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Ms Neha Bhatt
Assessment is an important component of
nursing process. A complete nursing assessment
includes both the collection of subjective data
and objective data.
The complete health history is performed to
collect as much subjective data about a client as
Objective data include information about the
client that the nurse directly observes during
interaction with him and information elicited
through physical assessment techniques.
1. Physical Examination:
Four basic techniques must be mastered before
professional can perform a thorough and
complete assessment of the client. By using a
systematic approach, examiner will less likely to
forget an area.
Four techniques used are:
• These techniques need to be organized in
sequence except while performing abdominal
assessment, as palpation and percussion can
alter bowel sounds. The sequence for assessing
the abdomen is inspection, auscultation,
percussion and palpation.
• Inspection involves vision, smell and hearing to
observe normal conditions and deviations.
Performed correctly, inspection can reveal more
than other techniques.
• Inspection begins from first meeting with the
patient and continues throughout the health
history and physical examination. As the
examiner assess each body system, observe for
color, size, location movement, texture,
symmetry, odor, and sounds.
Palpation required examiner to touch the patient
with different parts, using varying degrees of
pressure. To do this, examiner need short
fingernails and warm hands. Always palpate
tender areas last. Information about the
purpose of touch to different parts is essential.
Palpate to evaluate:
• Evaluation of the following features are required:
• Texture-rough or smooth?
• Temperature-warm, hot or cold?
• Moisture-dry, wet or moist?
• Motion-still or vibrating?
• Consistency of structures-solid or fluid filled?
Percussion involves tapping fingers or hands quickly and
sharply against parts of the patient’s body, usually the
chest or abdomen. The technique helps to locate organ
borders, identify organ shape and position and determine
if an organ is solid or filled with fluid or gas.
Percussion requires a skilled touch and trained ear to
detect slight variations in sound. Organs and tissues,
depending on their density, produce sounds of varying
loudness, pitch and duration. For instance, air-filled
cavities, such as the lungs, produce markedly different
sounds than do the liver and other dense tissues.
The examiner has to move gradually from areas of
resonance to those of dullness and them compare sounds.
Also, compare sounds on one side of the body with those
on the other side.
• Auscultation, usually the last assessment step,
involves listening for various breath, heart and
bowel sound with a stethoscope. To prevent the
spread of infection among patients, clean the
hearts and end pieces of the stethoscope with
alcohol or a disinfectant after every use.
2. History collection among neurological
• A thorough and accurate history of a neuro
patient is often very helpful in assessing their
condition. The character of symptoms,
distribution, temporal profile of symptoms,
epidemiological associations are often needed in
detail in neurological patients in comparison to
other general diseases. The fact that in
neurological patients their cerebral dysfunction
may limit or distort the account of history third
party sources of information are most often
3. Neurologic Examination
• Neurological examination is one of the key
components of nursing practice. It plays a
pivotal role in localization of the problem. It
encompasses history collection, and the physical
examination. Observation is the most important
key for neurological examination. The exam
requires skill and patience, from the examiner.
a) A thorough neurologic examination may take 1 to 3
hours; however, routine screening tests are usually
done first. If the results of these tests raise
questions, more extensive evaluations are made.
Three major considerations determine the extent of
a neurologic exam:
b) The client’s chief complaints
c) The client’s physical condition (i.e., level of
consciousness and ability to ambulate), as many
parts of the examination require movement and
coordination of the extremities
d) The client’s willingness to participate and
• Coffee powder/any scented material
• Disposable safety pin
• Tongue depressors
• Wisps of cotton to assess light- touch sensation
• Test tubes of hot and cold water for skin
3.2 The components of neurological
• Level of consciousness
• Mini Mental Status Exam.
• Cranial nerves
• Motor System.
• Sensory System.
• Deep tendon reflexes
• Coordination and balance
• Brain stem reflexes
3.3 Assessment of Level of consciousness
• Note the patient’s personal hygiene and dress. Is
it appropriate for the environment.
• Make a note of the age, height, build and
weight. Is the patient obese or cachectic?
• Check the vital signs including temperature,
pulse, respiratory rate and blood pressure.
Level of consciousness
• Glasgow coma scale is an objective method to
assess the level of consciousness in the patients
with neurological disorders. This scale describes
conscious level in terms of eye opening, verbal
response and motor response. These are having
4, 5, 6 categories each respectively. On
examination, observer has to assign one score to
the observed category to each parameter. The
minimum score is 3 and maximum is 15.
For children under 5, the verbal response criteria
are adjusted as follow
SCORE 2 to 5 yrs 0 to 23 months
Smiles or coos appropriately
Cries and consolable
Persistent inappropriate crying &/or
2 Grunts Grunts or is agitated or restless
1 No response No response
Children with a Glasgow Coma Scale of 3-8 are considered comatose
3.4 Mental Status Examination
• Evaluation of mental status is a part of the
neurological examination. The appearance,
behaviour, level of consciousness, attention,
concentration, memory, orientation, abstraction,
judgment, language and speech are assessed in
4. Examination of the Cranial Nerves
The following is a summary of the cranial nerves and
their respective functioning.
• I Olfactory- Smell
• II .optic-Visual acuity, visual fields and ocular fundi
• II,III . Occulo motor- Pupillary reactions
• III,IV,VI . Trochlear, Abducens- Extra-ocular
movements, including opening of the eyes
• V. Trigeminal- Facial sensation, movements of the jaw,
and corneal reflexes
• VII. Facial-Facial movements and gustation
• VIII. Vestibulo cohlear -Hearing and balance
• IX,X. Glassopharngeal,Vagus-Swallowing, elevation of
the palate, gag reflex and gustation
• V,VII,X,XII. Hypoglossal-Voice and speech
• XI. Spinal accessory, shrugging the shoulders and
turning the head
• XII. Hypoglossal-Movement and protrusion of tongue
4.1 Cranial Nerve I (olfactory)
• Evaluate the patency of the nasal passages
bilaterally. Ask the patient to close their eyes,
occlude one nostril, and place any familiar
scented substance near the patent nostril and
ask the patient to report what it is. Switch
nostrils and repeat.
4.2 Cranial Nerve II (optic)
• The components of testing include visual acuity, visual
field, optic fundus and pupillary reaction
• Severe deficit can be assessed testing whether patient
can see light or movements, or can the patient count
fingers. Patient may also be assessed to read
newspaper or book having bigger letter size. To
examine mild deficit, examiner record reading activity
with Snellen’s chart or hand chart.
• Perform this part of the examination in a well-lit room
and make certain that if the patient wears glasses,
during the exam. Hold the chart 14 inches from the
patient's face, and ask the patient to cover one of
their eyes completely with their hand and read the
lowest line on the chart possible. Have them repeat
the test covering the opposite eye. For Snellen’s chart,
6 meters distance is expected to read letters. Test
each eye separately.
Assessing Visual Fields by Confrontation test
• Stand two feet in front of the patient and have them look
into your eyes.
• Hold your hands about one foot away from the patient's
ears, and wiggle a finger on one hand.
• Ask the patient to indicate which side they see the finger
• Repeat two or three times to test both temporal fields.
• If an abnormality is suspected, test the four quadrants of
each eye while asking the patient to cover the opposite eye
with a card
• Using an ophthalmoscope, observe the optic
disc, physiological cup, retinal vessels. Note the
pulsations of the optic vessels, check for a
blurring of the optic disc margin and a change in
the optic disc's color form its normal yellowish
orange. The initial change in the
ophthalmoscopic examination in a patient with
increased intracranial pressure is the loss of
pulsations of the retinal vessels.
In the assessment of pupils note:
• Size (small- miosis/ large-mydriasis)
• Reaction to light: Both pupil constrict when light
is shown in either eye.
• Reaction to accommodation and convergence.
4.3 Cranial Nerves III, IV and VI (Oculomotor,
• Observe for Ptosis
• Test Extra ocular Movements
• Stand or sit 3 to 6 feet in front of the patient.
• Steady the patients head and ask him to follow your finger
with their eyes without moving their head.
• Check gaze in the six cardinal directions
• Check for nystagmus.
• Questions the patient about diplopia.
4.4 Cranial Nerve V ( Trigeminal )
• Assess for pain, temperature and touch. Palpate the
masseter muscles while you instruct the patient to
bite down hard. Also note masseter wasting on
observation. Next, ask the patient to open their
mouth against resistance applied by the instructor at
the base of the patient's chin
• Test the Three Divisions for Pain Sensation
• Explain what you intend to do.
• Use pin prick to test the sensation of the forehead, cheeks,
and jaw on both sides.
• Test the three divisions (maxillary, mandibular &ophthalmic)
for temperature sensation with a tuning fork heated or
cooled by water.
• Test the three divisions for sensation to light touch using a
wisp of cotton
• Test the Corneal Reflex
• Ask the patient to look up and away.
• From the other side, touch the cornea lightly with a
fine wisp of wet cottonwool.
• Look for the normal blink reaction of both eyes.
• Repeat on the other side
4.5 Cranial Nerve VII (Facial)
• Observe for any facial droop or asymmetry or
• Ask Patient to do the following, note any lag,
weakness, or asymmetry
• Raise eyebrows(to wrinkle forehead)
• Close both eyes to resistance
• Show teeth
• Puff out cheeks
4.6 Cranial Nerve VIII (Vestibulocochlear)
• Assess hearing by instructing the patient to close their
eyes and to say "left" or "right" when a sound is heard
in the respective ear. Vigorously rub your fingers
together very near to, yet not touching, each ear and
wait for the patient to respond. After this test, ask the
patient if the sound was the same in both ears, or
louder in a specific ear
Test for lateralization (Weber):
• Use a 512 Hz or 1024 Hz tuning fork.
• Start the fork vibrating by tapping it on your opposite
• Place the base of the tuning fork firmly on top of the
• Ask the patient where the sound appears to be
coming from (normally in the midline).
Compare air and bone Conduction (Rinne)
• Use a 512 Hz or 1024 Hz tuning fork.
• Start vibrating the tuning fork by tapping it on your
• Place the base of the tuning fork against the mastoid bone
behind the ear.
• When the patient no longer hears the sound, hold the end
of the fork near the patient's ear (air conduction is
normally greater than bone conduction).
4.7 Cranial Nerves IX and X (glossopharyngeal and
• Listen to the patient's voice. If there is vocal cord
paresis(X nerve palsy)voice may be high pitched.
• Ask Patient to Swallow to note swallowing difficulty.
• Watch the movements of the soft palate and the
pharynx by asking the patient to Say "Ah“
• Test Gag Reflex (Unconscious/Uncooperative Patient)
• Stimulate the back of the throat on each side.It is
normal to gag after each stimulus
4.8 Cranial Nerve XI (spinal accessory)
• Look for atrophy or asymmetry of the trapezius
• Ask patient to shrug shoulders against resistance.
• Ask patient to turn their head against resistance. Watch
and palpate the sternocleidomastoid muscle on the
• Repeat this manoeuvre on the opposite side. The
patient should normally overcome the resistance
applied by the examiner. Note any asymmetry.
4.9 Cranial Nerve XII (hypoglossal)
• The hypoglossal nerve controls the intrinsic
musculature of the tongue and is evaluated by having
the patient stick out their tongue and move it side to
side. Normally, the tongue will be protruded from the
mouth and remain midline. Note deviations of the
tongue from midline, a complete lack of ability to
protrude the tongue, tongue atrophy and fasciculations
on the tongue.
4.10 Sensory Examination
The sensory modalities tested include pain,
temperature, vibration, joint position and touch.
Pain: Break off the wooden part of a cotton swab to
make a sharp object or use a disposable, sterilized
safety pin. Ask the patient with eyes closed to
distinguish sharp end of the pin from dull.
Temperature: Test coldness with metal tuning fork. The
patient should be able to identify cool vs. warmer
objects or take two test tubes filled with hot water
and cold water separately. Surface on the body at
different times and observe reaction.
Vibration: Test with low-frequency (128) tuning fork.
The patient should be able to sense the vibration of
the tuning fork
Joint position or Proprioception: With eyes closed,
patient distinguishes whether finger and toe are
moved up or down.
Touch: Test light touch with a cotton swab. The patient
distinguishes touch vs. no touch.
Special tests of sensory function
Stereognosis: With eyes closed, patient identifies pen,
paper clip or coin placed in hand. This tests the
parietal sensory cortex and posterior columns
Graphesthesia: With eyes closed, patient identifies
numbers or figures or shapes written on palm. This
tests the sensory cortex and integration.
Two-point discrimination: Patients should be able to
distinguish two simultaneous points of different
intensity 2 to 10 mm apart on fingers and hands.
Compare patient's two sides
4.11 Motor System Examination
• The motor system evaluation is divided into the
following: Muscle bulk, muscle tone, involuntary
movements and muscle strength.
• Systematically examine all of the major muscle groups
of the body.
• Note the muscle bulk (atrophy, hypertrophy, normal).
• Feel the tone of the muscle (flaccid, clonic, normal).
• Presence of any abnormal movements like tremor,
• Test the strength of the muscle group.
Muscle strength grading: If pyramidal weakness is suspect
test the power of muscle with reference to pressure and
gravitation. Assign scores as follows:
• 0-No muscle contraction is detected
• 1-A flicker or trace contraction is noted in the muscle
while the patient attempts to contract it.
• 2-The patient is able to actively move the muscle with
• 3-The patient may move the muscle against gravity
but not against resistance from the examiner.
• 4-The patient may move the muscle group against
some resistance from the examiner.
• 5-The patient moves the muscle group and
overcomes the resistance of the examiner. This is
normal muscle strength
4.12 Deep Tendon Reflexes
Observing reflexes is the most objective part of the
neurological exam, since the reflexes are not under
voluntary control and testing does not depend on the
patient's cooperation, attitude, or awareness.
• Biceps reflex tests C5-6: The biceps reflex is elicited by
placing your thumb on the biceps tendon and striking
your thumb with the reflex hammer and observing the
• Brachioradialis reflex also tests C5-6. The
brachioradialis reflex is observed by striking the
brachioradialis tendon directly with the hammer when
the patient's arm is resting. Strike the tendon roughly 3
inches above the wrist. Note the reflex supination.
• Triceps: tests C7-8. The triceps reflex is measured by
striking the triceps tendon directly with the hammer
while holding the patient's arm with your other hand
• Quadriceps (knee jerk): tests L2-L4 With the lower leg
hanging freely off the edge of the bench, the knee
jerk is tested by striking the quadriceps tendon
directly with the reflex hammer.
• Achilles (ankle jerk): tests L5-S2 The ankle reflex is
elicited by holding the relaxed foot with one hand and
striking the Achilles tendon with the hammer and
noting plantar flexion.
Deep tendon reflex grading
• 4+ very brisk, hyperreflexive, with clonus
• 3+brisker or more reflexive than normally
• 1+ normal, diminished
• 0 no response
4.12 Co-ordination and Balance
• The stance (attitude of standing) and the gait of the
patient have to be observed for irregularities. The tests
of co-ordination include Finger –nose test, heel –shin
test, rapid alternating movements. Balance is tested
using the Romberg's sign test.
• Finger -nose test: Ask the patient to extend their index
finger and touch their nose, and then touch the
examiner's outstretched finger with the same finger. Ask
the patient to go back and forth between touching their
nose and examiner's finger. This tests the upper
Heel- shin test: ask the patient to place the heel on the
opposite shin and run up to the knee and back to
ankle. The patient should be able to perform it quickly
and without side-to-side wavering.
Rapid Alternating Movement
Ask the patient to place their hands on their thighs and
then rapidly turn their hands over and lift them off
their thighs. Ask the patient to repeat it rapidly for 10
seconds. Normally this is possible without difficulty.
Dysdiadochokinesis is the clinical term for an inability
to perform rapidly alternating movements
• Ask the patient to stand still with their heels
together, arms on the side and close their eyes.
If the patient loses their balance, the test is
4.13 Assessment of brain stem reflexes
Pupillary response to light: The response to bright light
should be absent in both eyes. The pupil should be
observed closely for one minute to allow time for a
slow response to become evident. Widely dilated
pupils are not a necessary criterion for brain death
but fixed pupils with no response to light are
Corneal reflex: This should be absent.
Oculo cephalic reflex (Doll’s eye phenomenon): This
test must not be performed in patients with an
unstable cervical spine. The head is turned from
starting position to a new steady position and briskly
to the opposite side. The eyes move denoting the
integrity of the medial longitudinal fasciculus in the
Gag reflexes: This should be absent. A tongue
depressor is used to stimulate each side of the
oropharynx and the patient observed for any
pharyngeal or palatal movement.
Cough reflex: A suction catheter is introduced into the
endotracheal or tracheostomy tube to deliberately stimulate
the carina. The patient is closely observed for any cough
response or movement of the chest or diaphragm.
Oculovestibular reflex: Slow irrigation with at least 5-ml of
ice-cold water is performed into the external auditory canal
while, the eyes are held open by an assistant. The eyes
should be observed for one minute after irrigation is
completed before repeating the test on the other side. An
intact oculovestibular reflex causes tonic deviation of the
eyes towards the irrigated ear. Any movement of one or both
eyes, whether conjugate or not, excludes the diagnosis of
brain death. In a brain dead patient the eyes remain fixed.
Combined ice-cold water caloric stimulation and head
rotation has been suggested as the most pro-found
stimulation for deeply unconscious patients.
A thorough physical examination including history
with focus on neurological examination helps the
nurse in nursing assessment and formulation of
diagnosis. An accurate and timely neurological
examination performed by a nurse can pick up the
subtle changes in patients, which often prove crucial
in areas like emergency department and critical care
units. Practicing the examination and examining the
practice makes one confident and skilled in the