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HA Neuro

HA #7: Neurologic System Assessment

  • Presenter: Ysis Mercado, MSN, RN, CNS

  • Adapted from Angie DeGenarro's DNP, FNP-BC, RN presentation.

Objectives

  • Identify and demonstrate major components of a neurologic examination:

    • Mental status

    • Cranial nerves

    • Motor system

    • Sensory system

    • Reflexes

  • Distinguish between normal and abnormal findings in the neurologic exam and document appropriately.

  • Describe nursing actions for abnormal findings.

Complete Neuro Assessment Sequence

  1. Mental status

  2. Cranial nerves

  3. Motor system

  4. Sensory system

  5. Reflexes

Mental Status

Level of Consciousness (LOC)

  • Alert & Oriented:

    • To Person, Place, Time

  • Glasgow Coma Scale (GCS):

    • Quantifies LOC (Score range: 3-15)

      • Eye Opening

      • Motor Response

      • Verbal Response

    • Coma indicated by a score <7

GCS Practice Question

  • Scenario: 35-year-old male struck by a car.

    • Eyes open to pain

    • No verbal response

    • Motor response: withdrawn to painWhat’s the GCS score?

  • A) 0

  • B) 3

  • C) 5

  • D) 7

Cranial Nerves (CNs)

  1. Olfactory (I) - Sensory

  2. Optic (II) - Sensory

  3. Oculomotor (III) - Motor

  4. Trochlear (IV) - Motor

  5. Trigeminal (V) - Both

  6. Abducens (VI) - Motor

  7. Facial (VII) - Both

  8. Acoustic (VIII) - Sensory

  9. Glossopharyngeal (IX) - Both

  10. Vagus (X) - Both

  11. Spinal Accessory (XI) - Motor

  12. Hypoglossal (XII) - Motor

Cranial Nerve Mnemonics

  • Numbering: On Old Olympus Towering Tops a Finn and German Viewed Some Hops

  • Function (Sensory, Motor, Both): Some Say Marry Money But My Brother Says Bad Business Marry Money

Individual Cranial Nerve Assessments

CN I: Olfactory Nerve

  • Test sense of smell

  • With eyes closed, occlude one nostril, present familiar aroma (e.g., coffee, orange).

CN II: Optic Nerve

  • Test visual acuity and fields by confrontation.

  • Examine ocular fundus with an ophthalmoscope.

CN III, IV, VI: Oculomotor, Trochlear, Abducens

  • Inspect palpebral fissures for equality; abnormal is ptosis.

  • Assess PERRLA.

  • Evaluate extraocular movements using cardinal gaze positions; look for nystagmus.

CN V: Trigeminal Nerve

  • Motor: assess muscles of mastication (temporal & masseter).

  • Sensory: light touch sensation testing across three divisions with eyes closed.

CN VII: Facial Nerve

  • Motor: mobility and facial symmetry.

  • Sensory: test sense of taste on the anterior 2/3 of tongue if facial nerve injury is suspected.

CN VIII: Acoustic Nerve

  • Assess hearing acuity via normal conversation and whispered voice test.

    • Test one ear at a time, standing behind the person, whisper numbers/letters.

CN IX & X: Glossopharyngeal and Vagus Nerves

  • Motor: say “ahhh,” note gag reflex, voice quality, swallow function.

  • Sensory: assess taste on posterior 1/3 of tongue, not routinely tested, note uvula deviation.

CN XI: Spinal Accessory

  • Inspect size of sternomastoid & trapezius muscles.

  • Check shoulder strength with resistance.

CN XII: Hypoglossal

  • Inspect tongue for wasting or tremors.

  • Ask patient to say “light, tight, dynamite.”

Motor System Assessment

Muscles

  • Size: inspect all muscle groups.

  • Strength: test bilaterally for comparison.

  • Tone: normal tension in relaxed muscles, assessed by mild resistance.

  • Involuntary Movements: observe for any abnormal movements.

Muscle Strength Scale

  • 0: No movement

  • 1: Trace of movement

  • 2: Full range against gravity only

  • 3: Full range against gravity, weak resistance

  • 4: Full range against gravity, full resistance

  • 5: Normal strength

Coordination and Skilled Movements

  • Rapid Alternating Movements (RAM):

    • Finger-Nose-Finger test

    • Finger-to-Nose test

    • Heel-to-Shin test

Cerebellar Function

  • Balance Tests:

    • Gait:

      • Straight walking

      • Heel-to-toe

      • Walking on heels and toes

Sensory System Assessment

  • Identify various sensory stimuli with eyes closed to assess intactness:

    • Spinothalamic Tract:

      • Pain (pinprick sharp vs. dull)

      • Light touch (cotton wisp)

      • Temperature (bilaterally)

  • Posterior Column Tract:

    • Vibration

    • Position

    • Tactile discrimination tests:

      • Stereognosis: identify objects by touch

      • Graphesthesia: identify numbers drawn on skin

      • Two-point discrimination: determine the smallest distance to distinguish two points

      • Extinction: identify simultaneous stimuli

      • Point location: identify where touch occurs

Reflexes Assessment

Deep Tendon Reflexes (DTRs)

  • Measure stretch reflexes to assess reflex arc integrity at spinal levels.

  • Limb should be relaxed, muscle partially stretched.

  • Stimulate reflex with a short, snappy blow, compare bilaterally for symmetry.

DTR Grading Scale

  • 0: No response

  • 1+: Sluggish/diminished

  • 2+: Active/expected response

  • 3+: Slightly hyperactive

  • 4+: Brisk/hyperactive

DTR Reinforcement Technique

  • Upper Extremities: Have patient clench teeth.

  • Lower Extremities: Patient locks fingers and tries to pull them apart (Jendrassik’s maneuver).

Specific DTRs to Assess

  • Biceps: C5 to C6

  • Brachioradialis: C5 to C6

  • Triceps: C7 to C8

  • Patellar (Knee jerk): L2 to L4

  • Achilles: L5 to S2

  • Plantar Reflex: L4 to S2

References

  • Jarvis, C. & Eckhardt, A. (2024). Physical Examination & Health Assessment. St. Louis: Elsevier.