1. Neurological Assessment

2. Neurological System The nervous system consists of the central nervous system (CNS), the peripheral nervous system, and the autonomic nervous system. Together these three components integrate all physical, emotional, and intellectual activities. The CNS includes the brain and spinal cord. These two structures collect and interpret voluntary and involuntary sensory and motor signals.

3. Neurological System A brief overview of the anatomy and physiology of the CNS. Brain: The brain collects, integrates, and interprets all stimuli. It also initiates voluntary and involuntary motor activity. The brain is composed of three areas: the cerebrum, brain stem, and cerebellum. Cerebrum: Divided into right and left hemispheres. Each hemisphere has four lobes: parietal, occipital, temporal, and frontal. The cerebral lobes control complex problem-solving; value judgements; language; emotions; interpretation of visual images; and interpretation of touch, pressure, temperature, and position sense.

4. Neurological System A brief overview of the anatomy and physiology of the CNS. Brain Stem: Composed of the midbrain, pons, and medulla. Is a major sensory and motor pathway for impulses running to and from the cerebrum. Regulates body functions such as respiration, auditory and visual reflexes, swallowing, and coughing. Cerebellum: Lies in the posterior portion of the skull and contains the major motor and sensory pathways. It controls smooth, coordinated muscle movements and helps to maintain equilibrium

5. Neurological System A brief overview of the anatomy and physiology of the CNS. Spinal Cord: The spinal cord is the primary pathway for messages traveling between the peripheral areas of the body and the brain. It also houses the reflex arc for actions such as the knee-jerk reflex. The manner in which you progress with your neurological assessment depends upon the patient’s level of consciousness. To perform a complete neurological exam on the patient, he/she must be able to cooperate.

6. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve I (Olfactory) After assessing patency of both nares, have client close eyes, obstruct one nare, and sniff. Use common, easily identifiable substances such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Use different substances for each side. Bilateral decreased sense of smell occurs with age, tobacco smoking, allergic rhinitis, cocaine use. Unilateral loss of sense of smell (neurologic anosmia) can indicate a frontal lobe lesion.

7. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve II (Optic) Check visual acuity (have the patient read newspaper print) and visual fields for each eye. Position the patient 20 feet in front of the Snellen eye chart. Have the patient cover one eye at a time with a card. Ask the patient to read progressively smaller letters until they can go no further. Record the smallest line the patient read successfully (20/20, 20/30, etc.) Repeat with the other eye.

8. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve III (Oculomotor) Observe for Ptosis Test Extraocular Movements – Stand or sit 3 to 6 feet in front of the patient. – Ask the patient to follow your finger with their eyes without moving their head. – Check gaze in the six cardinal directions using a cross or "H" pattern. – Pause during upward and lateral gaze to check for nystagmus. Nystagmus is a rhythmic oscillation of the eyes. – Check convergence by moving your finger toward the bridge of the patient's nose.

9. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve IV (Trochlear) and Cranial Nerve VI (Abducens) Have patient turn eyes downward, temporally, and nasally. If the eyes will not do this the patient may have a fracture of the eye orbit or a brain stem tumor. (Note: Cranial Nerves III, IV, and VI are examined together because they control eyelid elevation, eye movement, and pupillary constriction.)

10. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve V (Trigeminal) Motor – Palpate jaws and temples while patient clenches teeth. Sensory – Have patient close eyes, touch cotton ball to all areas of face. Unilateral deficit seen with trauma and tumors.

11. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve VII (Facial) Motor: Check symmetry and mobility of face by having patient frown, close eyes, lift eyebrows, and puff cheeks. Sensory Asses the patient’s ability to identify taste (sugar, salt, lemon juice) An asymmetrical deficit can be found in trauma, Bell’s palsy, CVA, tumor, and inflammation.

12. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve VIII (Acoustic or Vestibulocochlear) This tests hearing acuity. Impairment indicates inflammation or occlusion of the ear canal, drug toxicity, or a possible tumor.

13. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve IX (Glossopharyngeal) and X (Vagus) Motor: Depress the tongue with a tongue blade and have the patient say “ahh” or yawn. Uvula and soft palate should rise. Gag reflex should be present and the voice should sound smooth. Deficits can indicate a brain stem tumor or neck injury.

14. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve XI (Spinal Accessory) Have the patient rotate the head and shrug shoulders against resistance. If the patient is unable to do this it may indicate a neck injury.

15. Cranial Nerve Assessment Cranial Nerve Assessment Techniques Cranial Nerve XII (Hypoglossal) Motor: Assess tongue control. Wasting of the tongue, deviation to one side, tremors, and an inability to distinctly say l,t,d,n sounds can indicate a lower or upper motor neuron lesion.

16. Cranial Nerve Assessment NerveNameFunctionTest IOlfactorySmellHave patient smell a familiar odor IIOptic Visual Acuity Visual Field Have patient identify fingers Check peripheral vision IIIOculomotorPupillary ReactionShine Light in the eye IVTrochlearEye MovementFollow finger without moving the head VTrigeminal Facial Sensation Motor Function Touch the face Have athlete hold mouth open VIAbducensMotor FunctionLateral Eye movements VIIFacial Motor Function Sensory Smile, wrinkle face, puff cheeks Tastes VIIIAcoustic Hearing Balance Snap fingers by the ear Rhomberg's Test IXGlossopharyngealSwallowing and Voice Swallow and say "AH" XVagusGag Reflex Use tongue depressor XISpinal AccessoryNeck Motion Shoulder shrugging XIIHypoglossalTongue Movement and StrengthStick out tongue apply resistance with a tongue depressor

17. NerveClassificationMajor functionsAssessment I OlfactorySensorySmellHave patient identify a familiar scent with eyes closed (usually deferred). II OpticSensoryVision (acuity and field of vision); pupil reactivity to light and accommodation (afferent impulse) Have patient read from a card or newspaper, one eye at a time. Test visual fields by having patient cover one eye, focus on your nose, and identify the number of fingers you’re holding up in each of four visual quadrants. III OculomotorMotorEyelid elevation; most EOMs; pupil size and reactivity (efferent impulse) Check pupillary responses by shining a bright light on one pupil; both pupils should constrict. Do the same for the other eye. To check accommodation, move your finger toward the patient’s nose; the pupils should constrict and converge. Check EOMs by having patient look up, down, laterally, and diagonally. IV TrochlearMotorEOM (turns eye downward and laterally) Have patient look down and in. V TrigeminalBothChewing; facial and mouth sensation; corneal reflex (sensory) Ask patient to hold the mouth open while you try to close it and to move the jaw laterally against your hand. With patient’s eyes closed, touch her face with cotton and have her identify the area touched. In comatose patients, brush the cornea with a wisp of cotton; the patient should blink. VI AbducensMotorEOM (turns eye laterally) Have patient move the eyes from side to side. VII FacialBothFacial expression; taste; corneal reflex (motor); eyelid and lip closure Ask patient to smile, raise eyebrows, and keep eyes and lips closed while you try to open them. Have patient identify salt or sugar placed on the tongue (usually deferred). VIII AcousticSensoryHearing; equilibriumTo test hearing, use tuning fork or rub your fingers, place a ticking watch, or whisper near each ear. Equilibrium testing is usually deferred. IX Glossopharyng eal BothGagging and swallowing (sensory); taste Touch back of throat with sterile tongue depressor or cotton-tipped applicator. Have patient swallow. X VagusBothGagging and swallowing (motor); speech (phonation) Assess gag and swallowing with CN IX. Assess vocal quality. XI Spinal accessory MotorShoulder movement; head rotation Have patient shrug shoulders and turn head from side to side (not routinely tested). XII Hypoglossal MotorTongue movement; speech (articulation) Have patient stick out tongue and move it internally from cheek to cheek. Assess articulation.

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