Neurological System Assessment - NURS251

Equipment

Tongue depressor, tuning fork, Snellen eye chart, reflex hammer, pen light, cotton ball

5 Past Medical History Questions

Any history of seizures? Spinal/head injury? Alzheimer's? Cancer? Neuromuscular disorders?

3 Family Medical History Questions

Any history of neuromuscular disorders? Epilepsy? Migraines?

5 Review of System Questions

Are you currently experiencing any syncope (fainting resulting from stressful triggers)? Dizziness? Stiff neck? Seizures? Loss of smell?

Level of Conciousness

What day? Where? President?

Alert and oriented x3

Thought Processes

Logical train of thought

Appearance and Behavior

Well groomed, normal eye-contact

Speech

Voice quality, articulation, comprehension

Cranial Nerve I

Olfactory

Cranial Nerve II

Optic

Snellen eye chart in both eyes

Cranial Nerve III, IV, and VI

oculomotor, trochlear, abducens

6 cardinal points of gaze

No nystagmus

Cranial Nerve V

Trigeminal

Cotton ball in 3 regions

Cranial Nerve VII

Facial

Smiling, puffing out cheeks

Symmetrical

Cranial Nerve VIII

Vestibulocochlear

Rinne and Weber test

Cranial Nerve IX and X

Glossopharyngeal and Vagus

Stick out tongue, gag reflex, depress the tongue

Cranial Nerve XI

Accessory

Trapezius and sternoclenomastoid

Shrugging shoulders

Cranial Nerve XII

Hypoglossal

Stick out tongue, midline

Light, tight, dynamite

Pronunciation, no tics or tremors