors, or
lesions.

Abnormal:
Asymmetrical/diminished/
absent movement/deviation
from midline/protruded tongue:
- Peripheral nerve CN
XII damage.
Tongue paralysis results in
dysarthria.

Assessing Sensory Function

1. Light Touch
- Brush a light stimulus such as a cotton wisp over
patients skin in several locations, including torso
and extremities.
Abnormal:
Normal:
Diminished/absent cutaneous
perception:

Identifies areas
stimulated by light -Peripheral nerve damage or damage to
touch.
posterior column of spinal cord.
- Peripheral neuropathies can also cause
sensory deficits.
Hypesthesia: Increased sensitivity.
Paresthesia: Numbness and tingling.
Anesthesia: Loss of sensation.

2. Pain

- Stimulate skin lightly with sharp and dull ends of

toothpick/ paper clip
-Apply stimuli randomly and ask patient to identify
whether sensation is sharp or dull.

-Touch patients skin with test tubes filled with hot or

cold water.
-Apply stimuli randomly, and ask patient to identify
whether sensation is hot or cold.

Normal:

Abnormal:
Diminished or absent pain
perception:

Identifies areas
stimulated and type
- Peripheral nerve damage or damage
of stimulation.
to lateral spinothalamic tract.

Hyperalgia:
Increased pain sensation.

Hypoalgesia:
Decreased pain sensation.
Analgesia: No pain sensation.

Diminished/absent temperature
perception:
- Peripheral nerve damage or damage
to lateral spinothalamic tract

3. Vibration
-Place a vibrating tuning fork over a finger joint, and
then over a toe joint.
-Ask patient to tell you when vibration is felt and
when it stops.
- If patient is unable to detect vibration, test proximal
areas as well.

Normal:
Vibratory
sensation intact
bilaterally in
upper and lower
extremities.

Abnormal:
Diminished/absent vibration
sense:
- Peripheral nerve damage caused
by alcoholism, diabetes, or
damage to posterior column of
spinal cord.

4. Kinesthetics (Position Sense)

-Determine patients ability to perceive passive
movement of extremities.
- Hold fingers on sides and move up and down, and
have patient identify direction of movement.
-Flex and extend patients big toe, and ask patient to
describe movement as up or down.
Avoid moving the patients
finger by placing your finger on
top of the patients because the
patient may sense the pressure of
your finger rather than a true
position change.
If position sensation is intact
distally, it is intact
proximally.

Normal:

Abnormal:

Position sensation
intact bilaterally in
upper and lower
extremities.

Diminished or absent position

sense:
- Peripheral nerve damage or damage
to posterior column of spinal cord.

5. Stereognosis
With patients eyes closed, place a familiar object,
such as a coin or a button, in patients hand, and ask
patient to identify it.
Test both hands using different objects.

Normal:

Abnormal:

Abnormal findings suggest a

lesion or other disorder involving
sensory cortex or a disorder
affecting posterior
column.

Stereognosis
intact bilaterally.

6. Graphesthesia
- With patients eyes closed, use point of a closed
pen to trace a number on patients hand
- Ask patient to identify the number.
Abnormal:
Normal:
Abnormal findings suggest
Graphesthesia
lesion
or
other
disorder
involving
intact bilaterally.
sensory cortex or disorder
affecting posterior
column.

7. Two-Point Discrimination
Ability to differentiate between two points of
simultaneous stimulation.
- Using ends of two toothpicks/ paper clip,
stimulate two points on fingertips
simultaneously.
- Gradually move toothpicks together, and
assess
smallest distance at which patient can still
discriminate two points (minimal perceptible
distance).
- Document distance and location.

Normal:

Discriminates
between two
points on
fingertips no
more than 0.5 cm
apart and on hands
no more than 2 cm
apart.

Abnormal:

Abnormal findings suggest

lesion or other disorder involving
sensory cortex or disorder
affecting posterior
column.

8. Point Localization

Ability to sense and locate area being stimulated.

With patients eyes closed, touch an area; then
have
patient point to where he or she was touched.
Test both sides andAbnormal:
upper and lower extremities.
Normal:
Point localization Abnormal findings suggest lesion
or other disorder involving sensory
intact.
cortex or disorder affecting
posterior column.

9. Sensory Extinction

Simultaneously touch both sides of patients body

at same point.
Ask patient to point to where she or he was
touched.
Normal:
Abnormal:
Extinction intact. Identification of stimulus on only
one side suggests lesion or other
disorder involving sensory cortical
region in opposite hemisphere.

REFLEXES
Documenting Reflex Findings
Use these grading scales to rate the strength of each
reflex in a deep tendon and superficial reflex assessment.
Deep tendon reflex grades
0 absent
+ present but diminished
+ + normal
+ + + increased but not necessarily pathologic
+ + + + hyperactive or clonic (involuntary contraction
and relaxation of skeletal muscle)
Superficial reflex grades
0 absent
+ present

 Documentation of reflex finding

ASSESSING REFLEXES

1. Deep Tendon Reflexes

a. Biceps Reflex
Rest patients elbow in your nondominant hand,
with your thumb over biceps tendon.
Strike your thumbnail.
Normal:
Contraction of biceps with flexion of forearm.
+2

b. Triceps Reflex
Abduct patients arm and flex it at the elbow.
Support the arm with your nondominant hand.
Strike triceps tendon about 1 to 2 inches above
olecranon process, approaching it from directly
behind.
Normal:
Contraction of triceps with extension at elbow.
+2

c. Patellar Reflex

Have patient sit with legs dangling.

Strike tendon directly below patella..
Normal:

Contraction of quadriceps with extension of

knee.
+2

d. Achilles Reflex

Have patient lie supine or sit with one knee

flexed.
Holding patients foot slightly dorsiflexed,
strike Achilles tendon.
Normal:

Plantar flexion of foot.

+2

e. Test for Ankle Clonus

If you get 4 reflexes while supporting leg
and foot, quickly dorsiflex foot.
Normal:

No contraction

Abnormal:
Absent/diminished DTRs:
- Degenerative disease; damage to peripheral nerve
such as peripheral neuropathy; lower motor neuron
disorder, such as ALS and Guillain-Barr syndrome.
Hyperactive reflexes with clonus:
- Spinal cord injuries, upper motor neuron disease such
as MS.
Rhythmic contraction of leg muscles and foot is
positive sign of clonus
- indicates upper motor neuron disorder.

2. Superficial Reflexes
a. Abdominal Reflex
Stroke patients abdomen diagonally from upper
and lower quadrants toward umbilicus.
Contraction of rectus abdominis. Umbilicus
moves toward stimulus.

a. Abdominal Reflex
Gently stroke skin around anus with gloved
finger.
Normal:
Anus puckers.
b. Cremasteric Reflex
Gently stroke inner aspect of a males thigh.
Normal:
Testes rise.

c. Bulbocavernosus Reflex
Gently apply pressure over bulbocavernous
muscle on dorsal side of penis.
Normal:
Bulbocavernosus muscle contracts.
d. Plantar Reflex (Babinskis Response)
Stroke sole of patients foot in an arc from
lateral heel to medial ball.
Normal:
Flexion of all toes.

Assessing the Cerebellar Function

1. Balance tests

a. Gait
Observe as the person walks 10-20 feet, turns,
and returns to the starting point.
Normal:
Abnormal:

Person moves with a

sense of freedom.
Gait is smooth,
rhythmic, and
effortless
Opposing arm swing
is coordinated
The turns are smooth

Stiff, immobile posture. Staggering

or reeling. Wide base of support
Lack of arm swing or rigid arms
Unequal rhythm of steps. Slapping
of foot. Scraping of toe of shoe
Ataxia uncoordinated or unsteady
gait.

Perform Tandem Walking

- ask the person to walk a straight line in a heelto-toe fashion.
This decreases the base of support and will
accentuate any problem with coordination.

Normal:
Person can walk
straight and stay
balanced

Abnormal:
Crooked line walk
Widens base to maintain balance
Staggering, reeling, loss of
balance
An ataxia that did not appear
now. Inability to tandem walk is
sensitive for an upper motor
neuron lesion, such as multiple
sclerosis.

b. The Romberg Test

(discussed previously)

Ask the person to perform a shallow knee bend or

hop in place, first on one leg, then the other.
- this demonstrates normal position sense, muscle
strength, and cerebellar function.
(some individuals cannot hop owing to aging or
obesity)

Normal:

Abnormal:

Negative Romberg
test

Sways, falls, widens base of feet

to avoid falling
Positive Romberg sign
-Loss of balance that occurs
when closing the eyes.
-Occurs with cerebellar ataxia
(multiple sclerosis, alcohol
intoxication)
-Loss of proprioception, and
loss of vestibular function

2. Coordination and Skilled Movements

a. Rapid Alternating Movements (RAM)
Ask the person to pat the knees with both hands,
lift up, turn hands over, and pat the knees with the
backs of the hands.
Then ask to do this faster.
Abnormal:
Normal:
done with equal
turning and quick
rhythmic pace

Lack of coordination
Dysdiadochokinesia
- Slow, clumsy, and sloppy
response
- occurs with cerebellar
disease

b. Finger-to-Finger test
With the persons eyes open, ask that he or she use
index finger to touch your finger, then his or her
own nose.
After a few times move your finger to a different
spot.

Normal:

Abnormal:

Dysmetria
Movement is
- clumsy movement with
smooth and accurate
overshooting the mark
- occurs with cerebellar
disorder
Past-pointing
- constant deviation to one side

c. Finger-to-nose test
Ask the person to close the eyes and to stretch out
the arms.
Ask the person to touch the tip of his or her nose
with each index finger, alternating hands and
increasing speed.

Normal:

Abnormal:

Done with accurate Misses nose.

Worsening of coordination when
and smooth
the
eyes
are
closed
movement
- occurs with cerebellar disease

sources
Dillon, Patricia. Nursing Health Assessment. 2nd
Ed. F.A. Davis. 2007
Jarvis, Carolyn. Physical Examination and Health
Assessment. 3rd ed. New York: W.B. Saunder
Company.2000
Bickley. Lyn and Hoekenan, Robert. Bates Guide
to Physical Examination and History Taking. 7th
ed. New York: Lippincott Williams and Wilkins.
1999
Estes, Mary Ellen Zator. Health Assessment &
Physical Examination. 3rd ed. Delmar Learning.
2006

THANK YOU!!!