NEUROLOGIC ASSESSMENT

• Most important aspect of

Level of Consciousness

neurologic examination
• Level of consciousness
first to deteriorate;
changes often subtle,
therefore requiring careful
monitoring.
 Composed of Two
Components:
Consciousness

• Arousal (Alertness)
• Awareness (Content)
–Assessment: Orientation vs.
Disorientation
»Person, Place & Time
Categories of Consciousness The following terms are commonly used to describe a decreased LOC:
Full consciousness. The patient is alert, attentive, and follows
commands. If asleep, she responds promptly to external stimulation and,
once awake, remains attentive.
Lethargy. The patient is drowsy but awakens—although not fully—to
stimulation. She will answer questions and follow commands, but will do
so slowly and inattentively.
Obtundation. The patient is difficult to arouse and needs constant
stimulation in order to follow a simple command. She may respond
verbally with one or two words, but will drift back to sleep between
stimulation.
Stupor. The patient arouses to vigorous and continuous stimulation;
typically, a painful stimulus is required. She may moan briefly but does
not follow commands. Her only response may be an attempt to withdraw
from or remove the painful stimulus.
Coma. The patient does not respond to continuous or painful stimulation.
She does not move—except, possibly, reflexively—and does not make
any verbal sounds. It is a deep, prolonged state of unconsciousness.
 Especially useful for evaluating patients during the
acute stages of head injury or traumatic brain injury
(TBI)

ASSESSING LOC
 pain

/ flaccid
SCORING

• Highest or best possible score 15

• A score of < 8 indicates coma
• Lowest or worst possible score 3

Following are GCS scores and corresponding injury

severity:
GCS Score of 3 to 8: Severe
GCS Score of 9 to 12: Moderate
GCS Score of 13 to 15: Mild
 SCORE THE FF:
a) Adult, opens eyes and extends left elbow when
you put pressure on left nail bed. No response
on the right. Makes no sounds.
5 E2 V1 M2
b) Adult, moves hand towards head when you
apply pressure above the eye socket.
Disoriented but able to form sentences. Open
eyes in response to speech.
12 E3 V4 M5
c) Adult, opens their eyes when they hear you
shouting for help. They groan and make
sounds which you cannot recognize as words.
They do not respond to pain.
commands 6 E3 V2 M1
pain
d) Adult, moves their hand away when you apply
pressure to the nail bed. The patient can make
words but not form sentences. They open their
eyes to pain, but not to speech.
9 E2 V3 M4
CRANIAL NERVE ASSESSMENT
I Olfactory On Oh Out
II Optic Old Oh On
III Oculomotor Olympus Oh Our
IV Trochlear Towering To Table
V Trigeminal Tops Touch Top
VI Abducens A And Are
VII Facial Frenchman Feel Fruits,
VIII Auditory &/or
And Very Very
Vestibulococchlear
IX Glossopharyngeal German Green Green
X Vagus Viewed Vegetables Veggies
XI Spinal/Accessory Some Ah And
XII Hypoglossal Hops Heaven Hamburgers
 S=Sensory; M=Motor; B=Both

I II III IV V VI
Some Say Marry Money But My

VII VIII IX X XI XII

Brother Says Big Business Makes Money

Pure Sensory Cranial Nerves:Pure Motor Cranial Nerves:

1. Olfactory (I) - smell 4. Oculomotor (III) -eyeball & lid movt , pupil constriction
2. Optic (II) - vision 5. Trochlear (IV) - move eyes to side & down
3. Auditory (VIII)- hearing 6. Abducens (VI) - move eyes to side
7. Spinal accessory (XI) -controls trapezius
& sternocleidomastoid muscles
8. Hypoglossal (XII) -controls tongue movements
Mixed Function Cranial Nerves:
9. Trigeminal (V) - chewing; face & mouth, touch & pain; corneal reflex
10. Facial (VII) - facial expression; tears & saliva, taste
11. Glossopharyngeal (IX) (gag reflex); taste ; carotid BP
12. Vagus (X) – impulses for sensation to lower pharynx & larynx; taste
muscles for movement of soft palate, pharynx & larynx (gag reflex); swallowing,
motor & sensory functions of visceral organs (glands, digestive sys); aortic BP
Nervous system
Cranial Nerve: I OLFACTORY
• With the client’s eyes
closed, present
various odors
occluding one nostril
at a time.
• Note the client’s
ability to identify the
odor
 Nervous system
Cranial Nerve: II OPTIC
• Test visual acuity
(Snellen chart or
handheld snellen
chart or Jaeger card-
held 14 inches away
from
the patient’s eyes &
read)
• Test visual fields
(peripheral vision)
Nervous system
Cranial Nerve: II OPTIC
• Examine optic disc
with an
opthalmoscope.
Nervous system
Cranial Nerve: III OCULOMOTOR
• Check size and
shape of pupils
and pupillary
reactions to light
and accomodation
• Use penlight
 Nervous system
Cranial Nerve: III OCULOMOTOR
Cranial Nerve: IV TROCHLEAR
Cranial Nerve: VI ABDUCENS
• Evaluate 6 cardinal
positions of gaze;
note for nystagmus III Oculomotor eyelid & eyeball movement
IV Trochlear turns eye downward and laterally
• Perform cover/
uncover test. Note VI Abducens turns eye laterally
movement of eye when
uncovered or opposite
eye when contralateral
eye covered
 Six Positions of Cardinal Gaze:

Rt & Up gaze Lt & Up gaze

Rt gaze Lt gaze
PRIMARY GAZE

Rt & down gaze Lt & Down gaze

 Nervous system
Cranial Nerve: V TRIGEMINAL
MOTOR:
• Assess the client’s ability to
chew and strength to bite
SENSORY:
• Assess the client’s ability to
distinguish light touch and
pain
• Lightly stroke client’s face with
a cotton wisp and gently prick
the skin with a sterile pin or
toothpick on forehead, cheek
and chin
Handle slides off to expose hidden compartment with pin and brush.
 Nervous system
Cranial Nerve: VII FACIAL
MOTOR:
• Assess symmetry of
facial movements as
the client smiles,
frowns, grimaces,
clenches his teeth, etc.
SENSORY:
• Ask the client to identify
various distinct flavors
placed on the anterior
2/3 of the tongue
Nervous system
Cranial Nerve: VIII ACOUSTIC
• Assess client’s
ability to hear
spoken words
and vibration of
tuning fork
(cochlear
branch)
WEBER TEST
 Nervous system
Cranial Nerve: IX GLOSSOPHARYNGEAL
MOTOR:
• Ask client to move tongue
from side to side, up and
down. Test for the gag
reflex by gently touching the
posterior pharyngeal wall
with a tongue depressor
SENSORY:
• Apply tastes on posterior
tongue for identification
Nervous system
Cranial Nerve: X VAGUS
• Ask client to
swallow and note
swallowing and
vocal cord
movement.
• Assess client’s
speech for
hoarseness
 Nervous system
Cranial Nerve: XI SPINAL ACCESORY
• Assess strength of the
sternocliedomastoid and
upper trapezius muscles by
asking the client to move the
head against resistance of
your hand
• Tell the client to shrug
his/her shoulders then
observe and palpate the
contraction of the
sternocliedomastoid muscle.
 Nervous system
Cranial Nerve: XII HYPOGLOSSAL
• Test strength and articulation of
the tongue by having the client
push the tongue to the side of
the mouth against resistance
applied to the cheek
• Ask the client to stick out the
tongue and then returns it to the
mouth while you observe for
deviation, asymmetry tremors
and fasciculations
 COORDINATION, GAIT & EQUILIBRIUM

1. Finger To Nose Test

Finger To Nose Test:

With the patient seated, position your index finger at a

point in space in front of the patient.
Instruct the patient to move their index finger between
your finger and their nose.
Reposition your finger after each touch.

Then test the other hand.

Interpretation: The patient should be able to do this at a reasonable

rate of speed, trace a straight path, and hit the end points
accurately. Missing the mark, known as dysmetria, may be
indicative of disease.
 – Direct the patient to touch first the palm and then the
dorsal side of one hand repeatedly against their thigh.
– Then test the other hand.

• Interpretation: The movement should be

performed with speed and accuracy. Inability to
do this, known as dysdiadokinesia, may be
indicative of cerebellar disease.
• Rapid Alternating Finger Movements:
– Ask the patient to touch the tips of each finger to the
thumb of the same hand.
– Test both hands.

• Interpretation: The movement should be fluid

and accurate. Inability to do this, known as
dysdiadokinesia, may be indicative of cerebellar
disease.
 – Direct the patient to move the
heel of one foot up and down
along the top of the other shin.
– Then test the other foot.
• Intepretation: The movement
should trace a straight line
along the top of the shin and
be done with reasonable
speed.
• Patients with truncal ataxia caused by damage
to the cerebellar vermis or associated pathways
will have particular difficulty with this task, since
they tend to have a wide-based, unsteady gait,
and become more unsteady when attempting to
keep their feet close together.
• or reflex action, is an involuntary and
nearly instantaneous movement in
response to a stimulus.
• A reflex is made possible by neural
pathways called reflex arcs which can act
on an impulse before that impulse reaches
the brain.
 A few examples of reflex action are:

• When light acts as a stimulus, the pupil of the eye

changes in size.
• Sudden jerky withdrawal of hand or leg when pricked by
a pin.
• Coughing or sneezing, because of irritants in the nasal
passages.
• Knees jerk in response to a blow or someone stamping
the leg.
• The sudden removal of the hand from a sharp object.
• Sudden blinking when an insect comes very near to the
eyes.
 Stimulus–Response Pathway
The basic pathway for a nerve impulse
is described by the stimulus response
model
•A stimulus is a change in the environment
(either external or internal) that is detected
by a receptor
•Receptors transform the stimuli into nerve
impulses that are transmitted to
the brain where decision-making occurs
•When a response is selected, the signal is
transmitted via neurons to effectors,
promoting a change in the organism
Some responses may be involuntary
and occur without conscious thought –
these actions are called reflexes
• Reflex actions do not involve the brain – instead sensory information is directly
relayed to motor neurons within the spine
• This results in a faster response, but one that does not involve conscious thought
or deliberation
 Brainstem Reflexes
1.The oculo-cephalic reflex (OCR) is a reflex eye movement that
stabilizes images on the retina during head movement by
producing an eye movement in the direction opposite to head
movement, thus preserving the image on the center of the visual
field.
•This reflex can be tested by the Rapid head impulse test or
Halmagyi-Curthoys-test, in which the head is rapidly moved to the
side with force, and is controlled if the eyes succeed to remain
looking in the same direction.
•When the function of the right balance system is reduced, by a
disease or by an accident, quick head movement to the right
cannot be sensed properly anymore.
=As a consequence, no compensatory eye movement is
generated, and the patient cannot fixate a point in space during
this rapid head movement.
 NORMAL / brainstem is intact.

• In a positive / normal doll's eye reflex, the eyes move

in the direction opposite to that of the head
movement.
• A negative response is said to occur if
the eyes move in the direction of the head movement.
A negative doll's eye reflex signifies severe brain
damage or brain death.
 Brainstem Reflexes
2.The vestibulo-ocular reflex (VOR)
•Sometimes called caloric reflex, because a stimulation is based on pouring
of cold or warm water into the ear. It is better to put patient´s head a slight
reclining, because we want to influent (flow in; a stream) especially lateral
semicircular tubule of an inner ear.
A small amount of water flow induces movement of endolymph.
•There is one special rule for direction of nystagmus:
"Cold opposite, warm same (COWS)", which means that cold
water pouring into the left ear leads to eye movement to the left and a
direction of the nystagmus is on the right (opposite side).
It is the same for the second side – pouring of warm water into
the left ear leads to eye movement to the right and a direction of
the nystagmus is on the left (same side).

•Attention! Do not confuse the direction of nystagmus (COWS rule) and the
direction of motion of eyes.
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