Neurological System
Assessment – Neurological System
A complete neurological system assessment is divided into five parts:
- Level of consciousness/mental status (For More information see Mental Status Assessment)
- Cranial nerves
- Motor system
- Sensory system
- Reflexes
The assessment sequence starts with inspection and then observation for each of the five parts of the physical examination. The equipment needed includes coffee beans or vanilla, a wisp of cotton, penlight, tuning fork, reflex hammer, tongue depressor, salt, sugar, cotton-tipped applicator, a glass of water, and an ophthalmoscope.
Cranial Nerves
CN I, Olfactory
Check nasal patency and sense of smell in each nostril separately (Use two different scents).
CN II, Optic
Assess visual acuity using the Rosenbaum or Snellen chart, and screen visual fields by confrontation (patient looking directly at examiner)
- Stand in front of the patient and ask the patient to look in your eyes. Put both hands lateral to the patient’s ears. Wiggle fingers and bring hands forward one hand at a time until the patient can visualize your fingers. Repeat this in the upper and lower temporal quadrants. If you find a defect, check nasal fields–have the patient cover one eye at a time. Wiggle fingers of one hand on the same side as the eye that is covered and move from the ear across the face toward the opposite ear. Inspect the optic fundi using an ophthalmoscope.
- Darken the room and ask the patient to gaze into the distance and focus on one object across the room, which will help dilate the pupil (Stanford Medicine 25, n.d.).
- Place the ophthalmoscope against your cheek with your hand; this allows the head, hand, and ophthalmoscope to move as one unit.
- Use your right hand and right eye to examine the patient’s right eye. Look through the ophthalmoscope, adjusting the focus as needed. Direct the ophthalmoscope 15 degrees from the center and look for the red reflex; once found, follow the red reflex until you see the retina. If you lose the red reflex, return and repeat until you find it again. To look around the retina using a traditional direct ophthalmoscope, you should “pivot” the ophthalmoscope, angling up, down, left, and right (Stanford Medicine 25, n.d.). A normal optic fundus will have an optic cup, fovea, optic disc, smaller pale arteries, and a larger, darker vein structure.
Visual Acuity
| Normal Findings | Abnormal Findings |
|---|---|
| Normal distant visual acuity is 20/20; this means that the patient can read what a person with normal eyesight can read at 20 feet. | A higher denominator means poorer distant visual acuity. Nearsightedness • known as myopia, is poor visual acuity; distant objects appear blurred Farsightedness • known as hyperopia, is the ability to see distant objects clearly, but objects nearby may be blurry. Presbyopia • is the inability to focus clearly on near objects |
CN II, Optic and III, Oculomotor
- Assess the size, pupil shape, and reaction to light (direct an