This document provides information about a course on performing a focused neurological assessment. It includes:
1. An overview of the course objectives, which are to outline a systematic neurological assessment approach, discuss relevant history questions, and describe abnormal neurological exam findings.
2. Details of the neurological history that should be taken, including questions about head injuries, headaches, dizziness, seizures, swallowing issues, coordination, numbness, and past medical history. Considerations for pediatric and elderly patients are also provided.
3. An explanation of examining the mental status, 12 cranial nerves, motor system, cerebellar function, sensory system, spinal tracts, and reflexes during a complete neurological exam.
2. Acknowledgements ________________________________________________________3
Purpose & Objectives ______________________________________________________4
Introduction ______________________________________________________________5
Focused Neurological History _______________________________________________6
Adult Patient ____________________________________________________________6
Infant, Pediatric, and Aging Considerations __________________________________7
The Complete Neurologic Exam ______________________________________________8
Mental Status ___________________________________________________________8
12 Cranial Nerves ________________________________________________________8
Inspect and Palpate the Motor System______________________________________13
Check Cerebellar Function _______________________________________________14
Assess the Sensory System ______________________________________________15
Assess the Spinothalmic Tract ____________________________________________15
Assess Posterior Column Tract ___________________________________________16
Check the Reflexes ______________________________________________________17
The Neurological Recheck or Abbreviated Neuro Exam _________________________19
Motor Function _________________________________________________________19
Pupillary Response _____________________________________________________19
Glasgow Coma Scale ____________________________________________________20
Conclusion ______________________________________________________________21
References ______________________________________________________________22
Post Test Viewing Instructions______________________________________________23
2
3. Acknowledgements
RN.com acknowledges the valuable contributions of…
… Lori Constantine MSN, RN, C-FNP, a nurse of nine years with a broad range of clinical
experience. She has worked as a staff nurse, charge nurse and nurse preceptor on many
different medical surgical units including vascular, neurology, neurosurgery, urology,
gynecology, ENT, general medicine, geriatrics, oncology and blood and marrow
transplantation. She received her Bachelors in Nursing in 1994 and a Masters in Nursing in
1998, both from West Virginia University. Additionally, in 1998, she was certified as a Family
Nurse Practitioner. She has worked in staff development as a Nurse Clinician and Education
Specialist since 1999 at West Virginia University Hospitals, Morgantown, WV.
3
4. Purpose & Objectives
When nurses perform a focused neurological assessment it is important to understand the
fundamental processes of the brain and nervous system. If there is a disruption to any of
these processes, the whole body suffers. This course will discuss specific neurological
history questions and exam techniques for an adult patient. Physical exam techniques such
as inspection, palpation, percussion, and auscultation will be highlighted. Additionally,
throughout the course, you will learn how alterations in your neurological assessment findings
could indicate potential nervous system abnormalities.
After successful completion of this course, the participant will be able to:
1. Outline a systematic approach to neurological assessment.
2. Discuss history questions which will help you focus your neurological assessment.
3. Describe abnormal neurological assessment findings associated with inspection,
auscultation, percussion, and palpation.
Disclaimer
RN.com strives to keep its content fair and unbiased.
The author(s), planning committee, and reviewers have no conflicts of interest in
relation to this course. There is no commercial support being used for this
course.
There is no "off label" usage of drugs or products discussed in this course.
You may find that both generic and trade names are used in courses produced
by RN.com. The use of trade names does not indicate any preference of one
trade named agent or company over another. Trade names are provided to
enhance recognition of agents described in the course.
Note: All dosages given are for adults unless otherwise stated. The information
on medications contained in this course is not meant to be prescriptive or all-
encompassing.
You are encouraged to consult with physicians and pharmacists about all
medication issues for your patients.
4
5. Introduction
The neurological history and exam allows the examiner to pinpoint various areas of the brain
or nervous system that may be dysfunctional. Specific signs and symptoms manifested by
your patient are associated with specific areas of the brain. Nurses observe for signs and
symptoms that may be abnormal and link them to general areas of the nervous system that
may be causing the disturbance. It is also important to recognize when further neurological
injury is manifesting and intervene appropriately. Notifying the physician with your findings
will most likely result in a change in plans for the patient.
Integrate the process of obtaining the neurological history with the steps taken during the
complete physical examination. It may not be necessary to perform the entire neurological
exam on a patient with no suspicion of neurological disorders. You should perform a
complete, baseline neurological examination on any patient that has verbalized neurological
concerns in their history. Always perform the neuro exam at scheduled or periodic intervals
with any patient that has a neurological deficit (Agone et al., 1997; Jarvis, 1996).
Performing an exam and obtaining a history should be
completed in an orderly, symmetrical fashion. This way,
Neuro
you will be certain that all areas are assessed. Each
side of the body should be compared with the other side Most healthcare providers
to detect any abnormalities. Also when completing your shorten the term neurologic or
shift, it is beneficial to perform a brief exam with the neurological to “neuro”. In this
oncoming nurse at the bedside. This process ensures course “neuro” will also
that any subjective portion of your exam will not be represent neurological or
misinterpreted by the next examiner. It allows for neurologic.
baseline neurological status to be ascertained at the
beginning of each shift. Also, any changes in the
patient’s neurological function will be more rapidly
identified.
5
6. Focused Neurological History
If your patient is mentating normally, you can ask the patient the following history questions.
If the patient is not alert and oriented, a family member or friend can provide some of this
information. Past medical records may also provide some answers to the following questions
as well.
Adult Patient
When assessing the nervous system with your adult patient, ASK the following:
Any past history of head injury (location, loss of consciousness)? This question may give you
clues to underlying neurological damage that may change your patient’s baseline.
Do you have frequent or severe
headaches (when, where, how often)?
Pain is a neurologic phenomenon. Most
patients do not complain of pain in the
neurological history. Their complaints of
pain are mentioned more in association
with an extremity, back, or head
assessment.
Any dizziness or vertigo (frequency,
precipitating factors, gradual or sudden)?
Syncope is a sudden lack of strength, a
sudden loss of consciousness usually due
to a lack of cerebral blood flow. It is also Image courtesy of National Aeronautics and Space
known as fainting. Vertigo is experienced Administration (NASA)
as a rotational spinning. It is usually due http://exploration.nasa.gov/articles/05feb_superconduc
tor.html
to neurological disorder or an inner ear
disturbance.
Have you ever had/or do you have seizures (when did they start, frequency, course and
duration, motor activity associated with, associated signs, post-ictal phase, precipitating
factors, medications, coping strategies)? Seizures typically occur in disorders such as
epilepsy. Often, the patient will describe an aura; an auditory, visual, or motor warning of the
impending seizure.
Any difficulty swallowing (solids or liquids, excessive saliva)? Difficult swallowing may clue
you in to a possible abnormality with cranial nerves IX and X.
Any difficulty speaking (forming words or actually saying what you intended)? If the patient
answers yes to this question, then ask when it was first noticed and how long did it last.
These questions may clue you in to potential transischemic attacks (TIA’s), which may be a
warning signal for impending stroke.
6
7. Do you have any coordination problems (describe)? Muscle tone and strength may be
affected by both peripheral and central abnormalities.
Do you have any numbness or tingling (describe)? Any abnormal sensations such as
numbness or tingling may be referred to as parasthesias.
Do you have any significant past neurologic history (CVA, spinal cord injuries, neurologic
infections, congenital disorders)? Specific neurological infections include meningitis and
encephalitis.
Are you exposed to any environmental or occupational hazards? If so, explain type, length,
and nature of exposure. Exposure to insecticides, lead, organic solvents, drugs, and alcohol
may all manifest in neurological symptoms (Jarvis, 1996).
Infant, Pediatric, and Aging Considerations
To obtain the history of an infant or child, the nurse must rely on the parent or caregiver to
provide most of the information. Questions you may wish to ask regarding your infant,
pediatric, or aging patient are listed in the table below:
Additional History for Additional History for Additional History for
Infants Children Elderly Patients
Does the child have any
balance problems? Any
Did the mother have any
unexplained falling? Any problems with dizziness?
health problems during
Muscle weakness? If so when does it occur?
pregnancy?
Difficulty getting up and
down stairs?
Tell me about the baby’s Does the child have any
birth? Premature or term? seizures? Describe the Any decrease in memory or
Birth weight? Apnea? circumstances around change in mental functioning?
APGAR Scores? which they occurred.
Did motor and development
Any tremors in your hands or
Any congenital defects? milestones occur during the
face?
appropriate age range?
Has your child had any
Are sucking and swallowing Any sudden vision changes or
environmental exposure to
coordinated? sudden blindness?
lead?
Any sudden weakness on one
Does baby turn his head Any learning problems in
side of the body and not the
toward touch? school?
other?
Does baby startle with a Any family history of Ever experience loss of
loud noise? neurological disorders? consciousness?
(Jarvis, 1996)
7
8. The Complete Neurologic Exam
Not all Patients will require a complete neuro exam. Only patients that describe alterations in
their neuro status or those with altered levels of consciousness will require the most thorough
and complete neuro exam.
When perfoming the complete neuro exam, EXAMINE the following:
Mental Status
The mental status portion of the examination is a series of detailed but simple questions
designed to test cognitive ability. This includes:
• The patient's awareness and responsiveness to the environment
• The senses, appearance and general behavior, mood, content of thought
• Orientation with reference to time, place, and person
Most nurses will not find it necessary to perform a detailed mental status exam. Therefore,
assessing key parts of cognitive ability will usually be sufficient to ascertain mental status and
level of consciousness in their patients. Nurses should always establish if their patient is
oriented to person, place, and time. Additionally, it is important to determine if your patient is
alert. If not, how much stimulation is required - calling their name, light touch, vigorous touch,
pain? Verbal response to your questions should also be assessed and noted.
Nurses should be aware that many neurological diseases such as dementia can cause
changes in intellectual status or emotional responsiveness as well as specific personality
features. If other parts of the neurological exam are within normal limits and you still feel the
patient’s neurological status is impaired, contacting the patient’s physician with details about
the patient’s status and a suggestion for a neuro consult may be warranted.
12 Cranial Nerves
The cranial nerves arise directly from the central
nervous system. Most often, a neurological problem
is detected through the assessment of these nerves.
The cranial nerves are composed of twelve pairs of
nerves that stem from the nervous tissue of the
brain. Some nerves have only a sensory
component, some only a motor component, and
some both. The motor components of cranial nerves
transmit nerve impulses from the brain to target
tissue outside of the brain. Sensory components
transmit nerve impulses from sensory organs to the
brain. A summary of the functions of the cranial
nerves is listed in the table below.
8
9. Cranial Nerve Major Functions
Cranial Nerve I: Olfactory Sensory Smell
Cranial Nerve II: Optic Sensory Vision
Sensory and Motor Eyelid and eyeball
Cranial Nerve III: Oculomotor
– Primarily Motor movement
Innervates superior
Sensory and Motor oblique eye muscle
Cranial Nerve IV: Trochlear
– Primarily Motor Turns eye downward
and laterally
Chewing
Cranial Nerve V: Trigeminal Sensory and Motor Face and mouth touch
and pain
Turns eye laterally
Sensory and Motor Proprioception (sensory
Cranial Nerve VI: Abducens
– Primarily Motor awareness of part of the
body)
Controls most facial
expressions
Cranial Nerve VII: Facial Sensory and Motor
Secretion of tears and
saliva
Vestibulocochle
Hearing
Cranial Nerve VIII: ar Sensory
Equilibrium sensation
(auditory)
Taste
Senses carotid blood
Glossopharyng pressure
Cranial Nerve IX: Sensory and Motor
eal Muscle sense –
proprioception, sensory
awareness of the body
Senses aortic blood
pressure
Slows heart rate
Cranial Nerve X: Vagus Sensory and Motor
Stimulates digestive
organs
Taste
Controls trapezius and
sternocleidomastoid
Spinal Sensory and Motor controls swallowing
Cranial Nerve XI:
Accessory – Primarily Motor movements
Muscle sense -
proprioception
Controls tongue
Sensory and Motor movements
Cranial Nerve XII: Hypoglossal
– Primarily Motor Muscle sense -
proprioception
9
10. When testing the cranial nerves, follow the following guidelines for each cranial nerve.
Cranial Nerve I: Olfactory
Evaluate the patency of the nasal passages bilaterally by asking the patient to breathe in
through their nose while the examiner occludes one nostril at a time. Once patency is
established, ask the patient to close their eyes. Occlude one nostril, and place a small bar of
soap or other familiar smell near the patent nostril and ask the patient to smell the object and
report what it is. Make certain that the patient's eyes remain closed. Switch nostrils and
repeat. Furthermore, ask the patient to compare the strength of the smell in each nostril.
Very little localizing information can be obtained from testing the sense of smell. This part of
the exam is often omitted unless there is a reported history suggesting head trauma or toxic
inhalation.
Cranial Nerve II: Optic
Begin the exam by first testing visual
acuity using a pocket visual acuity chart.
Perform this part of the examination in a
well lit room and make certain that if the
patient wears glasses, they are wearing
them during the exam. Hold the visual
acuity chart 14 inches from the patient's
face, and ask the patient to cover one of
their eyes completely with one hand and
read the lowest line on the chart as
possible. Have them repeat the test Image courtesy of NASA
covering the opposite eye. If the patient http://exploration.nasa.gov/articles/22oct_cataracts.html
has difficulty reading a selected line, ask
them to read the line above. Note the
visual acuity for each eye.
Next evaluate the visual fields via confrontation. Face the patient about one foot away, at
eye level. Tell the patient to cover their right eye with their right hand and look the examiner
in the eyes. Instruct the patient to remain looking you in the eyes and have the patient
indicate when the examiner's fingers enter from out of sight, into their peripheral vision.
Then, extend your arm and first two fingers out to the side as far as possible. Beginning with
your hand and arm fully extended, slowly bring your outstretched fingers centrally, and notice
when your fingers enter your field of vision. The patient should indicate seeing your fingers at
the same time you see your fingers. Repeat this maneuver a total of eight times per eye,
once for every 45 degrees out of the 360 degrees of peripheral vision. Repeat the same
maneuver to test the other eye.
If you are an advanced practice nurse, you may want to use an ophthalmoscope to observe
the optic disc, physiological cup, retinal vessels, and fovea. 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
from its normal yellowish orange.
10
11. Cranial Nerves II & III:
Ask the patient to focus on any object in the distance.
Observe the diameter of the pupils in a dimly lit room.
Direct Light Response:
Note the symmetry between the pupils. Next, shine a
penlight or ophthalmoscope light into one eye at a time When a light shines into one
and check both the direct and consensual light eye the pupil constricts.
responses in each pupil. Note the rate of these reflexes.
If they are sluggish or absent, test for pupillary Consensual Light Response:
constriction via accommodation by asking the patient to When a light shines into one
focus on the light pen itself while the examiner moves it eye the other eye’s pupil will
closer and closer to their nose. Normally, as the eyes also constrict.
accommodate to the near object the pupils will constrict.
The test for accommodation should also be completed in
a dimly lit room.
Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, and
Abducens
Instruct the patient to follow the penlight or ophthalmoscope with their eyes without moving
their head. Move the penlight slowly at eye level, first to the left and then to the right. Repeat
this horizontal sweep with the penlight at the level of the patient's forehead and then chin.
Note extra-ocular muscle palsies and horizontal or vertical nystagmus, which would be
abnormal. Eye movements should be coordinated and smooth.
Cranial Nerve V: Trigeminal
Begin by first palpating the masseter muscles Palsy:
(muscles of chewing or of the jaw) while you Uncontrollable tremor or quivering
instruct the patient to bite down hard. Note via Nystagmus:
observation if there is any masseter muscle Rapid oscillation (movement) of the
wasting. Next, ask the patient to open their eye in any direction, but generally in a
mouth against resistance applied by the instructor back-and-forth manner.
at the base of the patient's chin.
Next, test gross sensation of Cranial Nerve V. Tell the patient to close their eyes and say
"sharp" or "dull" when they feel an object touch their face. Using a semi-sharp object and a
dull object, randomly touch the patient's face with either object. Touch the patient above
each temple, next to the nose and on each side of the chin, all bilaterally. Ask the patient to
also compare the strength of the sensation of both sides. If the patient has difficulty
distinguishing pinprick and light touch, then proceed to check the patient’s ability to sense
temperature and vibration.
Finally, test the corneal reflex using a large Q-tip with the cotton extended into a wisp. Ask
the patient to look at a distant object and then approaching laterally, touch the cornea (not the
sclera) and look for the eye to blink. Repeat this on the other eye. Often, the patient will
blink before the object touches the cornea. This is also normal.
11
12. Cranial Nerve VII: Facial Nerve
Inspect the face during conversation and rest noting any
facial asymmetry including drooping, sagging or smoothing of
normal facial creases. Ask the patient to raise their
eyebrows, smile showing their teeth, frown and puff out both
cheeks. Note asymmetry and difficulty performing these
tasks. Ask the patient to close their eyes strongly and not let
the examiner pull them open. When the patient closes their
eyes, simultaneously attempt to pull them open with your
fingertips. Normally the patient's eyes cannot be opened by
the examiner. Once again, note asymmetry and weakness.
Facial nerves
Cranial Nerve VIII: Acoustic (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. If lateralization (localization of a function
or activity to one side of the body) or hearing abnormalities exist,
and you are a nurse practitioner, perform the Rinne and Weber
tests. (The Rinne and Weber tests are hearing tests performed
using a vibrating tuning fork.)
Cranial Nerve IX & X: Glossopharyngeal and Vagus
Ask the patient to swallow and note any difficulty
doing so. Note the quality and sound of the
patient's voice. Is it hoarse or nasal? Ask the
patient to open their mouth wide, protrude their
tongue, and say "AHH." While the patient is
performing this task, flash your penlight into the
patient's mouth and observe the soft palate, uvula,
and pharynx. The soft palate should rise
symmetrically, the uvula should remain midline, and
the pharynx should constrict medially like a curtain.
Often the palate is not visualized well during this
task. Ask the patient to yawn, which often provides
a greater view of the elevated palate. Use a tongue
Image courtesy of
depressor and the butt of a long Q-tip to test the http://training.seer.cancer.gov/module_anato
gag reflex. Touch the pharynx with the instrument my/unit10_3_dige_region1_mouth.html
on both the left and then on the right side,
observing the normal gag or cough.
12
13. Cranial Nerve XI: Spinal Accessory
Inspect for wasting of the trapezius muscles by observing the patient while standing behind
them. Ask the patient to shrug their shoulders as strong as they can while the examiner
resists this motion by pressing down on the patient's shoulders with their hands. Next, ask
the patient to turn their head to the side as strongly as they possibly can while the examiner
once again resists with their hand. Repeat this test on the opposite side. The patient should
normally overcome the resistance. Note asymmetry.
Cranial Nerve XII: Hypoglossal
Have your patient "stick out their tongue" and move it side to side. Normally, the tongue will
be protruded from the mouth and remain midline. Have the patient say “light, tight, dynamite”
and note the clarity of each distinct word in pronunciation. Note deviations of the tongue from
midline, a complete lack of ability to protrude the tongue, tongue atrophy, and fasciculation
(muscle twitches) on the tongue.
Inspect and Palpate the Motor System
Muscle Size
Does your patient have appropriate size muscles for body type, age, and gender? Atrophy is
abnormally small muscles with a wasted appearance. This can occur with disuse, injury,
motor neuron diseases, and muscle diseases. Hypertrophy occurs with athletes and body
builders. It is characterized by increased size and strength of muscles.
Muscle Strength
Test muscle strength against resistance using a 0 – 5 scale, with 0 = no movement and 5 =
strong muscle strength. Muscle strength should be equal bilaterally.
When testing muscle strength in the arms ask your patient to do the following against
resistance:
• Lift arms away from side
• Push arms towards side
• Pull forearm towards upper arm
• Push forearm away from upper arm
• Lift wrist up; push wrist down
• Squeeze examiners finger
• Pull fingers apart
• Squeeze fingers together
13
14. When testing muscle strength in the legs ask your patient to do the following against
resistance:
• Lift legs up • Pull lower leg towards upper leg
• Push legs down • Push lower leg away from upper leg
• Pull legs apart • Push feet away from legs
• Push legs together • Pull feet towards legs
Muscle Tone
Muscle tone can be described as the amount of resistance or tension in a muscle. Muscle
tone enables us to move and affects posture. Abnormal findings can include: limited range of
motion, pain on motion, flaccidity, decreased resistance, spasticity, or rigidity.
Involuntary Movements
Tics, tremors, and fasciculations (involuntary contraction of a muscle) are all examples of
abnormal involuntary movements you may note on exam. Causes of involuntary movements
may be related to serious disease conditions or damage to specific areas within the brain.
Check Cerebellar Function
Checking cerebellar functioning includes testing
balance, coordination, and skilled movements.
Gait
Have the patient walk heel to toe in a straight line -
forwards and backwards. Assess for abnormalities
such as stiff posture, staggering, wide base of
support, lack of arm swing, unequal steps,
dragging or slapping of foot, and presence of
ataxia.
Romberg’s Test
With eyes closed, have the patient stand with feet together and arms extended to the front,
palms up. Your patient should be able to maintain their balance. Stay next to the patient
when they are performing this test in particular, so if they begin to fall, you can catch them.
Balance should be maintained.
Rapid Alternating Movements
Have your patient rapidly slap one hand on the palm of the other, alternating palm up and
then palm down - test both sides. Abnormal findings might be lack of coordination, or slow,
clumsy movements.
14
15. Finger to Finger Test
Have your patient touch your index finger with their
index finger, as you move your index finger in the space “-algesia” = sensation
around them. Patients with normal cerebellar function
should be able to do this without missing the mark.
Finger to Nose Test
Have your patient touch their nose with their index finger of each hand with eyes shut.
Patients should be able to do this without missing the mark.
Heel to Shin Test
While standing, have your patient touch the heel of one foot to the knee of the opposite leg.
While maintaining this contact, have the patient run the heel down the shin to the ankle. Test
each leg. If your patient misses the mark, lower extremity coordination may be impaired.
Assess the Sensory System
Testing the sensory system checks the intactness of
peripheral nerves, sensory tracts, and higher cortical
discrimination. Have your patient close his eyes while
checking sensory perception. Check the following bilaterally:
Light Touch Can your patient feel light touch equally
on both sides of the body?
Sharp/Dull Can your patient distinguish between a
sharp or dull object on both sides of the
body?
Hot/Cold Can your patient distinguish between a
hot or cold object on both sides of the
body? Sensory neuron
Assess the Spinothalmic Tract
To assess the spinothalmic tract, various sensory tests may be performed to test your
patient’s ability to sense pain, temperature, and light touch.
Presence of Pain
Pain can be tested by a simple pin prick to the arms or legs while the patient’s eyes are
closed. Abnormal findings would include hypalgesia, hyperalgesia, and analgesia.
15
16. Temperature
Temperature tests should be performed only if the pain test is normal. To test for
temperature sensation, hot and cold objects are placed on the patient’s skin at various
locations bilaterally to test for temperature sensation.
Light touch
With a cotton ball or soft side of a Q-tip, touch the patient’s
body bilaterally with their eyes closed. Ask them to indicate “-esthesia” = sensitivity
when you have touched them. Abnormal responses include
hypesthesia, anesthesia, and hyperesthesia.
Assess Posterior Column Tract
Assessing the posterior column tract may identify lesions of the sensory cortex or vertebral
column.
Vibration
Test the patient’s ability to feel vibrations by placing a tuning fork over
various boney locations on the patient’s toes and feet. If these areas
are normal, then you may assume the proximal areas are also normal.
Position
Position or kinesthesia is tested by having the patient close their eyes and move their big toe
up and down. The patient should be able to tell you which way there toes are moving.
Tactile discrimination
Tactile discrimination tests the discrimination ability of the sensory cortex. Stereognosis tests
the patient’s ability to recognize objects by feeling them. You can place car keys, a spoon, a
pencil, or other common object in your patient’s hand. They should be able to identify that
object by feel only. Graphesthesia is the ability to identify a number gently etched to their
palm.
Two point discrimination
Two point discrimination tests the brain’s ability to detect two distinct pin pricks on the skin.
An increase in the distance it normally takes to identify two distinct pricks occurs with sensory
cortex lesions (Jarvis, 1998; Shaw, 1998).
16
17. Check the Reflexes
Reflexes are involuntary actions in response to a stimulus sent to the central
nervous system. Alterations in reflexes are often the first sign of neurological
dysfunction such as upper motor neuron disease, diseases of the pyramidal tract,
or spinal cord injuries.
Stretch or Deep Tendon Reflexes
Deep tendon reflexes, also known as muscle stretch reflexes, are
reflexes elicited in response to stimuli applied to tendons. Normally,
when a specific area of the muscle tendon is tapped with a soft
rubber hammer, the muscle fibers contract. Abnormal responses
may indicate injury to the nervous system pathways that produce the
deep tendon reflex. Deep tendon reflexes can be influenced by age,
metabolic factors such as thyroid dysfunction or electrolyte
abnormalities, and anxiety level of the patient. The main spinal
nerve roots involved in testing the deep tendon reflexes are
summarized in the following table:
Reflex Main Spinal Nerve Roots Involved
Biceps C5, C6
Brachioradialis C6
Triceps C7
Patellar L4
Achilles Tendon S1
Check the deep tendon reflexes with a reflex hammer to stretch the muscle and tendon. The
limbs should be in a relaxed and symmetric position. Strike the reflex hammer across the
selected tendon with a moderate tap. If you cannot elicit a reflex, you can sometimes bring it
out by certain reinforcement procedures. For example, have the patient grit their teeth then
try to elicit the reflex again. Or you may have them clench their fists together when checking
lower extremity reflexes. When reflexes are very brisk, clonus is sometimes seen. This is a
repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon
stretch.
Deep tendon reflexes are often rated according to the following scale:
Rating Reflex Response
0 absent reflex
1+ trace, or seen only with reinforcement
2+ normal
3+ brisk
4+ Non-sustained clonus (i.e., repetitive vibratory movements)
5+ sustained clonus
17
18. Deep tendon reflexes are considered normal if they are 1+, 2+, or 3+. Reflexes that are
asymmetric, or there is a large difference between the arms and legs, or are rated as 0, 4+,
or 5+ abnormal (Jarvis, 1998).
Superficial Reflexes
The following reflexes are considered normal in adults.
• Upper Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side.
• Lower Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side.
• Cremasteric: Stroke inner thigh, elicits elevation of testes.
Can you define Ipsilateral?
It means on the same side or
affecting the same side
The following reflexes are considered ABNORMAL in adults. Absence of superficial reflexes
or unilateral suppression of superficial reflexes often results from upper motor lesions
subsequent to a stroke. Presence of primitive reflexes in adults is often a sign of frontal lobe
lesions.
Reflex Name Method to Elicit
Babinski Sign Stroking the bottom of the foot elicits fanning (eversion) of big toe.
When the external malleolar skin area is irritated, extension of the
Chaddock's Reflex great toe occurs in cases of organic disease of the corticospinal
reflex paths.
Scratching the inner side of leg elicits extension of toes. Sign of
Oppenheim's Sign
cerebral irritation.
Squeeze the calf muscles and note the response of the great toe.
Gordon's Sign
Fanning or extension is considered abnormal.
Flexion of the terminal phalanx of the thumb and of the second and
Hoffman's Sign third phalanges of one or more of the fingers when the palmar
surface of the terminal phalanx of the fingers is flicked.
Gently tapping or rubbing the upper lip elicits a reflexive sucking or
Suck Reflex
puckering response.
Grasp Reflex Stroking the patient's palm, causing him to grasp your fingers. A
positive test occurs when the patient does not let go of your fingers.
Palmomental Sign Rub the thenar eminence (area of palm just below the thumb) ------>
elicit reflexive contraction of the muscles of the chin.
(Agone et al., 1997; Jarvis, 1996)
18
19. The Neurological Recheck or Abbreviated Neuro Exam
Perform the neurological recheck exam at scheduled or periodic intervals with any patient
that has a neuro deficit. This exam is also useful for your inpatient with a head injury or
systemic disease process that may be manifesting as a neuro symptom. When performing
this abbreviated exam, EXAMINE the following, in addition to any previously identified
neurological deficits noted from the complete exam:
Level of Consciousness (Monitors for signs of increasing intracranial pressure)
• Is your patient oriented to person, place, and time?
• Is your patient alert? If not, what does it take to get them alert - calling their name, light
touch, vigorous touch, pain?
Motor Function
• Ask your patient to squeeze your fingers with their hands and let go (tests for strength and
symmetry of strength in the upper extremities).
• Ask your patient to push and pull their arms toward and away from you when their elbows
are bent. Provide some resistance. (tests for strength and symmetry of strength in upper
extremities).
• Ask your patient to dorsiflex and plantarflex their feet, while providing some resistance
(tests for strength and symmetry of strength in lower extremities).
• Ask your patient to perform straight leg raises with and without resistance (tests for
strength and symmetry of strength in lower extremities).
Pupillary Response
• Size, shape, and symmetry of both pupils should be the same.
• Each pupil should constrict briskly when a light is shined into the eyes.
• Each pupil should have consensual light reflex.
19
20. Glasgow Coma Scale
The Glasgow Coma Scale assesses how the brain functions as whole and not as individual
parts (Teasdale, 1975). The scale assesses three major brain functions: eye opening, motor
response, and verbal response. A completely normal person will score 15 on the scale
overall. Scores of less than 7 reflect coma. Using the scale consistently in the healthcare
setting allows healthcare providers to share a common language and monitor for trends
across time (Jarvis, 1996).
Glasgow Coma Scale
Best Eye Opening Response 1 = No response
2 = To pain
3 = To speech
4 = Spontaneously
Best Motor Response 1 = No response
2 = Extension – abnormal
3 = Flexion - abnormal
4 = Flexion – withdrawal
5 = Localizes pain
6 = Obeys verbal commands
Best Verbal Response 1 = No response
2 = Sounds - incomprehensible
3 = Speech - inappropriate
4 = Conversation - confused
5 = Oriented X 3
20
21. Conclusion
Integrating the neurological health history and physical exam takes practice. It is not enough
to simply ask the right questions and perform the physical exam. As the patient’s nurse, you
must critically analyze all of the data you are obtaining, synthesize the data into relevant
problem areas, and identify a plan of care for your patient based upon this synthesis. As the
plan of care is being carried out, reassessments must occur on a periodic basis. How often
these reassessments occur is unique to each patient and is based upon their physical
disorder. Knowing when and how often to reassess is based on the specific patient,
evidence presented, and facility policies, standards, and protocols.
Please Read:
This publication is intended solely for the use of healthcare professionals taking this course, for credit, from
RN.com It is designed to assist healthcare professionals, including nurses, in addressing many issues
associated with healthcare. The guidance provided in this publication is general in nature, and is not designed
to address any specific situation. This publication in no way absolves facilities of their responsibility for the
appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a
part of their own orientation processes should review the contents of this publication to ensure accuracy and
compliance before using this publication. Hospitals and facilities that use this publication agree to defend and
indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and
employees from liability resulting from the use of this publication. The contents of this publication may not be
reproduced without written permission from RN.com.
21
23. Post Test Viewing Instructions
In order to view the post test you may need to minimize this window and click “TAKE TEST.”
You can then restore the window in order to review the course material if needed.
23
