NEUROLOGICAL ASSESSMENT

Clinical Instructor: Prof. Alcantara

PERFORMANCE POINTS RATIONALE

KNOWLEDGE

1. State the purposes of Neurological Assessment. ● To obtain baseline data about the client’s
functional abilities.
● To supplement, confirm, or refute data obtained in
nursing history.
● To obtain data that will help establish nursing
diagnoses and plan of care.
● To evaluate the physiologic outcomes of health
care and thus the progress of a client’s health
problem.

2. Enumerate the Principles of Neurological ● Systematic approach: Follow a structured and

Assessment. organized method to ensure all aspects of
neurological function are evaluated thoroughly.
● Observation: Careful observation of the patient's
appearance, behavior, and movements provides
valuable insights into their neurological status.
● Standardized tools: Utilize validated and
standardized assessment tools to ensure
consistency and accuracy in evaluating
neurological function.
● Patient comfort: Prioritize patient comfort and
provide clear instructions throughout the
assessment to minimize anxiety and promote
cooperation.
● Safety: Maintain patient safety during the
assessment, especially when testing activities that
may pose a risk of injury.

3. Explain the Rationale of each suggested action.

4. Enumerate the materials used.

SKILLS

1. Wash hands. Reduces transmission of microorganisms.

2. Prepare all materials needed. Ensures smooth flow of the procedures.

3. Prepare a suitable environment. Eliminate drafts, control room temperature. Suitable

environment promotes client’s comfort and prevents
chilling.

4. Explain procedure to the client. Promotes cooperation.

5. Ask the client to empty the bladder or bowel. Provide for client’s comfort by allowing the opportunity to
empty the bowel or bladder.

ASSESSMENT OF NEUROLOGICAL FUNCTION

1. Assess client‘s mental status.

1.1 Ask client to state the place of residence, time Rationale: This helps assess the client's orientation to
of day and names of family members. person, place, and time, providing insight into their
awareness of their surroundings and current situation.
 Instructions: Ask the client the following questions: "Can
you tell me where you are right now?" "What time of day is
it?" "Can you tell me the names of your family members?"

1.2. To assess immediate recall: Ask to repeat a Rationale: This assesses the client's immediate recall and
series of 3 digits. short-term memory, indicating cognitive functioning and
attention span.

Instructions: Say three digits (e.g., "4, 7, 2") to the client

and ask them to repeat the digits back to you immediately
after hearing them.

1.3 To assess recent memory: Ask client to recall Rationale: This assesses the client's recent memory and
the recent events of the day. cognitive function, providing insight into their ability to
retain and recall information over a longer period.

Instructions: Ask the client to recall recent events of the

day, such as what they had for breakfast, any activities
they engaged in earlier, or any appointments they had
scheduled.

2. Test cranial nerve (CN) function.

2.1. Ask the patient to close the eyes, occlude Testing Olfactory Nerve (CN I)
one nostril, and then identify the smell of different
substances, such as coffee, chocolate, or alcohol. Rationale: Assessing smell helps evaluate the integrity of
Repeat with other nostril. the olfactory nerve and the sense of smell, which can be
indicative of certain neurological conditions.

Instructions: Ask the patient to close their eyes and

occlude one nostril. Present different substances with
distinct smells (e.g., coffee, chocolate, alcohol) to the open
nostril and ask the patient to identify each smell. Repeat
the process with the other nostril.

2.2. Test visual acuity and pupillary constriction. Testing Optic Nerve (CN II) and Oculomotor Nerve (CN
III)

Rationale: Testing visual acuity and pupillary constriction

assesses optic nerve function and pupillary reflexes, which
are essential for vision.

Instructions: Use a Snellen chart or similar tool to assess

visual acuity. Shine a light into each eye separately to
observe pupillary constriction and ensure equal
responses.

2.3. Move the patient‘s eyes through the six Testing Oculomotor (CN III), Trochlear (CN IV), and
cardinal positions of gaze. Abducens (CN VI) Nerves

Rationale: Moving the patient's eyes through the six

cardinal positions of gaze assesses extraocular muscle
function and the integrity of cranial nerves controlling eye
movements.

Instructions: Ask the patient to follow your finger or an

object as you move it horizontally and vertically through
the six cardinal positions of gaze.

2.4. Ask the patient to smile, frown, wrinkle Testing Facial Nerve (CN VII)
forehead, and puff out cheeks.
Rationale: Assessing facial movements evaluates facial
 nerve function, which controls facial expression.

Instructions: Ask the patient to perform various facial

movements, including smiling, frowning, wrinkling the
forehead, and puffing out the cheeks.

2.5. Test hearing. Testing Vestibulocochlear Nerve (CN VIII)

Rationale: Testing hearing evaluates the integrity of the

vestibulocochlear nerve and auditory function.

Instructions: Conduct a basic hearing test by whispering

words or numbers and asking the patient to repeat them.
Alternatively, use a tuning fork to assess hearing acuity.

2.6. Test the gag reflex by touching the posterior Testing Glossopharyngeal (CN IX) and Vagus (CN X)
pharynx with the tongue depressor. Explain to Nerves
patient that this may be uncomfortable.
Rationale: Testing the gag reflex assesses the function of
the glossopharyngeal and vagus nerves, which control
swallowing and the gag reflex.

Instructions: Explain to the patient that you will touch the

back of their throat with a tongue depressor to elicit the
gag reflex. Note that this may be uncomfortable.

2.7 Place your hands on the patient‘s shoulders Testing Accessory Nerve (CN XI)
while he or she shrugs against resistance. Then
place your hand on the patient‘s left cheek, then Rationale: Assessing shoulder and neck muscle strength
the right cheek, and have the patient push evaluates the function of the accessory nerve.
against it.
Instructions: Ask the patient to shrug their shoulders
against resistance while you place your hands on their
shoulders. Then, ask the patient to push their cheek
against your hand as you apply gentle resistance on each
side.

3. Inspect the ability of the patient to move his or Rationale: Assessing neck mobility helps evaluate the
her neck. Ask the patient to touch his or her chin range of motion of the cervical spine and can provide
to chest and to each shoulder, each ear to the information about potential injury, stiffness, or neurological
corresponding shoulder, and then tip head back impairment.
as far as possible.
Chin to Chest: Ask the patient to sit or stand comfortably
with their back straight. Instruct the patient to gently lower
their chin towards their chest, aiming to touch their chin to
their chest. Observe the range of motion and any
discomfort or limitations the patient may experience.

Ear to Shoulder: Ask the patient to tilt their head to the

right, aiming to bring their right ear towards their right
shoulder. Then, ask them to tilt their head to the left,
bringing their left ear towards their left shoulder. Observe
the range of motion and any asymmetry or difficulty in
movement.

Head Tilt: Instruct the patient to tilt their head back as far
as possible, aiming to look towards the ceiling. Observe
the range of motion and any discomfort or restrictions in
movement.

What to Say to the Patient: "Please sit comfortably and

relax your shoulders. I'm going to ask you to move your
neck in a few different ways to assess its mobility. First,
 can you please lower your chin towards your chest as far
as you can comfortably go? Good. Now, tilt your head to
the right, bringing your right ear towards your right
shoulder. And then tilt your head to the left, bringing your
left ear towards your left shoulder. Lastly, tilt your head
back as far as you can, as if you're trying to look at the
ceiling. Let me know if you feel any pain or discomfort
during these movements."

4. Inspect the upper extremities. Observe for skin Rationale: Examining the upper extremities allows for the
color, presence of lesions, rashes, and muscle assessment of skin integrity, circulation, muscle tone, and
mass. Palpate for skin temperature, texture, and potential abnormalities such as lesions or masses. This
presence of masses. assessment provides valuable information about the
patient's overall health and any potential neurological or
musculoskeletal issues.

Instructions: Skin Inspection: Ask the patient to expose

their arms and hands. Inspect the skin for any changes in
color, such as pallor, cyanosis, or erythema, which could
indicate circulatory or vascular issues. Look for the
presence of lesions, rashes, bruises, or scars, which may
suggest dermatological or systemic conditions. Note any
asymmetry or abnormalities in muscle bulk or contour.

Palpation for Skin Temperature and Texture: Palpate

the skin of the upper extremities, including the arms and
hands, to assess temperature and texture. Compare the
temperature of both sides for symmetry, noting any areas
of increased warmth or coolness. Assess the texture of the
skin for smoothness, moisture, or roughness, which could
indicate dehydration, dermatitis, or other skin conditions.

Palpation for Presence of Masses: Use gentle palpation

to assess for the presence of any masses or swelling in
the upper extremities. Pay attention to areas such as the
axilla, elbow, wrist, and hand joints. Note any tenderness,
swelling, or irregularities in tissue consistency.

What to Observe for: Skin color: Pallor, cyanosis,

erythema Presence of lesions, rashes, bruises, scars
Muscle mass and symmetry

Skin temperature: Warmth, coolness

Skin texture: Smoothness, moisture, roughness Presence

of masses or swelling

What to Say to the Patient: "I'm going to inspect and feel

your arms and hands now to check for any abnormalities.
Please relax your arms and hands as much as possible. I'll
be looking at the color of your skin, any marks or lesions,
and feeling for any unusual masses or changes in
temperature or texture. Let me know if you feel any
discomfort during the examination."

5. Ask patient to extend arms forward and then Asking the patient to extend their arms forward and then
rapidly turn palms up and down. rapidly turn their palms up and down is a simple yet
effective way to assess upper extremity strength,
coordination, and range of motion.

Instructions to the Patient: "I'm going to ask you to

perform a simple movement with your arms. Please
 extend both of your arms straight out in front of you,
parallel to the floor, with your palms facing down. Once
you're in this position, I want you to quickly turn your
palms up and then back down again, as fast as you can.
Let's try it a couple of times together."

Observation: Watch the patient carefully as they perform

the movement. Note any signs of weakness, tremors, or
asymmetry in arm movement. Assess the patient's ability
to coordinate the movement and maintain control
throughout.

6. Ask the patient to flex upper arm and resist To assess the strength of the patient's upper arm muscles,
examiner's opposing force. you can perform a manual muscle strength test by asking
the patient to flex their upper arm (biceps) and resist the
opposing force applied by the examiner.

Instructions to the Patient: "I'm going to assess the

strength of your upper arm muscles. Please bend your
elbow and bring your hand towards your shoulder, like
you're trying to flex your biceps. Keep your elbow close to
your body and your forearm facing upward. Once you're in
this position, I'll apply some resistance, and I want you to
push against my hand as hard as you can. Ready?"

Application of Resistance: Once the patient is in

position, apply resistance against the movement by gently
pushing against the patient's hand in the opposite
direction. Gradually increase the resistance while
assessing the patient's ability to maintain the flexed
position and resist the opposing force.

7. Inspect and palpate the hands, fingers, wrists, Rationale: Examining the hands and upper extremities is
and elbow joints. essential for assessing neurological function, including
sensation, muscle strength, and coordination. Palpation
allows for the detection of abnormalities such as muscle
atrophy, joint deformities, or tenderness, which may
indicate neurological or musculoskeletal issues.

Hand Inspection: Ask the patient to extend their hands

with palms facing upward. Inspect the hands for any
abnormalities such as swelling, deformities, discoloration,
or scars. Observe the fingers for any signs of muscle
wasting (atrophy) or abnormal positioning. Hand

Palpation: Palpate the joints of the fingers and thumbs,

feeling for any tenderness, swelling, or warmth. Gently
squeeze each finger and thumb joint individually to assess
for pain or discomfort. Palpate the palm and back of the
hand for any masses, nodules, or abnormalities.

Wrist Inspection and Palpation: Ask the patient to

extend their wrists with palms facing upward. Inspect and
palpate the wrists for any swelling, deformities, or
asymmetry. Feel for any tenderness, warmth, or
irregularities in the wrist joints.

Elbow Inspection and Palpation: Ask the patient to

extend their arms with palms facing upward. Inspect and
palpate the elbows for any swelling, redness, deformities,
or asymmetry. Feel for any tenderness, warmth, or
 irregularities in the elbow joints.

What to Say to the Patient: "I'm going to examine your

hands, wrists, and elbows now to check for any
abnormalities that might indicate issues with sensation,
muscle strength, or coordination. Please keep your hands
and arms relaxed as much as possible. I'll be looking at
each joint and gently feeling for any tenderness or
abnormalities. Let me know if you feel any discomfort
during the examination."

8. Palpate the radial and brachial pulses. Rationale: Palpating the radial and brachial pulses helps
assess peripheral circulation and vascular function. A
strong, regular pulse indicates adequate blood flow to the
extremities, while a weak or irregular pulse may suggest
vascular compromise or underlying cardiovascular issues.
This assessment is crucial for evaluating neurological
function, as adequate blood flow is essential for proper
nerve function and tissue perfusion.

Radial Pulse Palpation: Instruct the patient to extend

their arm with the palm facing upward or resting
comfortably on a flat surface. Locate the radial artery on
the thumb side of the wrist, just below the base of the
thumb. Place the index and middle fingers lightly over the
radial artery, avoiding excessive pressure that could
occlude the pulse. Gently press down and feel for the
pulsation of the radial artery. Assess the rate, rhythm, and
strength of the pulse by counting the number of pulsations
felt over a 15-second or 30-second interval and multiplying
by 4 or 2, respectively, to determine beats per minute.

Brachial Pulse Palpation: Ask the patient to relax their

arm and slightly bend their elbow to expose the inner
aspect of the upper arm. Locate the brachial artery in the
antecubital fossa, the groove between the biceps and
triceps muscles. Place the index and middle fingers gently
over the brachial artery. Apply light pressure and feel for
the pulsation of the brachial artery. Assess the rate,
rhythm, and strength of the pulse in a similar manner as
with the radial pulse.

What to Say to the Patient: "I'm going to check the

pulses in your arms now to assess your circulation. This
involves feeling for the pulsations in the arteries near your
wrist and elbow. It won't hurt, and it only takes a moment.
Please relax and let me know if you feel any discomfort."

9. Have the patient squeeze two of your fingers. Rationale: Testing grip strength by squeezing two fingers
provides valuable information about the integrity of hand
muscles and motor pathways. Adequate grip strength is
essential for performing everyday tasks such as grasping
objects, opening jars, and maintaining hand function. This
assessment helps evaluate motor control, muscle
strength, and neurological function in the hands.

Preparation: Position yourself facing the patient, ensuring

a comfortable and relaxed environment for the
assessment. Extend two of your fingers (typically the index
and middle fingers) towards the patient, keeping them
within the patient's reach.
 Instructions to the Patient: "I'm going to ask you to
squeeze my fingers as firmly as you can with your hand.
Please use your entire hand to grip, and squeeze for a few
seconds before releasing. Imagine you're trying to crush
something between your fingers. We'll do this a couple of
times. Ready?"

Execution: Extend your fingers towards the patient and

allow them to grasp your fingers with their hand.
Encourage the patient to squeeze your fingers firmly for a
few seconds, applying as much pressure as they
comfortably can. Repeat the process several times,
allowing the patient to rest briefly between repetitions.

10. Ask the patient to close his or her eyes. Using Rationale: This assessment, known as graphesthesia,
your finger or applicator, trace a one-digit number evaluates the patient's ability to recognize numbers or
on the patient‘s palm and ask him or her to letters traced on their skin. It helps assess sensory
identify the number. Repeat on the other hand perception and the integrity of the somatosensory
with a different number. pathways, which are essential for interpreting tactile
stimuli.

Preparation: Ensure a quiet environment to minimize

distractions. Position yourself facing the patient with
enough space to access their hands comfortably.

Instructions to the Patient: "I'm going to trace a number

on your palm with my finger, and I'd like you to tell me
what number you feel. Please close your eyes while we do
this. Ready?"

Execution: Ask the patient to close their eyes. Using your

finger or a blunt applicator, trace a single-digit number
(e.g., "5") on the patient's palm, applying gentle pressure.
Prompt the patient to identify the number they feel. Repeat
the process on the other hand with a different number
(e.g., "2"). Avoid tracing letters or numbers that may be
easily confused (e.g., 6 and 9).

11. Ask the patient to close his or her eyes. Place a Rationale: This assessment, known as stereognosis,
familiar object, such as a key, in the patient‘s evaluates the patient's ability to recognize objects through
hand and ask him or her to identify the object. tactile sensation without visual input. It assesses sensory
Repeat using another object for the other hand. perception and the integrity of the somatosensory
pathways, which are crucial for interpreting tactile stimuli
and object recognition.

Preparation: Ensure a quiet environment to minimize

distractions. Have two familiar objects readily available for
the assessment.

Instructions to the Patient: "I'm going to place an object

in your hand, and I'd like you to tell me what it is. Please
keep your eyes closed during the assessment. Ready?"

Execution: Ask the patient to close their eyes. Place a

familiar object (e.g., a key) in the patient's hand and ask
them to identify the object based on touch alone. Allow the
patient a moment to explore the object and provide their
response. Repeat the process on the other hand with a
different object (e.g., a coin).

12. Assist the patient to a supine position. Examine Rationale: Examining the lower extremities in a supine
the lower extremities. Inspect the legs and feet position allows for a comprehensive assessment of
 for color, lesions, varicosities, hair growth, nail vascular, musculoskeletal, and dermatological aspects.
growth, edema, and muscle mass. Inspection of the legs and feet helps identify abnormalities
such as skin discoloration, lesions, varicose veins, hair
and nail changes, edema, and muscle wasting, which can
indicate circulatory issues, neuropathy, or other
neurological or musculoskeletal conditions.

Preparation: Ensure a quiet and well-lit environment for

the examination. Provide privacy and dignity by covering
the patient appropriately.

Instructions to the Patient: "I'm going to examine your

legs and feet now. I'll be looking at various aspects such
as color, skin condition, hair and nail growth, and muscle
mass. Please lie down on your back comfortably, and I'll
guide you through the examination. Let me know if you
experience any discomfort during the examination."

Execution: Assist the patient to a supine position on the

examination table or bed. Inspect the legs and feet
visually, starting from the thighs down to the toes. Look for
any changes in skin color, lesions, varicose veins, or
scars. Assess the distribution of hair growth and the
condition of nails for signs of infection or trauma. Palpate
the lower extremities for edema, tenderness, or
abnormalities in muscle tone or bulk.

13. Test for pitting edema in the pretibial area by Rationale: Testing for pitting edema in the pretibial area
pressing fingers into the skin of the pretibial area. assesses the presence of fluid accumulation in the tissues,
If an indentation remains in the skin after the which can indicate circulatory or fluid balance issues.
fingers have been lifted, pitting edema is present. Pitting edema occurs when interstitial fluid accumulates in
the subcutaneous tissues, causing indentations or "pits" to
form when pressure is applied. This assessment is
essential for evaluating peripheral edema and monitoring
fluid status, which can be indicative of various medical
conditions such as heart failure, kidney disease, or venous
insufficiency.

Instructions to the Patient: "I'm going to check for

swelling in your legs by pressing gently on the skin of your
lower leg. This will help me assess if there is any fluid
buildup. Please let me know if you feel any discomfort
during the examination."

Execution: Position the patient comfortably with their legs

exposed, either sitting or lying down. Apply gentle
pressure with your fingers to the pretibial area, located on
the anterior aspect of the lower leg, just above the ankle.
Press down firmly but gently for a few seconds, then
release the pressure. Observe the area for the presence of
an indentation or pit in the skin. Note the depth and
duration of the indentation, if present.

Observation: Assess the presence and degree of pitting

edema based on the depth and duration of the indentation.
Grade the severity of edema using a scale (e.g., 1+ to 4+),
with higher grades indicating more severe edema. Note
any asymmetry between the legs or other signs of fluid
imbalance.

14. Palpate for pulses and skin temperature at the Rationale: Palpating pulses and assessing skin
posterior tibial, dorsalis pedis, and popliteal temperature at specific locations on the lower extremities
 areas. provides valuable information about peripheral circulation
and vascular health. The posterior tibial, dorsalis pedis,
and popliteal pulses are commonly evaluated as they are
indicative of blood flow to the foot and lower leg. Changes
in pulse quality or skin temperature can indicate vascular
insufficiency, arterial occlusion, or other circulatory
disorders.

Preparation: Ensure a quiet and comfortable environment

for the examination. Provide privacy and dignity by
covering the patient appropriately.

Instructions to the Patient: "I'm going to check the

pulses and skin temperature in your legs and feet. This
involves feeling for the pulse and assessing the warmth of
your skin. Please let me know if you feel any discomfort
during the examination."

Execution: Position the patient comfortably with their legs

exposed, either sitting or lying down. Begin by palpating
the posterior tibial pulse, located behind the medial
malleolus (inner ankle bone). Use gentle pressure with
your fingers to feel for the pulse. Next, palpate the dorsalis
pedis pulse, located on the dorsum (top) of the foot,
between the first and second metatarsal bones. Again, use
gentle pressure to feel for the pulse. Finally, palpate the
popliteal pulse, located behind the knee in the popliteal
fossa. Bend the patient's knee slightly and use your
fingers to feel for the pulse deep in the fossa. While
palpating each pulse, simultaneously assess the skin
temperature by lightly touching the surrounding skin with
the back of your hand.

15. Have the patient perform the straight leg test with Rationale: The straight leg test assesses nerve root
one leg at a time. irritation, particularly of the sciatic nerve, by stretching the
nerve when the leg is raised. Testing hip abduction and
16. Ask the patient to move one leg laterally with the adduction evaluates the function of the hip joint and
knee straight to test abduction and medially to associated muscles, while resistance testing assesses
test adduction of the hips. muscle strength and integrity of specific muscle groups.
These assessments provide valuable information about
17. Ask the patient to raise the thigh against the nerve function, muscle strength, and joint mobility, which
resistance of your hand; next have the patient are essential components of a neurological examination.
push outward against the resistance of your
hand; then have the patient pull backward against Straight Leg Test: Instruct the patient to lie flat on their
the resistance of your hand. Repeat on the back on an examination table. Ask the patient to raise one
opposite side. leg straight upward while keeping the knee extended.
Support the patient's leg under the thigh and gently lift it
until the patient reports pain or discomfort. Repeat the test
with the other leg.

Hip Abduction and Adduction: With the patient still lying

flat on their back, instruct them to move one leg laterally
away from the midline of the body to test abduction of the
hip joint. Next, ask the patient to move the same leg
medially towards the midline of the body to test adduction
of the hip joint. Repeat the movements with the other leg.

Resistance Testing: With the patient lying flat on their

back, ask them to raise one thigh upward against the
resistance of your hand placed on the anterior aspect of
the thigh. Next, apply resistance against the lateral aspect
of the thigh as the patient pushes outward, testing hip
 abduction strength. Then, apply resistance against the
posterior aspect of the thigh as the patient pulls backward,
testing hip extension strength. Repeat the resistance
testing with the other leg.

What to Say to the Patient: "I'm going to ask you to

perform a few movements to assess the function of your
legs and hips. Please let me know if you experience any
pain or discomfort during the tests."

18. Assess the patient‘s deep tendon reflexes (DTR). Rationale: Assessing deep tendon reflexes (DTR) helps
evaluate the integrity of the nervous system, particularly
18.1. Place your fingers above the patient‘s wrist the spinal cord and peripheral nerves. Changes in reflex
and tap with a reflex hammer; repeat on the other responses can indicate neurological abnormalities such as
arm. spinal cord injury, nerve compression, or neurological
diseases. Testing various reflexes at different anatomical
18.2. Place your fingers at the elbow area with locations provides a comprehensive assessment of the
the thumb over the antecubital area and tap with nervous system's function.
a reflex hammer; repeat on the other side.
Instructions to the Patient: "I'm going to check your
18.3. Place your fingers over the triceps tendon reflexes by tapping lightly on certain areas of your body
area and tap with a reflex hammer; repeat on the with a reflex hammer. It won't hurt, but you may feel a
other side. slight tapping sensation. Please relax and let your arm or
leg hang loosely during the assessment."
18.4. Tap just below the patella with a reflex
hammer; repeat on the other side. Execution: Begin by assessing the biceps reflex. Place
your fingers just above the patient's wrist and tap the
18.5. Tap over the Achilles‘ tendon area with tendon with the reflex hammer. Repeat on the other arm.
reflex hammer; repeat on the other side. Move to the brachioradialis reflex. Place your fingers over
the patient's elbow area with the thumb over the
antecubital area and tap the tendon with the reflex
hammer. Repeat on the other side. Proceed to the triceps
reflex. Place your fingers over the triceps tendon area and
tap with the reflex hammer. Repeat on the other side.
Assess the patellar reflex by tapping just below the patella
with the reflex hammer. Repeat on the other side. Finally,
evaluate the Achilles tendon reflex by tapping over the
Achilles tendon area with the reflex hammer. Repeat on
the other side.

19. Ask patient to dorsi flex and then plantar flex both Rationale: Assessing dorsiflexion and plantarflexion
feet against opposing resistance. strength of the feet against resistance evaluates the
integrity of the lower extremity muscles, particularly the
anterior tibialis and gastrocnemius muscles. This
assessment helps identify muscle weakness, nerve
dysfunction, or other neurological issues affecting foot and
ankle movement.

Instructions to the Patient: "I'm going to assess the

strength of your foot and ankle muscles. I'll ask you to
move your feet up and down against resistance. Please sit
or lie down comfortably and let me know if you experience
any discomfort during the assessment."

Execution: Ask the patient to sit or lie down comfortably

with their legs extended or slightly bent. Instruct the patient
to dorsiflex their feet by pulling their toes toward their body
against resistance applied by your hands placed on the
dorsum of their feet. Apply gentle but firm resistance as
the patient dorsiflexes their feet, ensuring they are pushing
against your hands. Next, ask the patient to plantarflex
their feet by pointing their toes downward against
 resistance applied by your hands placed on the soles of
their feet. Apply resistance as the patient plantarflexes
their feet, ensuring they are pushing against your hands.
Repeat the dorsiflexion and plantarflexion movements
several times to assess muscle strength and endurance.

20. Stroke the sole of the patient‘s foot with the end Rationale: Stroking the sole of the foot to elicit the
of a reflex hammer handle or other hard object Babinski reflex assesses the integrity of the corticospinal
such as a key; repeat on the other side. tract, particularly in the pyramidal system. A normal
response is flexion of the toes, while an abnormal
response, known as a positive Babinski sign, is
dorsiflexion of the big toe and fanning of the other toes.
This sign may indicate upper motor neuron dysfunction,
such as a spinal cord injury or neurological disorder.

Instructions to the Patient: "I'm going to gently stroke

the sole of your foot with the end of this reflex hammer
handle. It may tickle or feel slightly uncomfortable, but it
shouldn't cause any pain. Please let me know if you feel
anything unusual during the assessment."

Execution: Position the patient lying down comfortably on

their back with their legs extended. Hold the reflex
hammer handle or hard object perpendicular to the sole of
the foot. Gently stroke the lateral aspect of the sole from
the heel along the lateral border of the foot towards the
base of the toes. Repeat the stroking motion on the other
foot in the same manner. Observe and note the response
of the toes on each foot.

21. As needed, assist the patient to a standing Rationale: Observing the patient's gait and performing
position. Observe the patient as he or she walks specific walking maneuvers helps assess various aspects
with a regular gait, on the toes, on the heels, and of neurological function, including balance, coordination,
then heel to toe. muscle strength, and proprioception. A regular gait
indicates normal motor control and coordination, while
abnormalities in walking patterns may suggest
neurological deficits, musculoskeletal issues, or vestibular
dysfunction.

Instructions to the Patient: "I'm going to ask you to stand

up, walk, and perform some specific movements. Please
take your time, and don't worry if you need assistance or
support. Let me know if you feel unsteady or
uncomfortable at any point."

Execution: Assist the patient to a standing position,

ensuring they have adequate support if needed. Observe
the patient as they walk in a straight line with a regular
gait, noting any abnormalities such as limping, staggering,
or asymmetrical movements. Ask the patient to walk on
their toes, raising their heels off the ground with each step.
Observe for any difficulty or imbalance. Then, ask the
patient to walk on their heels, keeping their toes lifted off
the ground with each step. Again, observe for any difficulty
or imbalance. Finally, instruct the patient to walk in a
straight line by placing one foot directly in front of the
other, touching heel to toe with each step (heel-to-toe or
tandem gait).

22. Perform the Romberg‘s test; ask the patient to Rationale: The Romberg test assesses proprioception,
stand straight with feet together, both eyes closed which is the body's ability to sense its position in space. By
with arms at side. Wait 20 seconds and observe having the patient stand with their eyes closed, the visual
 for patient swaying and ability to maintain input is removed, making the test sensitive to
balance. Be alert to prevent patient fall or injury proprioceptive deficits. Swaying or loss of balance during
related to losing balance during this assessment. the test may indicate dysfunction in the proprioceptive
pathways, which can be associated with neurological
conditions affecting the spinal cord or peripheral nerves.

Instructions to the Patient: "I'm going to assess your

ability to maintain balance. Please stand up straight with
your feet together and your arms by your side. Close your
eyes and try to maintain your balance for about 20
seconds. I'll be right here to assist you if you need any
help."

Execution: Instruct the patient to stand with their feet

together, heels touching, and arms relaxed by their sides.
Ask the patient to close their eyes while maintaining the
standing position. Begin timing the test and observe the
patient for any swaying, loss of balance, or other signs of
instability. Be prepared to provide support or assistance if
the patient starts to lose balance to prevent falls or
injuries. After approximately 20 seconds, instruct the
patient to open their eyes and return to a normal standing
position.

23. Assist the patient to a comfortable position. Rationale: Assisting the patient to a comfortable position
and performing hand hygiene after completing a
24. Remove PPE, if used. Perform hand hygiene. neurological assessment ensures patient comfort, safety,
and infection control. It also promotes a respectful and
caring environment, enhancing the overall patient
experience.

Assisting the Patient to a Comfortable Position: Gently

assist the patient to a comfortable position, such as sitting
or lying down, depending on their preference and mobility
status. Ensure that the patient is adequately supported
with pillows or cushions as needed to maintain comfort.

Removing PPE and Performing Hand Hygiene: If

personal protective equipment (PPE) was used during the
assessment, carefully remove and discard it according to
proper protocol. Perform hand hygiene by washing hands
thoroughly with soap and water or using an alcohol-based
hand sanitizer, following recommended guidelines for
duration and technique.

What to Say to the Patient: "Let me help you get into a

comfortable position now. I'll make sure you're
well-supported and at ease. After that, I'll remove any
personal protective equipment I used during the
assessment and then wash my hands to keep us both safe
and healthy."

SENSORY FUNCTION ASSESSMENT (OPTIONAL)

25. Stroke skin with safety pin, alternating blunt and Pain Sensation - stroke skin with safety pin, alternating
with sharp end. blunt and with sharp end.

Rationale: Assessing pain sensation using a safety pin,

alternating between the blunt and sharp ends, helps
evaluate the integrity of the patient's sensory pathways,
specifically the ability to discriminate between sharp and
dull sensations. This assessment is crucial for detecting
 abnormalities in sensory perception, such as hypoesthesia
(decreased sensation) or hyperesthesia (increased
sensation), which may indicate nerve damage or
dysfunction.

Instructions to the Patient: "I'm going to test your ability

to feel sharp and dull sensations on your skin. I'll be using
the tip of this safety pin, which has both a blunt and a
sharp end. Please let me know if you feel a sharp or dull
sensation when I touch your skin."

Execution:
● Begin by identifying an area of intact skin on the
patient's body, such as the forearm or upper arm.
● Lightly stroke the skin with the blunt end of the
safety pin, ensuring consistent pressure.
● Ask the patient if they feel a sharp or dull
sensation, or if they feel nothing at all.
● Repeat the process using the sharp end of the
safety pin, again asking the patient to describe the
sensation.
● Alternate between stroking with the blunt and
sharp ends, covering different areas of the body
as needed.

26. Touch client with test tube filled with hot water Temperature Sensation - touch client with test tube filled
and another with cold water. with hot water and another with cold water.

Rationale: Assessing temperature sensation by touching

the patient with test tubes filled with hot and cold water
helps evaluate the integrity of their thermal sensory
pathways. Differential responses to hot and cold stimuli
provide valuable information about the function of
peripheral nerves and the central nervous system. This
assessment is essential for detecting abnormalities in
temperature perception, such as hypoesthesia (decreased
sensation) or hyperesthesia (increased sensation), which
may indicate nerve damage or dysfunction.

Instructions to the Patient: "I'm going to test your ability

to feel hot and cold sensations on your skin. I'll touch you
with these test tubes filled with hot and cold water. Please
let me know immediately if you feel any discomfort or if
you can distinguish between the two sensations."

Execution:
● Begin by identifying an area of intact skin on the
patient's body, such as the forearm or upper arm.
● Lightly touch the skin with the test tube filled with
hot water, ensuring the temperature is tolerable for
the patient.
● Ask the patient if they feel the sensation of heat
and to describe its intensity.
● Repeat the process using the test tube filled with
cold water, again asking the patient to describe
the sensation.
● Alternate between touching with the hot and cold
test tubes, covering different areas of the body as
needed.

27. Stroke client‘s skin with cotton wisp. Light-Touch Sensation - stroke client’s skin with cotton
wisp
Reflexes: Test reflexes using percussion hammer,
comparing one side of the body with the other to evaluate
symmetry of response.

Rationale: Assessing light-touch sensation by stroking the

client's skin with a cotton wisp helps evaluate the integrity
of their sensory pathways, specifically the ability to
perceive gentle tactile stimuli. This assessment is
essential for detecting abnormalities in light-touch
perception, such as hypoesthesia (decreased sensation)
or hyperesthesia (increased sensation), which may
indicate nerve damage or dysfunction. Testing reflexes
using a percussion hammer helps evaluate the integrity of
the client's reflex arcs and assesses the symmetry of their
reflex responses, which can provide valuable information
about the function of their nervous system.

Instructions to the Client: "I'm going to test your ability to

feel gentle touch on your skin by using this soft cotton
wisp. Please let me know if you feel anything as I stroke
your skin. After that, I'll test your reflexes using this
percussion hammer. I'll compare the response on one side
of your body with the other. Please try to relax during the
assessment."

Execution:
● Begin by gently stroking the client's skin with the
cotton wisp, starting from an area of intact skin
and moving in a systematic pattern.
● Ask the client to indicate if they feel the sensation
of touch and to describe its intensity.
● After assessing light-touch sensation, proceed to
test the client's reflexes using the percussion
hammer.
● Tap the appropriate tendon or reflex point with the
percussion hammer and observe the client's reflex
response.
● Compare the response on one side of the body
with the other to evaluate the symmetry of
reflexes.