MES COLLEGE OF NURSING

MEDICAL SURGICAL NURSING

SEMINAR
ON
NERVOUS SYSTEM ASSESSMENT

SUBMITTED BY SUBMITTED TO
Mrs. SALINI.R Mrs. SRUTHI
1st YEAR M.sc NURSING ASSISTANT PROFESSOR
MES COLLEGE OF NURSING MES COLLEGE OF NURSING

SUBMITTED ON 23/1/2021
INDEX
S CONTENT PAGE NUMBER
L
.N
1 CENTRAL AND SPECIFIC 3
OBJECTIVES
2 INTRODUCTION 4
3 ANATOMY PHYSIOLOGY OF 4
NERVOUS SYSTEM
4 ASSESSMENT OF NERVOUS SYSTEM 20
5 HISTORY COLLECTION 20
6 PHYSICAL EXAMINATION 30
7 MSE 31
8 LEVEL OF CONCIUOSNESS 39
9 EXAMINATION OF CRANEAL NERVE 43
10 MOTOR SYSTEM ASSESSMENT 49
11 CEREBELLAR FUNCTION 52
12 SENSORY ASSESSMENT 56
13 REFLEX ASSSESSMENT 61
14 DIAGNOSTIC STUDY 68
15 RECENT STUDIES 76
16 CONCLUSION 77
17 BIBLIOGRAPHY 78
GENERAL OBJECTIVES

At the end of this session the group acquires complete knowledge

regarding nervous system assessment and develop positive attitude towards
neurological assessment and will apply this knowledge in their daily practical situations.

SPECIFIC OBJECTIVES

At the end of the seminar students will able to :

 explain regarding anatomy of nervous system.

 describe the important points to keep in mind during history collection in the
nervous system assessment .
 explain regarding physical examination of nervous system
 defines neurological assessment.
 define mental status examinations.
 List down the articles needed for mental status examination.
 describes regarding testing of various cranial nerves.
 explains assessment of motor
 explain cerebellar functions and reflexes.
 explain sensory function
 explains regarding Glasgow coma scale.
 explains various diagnostic procedures used in the neurological assessment.
INTRODUCTION

Nurses in many types of practice settings encounter patients

with altered neurologic function. Disorders of the nervous system
can occur at any time during the life span and can vary from mild, self-limiting symptoms to
devastating, life-threatening disorders. The nurse must be skilled in the assessment of the
neurologic system whether the assessment is generalized or focused on specific areas of
function. Assessment in either case requires knowledge of the anatomy and physiology of the
nervous system and an understanding of the array of tests and procedures used to diagnose
neurologic disorders. Knowledge about the nursing implications and interventions related to
assessment and diagnostic testing is also essential.
Here in this seminar we are going to discuss in detail regarding the structure,
function, and also various forms of physical assessment which involves the nervous system and
few important diagnostic test to rule out the neurological diseases.

ANATOMY OF THE NERVOUS SYSTEM

Cells of the Nervous System

The basic functional unit of the brain is the neuron

It is composed of
 a cell body
 a dendrite
 and an axon.
The dendrite is a branch-type structure with synapses for receiving electrochemical messages.

The axon is a long projection that carries impulses away from the cell body.

Nerve cell bodies occurring in clusters are called ganglia or nuclei.

A cluster of cell bodies with the same function is called a centres (eg, the respiratory centres).

Neuroglial cells, another type of nerve cell, support, protect, and nourishes neuron.

Neurotransmitters

Neurotransmitters communicate messages from one neuron to

another or from a neuron to a specific target tissue. Neurotransmitters are manufactured and
stored in synaptic vesicles. They enable conduction of impulses across the synaptic cleft. The
neurotransmitter has an affinity for specific receptors in the postsynaptic bulb. When released,
the neurotransmitter crosses the synaptic cleft and binds to receptors in the postsynaptic cell
membrane.
The action of a neurotransmitter is to potentiate, terminate,
or modulate a specific action and can either excite or inhibit
the target cell’s activity. There are usually multiple neurotransmitter at work in the neural
synapse.
They are listed below

 Acetylcholine

Many parts of the brain and spinal cord, neuromuscular junction of skeletal muscle, and many
ANS synapses
A decrease in acetylcholine-secreting neurons is seen in Alzheimer's disease; myasthenia gravis
results from a reduction in acetylcholine receptors.

 Amines
 Epinephrine

Secreted in many areas of the brain

Acts as a hormone when secreted by the neurosecretory cells of the adrenal medulla.

 Norepinephrine

Secreted in many areas of the brain; also in postganglionic neurons of sympathetic nervous
system.

 Serotonin

Secreted in many areas of the brain and spinal cord.

Involved with moods, emotions, and sleep; levels of serotonin elevated in schizophrenia.

 Dopamine

Secreted in some areas of the brain

Involved in emotions and moods and regulating motor control. Parkinson's disease results from
destructions of dopamine- secreting neurons.

Amino Acids

γ-Aminobutyric acid (GABA)

seen in most neurons of the CNS

CENTRAL NERVOUS SYSTEM

The central nervous system consists of brain and spinal cord

ANATOMY OF THE BRAIN

The brain is divided into three major areas:
 the cerebrum
 the brain stem
 and the cerebellum.

The cerebrum is composed of two hemispheres

 the thalamus
 the hypothalamus,
and the basal ganglia.
Additionally, connections for the olfactory (cranial nerve I) and optic (cranial nerve III) nerves
are found in the cerebrum.

The brain stem includes

 the midbrain
 pons
 medulla, and connections for cranial nerves II and IV through XII.

The cerebellum is located under the cerebrum and behind the brain stem. The brain accounts for
approximately 2% of the total body weight; it weighs approximately 1,400 g in an average
young adult . In the elderly, the average brain weighs approximately 1,200 g.

Cerebrum.
The cerebrum is composed of the right and left hemispheres. Both hemispheres can be further
divided into four major lobes: frontal, temporal, parietal, and occipital .

The frontal lobe controls higher cognitive function, memory retention, voluntary eye
movements, voluntary motor movement, and expressive speech in Broca's area. Behind the
frontal lobe, the temporal lobe contains Wernicke's area, which is responsible for receptive
speech and for integration of somatic, visual, and auditory data. The parietal lobe is composed of
the sensory cortex, controlling and interpreting spatial information. Processing of sight takes
place in the occipital lobe.

These divisions are useful to delineate portions of the neocortex (gray matter), which makes up
the outer layer of the cerebral hemispheres. Neurons in specific parts of the neocortex are
essential for various highly complex and sophisticated aspects of mental functioning, such as
language, memory, and appreciation of visual-spatial relationships.

The functions of the cerebrum are multiple and complex.

The basal ganglia, thalamus, hypothalamus, and limbic system are also located in the cerebrum.
The basal ganglia are a group of paired structures located centrally in the cerebrum and
midbrain; most of them are on both sides of the thalamus. The function of the basal ganglia is to
modulate the initiation, execution, and completion of voluntary movements and automatic
movements associated with skeletal muscle activity, such as swinging of the arms while
walking, swallowing saliva, and blinking.

Brain Stem.

The brain stem consists of the midbrain, pons, and

medulla oblongata .

Midbrain

The midbrain contains sensory and motor pathways and serves as the centre for auditory and
visual reflexes. Cranial nerves III and IV originate in the midbrain.

Pons

The pons is situated in front of the cerebellum between the midbrain and the medulla and is a
bridge between the two halves of the cerebellum, and between the medulla and the cerebrum.
Cranial nerves V through VIII connect to the brain in the pons. The pons contains motor and
sensory pathways. Portions of the pons also control the heart, respiration, and blood pressure.

Medulla oblongata

The medulla oblongata contains motor fibres from the brain to the spinal cord and sensory fibres
from the spinal cord to the brain. Most of these fibres cross, or decussate, at this level. Cranial
nerves IX through XII connect to the brain in the medulla.

Cerebellum.

The cerebellum is separated from the cerebral hemispheres by a fold of dura mater, the
tentorium cerebelli. 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.
Ventricles and Cerebrospinal Fluid.
Several supporting structures located within the CNS are important in regulating neuronal
function and physical support of the brain. The ventricles are four fluid-filled cavities within the
brain that connect with one another and with the spinal canal. The lower portion of the fourth
ventricle becomes the central canal in the lower part of the brainstem. The spinal canal is located
in the center and extends the full length of the spinal cord.
Cerebrospinal fluid
 Circulates within the subarachnoid space that surrounds the brain, brainstem, and spinal
cord.
 This fluid provides cushioning for the brain and spinal cord, allows fluid shifts from the
cranial cavity to the spinal cavity, and carries nutrients.
 The formation of CSF in the choroid plexus in the ventricles involves both passive diffusion
and active transport of substances.

ANATOMY PHYSIOLOGY OF THE SPINAL CORD.

The spinal cord and medulla form a continuous structure extending from the cerebral
hemispheres and serving as the connection between the brain and the periphery. Approximately
45 cm (18 in) long and about the thickness of a finger, it extends from the foramen magnum at
the base of the skull to the lower border of the first lumbar vertebra, where it tapers to a fibrous
band called the conus medullaris. Continuing below the second
lumbar space are the nerve roots that extend beyond the conus, which are called the cauda
equina because they resemble a horse’s tail. Similar to the brain, the spinal cord consists of gray
and white matter. Gray matter in the brain is external and white matter is internal; in the spinal
cord, gray matter is in the center and is surrounded
on all sides by white matter .
The spinal cord is surrounded by the meninges, dura, arachnoid,and pia layers. Between the dura
mater and the vertebral canal is the epidural space. The spinal cord is an H-shaped structure with
nerve cell bodies (gray matter) surrounded by ascending and descending tracts (white matter)
The lower portion of the H is broader than the upper portion and corresponds to the anterior
horns. The anterior horns contain cells with fibers that form the anterior (motor) root end and are
essential for the voluntary and reflex activity of the muscles they innervate.
The thinner posterior (upper horns) portion contains
cells with fibers that enter over the posterior (sensory) root end and thus serve as a relay station
in the sensory/reflex pathway.
Ascending Tracts.

In general, the ascending tracts carry specific sensory information to higher levels of the CNS.
This information comes from special sensory endings (receptors) in the skin, muscles and joints,
viscera, and blood vessels and enters the spinal cord by way of the dorsal roots of the spinal
nerves. The fasciculus gracilis and the fasciculus cuneatus (commonly called the dorsal or
posterior columns) carry information and transmit impulses concerned with touch, deep
pressure, vibration, position sense, and kinesthesia (appreciation of movement, weight, and body
parts). The spinocerebellar tracts carry subconscious information about muscle tension and
body position to the cerebellum for coordination of movement. This information is not
consciously perceived. The spinothalamic tracts carry pain and temperature sensations.
Therefore the ascending tracts are organized by sensory modality, as well as by anatomy.

Although the functions of these pathways are generally accepted, other ascending tracts may
also carry sensory modalities. The symptoms of various neurologic diseases suggest that
additional pathways for touch, position sense, and vibration exist.

Descending Tracts.

Descending tracts carry impulses that are responsible for muscle movement. Among the most
important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the
pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial
and peripheral nerves, respectively. Another group of descending motor tracts carries impulses
from the extrapyramidal system, which includes all motor systems (except the pyramidal
system) concerned with voluntary movement. It includes descending pathways originating in the
brainstem, basal ganglia, and cerebellum. The motor output exits the spinal cord by way of the
ventral roots of the spinal nerves.

The Peripheral Nervous System

The peripheral nervous system includes the cranial nerves, the spinal nerves, and the autonomic
nervous system.

CRANIAL NERVES

There are 12 pairs of cranial nerves that emerge from the lower surface of the brain and pass
through the foramina in the skull.

 I - Olfactory – Smell
 II – Optic - vision
 III – oculomotor –eye movement and pupilconstriction
 IV – Trochlear – eye movement
 V - Trigeminal – touch , pain from face and head muscles of chewing.
 VI – Abducens nerve – eye movement
 VII – Facial nerve - anterior 2/3 of tongue taste
And controls of facial muscles
For facial expression, sensory
Information from ear.
 VIII - vestibulochoclear nerve – hearing balance
 IX - Glossopharyngeal nerve -posterior 2/3 of the tongue taste and somatosensory
perception from tonsil and pharynx, controls some muscles in chewing.
 X -Vagus nerve – sensory , motor and autonomic functions of vital organs like heart
,intestine .
 XI – Spinal accessory nerve – controls muscles used in head movement.
 XII - Hypoglossal nerve – controls muscles of tongue.

SPINAL NERVES
The spinal cord is composed of 31 pairs of spinal nerves: 8 cervical,
12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each spinal nerve has a ventral root and a
dorsal root.

The dorsal roots are sensory and transmit sensory impulses from specific areas of the body
known As dermatomes to the dorsal ganglia.
The ventral roots are motor and transmit impulses from the spinal cord to the body. These fibers
are also either somatic or visceral.The visceral fibers include autonomic fibers that control the
cardiac muscles and glandular secretions.
 AUTONOMIC NERVOUS SYSTEM

The autonomic nervous system regulates the activities of internal organs such as the heart,
lungs, blood vessels, digestive organs, and glands. Maintenance and restoration of internal
homeostasis is largely the responsibility of the autonomic nervous system.

There are two major divisions:

 sympathetic nervous system, - with predominantly excitatory responses, most notably the
“fight
or flight” response,
 parasympathetic nervous system, - which controls mostly visceral functions.
The autonomic nervous system innervates most body organs. Although usually considered part
of the peripheral nervous system, it is regulated by centers in the spinal cord, brain stem, and
hypothalamus.

ASSESSMENT OF THE NERVOUS SYSTEM

Subjective Data

Important Health Information

Past Health History.

Consider three points when taking a history of a patient with neurologic problems. First, avoid
suggesting symptoms or asking leading questions. Second, the mode of onset and the course of
the illness are especially important aspects of the history. Often the nature of a neurologic
disease process can be described by these facts alone. Obtain all pertinent data in the history of
the present illness, especially data related to the characteristics and progression of the
symptoms. In some cases the history may include birth injury (e.g., cerebral palsy as a
consequence of hypoxia). Third, if the patient is not considered a reliable historian, confirm or
obtain the history from someone with firsthand knowledge of the patient. Medications. Obtain a
careful medication history, especially the use of sedatives, opioids, tranquilizers, and mood
elevating drugs. Many other drugs can also cause neurologic side effects. Surgery or Other
Treatments. Inquire about any surgery involving any part of the nervous system, such as head,
spine, or sensory organs. If a patient had surgery, determine the date, cause, procedure,
recovery, and current status. Growth and developmental history can be important in ascertaining
whether nervous system dysfunction was present at an early age. Specifically inquire about
major developmental tasks such as walking and talking.

Present Health History

An important aspect of the neurologic assessment is the history of the present illness. The initial
interview provides an excellent opportunity to systematically explore the patient’s current
condition and related events while simultaneously observing overall appearance, mental status,
posture, movement and affect. Depending
on the patient’s condition, the nurse may need to rely on yes-or-no answers to questions, on a
review of the medical record, or input from the family or a combination of these.

The health history therefore includes details about the onset, character, severity, location,
duration, and frequency of symptoms and signs; associated complaints; precipitating,
aggravating, and relieving factors; progression, remission, and exacerbation; and the presence or
absence of similar symptoms
among family members. The nurse may also use the interview to inquire about any family
history of genetic diseases.
The nurse should be aware of any history of trauma or falls that may have involved the head or
spinal cord. Questions regarding the use of alcohol, medications, and recreational drugs are also
included.

CLINICAL MANIFESTATIONS
The clinical manifestations of neurologic disease are as varied as the disease processes
themselves.

Pain
Pain is considered an unpleasant sensory perception and emotional experience associated with
actual or potential tissue damage or described in terms of such damage.

Pain can be acute or chronic. In general, acute pain lasts for a relatively short period of time and
remits as the pathology resolves. In neurologic disease, this type of pain is often associated with
spinal disc disease, trigeminal neuralgia, or other neuropathic pathology (eg, post therapeutic
neuralgia, or painful neuropathies). In contrast, chronic pain extends for long periods of time
and may represent a low level of pathology. This type of pain might also occur with discogenic
disease.

Seizures
Seizures are the result of abnormal paroxysmal discharges in the cerebral cortex, which then
manifest as an alteration in sensation, behaviour, movement, perception, or consciousness.
Seizures can occur as isolated events, such as when induced by a high fever, alcohol or drug
withdrawal, or hypoglycaemia. A seizure may also
be the first obvious sign of a brain lesion.

Dizziness

Dizziness is an abnormal sensation of imbalance or movement. It is fairly common in the elderly

and one of the most common complaints encountered by health professionals. Dizziness can
have a variety of causes, including viral syndromes, hot weather, roller coaster rides, and middle
ear infections, to name a few.
Vertigo, a specific form of dizziness, is defined as a sensation that is usually a manifestation of
vestibular dysfunction. It can be so severe as to result in spatial disorientation, loss of
equilibrium, and nausea and vomiting.

Visual disturbances
Lesions of the eye itself (eg, cataract), lesions along the pathway (eg,tumor), or lesions in the
visual cortex (from stroke) interfere with normal visual acuity. Abnormalities of eye movement
(as in the nystagmus associated with multiple sclerosis) can also compromise vision by causing
diplopia or double vision.

Weakness

Weakness, specifically muscle weakness, is a common manifestation of neurologic disease.

Weakness frequently coexists with other symptoms of disease and can affect a variety of
muscles, causing a wide range of disability. Weakness can be sudden and permanent, as in
stroke, or progressive, as in many neuromuscular diseases such as amyotrophic lateral sclerosis.
Any muscle group can be affected.

Abnormal Sensation
Numbness, abnormal sensation, or loss of sensation is a neurologic manifestation of both central
and peripheral nervous system disease. Altered sensation can affect small or large areas of the
body.

Health Perception–Health Management Pattern.

Ask about the patient’s health practices related to the nervous system, such as substance abuse,
smoking, adequate nutrition, blood pressure control, safe participation in physical and
recreational activities, and use of seat belts or helmets. Also ask about previous hospitalizations
for neurologic problems.
If the patient has an existing neurologic problem, assess how it affects daily living and the
ability to carry out self-care. After a careful review of information, ask someone who knows the
patient well whether he or she has noticed any mental or physical changes in the patient. The
patient with a neurologic problem may not be aware of it or may be a poor historian.

Nutritional-Metabolic Pattern.

Neurologic problems can result in poor nutrition. Problems related to chewing, swallowing,
facial nerve paralysis, and muscle coordination could make it difficult for the patient to ingest
adequate nutrients.7 Also, certain vitamins such as thiamine (B1), niacin, and pyridoxine (B6)
are essential for the maintenance and health of the CNS. Deficiencies in one or more of these
vitamins could result in such nonspecific complaints as depression, apathy, neuritis, weakness,
mental confusion, and irritability. Cobalamin (vitamin B12) deficiency can occur in older adults,
who tend to have problems with vitamin absorption from both supplements and natural food
sources such as meat, fish, and poultry. Untreated, cobalamin deficiency can cause mental
function decline.

Elimination Pattern.

Bowel and bladder problems are often associated with neurologic problems such as stroke, head
injury, spinal cord injury, multiple sclerosis, and dementia. It is important to determine if the
bowel or bladder problem was present before or after the neurologic event to plan appropriate
interventions. Incontinence of urine and feces and urinary retention are the most common
elimination problems associated with a neurologic problem or its treatment.8 For example, nerve
root compression (as occurs in cauda equina conditions) leads to a sudden onset of incontinence.
Document key details, such as number of episodes, accompanying sensations or lack of
sensations, and measures to control the problem.

Activity-Exercise Pattern.

Many neurologic disorders can cause problems in the patient’s mobility, strength, and
coordination. Neurologic problems can result in changes in the patient’s usual activity and
exercise patterns. These problems can also result in falls.9 Assess the person’s activities of daily
living, since neurologic diseases can affect the ability to perform motor tasks, which increases
the possibility of injury.

Sleep-Rest Pattern.

Sleep pattern alteration can be both a cause and a response to neurologic problems. Pain and
reduced ability to change position because of muscle weakness and paralysis could interfere
with sleep quality. Hallucinations resulting from dementia or drugs can also interrupt sleep.
Carefully assess and document the patient’s sleep pattern and bedtime routines.
Cognitive-Perceptual Pattern.

Because the nervous system controls cognition and sensory integration, many neurologic
disorders affect these functions. Assess memory, language, calculation ability, problem-solving
ability, insight, and judgment.

Ask the patient hypothetical questions such as, “What is a reasonable price for a cup of coffee?”
or “What would you do if you saw a car crash outside your house?” Often a structured mental
status questionnaire is used to evaluate these functions and provide baseline data. Delirium is an
acute and transient disorder of cognition that can be seen at any time during a patient’s illness.

Assess a person’s ability to use and understand language. Appropriateness of responses is a

useful indicator of cognitive and perceptual ability. Determine the patient’s understanding and
ability to carry out necessary treatments. Neurologic related cognitive changes can interfere with
the patient’s understanding of the disease and adherence to related treatment.

Self-Perception–Self-Concept Pattern

Neurologic diseases can drastically alter control over one’s life and create dependency on others
for meeting daily needs. Also, the patient’s physical appearance and emotional control can be
affected. Sensitively inquire about the patient’s evaluation of self-worth, perception of abilities,
body image, and general emotional pattern.

Role-Relationship Pattern.

Physical impairments such as weakness and paralysis can alter or limit participation in usual
roles and activities. Cognitive changes can permanently alter a person’s ability to maintain
previous roles. These changes can dramatically affect the patient, caregiver, and family. Ask
patients if their role (e.g., spouse or breadwinner) has changed as a result of their neurologic
problems.

Sexuality-Reproductive Pattern.

Assess the person’s ability to participate in sexual activity because many neurologic disorders
can affect sexual response. Cerebral lesions may inhibit the desire phase or the reflex responses
of the excitement phase. The hypothalamus stimulates the pituitary gland to release hormones
that influence sexual desire. Brainstem and spinal cord lesions may partially or completely
interrupt the desire or ability to have intercourse. Neuropathies and spinal cord lesions may
prevent reflex activities of the sexual response or affect sensation and decrease desire. Despite
neurologically related changes in sexual function, many persons can achieve satisfying
expression of intimacy and affection.

Coping–Stress Tolerance Pattern.

The physical sequence of a neurologic problem can seriously strain a patient’s coping patterns.
Often the problem is chronic and requires that the patient learn new coping skills. Assess the
patient’s usual coping pattern to determine if coping skills are adequate to meet the stress of a
problem. Also assess the patient’s support system.

Value-Belief Pattern.

Many neurologic problems have serious, long-term, life-changing effects. Determine what these
effects are, since they can strain the patient’s belief system. Also determine if any religious or
cultural beliefs could interfere with the planned treatment regimen.
 PHYSICAL EXAMINATION

NEUROLOGICAL ASSESSMENT

DEFINITION

The neurologic examination is a systematic process that includes a variety of clinical tests,
observations, and assessments designed to evaluate a complex nervous system. Although the
neurologic examination is often limited to a simple screening, the examiner must be able to
conduct a thorough neurologic assessment when the patient’s history or other physical findings
warrant it.

Equipments

 Safety pins
 Cottons
 Tuning fork
 Reflex hammer
 Flashlight
 Tongue blade
 Ophthalmoscope
 Vision screener
 Cloves, coffee, or other scent

Components of the neurologic examination

There are six components of the neurologic examination
 Mental status (cerebral function)
 Level of consciousness
 Cranial nerve function
 Special cerebral function
 Cerebellar function
 Motor function
 Sensory function
 Deep tendon reflex

MENTAL STATUS EXAMINATION

Mental status examination is an assessment of general motor behaviour, emotional functioning

along with evaluation of judgment and insight.

Major components of MSE include,

 General appearance and behaviour.

 Psychomotor activity
 Speech
 Thought
 Mood
 Perception
 Cognitive function
 Judgement
 Insight
1. General appearance

Observe for patients appearance , facial expression and movement , hygiene and grooming .

 Appearance - note how the patients appearance is that the way he is dressed in terms of
time , place and occasion .

Normal finding: clothes are normal and fits for the occasions , place and weather.

Abnormal findings : inappropriate dressings may seen in schizophrenia , dementia and

Alzheimer’s.
y posture and movement

 Facial expression – note particularly eye contact and affect

Normal findings : good eye contact and smile appropriately .

Abnormal findings : poor eye contact is seen in patient in depression and apathy.extream facial
expression of happiness ,fear ,or anger may be seen in anxious patient.

 Hygiene and grooming - observe for the patients degree of hygiene and grooming by
keeping in mind from the place he arrived for example if the patient comes directly from home
he may appear neater than if he arrive from work place.

Normal findings : clean skin and nails and hair trimmed ,facial hair shaven or trimmed.

Abnormal findings : usually meticulous grooming and finicky mannerism may be seen in
obsessive compulsive disorder ,poor hygiene may be seen in depressed patients.

2. Psychomotor activities

Observe the psychomotor activities whether it is increased, decreased , assess for any other
psychomotor abnormalities like stereotyped movements , mannerisms gestures and restlessness

Body posture and movement and gait - observe for tensed / nervousness and restlessness from
the body movements the person exhibits during examining .

Normal findings : clients appear to be relaxed , with shoulders and back erect when standing
or sitting.

Abnormal findings - Slumped postures may indicate powerlessness , characteristics of

depression , or organic brain disease . bizarre body movements can be noted in schizophrenia
and may be side effects of drug therapy.

3. Speech
 A neutral topic like festival, rain , sea can be given to patient so as to elicit the
characteristics of speech.
 Note the initiation of speech reaction and time.
 Observe the amount of speech like little or minimal or excessive , is speech is high toned or
low toned?
Is speech relevant? , and observe for speech abnormalities

Normal findings : clear and with moderate pace and tone

 Abnormal findings : slow repetitive speech is seen in patient with depression and Parkinson’s
disease,
Loud , rapid speech may occur in manic phases of bipolar disorder .

If the patient has difficulty in speech perform additional tests

 Ask the patient to name the objects in the room

 Ask the patient to read from printed materials appropriate for his educational level.
 If client is normal he may perform the activities without fault.

4. Thought process and perceptions

Thought has to be assessed in the areas of form and stream, content and possession .

 Forms – note whether form of thought is normal and assess for the presence of thought
disorder.
Normal findings – normal form of thoughts
Abnormal findings – not understandable, circumstantiality , tangentially neologism , word
salad , ambivalence , preservations will be seen
 Stream (flow of thoughts )
Normal findings – normal flow of thoughts
Abnormal findings – racy thought ( preasure of thoughts , retarded thinking (poverty of
thought) , thought block , muddleled or unclear thought , flight of ideas , clang association and
mutism can be find in abnormal cases .

 Content ; specific questions can be used to elicit delusions .

Findings
Delusion - patient may exhibit different types of
Delusions like
 Persecutory delusion –  unable to recognize reality. They strongly believe people or
groups, like the government, intend to harm them
 Delusion of reference – patient believes that unsuspicious occurrences refer to him or her in
person.
 Delusion of influence- the false supposition that other people or external agents are covertly
exerting powers over oneself.
 Hypochondriacal delusion – hypochondriacal delusions are based on altered body
perceptions in mental illness, characterized by primary local or general dysaesthesias to the
point of depersonalisation, or caused secondarily by the patient's increased attention to his own
body.
 Delusion of grandeur – false belief
 Nihilistic delusion - This theme involves intense feelings of emptiness.
 Delusion of control - Delusion of control is the narrative that expresses in an elaborate way
the meaning that the lived experience has for the patient.
 Bizzare delusion- A bizarre delusion, by contrast, is something that could never happen in
real life, such as being cloned by aliens or having your thoughts broadcast on TV. A person who
has such thoughts might be considered delusional with bizarre-type delusions.

 Ideas – patient may have depressive ideas like worthlessness , helplessness , and
hopelessness, suicidal ideas ,phobia, obsession, etc.

 Possessions - Patient may have thought alienation like thought insertion, thought
withdrawal and thought broadcasting.
5. Mood

Observe for mood and feelings. It can be assessed by subjectively and objectively.
Subjective – ask the client “how do you feel?” or “how was your day?”
Normal findings – cooperative or friendly, express feeling appropriate to situations, express
positive response about the question.
Abnormal findings – eccentric mood not appropriate to the situation is seen in schizophrenia
,excessive worries may be seen in anxiety.

6. Perception

Normal findings – Express realistic expression.

Abnormal findings – hallucination ( visual, auditory , tactile , and okfactory)

7.Cognitive functions

Orientation – ask the client name and names of family members ,the time ,date, day or season
where the client live or is now.

Normal findings – client is aware of self , time , place ,day which he is now.
Abnormal findings – reduced degree of orientation may seen with organic brain disorders or
psychiatric illness such as withdrawal from chronic alcoholism and schizophrenia .

Concentration.

Note the clients ability to focus and stay attentive to you during interview and examination.
Give the client instructions like “please take the pencil with your left hand and place it in your
right hand and hand it over to me.”

Normal findings – listen and can follow the directions without difficulty .

Abnormal findings – distraction and inability to focus on task at hand are noted in anxiety
,fatigue , attention deficit disorder and impaired
State due to drug or alcohol use .

Abstract reasoning

Ask the client to compare objects , for example

How are an apple and orange same ? how are they differ ?also ask the client to explain a
proverb
Normal findings – explains similarities and difference between the object and proverbs correctly
.

Abnormal findings – inability to compare and contrast objects correctly is seen in

schizophrenia , mental retardation and dementia.

Judgement

Ask the client what do you do if you have pain ?

Normal findings – answers based on sound rationale .

Abnormal findings – impaired judgment seen in organic brain syndrome ,emotional disturbances
and mental retardation and schizophrenia .
Insight

This test the patient awareness of his illness

Grading insight is as following
 Grade-1 - complete denial of illness .
 Grade-2 - slight awareness of being sick, need help but denying it at the same time.
 Grade-3 – awareness of being sick but blaming it on a external factors
 Grade–4 – awareness that illness is due to something unknown in patient .
 Grade–5 - intellectual insight.
 Grade–6 – true emotional insight .

LEVEL OF CONCIOUSNESS

Level of Consciousness Depending on the client’s symptoms, evaluation of the level of

consciousness (LOC) is often necessary. The following classification of LOC applies to altered
consciousness from any cause. Differentiating between each level can be difficult; some clients
show characteristics of two or more levels:
• Conscious: The client responds immediately, fully, and appropriately to visual, auditory, and
other stimulation.
• Somnolent or lethargic: The client is drowsy or sleepy at inappropriate times but can be
aroused, only to fall asleep again. Responses to questions and verbal commands are delayed or
inappropriate. Speech is incoherent. Painful stimuli elicit a response.
• Stuporous: The client is aroused only by vigorous and continuous stimulation, usually by
manipulation or strong auditory or visual stimuli. Stimulation results in one- or two-word
answers or in motor activity or purposeful behavior directed toward avoiding further
stimulation.
• Semicomatose: The client is unresponsive except to superficial, relatively mild painful stimuli
to which the client makes some purposeful motor response (movement) to evade stimulation.
Spontaneous motion is uncommon, but the client may groan or mutter.
• Comatose: The client responds only to very painful stimuli by fragmentary, delayed reflex
withdrawal; in deeper stages, he or she loses all responsiveness. There is no spontaneous
movement, and the respiratory rate is irregular.

The Glasgow Coma Scale is a measure of the LOC. The scale consists of three parts: eye
opening response, best verbal response, and best motor response. To evaluate responses
correctly, several verbal and motor responses are elicited, and the best response is recorded.
The eye opening response is determined by talking to the client and calling his or her name. If
no response is noted (i.e., the eyes do not open spontaneously),
A painful stimulus is introduced and the response noted.
The verbal response is evaluated by a verbal reply to questions. The motor response is the
ability of the client to follow commands, such as ‘‘Wiggle your toes’’ or ‘‘Move your left
hand.’’
If there is no response, a painful stimulus is applied and the response noted. The responses are
assigned numbers and the numbers are totaled. A normal response is 15. A score of 7 or less is
considered coma. The evaluations are recorded on a graphic line.
The Rancho Los Amigos Scale is another tool for assessing LOC. Some rehabilitation centers
prefer this scale because it is a more flexible assessment tool for identifying the client’s status.

The Rancho Los Amigos Scale

 Level I: No response to stimuli. Appears in deep sleep.

 Level II: Generalized response. First reaction may be to deep pain. Has delayed,
inconsistent responses.
 Level III: Localized response. Inconsistent responses, but reacts in a more specific manner
to stimulus. Might follow simple command ‘‘squeeze my hand.’’
 Level IV: Confused. Agitated. Reacts to own inner confusion, fear, disorientation. Excitable
behavior, may be abusive.
 Level V: Nonagitated. Confused. Inappropriate. Usually disoriented. Follows tasks for 2 to
3 minutes, but easily distracted by environment, frustrated.
 Level VI: Confused appropriate. Follows simple directions consistently. Memory and
attention increasing. Self-care tasks performed without help.
 Level VII: Automatic appropriate. If physically able, can carry out routine activities.
Appears normal. Needs supervision for safety.
 Level VIII: Purposeful. Alert. Oriented. May have decreased abilities relative to premorbid
state.

EXAMINING THE CRANIAL NERVE

I (olfactory)

 Do not test routinely.

 Test the sense of smell in those who report loss of smell, those with head trauma, and those
with abnormal mental status and when the presence of an intracranial lesion is suspected.
 First assess patency by occluding one nostril at a time and asking the person to sniff.
 Then with the person’s eyes closed, occlude one nostril and present an aromatic substance.
Use familiar, conveniently obtainable, and nonnoxious smells such as coffee, toothpaste, orange,
vanilla, soap, or peppermint. Alcohol wipes smell familiar and are easy to find but are irritating.
 Normal findings –
Normally a person can identify an odour on each side of the nose.
Smell normally is decreased bilaterally with aging. Any asymmetry in the sense of smell is
important.
 Abnormal findings - One cannot test smell when air passages are occluded with upper
respiratory infection or sinusitis. Anosmia—Decrease or loss of smell occurs bilaterally with
tobacco smoking, allergic rhinitis, and cocaine use.

Unilateral loss of smell in the absence of nasal disease is neurogenic anosmia

II (optic)

 Use a Snellens chart to assess vision in each eyes.

o Normal findings – 20/20 vision
o Abnormal findings –difficulty reading snellens chart , misses letters .
 Ask the client to read news paper to assess near vision.
o Norml findings – read print without difficulty in 14 inches distance .
o Abnormal findings - read print in holding closer than 14inches or hold print further away is
in presbyopia which occur in aging .
 Use an ophthalmoscope to view the retina and optic disc of each eye .
o Normal findings – round red reflex present ,optic disc 1.5 mm, round or slightly oval ,well
defined margins ,retina pink.
o Abnormal findings –papilledema , pulsating veins papilledema occurs with increased intra
cranial pressure , optic atrophy occurs with brain tumour
III (oculomotor) IV (Trochlear) VI (Abducen)
 Check pupils for size, regularity, equality, direct and consensual light reaction, and
accommodation
 Assess extra ocular movements by the cardinal positions of gaze
 Normal findings ; Nystagmus is a back-and-forth oscillation of the eyes.
 End-point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs
normally.
 Assess any other nystagmus carefully, noting:
• Presence of nystagmus in one or both eyes.
• Pendular movement (oscillations move equally left to right) or jerk (a quick phase in one
direction, then a slow phase in the other).
Classify the jerk nystagmus in the direction of the quick phase.
• Amplitude.Judge whether the degree of movement is fine, medium, or coarse.
• Frequency. Is it constant or does it fade after a few beats?
• Plane of movement. Horizontal, vertical, rotary, or a combination?
 Abnormal findings : Increasing intracranial pressure causes a sudden, unilateral, dilated,
and nonreactive pupil. Assess extra ocular movements by the cardinal positions of gaze .
Strabismus (deviated gaze) or limited movement.
Nystagmus occurs with disease of the vestibular system, cerebellum, or brain stem

V (trigeminal)
 Motor Function.
 Assess the muscles of mastication by palpating the temporal and masseter muscles as the
person clenches the teeth . Muscles should feel equally strong on both sides.
 Next try to separate the jaws by pushing down on the chin; normally you cannot.
 Abnormal findings ; Decreased strength on one or both sides. Asymmetry in jaw
movement. Pain with clenching of teeth.
 Sensory : With the person’s eyes closed, test light touch sensation by touching a cotton wisp
to these designated areas on person’s face: forehead, cheeks, and chin .
 Ask the person to say “Now” whenever the touch is felt. This tests all three divisions of the
nerve:
(1) ophthalmic, (2) maxillary and (3)mandibular .
o Abnormal findings - Decreased or unequal sensation. With a stroke, sensation of face and
body is lost on the opposite side of the lesion.
 VII (facial)
 Motor function : Note mobility and facial symmetry as the person responds to these
requests: smile , frown, close eyes tightly (against your attempt to open them), lift eyebrows,
show teeth, and puff cheeks .
 Press the person’s puffed cheeks in and note that the air should escape equally from both
sides.
Abnormal findings : Muscle weakness is shown by flattening of the nasolabial fold, drooping
of one side of the face, lower eyelid sagging, and escape of air from only one cheek that is
pressed in.
Loss of movement and asymmetry of movement occur with both CNS lesions (e.g., stroke that
affects lower face on one side) and peripheral nervous system lesions (e.g., Bell palsy that
affects the upper and lower face on one side.

VIII (acoustic) –

 Vestibular branch (balance):

 Ask patient to march in place (Mittlemeyer Marching) with eyes closed.
 Abnormal findings : Inability to do so is positive for Vestibular branch lesion.
 Ask patient to focus on your nose while you passively rotate their head from left to right.
Abnormal findings :Inabibility to remain focused on your nose is positive for Vestibular branch
lesion.
 Cochlear branch: Part 1
 Tap a tuning fork and place it on the vertex of the patient’s skull. Ask patient if he/she hears
it louder in one ear over the other.
 Part 2: If so, tap tuning fork and place it on the mastoid process of the ear that is louder and
ask them to tell you when they can no longer hear it.
 Then, place the tines of the fork next to the ear without tapping it again, patient should
continue to be able to hear it for at least as long as they heard it through the mastoid.
 Then, do the same in the ear that was quieter than that other. This is called the
Webber/Rinne test.
Findings / Results: If equal in part 1, test is considered negative and over. If patient can’t hear
at all in Part 2 when the fork is on the quieter side, then it is a Cochlear lesion on the same side.
-
IX (glossopharyngeal)
 Depress the tongue with a tongue blade and note pharyngeal movement as the person says
“ahhh” or yawns; the uvula and soft palate should rise in the midline, and the tonsillar pillars
should move medially

o Abnormal findings : Absence or asymmetry of soft palate movement or tonsillar pillar

movement. Following a stroke, dysfunction in swallowing may increase risk for aspiratio
 X( vagus)
o Touch the posterior pharyngeal wall with a tongue blade and note the gag reflex. Also note
that the voice sounds smooth and not strained.
o Abnormal findings : Hoarse or brassy voice occurs with vocal cord dysfunction; nasal
twang occurs with weakness of soft palate
XI (spinal accessory)

 Palpate and note strength of trapezius muscles while patient shrugs shoulders against
resistance.
 Palpate and note strength of each sternocleidomastoid muscle as patient turns head against
opposing pressure of the examiner’s hand.
 Abnormal findings - Atrophy. Muscle weakness or paralysis occurs with a stroke or
following injury to the peripheral nerve (e.g., surgical removal of lymph nodes).

XII (hypoglossal) -

 Inspect the tongue.

 No wasting or tremors should be present.
 Note the forward thrust in the midline as the person protrudes the tongue. Also ask the
person to say “light, tight, dynamite” and note that it is clear.
 Abnormal findings - Atrophy. Fasciculation’s. Tongue deviates to side with lesions of the
hypoglossal nerve (when this occurs, deviation is toward the paralyzed side)

EXAMINING THE MOTOR SYSTEM

SIZE OF THE MUSCLE

 As you proceed through the examination, inspect all muscle groups for size. Compare the
right side with the left. Muscle groups should be within the normal size limits for age and
symmetric bilaterally. When muscles in the extremities look asymmetric, measure each in
centimetres and record the difference.
A difference of 1 cm or less is not significant.
 Abnormal findings - Atrophy - Abnormally small muscle with a wasted appearance;
occurs with
injury, LMN disease such as diabetic neuropathy. Hypertrophy—Increased size and
strength; occurs with isometric exercise .

TONE OF THE MUSCLE

Tone is the normal degree of tension (contraction) in voluntarily
relaxed muscles. It shows as a mild resistance to passive stretch. To test muscle tone, move the
extremities through a passive range of motion. First persuade the person to relax completely, to
“go loose like a rag doll.” Move each extremity smoothly through a full range of motion.
Support the arm at the elbow and the leg at the knee . Normally you will note a mild, even
resistance to
movement.
Abnormal findings - Limited range of motion ,Pain with motion.
Flaccidity—Decreased resistance, hypotonia occur with peripheral weakness. Spasticity and
rigidity—Types of
increased resistance that occur with central weakness.
STREGNTH OF MUSCLES
Test the strength of the prime-mover muscle groups for each joint. Repeat the
motions that you elicited for active ROM. Now ask the person to flex and hold
as you apply opposing force. Muscle strength should be equal bilaterally and
fully resist your opposing force
A wide variability of strength exists among people. You may wish to use a
grading system from no voluntary movement to full strength, as shown.

GRADE DESCRIPTIO % ASSESSMEN

N NORMAL T
5 Full ROM 100 NORMAL
against gravity,
full resistance
4 Full ROM 75 GOOD
against gravity,
some resistance
3 Full ROM with 50 FAIR
gravity
2 Full ROM with 25 POOR
gravity
eliminated
(passive motion)
1 Slight 10 TRCE
contraction
0 No contraction 0 0

ABNORMAL FINDINGS - Paresis or weakness is diminished

strength; paralysis or plegia is absence of strength.

CEREBELLAR FUNCTION
COORDINATION AND SKILLED MOVEMENT

RAPID ALTERNATING MOVEMENTS

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 the person to do this faster.

Normally this is done with equal turning and a quick, rhythmic pace.

Alternatively ask the person to touch the thumb to each finger on the same
hand, starting with the index finger; then reverse direction .

Normally this can be done quickly and accurately.

ABNORMAL FINDINGS - Lack of coordination.

Slow, clumsy, and sloppy response is termed dysdiadochokinesia and occurs with cerebellar
disease.

FINGER TO FINGER TEST

With the person’s eyes open, ask that he or she use the
index finger to touch your finger and then his or her own nose . After a few times, move your
finger to a different spot. The person’s movement should
be smooth and accurate.

ABNORMAL FINDINGS : Lack of coordination.

Dysmetria is clumsy movement with overshooting the mark and occurs with
cerebellar disorders or acute alcohol intoxication.
Past-pointing is a constant deviation to one side.
Intention tremor when reaching to a visually directed object.

FINGER TO NOSE TEST

Ask the person to close the eyes and stretch out the arms. Ask him or her to touch the tip of his
or her nose with each index finger, alternating hands and increasing speed. Normally this is done
with accurate and smooth movement.
ABNORMAL FINDINGS - Misses nose.
Worsening of coordination when the eyes are closed occurs with cerebellar disease or alcohol
intoxication
HEAL TO SHIN TEST
Test lower-extremity coordination by asking the person,
who is in a supine position, to place the heel on the opposite knee and run it
down the shin from the knee to the ankle . Normally the person moves the heel in a straight line
down the shin.

ABNORMAL FINDINGS - Lack of coordination, heel falls off shin; occurs with cerebellar
disease.
BALANCE TEST
GAIT
Observe as the person walks 10 to 20 feet, turns, and returns to the
starting point.
Normally the person moves with a sense of freedom. The gait is
smooth, rhythmic, and effortless; the opposing arm swing is coordinated; the
turns are smooth. The step length is about 15 inches from heel to heel.
 ABNORMAL FINDINGS - 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 .

HEEL TO TOA TEST

Ask the person to walk a straight line in a heel-to-toe fashion (tandem walking) . This decreases
the base of support and will accentuate any
problem with coordination. Normally the person can walk straight and stay
balanced .

ABNORMAL FINDINGS - Crooked line of walk.

Widens base to maintain balance.
Staggering, reeling, loss of balance.
An ataxia that did not appear with regular gait may appear now.
Inability to tandem walk is sensitive for an upper motor neuron lesion such as multiple sclerosis
and for acute cerebellar dysfunction such as alcohol intoxication .

You may also test for balance by asking the person to walk on his or her toes
and then on the heels for a few steps.
Normally plantar flexion and dorsiflexion are strong enough to permit this.

ABNORMAL FINDINGS - Muscle weakness in the legs prevents this .

ROMBERGS TEST

Ask the person to stand up with feet together and arms at the sides. Once in a stable position, ask
him or her to close the eyes and to hold the position. Wait about 20 seconds. Normally a person
can maintain posture and balance even with the visual orienting information blocked, although
slight swaying may occur. (Stand close to catch the person in case he or she falls.)

ABNORMAL FINDINGS -Sways, falls, widens base of feet to avoid falling.

Positive Romberg sign is loss of balance that occurs when closing the eyes. You eliminate the
advantage of orientation with the eyes, which had compensated for sensory loss.
A positive Romberg sign occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication),
loss of proprioception, and loss of vestibular function.

Ask the person to perform a shallow knee bend or to hop in place, first on one leg and then the
other . This demonstrates normal position sense, muscle strength, and cerebellar function.
Note that some individuals cannot hop because of aging or obesity. Alternatively you can ask
them to rise from a chair without using the arm rests for support.

ABNORMAL FINDINGS - Unable to perform knee bend because of weakness in quadriceps

muscle or hip extensors.

SENSORY EXAMINATIONS

Ask the person to identify various sensory stimuli to test the intactness of the
peripheral nerve fibers, the sensory tracts, and higher cortical discrimination.
Ensure validity of sensory system testing by making sure that the person is
alert, cooperative, and comfortable and has an adequate attention span. Otherwise you may get
misleading and invalid results. Testing the sensory system can be fatiguing. You may need to
repeat the examination later or to break it into parts when the person is tired.
Screening procedures include testing superficial pain or light touch and vibration in a few distal
locations and testing stereognosis. Complete testing of the sensory system is warranted only in
those with neurologic symptoms (e.g., localized pain, numbness, and tingling) or when you
discover abnormalities (e.g., motor deficit). Then test all sensory modalities and cover most
dermatomes of the body. Compare sensations on symmetric parts of the body. When you find a
definite decrease in sensation, map it out by systematic testing in that area. Proceed from the
point of decreased sensation toward the sensitive area. By asking the person to tell you where
the sensation changes, you can map the exact borders of the deficient area.

Spinothalamic test

Pain

Pain is tested by the person’s ability to perceive a pinprick.

Break a tongue blade lengthwise, forming a sharp point at the fractured end and a dull spot at the
rounded end. Lightly apply the sharp point or the dull end to the person’s body in a random,
unpredictable order .
Ask the person to say “sharp” or “dull,” depending on the sensation felt.
(Note that the sharp edge is used to test for pain; the dull edge is used as a general test of the
person’s response).

Let at least 2 seconds elapse between each stimulus to avoid summation. With
Summation , frequent consecutive stimuli are perceived as one strong stimulus.
Discard tongue blade to prevent transmitting any possible infection .

ABNORMAL FINDINGS - Hypoalgesia—Decreased pain sensation.

Analgesia—Absent pain sensation.
Hyperalgesia—Increased pain sensation .

LIGHT TOUCH

Apply a wisp of cotton to the skin. Stretch a cotton ball to make a long end and brush it over the
skin in a random order of sites and at irregular intervals. This prevents the person from
responding just from repetition. Include the arms, forearms, hands, chest, thighs, and legs. Ask
the person to say “now” or “yes” when touch is felt. Compare symmetric points.

ABNORMAL FINDINGDS - Hypoesthesia—Decreased touch sensation.

Anesthesia—Absent touch sensation.
Hyperesthesia—Increased touch sensation.

VIBRATION
Test the person’s ability to feel vibrations of a tuning fork over
bony prominences. Use a low-pitch tuning fork (128 Hz or 256 Hz) because its
vibration has a slower decay. Strike the tuning fork on the heel of your hand and hold the base
on a bony surface of the fingers and great toe . Ask the
person to indicate when the vibration starts and stops. If he or she feels a normal vibration or
buzzing sensation on these distal areas, you may assume that proximal spots are normal and
proceed no further. If no vibrations are felt, move proximally and test ulnar processes and
ankles, patellae, and iliac crests. Compare the right side with the left side. If you find a deficit,
note whether it is gradual or abrupt.

ABNORMAL FINDINGS - Unable to feel vibration.

Loss of vibration sense occurs with peripheral neuropathy
(e.g., diabetes and alcoholism).

POSITION ( KINESTHESIA)
Test the person’s ability to perceive passive movements of the extremities. Move a finger or the
big toe up and down and ask the person to tell you which way it is moved . The test is done with
the eyes closed; but, to be sure that it is understood, have the person watch a few trials first.
Vary the order of movement up or down. Hold the digit by the sides since upward or downward
pressure on the skin may provide a clue as to how
it has been moved.
Normally a person can detect movement of a few millimeters.

ABNORMAL FINDINGS - Loss of position sense

TACTILE DISCRIMINATION (FINE TOUCH)

The following tests also measure the discrimination ability of the sensory cortex. As a
prerequisite the person needs a normal or near-normal sense of touch and position sense.

ABNORMAL FINDINGS - Problems with tactile discrimination occur with lesions of the
sensory cortex or posterior column.

STERIOGNOSIS
Test the person’s ability to recognize objects by feeling their forms, sizes, and weights. With his
or her eyes closed, place a familiar object (paper clip, key, coin, cotton ball, or pencil) in the
person’s hand and ask him or her to identify it. Normally a person will explore it with the
fingers and correctly name it. Test a different object in each hand; testing the left hand assesses
right parietal lobe functioning.

ABNORMAL FINDINGS - Astereognosis—Inability to identify object correctly. Occurs in

sensory cortex lesions (e.g., stroke) .

GRAPHESTHESIA

Graphesthesia is the ability to “read” a number by having it traced on the skin. With the person’s
eyes closed, use a blunt instrument to trace a single digit number or a letter on the palm . Ask the
person to tell you what it is. Graphesthesia is a good measure of sensory loss if the person
cannot make the hand movements needed for stereognosis, as occurs in arthritis.

ABNORMAL FINDINGS - Inability to distinguish number occurs with lesions of the sensory
cortex.

EXAMINING THE REFLEX

The motor reflexes are involuntary contractions of muscles or muscle groups in response to
abrupt stretching near the site of the muscle’s insertion. The tendon is struck directly with a
reflex hammer or indirectly by striking the examiner’s thumb, which is placed firmly against the
tendon. Testing these reflexes enables the examiner to assess involuntary reflex arcs that depend
on the presence of afferent stretch receptors, spinal synapses, efferent motor fibers, and a variety
of modifying influences from higher levels. Common reflexes that may be tested include the
deep tendon reflexes (biceps, brachioradialis, triceps, patellar, and ankle reflexes) and
superficial or cutaneous reflexes (abdominal reflexes
and plantar or Babinski response.

TECHNIQUE
A reflex hammer is used to elicit a deep tendon reflex. The handle of the hammer is held loosely
between the thumb and index finger, allowing a full swinging motion. The extremity is
positioned so that the tendon is slightly stretched. This requires a sound knowledge of the
location of muscles and their tendon attachments.
The tendon is then struck briskly, and the response is
compared with that on the opposite side of the body.
When the comparison is made, both sides should be equivalently relaxed and each tendon struck
with equal force. Valid findings depend on several factors:
 proper use of the reflex hammer
 proper positioning of the extremity,
 relaxed patient.
.
GRADING THE REFLEXES
 The absence of reflexes is significant, although ankle jerks (Achilles reflex) may be
normally absent in older people.
 Deep tendon reflex responses are often graded on a scale of 0 to 4.
 A 4 indicates a hyperactive reflex, often indicating pathology; 3 indicates a response that is
more brisk than average but may be normal or indicative of disease; 2 indicates an average or
normal response;
1 indicates a hypoactive or diminished response; and 0 indicates no response. As stated
previously, scale ratings are highly subjective.
 Findings can be recorded as a fraction, indicating the scale range (eg, 2/4). Some examiners
prefer to use the terms present, absent,
and diminished when describing reflexes
BICEPS REFLEX
The biceps reflex is elicited by striking the biceps tendon of the flexed elbow. The examiner
supports the forearm with one arm while placing the thumb against the tendon and striking the
thumb with the reflex hammer. The normal response is flexion at the elbow and contraction of
the biceps

TRICEPS REFLEX
To elicit a triceps reflex, the patient’s arm is flexed at the elbow and positioned in front of the
chest. The examiner supports the patient’s arm and identifies the triceps tendon by palpating 2.5
to 5 cm (1 to 2 in)
above the elbow. A direct blow on the tendon normally produces contraction of the triceps
muscle and extension of the elbow .

BRACHIORADIALIS REFLEX

With the patient’s forearm resting on the lap or across the abdomen, the brachioradialis reflex is
assessed. A gentle strike of the hammer 2.5 to 5 cm (1 to 2 in) above the wrist results in flexion
and supination of the forearm.

PATELLAR REFLEX
The patellar reflex is elicited by striking the patellar tendon just below the patella. The patient
may be in a sitting or a lying position. If the patient is supine, the examiner supports the legs to
facilitate relaxation of the muscles. Contractions of the quadriceps and knee extension are
normal responses

ANKLE REFLEX
To elicit an ankle (Achilles) reflex, the foot is dorsiflexed at the ankle and the hammer strikes
the stretched Achilles tendon . This reflex normally produces plantar flexion.

SUPERFICIAL REFLEXES
The major superficial reflexes include corneal, gag or swallowing, upper/lower abdominal,
cremasteric (men only), plantar, and perianal. These reflexes are graded differently than the
motor reflexes and are noted to be present () or absent (-). Of these, only three are tested
commonly.

CORNEAL REFLEX

The corneal reflex is tested carefully using a clean wisp of cotton and lightly touching the outer
corner of each eye on the sclera. The reflex is present if the action elicits a blink.

Conditions such as a cerebrovascular accident or coma might result in loss of this reflex, either
unilaterally or bilaterally. Loss of this reflex indicates the need for eye protection and possible
lubrication to prevent corneal damage.

GAG REFLEX
The gag reflex is elicited by gently touching the posterior pharynx with a cotton-tipped
applicator; first on one side of the uvula and then the other. Positive response is an equal
elevation of the uvula and “gag” with stimulation.

ABNORMAL FINDINGS - Absent response on one or both sides can be seen following a
cerebrovascular accident and requires careful evaluation and treatment of the resultant
swallowing dysfunction to prevent aspiration of food and fluids into the lungs.

PLANTAR REFLEX

The plantar reflex is elicited by stroking the lateral side of the foot with a tongue blade or the
handle of a reflex hammer. Stimulation normally causes toe flexion.

ABNORMAL FINDINGS - Fanning of the toes is abnormal which is called as Babinski

response. A well-known reflex indicative of central nervous system disease affecting the
corticospinal tract is the Babinski reflex.

DIAGNOSTIC STUDIES: Nervous System

Lumbar Puncture
Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is
performed to obtain samples of CSF from the subarachnoid space for laboratory examination
and to measure CSF pressure . Bacteriologic tests
on specimens of CSF reveal the presence of pathogenic microorganisms. Strict aseptic technique
is required during the procedure. The CSF normally is clear and colorless, with a pressure of 80
to 180 mm H2O; a pressure over 200 mm
H2O is considered abnormal. A lumbar puncture also is performed to inject a drug into the
subarachnoid space (intrathecal injection), to administer a spinal anesthetic, to withdraw CSF for
the relief of intracranial pressure, or to inject air, gas, or dye for a neurologic diagnostic
procedure.

Radiologic Studies

Cerebral Angiography.

Cerebral angiography is indicated when vascular lesions or tumors are suspected.

A catheter is inserted into the femoral (sometimes brachial) artery. It is then passed up the artery
to the aortic arch and into the base of a carotid or a vertebral artery for injection of radiopaque
contrast medium. A series of x-rays is taken in a timed sequence so that pictures of the arteries,
smaller vessels, and veins can be obtained . This study can help to localize and determine the
presence of abscesses, aneurysms, hematomas, arteriovenous malformations, arterial spasm, and
certain tumors. Because this is an invasive procedure, adverse reactions may occur. The patient
may have an allergic (anaphylactic) reaction to the contrast medium. This reaction usually
occurs immediately after injection of the contrast medium and may require emergency
resuscitation measures in the procedure room. The most common precaution for nurses to take
in caring for the patient after the return to the room is observation for bleeding at the catheter
puncture site (usually the groin). A pressure dressing and ice are usually placed on the site to
promote hemostasis and prevent swelling.

Skull and spine x-rays

Simple x-ray of skull and spinal column is done to detect fractures, bone erosion, calcifications,
abnormal vascularity. Explain that procedure is noninvasive. Explain positions to be assumed.

Computed tomography (CT) scan

 Computer-assisted x-ray of several levels or thin cross sections of body parts are done
to detect problems such as hemorrhage, tumor, cyst, edema, infarction, brain atrophy, and other
abnormalities. Contrast media may be used to enhance visualization of brain structures.

Assess for contraindications to contrast media, including shell fish/iodine/dye allergy. Explain
that procedure is noninvasive (if no contrast medium used). Observe for allergic reaction and
note puncture site (if contrast medium used). Explain appearance of scanner. Instruct patient to
remain still during procedure.

Magnetic resonance imaging (MRI)

Imaging of brain, spinal cord, and spinal canal by means of magnetic energy . Used in detection
of strokes, multiple sclerosis, tumors, trauma, herniation, and seizures. No invasive procedures
are required. Gadolinium contrast media may be used to enhance visualization. Has greater
contrast in images of soft tissue structures than does CT scan.
Assess for contraindications, including heart pacemaker. Screen patient for metal parts and
pacemaker in body. Instruct patient on need to lie very still for up to 1 hr. Sedation may be
necessary if patient is claustrophobic.

Magnetic resonance angiography (MRA)

Uses differential signal characteristics of flowing blood to evaluate extracranial and intracranial
blood vessels. Provides both anatomic and hemodynamic information. Can be used in
conjunction with contrast media (contrast-enhanced MRA [cMRA]). Rapidly replacing cerebral
angiography for use in diagnosing cerebrovascular diseases.

Magnetic resonance spectroscopy (MRS)

Provides information about chemical composition of tissue. Used to study brain diseases,
including brain tumors, Alzheimer's disease, strokes, , seizure disorders, and multiple sclerosis.
Markers of neuronal integrity (e.g., N-acetyl aspartate) used to determine loss of neurons.

Myelography

X-ray of spinal cord and vertebral column after injection of contrast medium into subarachnoid
space. Used to detect spinal lesions (e.g., herniated or ruptured disk, spinal tumor).

Administer preprocedure sedation as ordered. Instruct patient to empty bladder. Inform patient
that test is performed with patient on tilting table that is moved during test. After procedure,
patient should lie flat for a few hours. Encourage fluids. Monitor neurologic and VS. Headache,
nausea, and vomiting may occur after procedure.

Functional MRI (fMRI)

Use of MRI to detect changes in cerebral metabolism or blood flow, volume, or oxygenation in
response to specific tasks, consisting of periods of activity and periods of rest. Can functionally
map brain.

Positron emission tomography (PET)

Measures metabolic activity of brain to assess cell death or damage. Uses radioactive material
that shows up as a bright spot on the image. Used for patients with stroke, Alzheimer's disease,
seizure disorders, Parkinson's disease, and tumors.

Explain procedure to patient. Explain that two IV lines will be inserted. Instruct patient not to
take sedatives or tranquilizers. Empty bladder before procedure. Assure glucose monitoring due
to injected venous scan material. May be asked to perform different activities during test.

Single-photon emission computed tomography (SPECT)

A method of scanning similar to PET, but it uses more stable substances and different detectors.
Radiolabeled compounds are injected and their photon emissions can be detected. Images made
are accumulation of labeled compound. Used to visualize blood flow or oxygen or glucose
metabolism in the brain. Useful in diagnosing strokes, brain tumors, and seizure disorders.

Electrographic Studies

Electroencephalography (EEG)

Electrical activity of brain is recorded by scalp electrodes to evaluate seizure disorders, cerebral
disease, CNS effects of systemic diseases, brain death.

Inform patient that procedure is painless and without danger of electric shock. Withhold
stimulants. Determine whether any medications (e.g., tranquilizers, antiseizure drugs) should be
withheld. Resume medications after test. Assist patient to wash electrode paste out of hair.

Magnetoencephalography (MEG)

Uses a sensitivity machine called a biomagnetometer, which detects very small magnetic fields
generated by neural activity. It can accurately pinpoint the part of the brain involved in a stroke,
seizure, or other disorder or injury. Measures extracranial magnetic fields as well as scalp
electric field (EEG).

MEG, a passive sensor, does not make physical contact with patient. Explain procedure to
patient.

Electromyography (EMG) and nerve conduction studies

Electrical activity associated with nerve and skeletal muscle is recorded by insertion of needle
electrodes to detect muscle and peripheral nerve disease.

Inform patient of slight discomfort associated with insertion of needles.

Evoked potentials

Electrical activity associated with nerve conduction along sensory pathways is recorded by
electrodes placed on skin and scalp. Stimulus generates the impulse. Procedure is used to
diagnose disease, locate nerve damage, and monitor function intraoperatively.

Explain procedure to patient.

• Visual evoked potentials

Electrical activity in visual pathway is recorded with rapidly reversing checkerboard pattern on
television screen. One eye is tested at a time.

Explain procedure to patient.

• Brainstem auditory evoked potentials

Electrical activity in auditory pathway is recorded with earphones that produce clicking sounds.
One ear is tested at a time.

Explain procedure to patient.

• Somatosensory evoked potentials

Electrical activity in certain nerve pathways is recorded with mild electrical pulse (several per
second).

Inform patient that stimulus may cause mild discomfort or muscle twitch.

Ultrasound

Carotid duplex studies

Combined ultrasound and pulsed Doppler technology. Probe is placed over the carotid artery
and slowly moved along the course of the common carotid to the bifurcation of the external and
internal carotid arteries. Frequency of reflected ultrasound signal corresponds to the blood
velocity. Increased blood flow velocity can indicate stenosis of a vessel. Duplex scanning is a
noninvasive study that evaluates the degree of stenosis of the carotid and vertebral arteries.

RECENT STUDIES

Nucleic acid in vitro amplification based molecular method

Nucleic acid in vitro amplification based molecular methods are being applied for routine
microbial detection . additionally the molecular methods performed on cerebro spinal fluid
samples are considered the new gold standard for diagnosing CNS infection caused by
pathogens which are otherwise difficult to diagnose .

To overcome the several limitations of conventional diagnostic techniques, molecular methods,

dominantly PCR based amplification, have gradually become mainstay tools in detection and
identification of microbial pathogens in CSF . When compared to conventional methods,
molecular methods show greater detection rates: one study reported 16S rRNA PCR-based
assays were able to accurately detect the causative organism in 65% of banked CSF samples,
compared to 35% when using culture and microscopy . In another report, improved diagnostic
yield based on molecular methods were used to optimize antibiotic treatment of patients with
infectious meningitis when conventional methods provided a negative result . Currently,
molecular methods performed on CSF samples are considered a “platinum” standard, in contrast
of the culture gold standard, in diagnosis of CNS infections caused by viruses which are difficult
to detect and identify.
Recent study conducted on Parkinson s disease diagnosis.

Parkinson's disease (PD) is a degenerative disorder of the brain characterized by the

impairment of the nigrostriatal system. This impairment leads to specific motor
manifestations (i.e., bradykinesia, tremor, and rigidity) that are assessed through clinical
examination, scales, and patient-reported outcomes. New sensor-based and wearable
technologies are progressively revolutionizing PD care by objectively measuring these
manifestations and improving PD diagnosis and treatment monitoring. However, their use
is still limited in clinical practice, perhaps because of the absence of external validation
and standards for their continuous use at home. In the near future, these systems will
progressively complement traditional tools and revolutionize the way we diagnose and
monitor patients with PD.

CONCLUSION

This seminar explains in detail about the assessment of neurological system and at the end
of the session students will be able to understand the subjective data and objective data ,
testing of different cranial nerves , and the main diagnostic procedures involved in the
detection of nervous system disorders. And also recent studies conducted on nervous
system diagnostic tests.

BIBLIOGRAPHY

 Chinthamani, Lewis’s Medical Surgical nursing, south Asian edition, Elsevier

publications, 2011
 Smeltzer C S, Base G.B, Brunner &Suddarth’s text book of medical surgical nursing,
10th edition, Lippincott publishers,
 Swainson C P ,Cumming A D, Davidson’s principles and practice of internal medicine,
1st edition
 Nettina, M Sandra.; Mills, Jacqueline E, Lippincott Manual of Nursing Practice, 8th
Edition,Lippincott Williams & Wilkins, 2006
 Gold man ,ausiello CECIL medicine 23rd edition ,volume 1 ,saunders publication ,
2007
 Taojun He , Samuel Kaplan, Yiwei Tang laboratory diadnosis of central nervous
system infection Current infectious disease report (internet) Available from
www.ncbi.nlm.gov