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Lyceum of the Philippines University Batangas Batangas City College of Nursing CHECKLIST:

NEUROLOGIC SYSTEM ASSESSMENT

Date:___________ Rating:__________ 2 1 0
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Name:______________________________________ Course/Year and Section: ______________________ PROCEDURE

Part I. Mental Status and Level of Consciousness

1. Observe level of consciousness 1.1 Call the clients name and note the response. If the client does not respond, call the name louder. 1.2 Shake the clients hand gently. If the client does not respond, apply a painful stimulus. 1.3 Use the Glasgow Coma Scale* for clients at high risk for rapid deterioration of the nervous system. 1.4 Observe posture and body movements. 1.5 Observe dress, grooming and hygiene. 1.6 Observe facial expression. 1.7 Observe speech. 1.8 Observe thought process and perceptions 1.9 Observe cognitive abilities such as orientation; concentration; recent memory and remote memory; use of memory to learn new information; abstract reasoning and judgement. 1.10 Visual perceptual and construction ability.

Part II. Cranial Nerve Assessment

2. Assess Cranial Nerve I (Olfactory) 2.1 Have the client sit in a comfortable position at your eye level. 2.2 Ask the client to clear the nose to remove any mucous or secretions. 2.3 Close the eyes, occlude one nostril and let the client identify a scented object that the client is holding. 3. Assess Cranial Nerve II (Optic) 3.1 Use a snellen chart to assess vision in each eye 3.2 Ask the client to read a newspaper or magazine to assess near vision 3.3 Assess visual fields of the eye by confrontation.

4. Assess Cranial Nerve III (Oculomotor), IV (Trochlear), and VI (Abducens) 4.1 Inspection of the eyelids of each eye 4.2 Assess extraocular movements 4.3 Assess pupillary response to light (direct and indirect) 5. Assess Cranial Nerve V (Trigeminal) 5.1 Ask the client to clench the teeth while palpating the temporal and masseter muscle for contraction. Test Sensory Function 5.2 Touch the forehead, cheeks, and chin of the client with a sharp or dull side of the safety pin or paper clip. 5.3 Ask to close the eyes and tell if he feel a sharp or dull sensation 5.4 Repeat test for light with a wisp of cotton Test the Corneal Reflex 5.5 Ask the client to look away and up while gently touching the cornea with a fine wisp of cotton. Repeat on other side. 6. Assess Cranial Nerve VII (Facial) Test Motor Function 6.1 Ask the client to smile; frown and wrinkle forehead; show teeth; puff out cheeks, purse lips; raise eyebrows; and close eyes tightly against resistance. 7. Assess Cranial Nerve VIII (Auditory/Acoustic/Vestibulocochlear) 7.1 Whisper or Watch-tick test 7.2 Ask the client to hum. 7.3 Perform Webers (Sound Lateralization) and Rinnes (Air & Bone Conduction) Tests. 8. Assess Cranial Nerve IX (Glossopharyngeal), and X (Vagus) 8.1 Ask the client to open mouth wide and say ah while using the tongue depressor on a clients tongue. 8.2 Test the gag reflex. Touch the posterior pharynx with tongue depressor. 8.3 Check the clients ability to swallow by giving the client a water to drink. Note also the clients voice quality (Hoarseness of voice) 9. Assess Cranial Nerve XI (Spinal Accessory) 9.1 Ask the client to shrug the shoulders against resistance to assess the trapezius muscle 9.2 Ask the client to turn the head against resistance, first to the right and to the left to assess the sternocleidomastoid muscles.

10. Assess Cranial Nerve XII (Hypoglossal) 10.1 Ask the client to protrude the tongue 10.2 Ask the client to move tongue side to side against resistance of a tongue depressor, then put it back in the mouth.

Part III. Motor and Cerebellar Systems (Gross Motor and Balance Test)
11. Assess condition and movement of muscles 11.1 Assess the size and symmetry of all muscles. 12. Assess the strength and tone of all muscle groups. 12.1 Note any unusual involuntary movements such as fasciculations, tics or tremors. 13. Evaluate balance 13.1 To assess gait, ask the client to walk naturally across the room. 13. 2 Note posture, freedom of movement, symmetry, rhythm and balance. 14. Rombergs Test 14.1 Ask the client to stand erect with arms at side and feet together. Note any unsteadiness or swaying. Then with the client in the same body position, ask the client to close the eyes for 20 seconds. Again note any imbalance or swaying. Stand close to the client during this test. 15. Standing on One Foot with Eyes closed 15.1 Ask the client to close the eyes and stand on one foot. Repeat on the other foot. Stand close to the client during this test. 16. Heel-to-toe Walking 16.1 Ask the client to walk a straight line, placing the heel of one foot directly in front of the toes of the other foot. Demonstrate the walk first; then stand close by in case the client loses balance. 16.2 Ask the client to walk several steps on the toes and then on the heels.

Part IV. Fine Motor Test

17. Finger-to-Nose Test 17.1 Ask the client to abduct and extend the arms at shoulder level and then rapidly touch the nose alternatively with one index finger and then the other. 17.2 The client repeats the test with the eyes closed if test is performed easily. 18. Alternate Supination and Pronation of Hands on Knees 18.1 Ask the client to pat both knees with the palms of both hands and then with the backs of the hands alternatively at an increasing rate.

19. Finger to Nose and to the Nurses Finger 19.1 Ask the client to touch the nose and then your index finger (nurse), held at a distance of about 45 cm (18 in) at a rapid and increasing rate. 20. Fingers to Fingers 20.1 Ask the client to spread the arms broadly at shoulder height at the midline, first with the eyes open and then closed, first slowly then rapidly. 21. Fingers to Thumbs (Same Hand) 21.1 Ask the client to touch each finger of one hand to the thumb of the same hand as rapidly as possible. 22. Heel Down Opposite Shin 22.1 Ask the client to place the heel of one foot just below the opposite knee and run the heel down the shin to the foot. 22.2 Repeat with the other foot. The client may also use a sitting position for this test. 23. Toe or Ball of Foot to the Nurses Finger 23.1 Ask the client to touch your finger with the large toe of each foot.

Part V. Sensory System

24. Light touch Sensation 24.1 Ask the client to close the eyes and to respond by saying yes or now whenever the client feels the cotton wisp touching the clients skin. 24.2 With a wisp of cotton, lightly touch one specific spot and then the same spot on the other side of the body. 24.3 Test areas on forehead, cheek, hand, lower arm, abdomen, foot and lower leg. Check a distal area of the limb first (the hand before the arm and the foot before the leg) 24.4 Ask the client to point to the spot where the touch was felt. 25. Pain Sensation 25.1 Ask the client to close the eyes and to say sharp, dull or dont know when the sharp or dull end of the broken tongue depressor is felt. 25.2 Alternately, use the sharp and dull end to lightly prick designated anatomic areas at random (e.g., hand, forearm, foot, lower leg, and abdomen). The face is tested in this manner. 25.3 Allow at least 2 seconds between each test to prevent summation effects of stimuli.

26. Temperature Sensation 26.1 Touch skin areas with test tubes filled with hot or cold water. 26.2 Have the client respond by saying hot or cold or dont know. 27. Position or Kinesthetic Sensation 27.1 To test the fingers, support the clients arm and hand with one hand. 27.2 To test the toes, place the clients heels on the examining table 27.3 Ask the client to close the eyes. 27.4 Grasp a middle finger or big toe firmly between your thumb and index finger. 27.5 Exert the same pressure on both sides of the finger or toe while moving it. 27.6 Move the finger or toe until it is up, down or straight out and ask the client to identify the position. 27.7 Use a series of brisk up and down movements before bringing the finger or toe suddenly to rest in one of the three positions. 28. Tactile Discrimination (Fine Touch)
-Clients eyes need to be closed in all the tests.

One and Two Point Discrimination 28.1 Alternately stimulate the skin with two pins simultaneously and then with one pin. 29. Stereognosis 29.1 Place familiar objects such as key, paper clip, coin, in the clients hand and ask the client to identify them. 29.2 If the client has a motor impairment of the hand and is unable to manipulate an object, write a number or letter on the clients palm using a blunt instrument. Ask the client to identify it. (Graphestesia) 30. Extinction Phenomenon 30.1 Simultaneously stimulate two symmetric areas of the body, the thigh, cheeks, and hands.

Part VI. Reflexes

31. Assess Biceps Reflex (c5,c6) 31.1 Ask the client to partially bend arm at elbow with palm up. 31.2 Place your thumb over the biceps tendon and strike your thumb with the reflex hammer. 31.3 Repeat on the other side.

32. Assess Brachioradialis Reflex (c5,c6) 32.1 Ask the client to flex elbow with palm down and hand resting on the abdomen or lap. 32.2 Tap the tendon at the radius about 2 inches above the wrist. 32.3 Repeat on the other side. 33. Assess Triceps Reflex (c6,c7,c8) 33.1 Ask the client to hang his or her arm freely (limp like it is hanging from a clothesline to dry) while you support it with your nondominant hand. 33.2 With the elbow flexed, tap the tendon above the olecranon process 33.3 Repeat on the other side. 34. Assess Patellar Reflex (l2,l3.l4) 34.1 Ask the client to let both legs hang freely of the side of the examination table. 34.2 Tap the patellar tendon. 34.3 Repeat on the other side. 35. Assess Achilles Reflex (s1,s2) 35.1 With the clients leg hanging freely, dorsiflex the foot. 35.2 Tap the Achilles tendon with the reflex hammer. 35.3 Repeat on the other side. 36. Test ankle clonus when the other reflexes tested have been hyperactive 36.1 Place one hand under the knee to support the leg. 36.2 Briskly dorsiflex the foot towards the clients head 36.3 Repeat on the other side. 37. Test Superficial Reflexes (t12,l1,l2) 37.1 Assess plantar reflex. With the end of the reflex hammer, stroke the lateral aspect of the sole from the heel to the ball of the foot curving medially across the ball. 37.2 Repeat on the other side. 38. Test Abdominal Reflex (Lower-t8,t9,t10; Upper-t10,t11,t12) 38.1 Lightly stroke the abdomen on each side, above and below the umbilicus. 39. Test Cremasteric Reflex for male patients (t12,l1,l2) 39.1 Lightly stroke the inner aspect of the upper thigh 40. Documentation of findings

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