Assessing the Neurological System

Preparation Performed Mastered Comments

Yes No

1. Assemble equipment:
 Sugar, salt, lemon juice, quinine flavors
 Percussion hammer
 Tongue depressors ( one broken diagonally,
for testing pain sensation)
 Wisps of cotton, to assess light touch
sensation
 Test tubes of hot and cold water, for skin
temperature assessment (optional)
 Pins or needles for tactile discrimination
Procedure

1. Introduce yourself, and verify the client’s identity.

Explain to the client what you are going to do, why it
is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other

appropriate infection control procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following:

 Presence of pain in the head, back, or
extremities, as well as onset and aggravating
and alleviating factors.
 Disorientation to time, place, or person.
 Speech disorders.
 Any history of loss of consciousness, fainting,
convulsions, trauma, tingling or numbness,
tremors or tics, limping, paralysis,
uncontrolled muscle movements, loss of
memory, or mood swings.
 Problems with smell, vision, taste, touch, or
hearing.
Language

5. If the client displays difficulty speaking:

Point to common objects, and ask the client to name

them.
Ask the client to read some words and to match the
printed and written words and pictures.
Ask the client to respond to simple verbal and written
commands-e.g.,”Point to your toes,” or “Raise your
left arm.”

Orientation

6. Determine the client’s orientation to the time, place,

and person by tactful questioning.
 Ask the client the city and state of residence, time of
day, date, day of week, duration of illness, and names
of family members.

More direct questioning might be necessary for some

people –e.g., “Where are you now?”, “What day is it
today?”

Memory

7. Listen for lapses in memory.

Ask the client about difficulty with memory. If

problems are apparent, three categories of memory
are tested: immediate recall, recent memory, and
remote memory.

To assess immediate recall:

 Ask the client to repeat a series of three digits
– e.g. 7-4-3 – spoken slowly.
 Gradually increase the number of digits – e.g. -
7-4-3-5, 7-4-3-5-6, and 7-4-3-5-6-7-2 – until
the client fails to repeat the series correctly.
 Start again with a series of three digits, but
this time, ask the client to repeat them
backwards.
 The average person can repeat a series of 5-8
digits in sequence, and 4-6 digits in reverse
order.
To assess recent memory:
 Ask the client to recall the recent events of
the day, such as how he got to the clinic. This
information must be validated, however.
 Ask the client to recall information given early
in the interview – e.g., the name of a doctor.
 Provide the client with three facts to recall –
e.g., a color, an object, an address, or a three-
digit number – and ask the client to repeat all
three. Later in the interview, ask the client to
recall all three items.

To assess remote memory:

 Ask the client to describe a previous illness or
surgery.

Attention Span and Calculation

8. Test the ability to concentrate or attention span by

asking the client to recite the alphabet or to count
backward from 100.

Test the ability to calculate by asking the clients to

subtract 7 or 3 progressively from 100 – i.e., 100, 93,
86, 79, or 100, 97, 94.
Level of Consciousness

9. Apply the Glasgow Coma Scale:

Eye response, motor response, and verbal response.
Cranial Nerves

10. Test the cranial nerves.

Cranial Nerve I – Olfactory

Ask client to close eyes and identify different mild
aromas such as coffee and vanilla.
Cranial Nerve II – Optic
Ask the client to read Snellen’s chart; check visual
fields by confrontation, and conduct an
ophthalmoscopic examination.
Cranial Nerve III – Oculomotor
Assess six ocular movements and pupil reaction
Cranial Nerve IV – Trochlear
Assess six ocular movements.
Cranial Nerve V – Trigeminal
While client looks upward, lightly touch the lateral
sclera of the eye to elicit the blink reflex. To test light
sensation, have the client close eyes, and wipe a wisp
of cotton over client’s forehead and paranasal sinuses.
To test deep sensation, use alternating blunt and
sharp ends of a safety pin over the same area.
Cranial Nerve VI – Abducens
Assess directions of gaze.
Cranial Nerve VII – Facial
Ask the client to smile, raise the eyebrows, frown, puff
out cheeks, and close eyes tightly. Ask the client to
identify various tastes placed on the tip and sides of
tongue – sugar, salt – and to identify areas of taste.
Cranial Nerve VIII – Auditory
Assess the client’s ability to hear the spoken word and
the vibrations of a tuning fork.
Cranial Nerve IX – Glossopharyngeal
Apply tastes on the posterior tongue for identification.
Ask the client to move tongue from side to side and up
and down.
Cranial Nerve X – Vagus
Assessed with CN IX; assess the client’s speech for
hoarseness.
Cranial Nerve XI – Accessory
Ask the client to shrug shoulders against resistance
from your hands and to turn head to the side against
resistance from your hand. Repeat for the other side.
Cranial Nerve XII – Hypoglossal
Ask the client to protrude tongue at midline, then
move it side to side.
Reflexes

11. Test reflexes using a percussion hammer, comparing

one side of the body with other to evaluate the
symmetry of response.
Biceps Reflex
The biceps reflex tests the spinal cord levels C-5, C-6.
Partially flex the client’s arm at the elbow, and rest the
forearm over the thighs, placing the palm of the hand
down.
Place the thumb of your nondominant hand
horizontally over the biceps tendon.
Deliver a blow (slight downward thrust) with the
percussion hammer to your thumb.
Observe the normal slight flexion of the elbow, and
feel the biceps’s contraction through your thumb.
Triceps Reflex
The triceps reflex tests the spinal cord levels C-7, C-8
 Flex the client’s arm at the elbow, and support it in the
palm of your nondominant hand.
Palpate the triceps tendon about 2-5 cm (1-2 inches)
above the elbow.
Deliver a blow with the percussion hammer directly to
the tendon.
Observe for the normal slight extension of the elbow.

Brachioradialis Reflex
The brachioradialis reflex tests the spinal cord
levels C-3, C-6
Rest the client’s arm in a relaxed position on your
forearm or on the client’s own leg.
Deliver a blow with the percussion hammer directly on
the radius 2-5cm (1-2inches) above the wrist or the
styloid process, the bony prominence on the thumb
side of the wrist.
Observe the normal flexion and supination of the
forearm. The fingers of the hand might also extend
slightly.
Patellar Reflex
The patellar reflex tests the spinal cord level L-2, L-3, L-4.
Ask the client to sit on the edge of the examining table
so that the legs hang freely.
Locate the patellar tendon directly below the patella.

Deliver a blow with the percussion hammer directly to

the tendon.
Observe the normal extension or kicking out of the leg
as the quadriceps muscle contracts.
If no response occurs, and you suspect the client is not
relaxed, ask the client to interlock fingers and pull.
Achilles Reflex
The Achilles reflex tests the spinal cord levels S-1, S-2.
With the client in the same position as for the patellar
reflex test, slightly dorsiflex the client’s ankle by
supporting the foot lightly in your hand.
Deliver a blow with the percussion hammer directly to
the Achilles tendon just above the heel.
Observe and feel the normal plantar flexion
(downward jerk) of the foot.
Plantar (Babinski’s) Reflex
The plantar or Babinski’s reflex is superficial.
It might be absent in adults without pathology
or overridden by voluntary control.
Use a moderately sharp object such as the handle of
the percussion hammer, a key, or the dull end of a pin
or applicator stick.
Stroke the lateral border of the sole of the client’s
foot, starting at the heel, continuing to the ball of the
foot, and then proceeding across the ball of the foot
toward the big toe.
Obeserve the response. Normally, all five toes bend
downward; this reaction is negative Babinski’s. In an
abnormal Babinski response, the toes spread outward
and the big toe moves upward.
Motor Function

Assessment

12. Gross Motor and Balance Tests

Walking Gait
Ask the client to walk across the room and back, and
assess the client’s gait.
 Romberg’s Test
Ask the client to stand with feet together and arms
resting at the sides, first with eyes open, then closed.
Standing On One Foot With Eyes Closed
Ask the client to close eyes and stand on one foot,
then the other. Stand close to the client during this
test.
Heel-Toe Walking
Ask the client to walk a straight line, placing the heel
of one foot directly in front of the toes of the other
foot.
Toe or Heel Walking
Ask the client to walk several steps on the toes and
then on the heels.

13. Fine Motor Tests for the Upper Extremities

Finger-to-Nose Test
Ask the client to abduct and extend arms at shoulder
height and rapidly touch nose alternately with one
index finger and then the other. Have the client repeat
the test with eyes closed if the test is performed
easily.
Alternating Supination and Pronation of Hands on
Knees
Ask the client to pat both knees with the palms of both
hands and then with the backs of hands, alternately, at
an ever-increasing rate.
Finger to Nose and to the Nurse’s Finger
Ask the client to touch nose and then your index
finger, held at distance at about 45cm (18 inches), at a
rapid and increasing rate.
Fingers to Fingers
Ask the client to spread arms broadly at shoulder
height and then bring fingers together at the midline,
first with the eyes open and then closed, first slowly
and then rapidly.
Fingers to Thumb (Same Hand)
Ask the client to touch each finger of one hand to the
thumb of the same hand as rapidly as possible.
14. Fine Motor Tests for the Lower Extremeties
Ask the client to lie supine and to perform these tests:
Heel Down Opposite Shin
Ask the client to place the heel of one foot just below
the opposite knee and run the heel down the shin to
foot. Repeat with the other foot. The client may also
use a sitting position for this test.
Toe or Ball of Foot to the Nurse’s Finger
Ask the client to touch your finger with the large toe of
each foot.
15. Light-Touch Sensation

Compare the light-touch sensation of symmetric areas

of the body.
Ask the client to close eyes and to respond by saying,
“yes” or “now” whenever the client feels the cotton
wisp touching the skin.
With a wisp of cotton, lightly touch one specific spot
and then the same spot on the other side of the body.
Test areas on the forehead, cheek, hand, lower arm,
abdomen, foot, and lower leg. Check a distal area of
the limb first.
Ask the client to point to the spot where the touch
was felt.
 If areas of sensory dysfunction are found, determine
the boundaries of sensation by testing responses
approximately every 2.5cm (1inch) in the area. Make a
sketch of the sensory loss area for recording purposes.

16. Pain Sensation

Assess pain sensation as follows:

Ask the client to close his/her eyes and to say, “sharp,”
“dull,” or “don’t know” when the sharp or dull end of
the broken tongue depressor is felt.
Alternately, use the sharp and dull end of the sterile
pin or needle to lightly prick designated anatomic
areas at random. The face is not tested in this manner.
Allow at least two seconds between each test.

17. Temperature Sensation

Touch skin areas with test tubes filled with hot or cold
water.
Have the client respond say saying, “hot,” “cold/” or
“don’t know.”
18. Position or Kinesthetic Sensation

Commonly, the middle fingers and the large toes are

tested for the kinesthetic sensation.
To test the fingers, support the client’s arm with one
hand and hold the client’s palm in the other. To test
the toes, place the client’s heels on the examining
table.
Ask the client to close his/her eyes

Grasp a middle finger or a big toe firmly between your

thumb and index finger, and exert the same pressure
on both sides of the finger or toe while moving it.
Move the finger or toe until it is up, down, or straight
out, and ask the client to identify the position.
Use a series of brisk up-and-down movements before
bringing the finger or toe suddenly to rest in one of
the three positions.
19. Tactile Discrimination

For all tests, the client’s eyes need to be closed.

One-and Two-Point Discrimination

Alternately stimulate the skin with two pins
simultaneously and then with one pin. Ask whether
the client feels one or two pinpricks.
Stereognosis
Place familiar objects – such as a key, paper clip, or
coin – in the client’s hand, and ask the client to
identify them.

If the client has a motor impairment of the hand and is

unable to manipulate an object, write a number or
letter on the client’s pal, using a blunt instrument, and
ask the client to identify it.
Extinction Phenomenon
Simultaneously stimulate two symmetric areas of the
body, such as thighs, the cheeks, or the hands.
20. Document findings in the client record
 Performing Urethral Urinary Catheterization
Performed
Preparation Mastered Comments
Yes No
1. Assess
 The client’s overall condition.
 If the client is able to cooperate and hold
still during the procedure.
 If the client can be positioned supine, with
head relatively flat.
 When the client last voided or was last
catheterized
Percuss the bladder to check for fullness or
distension.
2. Determine:
 The most appropriate method of
catheterization.
3. Assemble equipment and supplies:
 Sterile catheter of appropriate size. An
extra catheter should also be at hand.
 Catheterization kit or individual sterile
items:
 1-2 pairs of sterile gloves
 Waterproof drape(s)
 Antiseptic solution
 Cleansing balls
 Forceps
 Water-soluble lubricant
 Urine receptacle
 Specimen container
 For an indwelling catheter:
 Syringe prefilled with sterile water
in amount specified by the catheter’s
manufacturer
 Collection bag and tubing
 2% Xylocaine gel (if agency permits)
 Disposable clean gloves
 Supplies for performing perineal cleansing.
 Bath blanket or sheet for draping the client
 Adequate lighting – obtain a flashlight or
lamp, if necessary.
4. Perform routine perineal care to cleanse the
meatus from gross contamination.
Procedure

1. Introduce yourself, and verify the client’s identity.

Explain to the client what you are going to do, why
it is necessary, and how the client can cooperate.
2. Perform hand hygiene, and observe other
appropriate infection control procedures.
3. Provide for client privacy.

4. Place the client in the appropriate position, and

drape all areas except the perinuim:
Female: supine, with knees flexed, feet about 2 feet
apart, and hips slightly externally rotated.
Male: supine, legs slightly abducted
5. Establish adequate lighting. Stand on the client’s
right if you are right-handed, on the client’s left if
you are left-handed.
6. If using a collecting bag not contained within the
catheterization kit, open the drainage package,
and place the end of the tubing within reach.
7. If agency policy permits, apply clean gloves, and
inject 10-15mL Xylocaine gel into the urethra of
the male client. Wipe the underside of the shaft to
distribute the gel up the urethra. Wait at least 5
minutes for the gel to take effect before inserting
the catheter. Remove gloves.
8. Open the catheterization kit. Place a waterproof
drape under the buttocks (Female) or penis (male)
without contaminating the center of the drape
with your hands.
9. Apply sterile gloves.
10. Organize the remaining supplies:
Saturate the cleansing balls with the antiseptic
solution.
Open the lubricant package.
Remove the specimen container, and place it
nearby, with the lid loosely on top.
11. Attach the prefilled syringe to the indwelling
catheter inflation hub, and test the balloon.
12. Lubricate the catheter, and place it with the
drainage end inside the collection container.
13. If desired, place the fenestrated drape over the
perineum, exposing the urinary meatus.
14. Cleanse the meatus.
Note: The nondominant hand is considered
contaminated one it touches the client’s skin.
Female

Use your nondominant hand to spread the labia.

Establish a firm but gentle position.
Pick up a cleansing ball with the forceps in your
dominant hand, and wipe one side of the labia
majora in an anteroposterior direction.
Use a new ball for the opposite side.
Repeat for the labia minora.
Use the last ball to cleanse directly over the
meatus.
Male
Use your nondominant hand to grasp the penis just
below the glans. If necessary, retract the foreskin.
Hold the penis firmly upright, with slight tension.

Pick up a cleansing ball with the forceps in your

dominant hand, and wipe from the center of the
meatus in a circular motion around the glans.
Use a new ball, and repeat three more times.
15. Insert the catheter.
Grasp the catheter firmly 2-3 inches from the tip.
Ask the client to take a slow deep breath, and
insert the catheter as the client exhales.
Advance the catheter 2 inches further after urine
begins to flow through it or per agency policy.
If the catheter accidentally contacts the labia or
slips into the vagina, it is considered contaminated,
and a new, sterile catheter must be used. The
contaminated catheter may be left in the vagina
until the new catheter is inserted to help avoid
mistaking the vaginal opening for the urethral
meatus.
16. Hold the catheter with the nondominant hand. In
males, lay the penis down onto the drape, being
careful that the catheter does not pull out.
17. For an indwelling catheter, inflate the retention
balloon with the designated volume.
 Without releasing the catheter, hold the inflation
valve between two fingers of your nondominant
hand while you attach the syringe (if not left
attached earlier when testing the balloon), and
inflate with your dominant hand.
If the client complains of discomfort, immediately
withdraw the instilled fluid, advance the catheter
further, and attempt to inflate the balloon again.
Pull gently on the catheter until resistance is felt to
insure that the balloon has inflated and to place it
in the trigone of the bladder.
18 Collect all urine specimen, if needed. Allow 20-30
mL to flow into the bottle without touching the
catheter to the bottle.
19. Allow the straight catheter tp continue draining. if
necessary, attach the drainage end of an
indwelling catheter to the collecting tubing and
bag.
20. Examine and measure the urine. In some cases,
only 750-1000 mL of urine are to be drained from
the bladder at one time. check agency policies.
21. Remove the straight catheter when urine flow
stops.
For an indwelling catheter, secure the catheter
tubing to the inner thigh for female clients, or the
upper thigh/abdomen for male clients, with enough
slack to allow usual movement.
Also secure the collecting tubing to the bed linens.
and hang the bag below the level of the bladder.
No tubing should fall below the top of the bag
22. Wipe the perineal area of any remaining antiseptic
or lubrication. Replace foreskin, if retracted
earlier. return the client to comfortable position.
23. Discard all used supplies in appropriate
receptacles, and perform hand hygiene.
24. Document the catheterization procedure including
catheter size and resukts in the client record

Self-evaluation: