Ministry of Higher Education
and Scientific Research
Al-Muthanna University
College of Nursing
Health assessment
Lab. 7 part 2
Neurologic examination
Assistant teacher
Israa saleh
neurologic system
central nervous system peripheral nervous system
autonomic nervous system
brain spinal cord
cranial nerves
peripheral nerves
pairs of cranial nerves 12
Sensory, Motor examination
⚫ Sensory assessment:
1- Exteroception sensation:
A. Light touch
⚫ A- Use wisp of cotton
⚫ B- brush it over the skin in a random order of sites and at irregular
Intervals to prevent patient predict the next step.
⚫ C- Test arms, forearms, hands, chest, thighs, and legs.
⚫ D- Instruct the patient to responded by “now” “yes” when touch is felt.
⚫ Abnormal finding:
⚫ Hypoesthesia—Decreased touch sensation.
⚫ Anesthesia: Absent touch sensation.
⚫ Hyperesthesia—Increased touch sensation.
Sensory, Motor examination
⚫ B. Superficial pain:
1- Use sharp object: sterile needle or tongue blade .
2- Lightly apply the sharp point or the dull end to the person’s body in a
random, unpredictable order.
3- Move from impaired area to the normal area.
4- Alternate sharp with dull end to test the patient accuracy of sensation.
5- Instruct the patient to replay “sharp” “dull” “I don't know
Note
1- sharp edge is used to test for pain.
2- dull edge is used as a general test of the person’s responses.
3- Let at least 2 seconds between each stimulus to avoid summation.
⚫ Normal findings:
⚫ Patient feel the site of stimulation.
⚫ Abnormal findings:
⚫ Analgesia: insensitivity of pain.
⚫ Hypoaglasia: diminished sensitivity of pain.
⚫ Hyperalgesia: increased sensitivity of pain
[Link] sensation
⚫ Deep sensation with sensory preceptors in the muscle, joint and
ligaments
⚫ Tested with motion and vibration sense
A. Vibration:
1) Strike the tuning fork of your hand and place the base of the tuning
fork firmly on the patient skin over bony prominence. (ankles, knees,
wrists, elbow, rips, sternum).
2) Begin in distal area such as toe or finger testing each extremity.
3) Instruct the patient to say “now” when the vibrating tuning fork is felt,
and report immediately when the vibration no longer felt.
⚫ Normal findings:
⚫ Normally, the patient should be able to perceive vibration all the
bony prominence (ankles, knees, wrists, elbow, rips, sternum(.
⚫ Abnormal Findings:
⚫ Inability to perceive vibration sensation
⚫ Polyneuropathies (diabetic foot).
⚫ Spinal cord lesion.
Cranial nerves
1. Cranial Nerve I: Olfactory Nerve
⚫ 1- the person’s eyes closed
⚫ 2- occlude one nostril and present an aromatic substance.
⚫ 3- Use familiar, conveniently obtainable, and non-noxious smells
such as coffee, toothpaste, orange, vanilla, soap, or peppermint.
⚫ 4- Normally a person can identify an odor on each side of the
nose.
⚫ Abnormal findings
⚫ Anosmia: Decrease or loss of smell occurs bilaterally with
tobacco smoking, allergic rhinitis, and cocaine use.
⚫ Smell normally is decreased bilaterally with aging.
2. Cranial Nerve II: Optic Nerve
Test visual acuity with a Snellen chart and the Rosenbaum
near-vision card. use the ophthalmoscope to examine the ocular
fundus
Abnormal findings
1- Visual loss
2- Papilledema with increased intracranial pressure
3.4.6. Test Cranial Nerves III, IV, and VI:
Occulomotor, Trochlear, Abducens Nerves (test as a unit)
1- Ask the patient to remain still while you hold a pencil or other small
object directly in front of his nose at a distance of about 18 (45 cm).
2- Ask him to follow the object with his eyes, without moving his head.
3- Move the object to each of the six cardinal positions shown, returning
to the midpoint after each movement.
⚫ Abnormal finding:
1- Ptosis (drooping) occurs with myasthenia gravis, dysfunction of
cranial nerve III, or Horner syndrome.
2- Increasing intracranial pressure causes a sudden, unilateral, dilated,
and nonreactive pupil.
Right superior (RS) Left superior (LS)
Right lateral (RL) Left lateral (LL)
Right inferior (RI) Left inferior (LI)
5. Cranial Nerve V: Trigeminal Nerve
Sensory test:
1- ask the patient to close his eyes.
2- then touch him with a wisp of cotton on his forehead,
cheek, and jaw on each side.
3- Ask the person to say “Now” whenever the touch is felt.
⚫ Abnormal finding:
Decreased or unequal sensation. With a stroke, sensation of
face and body is lost on the opposite side of the lesion
Trigeminal nerve assessment sites
Cranial Nerve V—Trigeminal Nerve
⚫ Motor Test:
⚫ 1- ask the patient to clench his teeth while you palpate the
⚫ temporal and masseter muscles.
⚫ 2- Note the strength of the muscle contraction; it should be equal
bilaterally.
7. Test Cranial Nerve VII— Facial Nerve
1- Sensory function:
⚫ Test taste by placing items with various tastes on the anterior
portion of the patient’s tongue for example,
⚫ Sugar (sweet), salt, lemon juice (sour), (bitter).
7. Test Cranial Nerve VII—Facial Nerve
2- Motor function:
observe the patient’s face for :
1- symmetry at rest and while he smiles, frowns, and raises his
eyebrows, puff cheeks.
2- Then have the patient close both eyes tightly. Test muscle
strength by attempting to open his eyes, as shown.
⚫ Abnormal findings:
⚫ dropping one side of the face bells palsy
bells palsy
Loss of movement and asymmetry of movement occur with both
. CNS lesions ( stroke) and peripheral nervous system lesions -1
.(Bell palsy that affects the upper and lower face on one side) -2
Cranial Nerve VIII—Acoustic (Vestibulocochlear)
Nerve
⚫ Test hearing acuity by the ability to hear normal
conversation and by the whispered voice test
9. 10. Test CN IX (glossopharyngeal) and X
(vagus).
⚫ Test motor function:
⚫ Ask the client to open mouth wide and say “ah” while you
use a tongue depressor on the client’s tongue.
⚫ Watch for the symmetrical upward movement of the soft
palate and uvula and for the midline position of the uvula.
⚫ Normal findings:
⚫ the uvula and soft palate should rise in the midline.
9. 10. Test CN IX (glossopharyngeal) and X (vagus).
Test gag reflex:
⚫ Touch the posterior pharyngeal wall with a tongue blade and note
the gag reflex. Also note that the voice sounds
⚫ Abnormal Findings :
⚫ Absence gag reflex
⚫ Dysphagia or hoarseness may indicate a lesion of cranial nerve
IX (glossopharyngeal) or X (vagus) or other neurologic disorder.
11. Test Cranial Nerve XI—Spinal Accessory Nerve
1- Test trapezius muscle :
Ask the client to shrug the shoulders against resistance to
Normal findings:
•There is symmetric, strong contraction of the trapezius muscles.
Abnormal findings:
• Asymmetric muscle contraction or drooping of the shoulder may
be seen with paralysis or muscle weakness due to neck injury
11. Test Cranial Nerve XI—Spinal Accessory
Nerve
⚫ 2- Test the sternocleidomastoid muscle:
⚫ Ask the client to turn the head against resistance, first to the
right then to the left.
Normal findings:
⚫ There is strong contraction of sternocleidomastoid muscle
on the side opposite the turned face.
Abnormal findings:
⚫ Atrophy may be seen with peripheral nerve disease.
11. Test Cranial Nerve XI—Spinal Accessory
Nerve
12. Test CN XII (hypoglossal)
To assess strength and mobility of the tongue, ask the client to:
1) Protrude tongue
2) asking the patient to push his tongue against his cheek as you
apply resistance.
Normal findings:
Tongue movement is symmetric and smooth, and bilateral strength
is apparent.
Abnormal findings:
2- Tongue deviates to side with lesions
of the hypoglossal nerve
3. Motor test
⚫ 1- Coordination:
⚫ 2- Gait
1- Coordination:
1- 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.
Normal finding:
⚫ The person’s movement should be smooth and accurate.
Abnormal finding:
⚫ Lack of coordination occurs with cerebellar disorders or acute
alcohol intoxication.
1- Finger-to-Finger Test:
b. Gait
⚫ Balance Tests:
⚫ 1- Ask to walk in straight line, touching heel to toe.
⚫ 2- The arm should be held at the side and the eyes should be open.
⚫ 3- Note the person ability to maintain balance.
Normal finding:
the person can walk straight and stay balanced.
Abnormal finding:
Ataxia: Uncoordinated or unsteady gait
Inability to tandem walk occurs with upper motor neuron lesion such as
multiple sclerosis and for acute cerebellar dysfunction such as alcohol
intoxication
Balance Tests
the Romberg Test
1- Ask the person to stand up with feet together and arms at the sides.
2- Once in a stable position, ask him or her to close the eyes and to hold
the position.
3- Wait about 20 seconds.
4- Note the ability maintain balance when the eyes open, then closed
⚫ Normal finding:
⚫ a person can maintain posture and balance even with the visual
blocked, although slight swaying may occur.
⚫ Abnormal finding:
⚫ Sways, falls.
⚫ Positive Romberg sign is loss of balance that occurs when
closing the eyes.
⚫ A positive Romberg sign occurs with cerebellar ataxia (multiple
sclerosis, alcohol intoxication), loss of proprioception, and loss
of vestibular function.
the Romberg Test.
