Health Assessment Lecture
Neurologic Assessment
Cervical Nerve Region
 Head and neck
 Diaphram (or diaphragm?)
 Arms and hands
Thoracic Nerve Region
 Chest muscles
 Breathing
 Abdominal muscles
Lumbar Nerve Region
 Legs and feet
Sacral Nerve Region
 Bowel and bladder control
 Sexual functions
Perception and Coordination Assessment
Things to consider:
 The client’s chief complaints
 The client’s physical condition (LOC, ability to
ambulate)
 The client’s willingness to cooperate
What to Assess?
 Mental status including LOC
 Cranial nerves
 Reflexes
 Motor functions
 Sensory functions
Equipments
 Sugar, salt, lemon juice, quinine flavours
 Percussion hammer
 Tongue depressors
 Cotton balls
 Optional: test tubes of hot and cold water
 Pins or needle for tactile discrimination
Mental status
 Reveals the client’s general cerebral function
(language, memory, concentration, or thought
process)
o Intellectual (cognitive)
o Emotional (affective)
1. Language
If the client displays difficulty speaking:
 Point to common objects, and ask the client to
name them
 Ask the client to read some words and to match
the printed and written words with pictures
 Ask the client to respond to simple verbal and
written commands
Aphasia
 Any defects in or loss of the power to express
oneself by speech, writing, or signs, or to
comprehend spoken or written language due to
disease or injury of the cerebral cortex
1. Sensory or Receptive Aphasia
 The loss of the ability to comprehend written or
spoken words
o Auditory/Accoustic – lost the ability to
understand the symbolic content
associated with sounds
o Visual – lost the ability to understand
printed or written figures
2. Motor or Expressive Aphasia
 Involves loss of the power to express oneself by
writing, making signs, or speaking
 Inability to combine speech sounds into words
2. Orientation




Ability to recognize other persons, awareness of
when and where they presently are (time and
place), and who they, themselves are
Reminder
o The client is awake, alert, and oriented
o This refers to the accurate awareness of
persons, time and place
Determine the client’s orientation to person,
time, and place by tactful questioning
Ask:
o Place of residency
o Time of day
o Date
o Day of the week
o Duration of illness
o Names of family members
o Others
 Be sure you know the correct
answers
3. Memory
Assess the client’s recall of information
A. Immediate recall
 If client can only remember information
presented seconds previously
B. Recent memory
 If client can only remember events or
information from earlier in the day or
examination
C. Long term memory
 Knowledge recalled from months or years ago
4. Attention span and Calculation

The client’s ability to focus on a mental task
that is expected to be able to be performed by
persons of normal intelligence
Level of Consciousness (LOC)
I – Alert
 Oriented 3x, follows simple command and
responds completely and appropriately to
stimuli
 The patient does not require stimulation
II – Lethargic (sleepy, drowsy, obtunded, somnolent)
 Requires stimulation but when awakened,
remained oriented 3x
 Awakened when called loudly then immediately
fell asleep
 May drift off to sleep during examination
III – Stuporous
 Requires more stimulation, but when awakened
the patient is disoriented to time, person, and
place
 Example: person under the influence of drugs
and alcohol
IV – Semi-comatose
 May respond to painful stimuli but not to verbal
command
 With reflexes present
V – Deep coma
 Clinical state of unconsciousness in which the
patient is unaware of self or environment
 May or may not respond to noxious or painful
stimuli
 Areflexic: no gag reflex when suctioned
 With brain injury
 May assyme decorticate or decerebrate
posturing
Glasgow Coma Scale
 Developed to predict recovery from a head
injury
 Used also to assess the Level of Consciousness
(LOC)
A. Eye response
B. Motor response
C. Verbal response
CN
CN 1
Nerve
Olfactory
Maximum points/score: 15
Lowest possible score: 3
State of coma: 7 and below
CN II
Optic
Faculty measured
1. Eye opening
Response:
 Spontaneous = score: 4
 To verbal command = score: 3
 To pain = score: 2
 No response = score: 1
2. Motor response
Response:
 To verbal command. Score: 6
 To localized pain. Score: 5
 Flexes and withdraws. Score: 4
 Decorticate. Score: 3
 Decerebrate. Score: 2
 No response. Score: 1
3. Verbal Response
Response:
 Oriented, converses. Score: 5
 Disoriented, converses. Score: 4
 Uses inappropriate words. Score: 3
 Makes incomprehensible sounds. Score: 2
 No response. Score: 1
Example:
1. Eye opening: client reacts to pain = score: 2
Motor response: no response = score 1
Verbal response: uses inappropriate words = score: 3
Total score: 6
Cranial nerves
Function
Type
Smell
Sensory
sight
Sensory
Test
Ask the
patient
to
identify
smell
Assess
vision in
OU
(Snellen’s
Chart)
Abnormal Findings of CN I
 Inability to smell (neurogenic anosmia) or
identify the correct scent may indicate olfactory
tract lesion or tumor lesion of the frontal lobe
 Loss of smell may also be congenital or due to
other causes such as nasal or sinus problems
 It may also be caused by injury of nerve tissue
at the top of the nose or the higher smell
pathways in the brain due to viral upper
respiratory infection
 Smoking and use of cocaine may also impair
one’s sense of smell
Abnormal Findings of CN II
 Abnormal findings include difficulty reading
Snellen Chart, missing letters, and squinting
 Client reads print by holding closer than 14
inches or holds print farther away as in
presbyopia, which occurs with aging
CN
CN III
CN IV
CN V
CN VI
Nerve
Function
Oculomotor Eye
movements
Trochlear
Superior
oblique
Trigeminal
Mastication
and facial
sensation,
corneal
reflex
Abducens
Facial
movements,
expression,
tear and
saliva
secretion
Type
Motor
Test
Check pupil constriction; eye movement
Motor
Assess patient ability to look downward and inward
Both
M: assess the patient to clench jaw
S: facial response to touch
Motor
Assess lateral deviation of the eye
Abnormal Findings of CN III, IV, V, VI
 Ptosis (drooping of the eyelids) is seen with
weak eye muscles such as in myasthenia gravis
 Inability to feel and correctly identify facial
stimuli occurs with lesions of the trigeminal
nerve or lesions in the spinothalamic tract or
posterior columns
CN
CN VII
Nerve
Facial
Function
Type
Posterior
Both
external
ear, taste
(Ant 2/3)
muscles of
facial
expressions
Test
M:
Assess
patient’s
ability to
smile,
elevates
eyebrows
S: check
taste on
anterior
2/3 of
the
tongue
(sugar
and salt)
Abnormal Findings of CN VII
 Inability to close eyes, wrinkle forehead, or raise
forehead along with paralysis of the lower part
of the face on the affected side is seen with
Bell’s palsy (a peripheral injury to cranial nerve
VII (facial)
 Paralysis of the lower part of the face on the
opposite side affected may be seen with a
central lesion that affects the upper motor
neurons, such as from stroke
Reflexes
 Are assessed using a percussion hammer
 Described on a scale of 0-4
Grade
0
1+
2+
3+
4+
Abnormal Findings of CN IX, X
 Soft palpate does not rise with bilateral lesions
of cranial nerve X (vagus). Unilateral rising of
the soft palate and deviation of the uvula to the
normal side are seen with a unilateral lesion of
the cranial nerve X (vagus)
 Dysphagia or hoarseness may indicate a lesion
of cranial nerve IX (glossopharyngeal) or X
(vagus) or other neurologic disorder
Abnormal Findings of CN XI
 Asymmetric muscle contraction or drooping of
the shoulder may be seen with paralysis or
muscle weakness due to neck injury
Abnormal Findings of CN XII
 Atrophy of the tongue may be seen with
peripheral nerve disease
 Deviation of the affected side is seen with a
unilateral lesion
Deep tendon reflexes
Interpretations
None
Hypoactive
Normal
Mild hyperactive with
clonus (uncontrollable
jerks of the muscle)
Hyperactive with clonus
Babinski response
 Stroke the lateral aspect of the sole of each foot
using a blunt object
 Note movements of toes
o Normal – withdrawal
o Abnormal – extension of big toe with
fanning of other toe
Biceps reflex
 Test the spinal cord level C5-C6
Triceps reflex
 Test the spinal cord C7-C8
Brachioradialis reflex
 Test the spinal cord C5-C6
Patellar reflex
 Test the spinal cord level L2-L4
(continuation ata ito? sa page 3, upper left corner)
Achilles reflex
 Test the spinal cord level S1-S2
D. Reflex
 An automatic response of the body to a
stimulus
 Not voluntary learned or conscious
Plantar reflex (Babinski)
 Normal: (-)
 Babinski: all five toes bend down
Deep tendon reflex
 It is activated when a tendon is stimulated
(tapped) and its associated muscle contracts
 As persons ages, reflex response may become
less intense
E. Motor Function
 Evaluates proprioception and cerebellar
function
Abnormal response to touch
Anesthesia
 Loss of sensation
Structures involved:
 Proprioceptors – are sensory nerve terminals,
occurring chiefly in the muscles, tendons, joints,
and the internal ears, that give information
about movements and the position of the body
 Posterior columns of the spinal cord
 Cerebellum
 Vestibular apparatus in the labyrinth of the
inner ear
Hyperesthesia
 More than normal sensation
F. Sensory Function
Includes:
 Touch
 Pain
 Temperature
 Position
 Tactile discrimination
Types of Tactile Discrimination
1. One and Two Point Discrimination
 The ability to sense whether one or two areas
of the skin are being stimulated by pressure
Check for the sense of touch, presence of pain, and
temperature
 Face
 Arms
 Legs
 Hands
 Feet
If with numbness, peculiar sensation, paralysis
 Check sensation more carefully over flexor and
extensor surfaces of the limb, examining about
every 2cm (1inch)
Hypoesthesia
 Less than normal sensation
Paresthesia
 Abnormal sensation such as burning, pain, or an
electric shock
2. Stereognosis
 The act of recognizing objects by touching and
manipulating them
Graphestesia
 Ability to recognize writing on the skin purely by
the sensation of touch
Sensory exam: Vibration
(huy gagi, hindi ko na alam saang part ito, sorry T^T)
Extinction Phenomenon
Normal findings
 Both points of stimulus are felt
Deviation from normal
 Failure to perceive touch on one side of the
body when two symmetric areas of the body
are focused simultenously (common to clients
with lesions of the sensory cortex)
Commented [T1]: Ito rin, nakakalito na yung Page 57 onwards
ng PDF file ni maam T^T
Motor function

Gross motor and balance test
1. Walking Gait
Normal findings
 Has upright posture and steady
 Gait with opposing arm swing; walks unaided,
maintains balance
Deviation from normal
 Has poor posture and unsteady; irregular
staggering gait with wide stance, bends legs
only from hips
 Has rigid or no arm movements
Walking Abnormalities
Waddling Gait
 A distinctive duck-like walk that may appear in
childhood or later in life
Propulsive Gait
 A stooped, rigid posture, with the head and
neck bent forward
Scissors Gait
 Legs flexed slightly at the hips and knees, giving
the appearance of crouching, with the knees
and thighs hitting or crossing in a scissors-like
movement
Spastic Gait
 A stiff, foot-dragging walk caused by one-sided,
long term, muscle contraction
Steppage Gait
 Foot drop where the foot hangs with the toes
pointing down, causing the toes to scrape the
ground while walking



Neurodegenerative illnesses
Skeletal abnormalities and disease
Toxic reactions
Romberg Test
Normal findings
 Negative romber: may sway slightly but is able
to maintain an upright posture and foot stance
Deviation from normal
 Positive Romberg: cannot maintain foot stance;
moves feet apart to maintain stance
 Ataxia – lack of coordination of the voluntary
muscles
 Cebellar ataxia – cannot maintain balance
whether eyes are shut or open
Standing on One Foot with Eyes Closed
Normal findings
 Maintain stance for at least 5 seconds
Deviation from normal
 Cannot maintain stance for 5 seconds
Heel-Toe Walking
Normal findings
 Maintains heel-toe walking along a straight line
Deviation from normal
 Assumes a wider foot gait to stay upright
Toe or Heel Walking
Normal findings
 Able to walk several steps on toes or heels
Deviation from normal
 Cannot maintain balance on toes or heels
Fine Motor Test for the Upper Extremities
Abnormal Gait may be caused by:
 Central Nervous System disorders of the brain
tha cause muscular problems resulting in gain
disturbance
 Spinal cord abnormalities
 Degenerative muscle diseases
A. Finger-to-Nose Test
Normal findings
 Repeatedly and rhythmically touches the nose
Deviation from Normal
 Misses the nose or gives slow response
B. Alternating Supination and Pronation of Hands and
Knees
Normal findings
 Can alternately supinate and pronate hands at
rapid pace
Deviation from normal
 Performs with slow, clumsy movements and
irregular timing; has difficulty alternating from
supination to pronation
C. Finger to Nose and to the Nurse’s fingers
Normal findings
 Performs with coordination and rapidly
Deviation from normal
 Misses the finger and moves slowly
B. Toe or Ball of Foot to the Nurse’s Fingers
Normal findings
 Moves smoothly, with coordination
Deviation from normal
 Misses your finger; cannot coordinate
movement
(Hinid ko sure kung part pa ba ito for lower extremities)
Light-Touch Sensation
Normal findings
 Light tickling or touch sensation
Deviation from normal
 Anesthesia, hyperesthesia, hypoesthesia or
paresthesia
D. Fingers to fingers
Normal findings
 Performs with accuracy and rapidity
Pain sensation
Normal findings
 Able to discriminate “sharp” and “dull”
sensations
Deviation from normal
 Moves slowly and is unable to touch fingers
consistently
Deviation from normal
 Areas of reduced, heightened, or absent
sensation (map them for recording purposes)
E. Fingers to Thumb (same hand)
Normal findings
 Rapidly touches each finger to thumb with each
hand
Temperature sensation
 Not normally done if client’s pain sensation is
intact
Normal findings
 Able to discriminate between “hot” or “cold”
sensations
Deviation from normal
 Cannot coordinate this fine discrete movement
with either one or both hands
Fine Motor Tests for the Lower Extremities

Done in a supine position
A. Heel down opposite Shin
Normal findings
 Demonstrates bilateral equal coordination
Deviation from normal
 Has tremors or is awkward; heel moves off shin
Deviation from normal
 Areas of dulled or lost sensation
Position or Kinesthetic sensation
Normal findings
 Can readily determine the position of fingers
and toes
Deviation from normal
 Unable to determine the position of one or
more fingers or toes
Assessment of the Musculo-Skeletal
System
Nursing Assessment
Health history
Pain
 Bone – dull, deep ache “boring” in nature
 Fx-sharp and piercing relieved by immobility
 Muscle-soreness
Paresthesia
 Burning, tingling sensation or numbness
Diet
 High purine diet
Family history
Allergy
Physical Exam
Gait

Smoothness and rhythm
Shuffling gait
 Ataxic gait is an unsteady, uncoordinated walk
with a wide base of support and the feet
thrown outward.
Festinating gait
 Antalgic gait an abnormal pattern of walking
secondary to pain that ultimately causes a limp,
whereby the stance phase is shortened relative
to the swing phase.
Posture
 Kyphosis - an increased front-to-back curve of
the spine
 Lordosis - the inward curve of the lumbar spine
(just above the buttocks)
 Scoliosis - abnormal lateral curvature of the
spine.
Bone integrity
 Deformities and alignment
Joint function
 Range of motion
 Effusion (presence of fluid)
 Crepitus (abnormal sound)
Neurovascular function
 Assessment of the CNS
 Circulation
 Motion
 Sensation
Indicators of Peripheral Neurovascular Dysfunction
Circulation
 Color: pale or cyanotic
 Temperature: cool
 Capillary refill: more than 3 seconds
Sensation
 Paresthesia
 Pain
 Pain on passive stretch
 Absence of feeling
Motion
 Weakness
 Paralysis
Assessing Joints
 Inspect size, shape, color, and symmetry. Note
any masses, deformities, or muscle atrophy
 Palpate for edema, heat, tenderness, pain,
nodules, or crepitus
 Test each joint’s range of motion (ROM)
Assessing Muscles
 Test muscle strength by asking the client to
move each extremity through its full ROM
against reference
Rating
5
4
3
2
1
0
Explanation
Active motion
against full
resistance
Active motion
against some
resistance
Active motion
against gravity
Passive ROM
(gravity
removed and
assisted by
examiner)
Slight flicker of
contraction
No muscular
contraction
Strength
classification
Normal
Slight weakness
Average
weakness
Poor ROM
Severe
weakness
paralysis