M.M.

COLLEGE OF NURSING, MULLANA, AMBALA

MEDICAL SURGICAL NURSING

DEMONSTRATION

ON

NEUROLOGICAL EXAMINATION

Submitted to:-

Respected Kanika mam

Assistant Professor

MMU College of Nursing

Submitted on:-
19th/Aug/2017

Submitted by:-

Ms. Shakuntala

M.Sc Nursing student 1st year

NEUROLOGICAL EXAMINATION

Identification data of patient

Name

Age

Sex

Marital status

Occupation

Date of admission

Bed no

Ward

Education qualification

Address

Diagnose

Chief complaints of patient:-

Definition:-A neurological examination is the assessment of sensory neuron and motor
responses, especially reflexes, to determine whether the nervous system is impaired

Objective of neurological examination:-

 To find out any neurological disorder.

 To check the consciousness and orientation of patient.
 To check the behavior of patient.
 To determine the cause of impairment of problem

Indication of neurological examination:-

 Neurological disorder like electrical abnormality in the brain, paralysis, muscle

weakness, poor coordination, loss of sensation etc.
 Trauma

Equipment:-

Equipment Rationale
 Tray container  To place the all
 Reflex hammer article
 Flashlight  To check the
 Tongue blade reflexes of patient
 Ophthalmoscope  To check pupils of
 Kidney tray patient
 Otoscope  To check gag reflex
 Coloured pensils  To check eye
 Pins with sharp reflexes
and blunt ends  To collect waste
 Tuning fork  To check the ear
 Cotton balls  To check the
 Stoppered vials sensation
containing:-  To check the
 Oil of cloves, auditory capacity of
coffee and patient
soap(smell)  To check the smell
 Sugar, salt (taste)  To check the taste
 Cold and hot  To check the
water (tempature tempature

Preparation of patient and environment:-

  Explain the procedure to patient
 Provide comfortable position to patient
 Provide provide privacy to patient
 Provide comfortable and calm environment to patient

Components of neurological examination:-

There are eight components of neurological examinations

1. Level of consciousness
2. Mental status examination (MSE)
3. Special cerebral function
4. Cranial nerve examination
5. Motor function assessment
6. Sensory function assessment
7. Assessment of cerebellar function
8. Assessment of reflexes

1. Level of consciousness:-
 Alert /lethargy/stuporous/semi comatose/ comatose
 Score of Glasgow coma scale

PARAMETE FINDING SCORE

R
Eye opening Spontaneously 4
To speech 3
To pain 2
Do not open 1
Best verbal Oriented 5
response Confused 4
Inappropriate 3
speech 2
Incomprehensible 1
sounds
No verbalization
Best motor Obeys command 6
response Localizes pain 5
Withdraws from 4
pain 3
Abnormal flexion 2
Abnormal 1
extension
No motor
response
 Best score =15

Worst score = 3 to 7or less generally indicates coma

1. Mental status examination

Step Rationale
a. General appearance:- To assess the baseline
 Nourishment:-nourished or data of the patient.
undernourished
 Body build:- thin or obese To assess any speech
 Health :- healthy or abnormality
unhealthy
 Activity:- active or dull To assess any thought
b. Speech :- abnormality of patient
 Initiation :- Spontaneous/
speak when spoken/mute To check the current
 Reaction time (time taken mood and affect of the
to answer the question):- patient
Normal/delayed
To assess the
 Volume :- Normal/ loud/
concentration and
soft
attention of patient
 Coherence:- fully coherent/
loosening of association
To assess the patient is
 Others:- Echolalia/ oriented or not about
neologism time, place and person
c. Thought process:-
 Stream (flow of thought):- To assess the cognitive
Normal/ pressure thought / function of patient
retarded thinking / thought
block To assess the
 Content:- Delusion / phobia intellectual level of
d. Mood and affect:- patient
 Subjective
 Objective To assess the
e. Cognitive function:- awareness of patient
 Attention:- digit forward regarding disease
and digit backward
 Concentration:-
Normally sustained /
sustained with
difficulty / distractible
e.g. name of months
(backwards), name of
week days
 (backwards)
 Orientation :-
 Time:-appropriate
time / day / night /
date / day / month /
year.
 Place:- kind of place /
area / city
 Person:- self / close
friend / hospital staff
 Memory:-
 Immediate :- digit
forward and digit
backward
 Recent:-last meal, last
visitor etc.
 Remote:-personal
event, past illness
 Intelligence
 General knowledge: -
Who is the prime
minister of India?
 Arithmetic ability:-
2+5=
 Insight:- Insight is
rated on a 6 point
scale from 1 to 6
 Complete denial of
illness
 Slight awareness being
sick
 Awareness of being
sick attributed it to
external or physical
factor
 Awareness of being
sick but due to
something unknown in
himself
 Intellectual insight
 True emotional insight

2. Special cerebral functions

Steps Rationale
  Agnosia :- Inability to recognize common objects
through the senses
 Apraxia:- patient cannot carry out skilled act in the
absence of paralysis
 Aphasia:- inability to communicate

3. Cranial nerve examination:- cranial nerve examination provides information about

the brain stem and related pathway.

Steps Rationale
 Olfactory nerve (sensory nerve):- assess cranial nerve To find the loss of
with eye closed, patient asked to identify familiar odors sense of smell
(alcohol, toothpaste, powder, coffee). Each nostril is
tested separate
 Sense of smell:- present/ absent
 Optic nerve (sensory nerve):- To find the visual
 Inspection of eye:- inflammation / foreign bodies field
/cataract
 Visual acuity by senllen’s chart
 Visual field examination:- right eye
Left eye
 Opthalmoscope examination
 Color vision:-present / absent
 Oculomotor , trochlear, abducent nerve (motor To find out the
nerve):- double vision, dilated
 Pupillary reaction to light:- reacting / not reacting pupils, pupillary
 Pupillary size:-equal / unequal reaction to light
 Eye movement in six directions:-normal / abnormal
 Nystagmus :- present / absent
 Diplopia :-present / absent

 Trigeminal nerve (motor and sensory):-

 Corneal reflex:- present / absent
 Facial sensory response:- present/ absent
 Mandibular strength:- adequate/ hypotonia

 Facial nerve (motor and sensory):-

 Facial expression:- normal / hypotonia To find out the facial
 Taste sensation:- present / absent weakness and taste of
 Acoustic nerve or vestibulocochlear (:- perform mouth
whisper or watch tick test for lateralization (weber test). To assess the bone
Test for air and bone conduction (rinne test). Assess conduction and air
balance with eye open and thenclosed for 20 second conduction test
(Romberg test)
To assess the ability
  Glossopharyngeal nerve (motor and sensory):- of swallowing and
 Gag reflex:- present / absent impaired taste
 Swallowing reflex:- present / absent To assess the gag
 Sensation of taste:- present / absent reflex, difficulty in
 Vagus nerve (motor and sensory):- depress a tongue swallowing,
blade on posterior tongue, or stimulate posterior aspiration, hoarseness
pharynx to elicit gag reflex. Note any hoarseness of etc
voice and check ability to swallow. To assess the weak
 Spinal accessory nerve (motor):- while patient shrugs and absent shoulder
shoulders against resistance, palpate and note strength of shrug and inability to
trapezius muscle. As patient turns head against opposing turn the head to the
pressure of the examiner’s hand, palpate and note side
strength of each sternocleidomastoid muscle To assess difficulty of
 Hypoglossal nerve (motor):- while patient protrudes swallowing and
the tongue, note any deviation or tremors. Test the slurred speech
strength of the tongue by having patient move the
protruded tongue from side to side against a tongue
depressor.
 Tongue movement:- normal / abnormal

4. Motor function:-

Steps Rationale
 Muscle size:- Inspect all major muscle groups To assess the muscle
bilaterally for symmetry, hypertrophy, and atrophy size of patient
 Muscle strength:-Assess the power in major muscle To assess the muscle
groups against resistance. Assess and rate muscle strength
strength on a 5 point scale in all four extremities,
comparing one side with the other as follows.
 5 / 5 :-normal full strength. Muscle moves actively
through the full range of motion against the effects of
gravity and applied resistance.
 4 / 5:- muscle moves actively through the full range of
motion against the effect of gravity with weakness to
applied resistance.
 3 / 5:- muscle moves actively against the effect of
gravity alone.
 2 / 5:- muscle moves across a surface but cannot
overcome gravity.
 1 / 5:- muscle contraction is palpable and visible, trace
or flicker movement occurs
 0 / 5:- muscle contraction or movement is undetectable..
 Muscle tone:- assess muscle tone while moving each
extremity through its range of passive motion. When
tone is decreased (hypotonicity), the muscles are soft,
 flabby, or flaccid. When tone is increased
(hypertonicity), the muscles are resistant to movement,
rigid, or spastic. Note the presence of abnormal flexion
or extension posture
 Muscle coordination:- disorder related to coordination To assess the muscle
indicate cerebellar or posterior column lesions. coordination
 Gait and station:-assess gait and station by having the To check the gait and
patient stand still, walk and walk in tandem ( one foot in station of patient
front of the other in a straight line). Walking involves
the functions of motor power, sensation, and
coordination. The ability to stand quietly with the feet
together require coordination and intact proprioception
(sense of body position). If the patient has difficulty
standing, assess further to determine whether the patient
is weak or unsteady. If the patient is weak, protect him
for falling.
 Movement:- examine the muscles for fine and gross To assess the
abnormal movements. Move all the joints through a full movement of joints
range of passive motion. Abnormal finding include pain,
joint contractures, and muscle resistance.

5. Sensory function:- sensory assessment involves testing for touch, pain, vibration,
position. A complete sensory examination is possible only on a conscious and
cooperative patient. Always test sensation with the patient’s eyes closed. Help the
patient reflex and keep warm. Conduct sensory assessment systematically.
6. Assessment of cerebellar function:-

Steps Rationale
 Finger to finger test: - it is performed by instructing
the patient to place her index finger on the nurse’s index
finger. He is asked to repeat this for several times in
succession on both sides.
 Finger to nose test: - tell the patient to extend his index
finger and then touch the tip of his nose several times in To assess the
rapid succession. This test is done with patient eye both cerebellar function of
open and closed. patient
 Romberg test: - here the nurse instructs the patient to
stand with his feet together with arms positioned at his
sides. He is told to close his eyes. This position is
maintained for 10 seconds. This test is considered
positive only if there is actual loss of balance.
 Tandom walking test: - this is tested by having the
patient assume a normal standing position. He is then
instructed to walk over heel on a straight line
 7. Reflex activity:- two type of reflexes are
 Superficial or cutaneous reflexes
 Deep tendon or muscle stretch reflex

Steps Rationale
Superficial (cutaneous) reflexes:-
 Abdominal reflex:- lightly stroking the skin on an
abdominal quadrant normally contracts the abdominal
muscle, moving the umbilicus towards the stimulated
side.
 Plantar reflex:-scratching the foot’s outer aspect of the
plantar surface (outer sole) from the heel toward the toes
normally contracts of flexes the toes in patients older
than 2 years of age. To check the
 Corneal reflex: - gently touching the cornea with a superficial reflex of
wisp of cotton causes reflex blinking. For example, to patient
test the left eye, have the patient look up and to the
right, and bring the cotton wisp in from the side so that
the patient cannot see your hand.
 Pharyngeal (gag) reflex:- gentle stimulation with a
tongue blade at the back of the throat and pharynx
normally produces gagging. The corneal and pharyngeal
reflexes are usually assessed with the cranial nerves
 Cremasteric reflex :-stroking the inner thigh of a man
normally elevates the ipsilateral testicle.
Deep tendon reflex
 Biceps jerk (forearm flexion):-is produce by tapping
the biceps brachii tendon.
To assess deep tendon
 Triceps jerk (forearm extension):-is produced by
reflex of patient
tapping the triceps brachii tendon at the elbow.
 Brachioradial jerk ( elbow flexion, supination of
forearm and flexion of fingers and hand) is produced
by tapping the quadriceps femoris tendon just below the
patella.
 Ankle jerk:-is produced by tapping the Achilles tendon.

 Care of the articles after procedure:-

 Take all the articles in the utility room
 Note down all the finding of patient
 Record the procedure with date and time
 Wash the hand
 Health education

1. Diet:- Educate the patient to take healthy diet like fruits and green leafy vegetables
 Educate the patient to take more fluid at least 6 to 8 glass of water daily
 Educate patient to avoid spicy and oily food.
 Educate patient to avoid more fat

2. Exercise:- Educate the patient to do exercise daily

 Educate the patient to go for morning walk daily
 Educate the patient to do yoga daily
 Educate the patient about the breathing exercise

3. Personal hygiene:- Educate the patient to maintain proper personal hygiene

 Educate the patient to cut the nails short
 Educate the patient to take bath daily
 Educate the patient to wash the hand after and before meal

4. Psychological support:-Clear the all doubts of patient about the disease condition
 Educate the patient do not take any stress tension
 Educate the family member about the patient condition
 Educate the patient to share their feeling with their family member and with their
friends
5. Environmental hygiene:- Educate the patient to maintain their environmental and
surrounding hygiene. Do the mosquito spray around their living area because mosquito
can cause dengue and malaria.
BIBLIOGRAPHY

1. Brunner and Siddarth’s.Medical Surgical Nursing.13th ed.volume2.New

Delhi:Wolters Kluwer;2014.p1920-27
2. R.Sreevani.Mental Health and Psychiatric Nursing.3rd ed.New Delhi:Jaypee
Brother.2010.p72-77.
3. Lippincott.Manual of nursing practice.9th ed.New Delhi:Walter Kluwer;2009.p77-82