ASSESSMENT OF THE NERVOUS SYSTEM

The nervous system consists of :
the central nervous system (CNS)
the peripheral nervous system,(PNS)
the autonomic nervous system(ANS)
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.
neurological assessment
A complete neurological assessment consists of five steps:
o Mental status exam
o Cranial nerve assessment
o Reflex testing
o Motor system assessment
o Sensory system assessment.
ON YOUR EXAM Observe the patient walking, talking, seeing, and hearing. Watching the patient when he is enter the room .
As the patient enters the room, check the following:
Posture and motor behavior.
Dress, grooming, and personal hygiene.
Facial expression.
Speech manner, mood, and relation to persons and things around him
Level of consciousness.
Alert. The patient is awake and verbally and motorally responsive.
Lethargic. The patient is sleepy or drowsy and will awaken and respond appropriately to command.
Stupor. The patient becomes unconscious spontaneously and is very hard to awaken.
Semi coma. The patient is not awake but will respond purposefully to deep pain.
Coma. The patient is completely unresponsive.
The Glasgow coma scale (GCS
ASSESS GRADES OF BEST MOTOR RESPONSE

ASSESS GRADES OF BEST VERBAL RESPONSE

BEST EYE OPENING
Memory (recent and remote)
Orientation
If the patient oriented by :place ,person and time or not

Knowledge (normal intellect)

Ask the patient to name five large cities, major rivers, etc.
These include tests for balance and coordination.
The cerebellum controls the skeletal muscles and coordinates voluntar Cranial Nerve I, The Olfactory Nervey muscular movement
Each nostril should first be evaluated for potency by compressing one nostril and having the patient breath through the opposite.
Each nostril should then be tested separately with a volatile, non-irritating substance such as, coffee or vanilla. The patient should close his eyes, occlude one nostril and identify the substance placed under the open nostril. 
Pupils: Reaction to Light To examine cranial nerves II , III and mid-brain connections
Have the patient look at a distant object
Look at size, shape and symmetry of pupils.
Shine a light into each eye and observe constriction of pupil.
Flash a light on one pupil and watch it contract briskly.
Flash the light again and watch the opposite pupil constrict (consensual reflex).
Repeat this procedure on the opposite eye.
Normal:   
Pupil size is 3-5 mm in diameter.
They react briskly to light. 
Both pupils constrict consensually
Position yourself in front of the patient.Test the patient s visual acuity, each eye separately covering one at a time.
Snellen s chart is used by Ophthalmologists. Visual acuity is recorded as a fraction. The numerator indicates the distance (in feet) from the chart which the subject can read the line.
The denominator indicates the distance at which a normal eye can read the line. Normal vision is 20/20.

Extraocular Muscles To examine cranial nerves III, IV and VI
Inspect the eyes.
Look for symmetry of eyelids.
Note the alignment of the eyes at rest.
Have the patient follow an object into each of the nine cardinal fields of gaze.
Note that both eyes move together into each field.
Eye movements should be smooth and without jerking. 
Eyelids should be gently lifted up by the examiner s fingers when testing downward gaze.

Jerky eye movements,nystagmus) abnormal.)
Corneal reflex: patient looks up and away.• Touch cotton wool to other side.• Look for blink in both eyes, ask if can sense it.• Repeat other side [tests V sensory, VII motor].
Facial sensation: sterile sharp item on forehead, cheek, jaw.• Repeat with dull object. Ask to report sharp or dull.• If abnormal, then temperature [heated/ water-cooled tuning fork], light touch [cotton].
Motor: pt opens mouth, clenches teeth (pterygoids).• Palpate temporal, masseter muscles as they clench.
Motor Function: Facial MusclesTo test cranial nerve VII
Ask the patient to wrinkle his forehead or raise his eyebrows, enabling you to test the upper face
Next, have the patient tightly close his eyes. Test the strength of the orbicularis oculi by gently trying to pry open the patient s upper eyelid.
Instruct him to puff out both cheeks. Check tension by tapping his cheeks with your fingers.
Have the patient smile broadly and show his teeth, testing the lower face.
With eyes closed, the patient should be instructed to acknowledge hearing the gentle rubbing of the examiner s fingers approximately 3-4 inches away from his right and left ear.


A watch, which the examiner can hear at a specific distance from his ear, is placed next to the patient s ear. Ask him to note when the watch sound disappears. Note that the examiner has to have normal hearing to do this exam
The nurse ask the patient to say "aah" and can detect abnormal positioning of certain structures such as the palatel-uvula.
The examiner will also assess the sensation capabilities of the pharynx, by stimulating the area with a tongue depressor, causing a gag reflex.
Inspect Trapezius and Sternocleidomastoid muscles
Note muscle size (bulk).
Look for asymmetry, atrophy .
Determine muscle power by gently trying to overpower contraction of each group of muscles.
Have patient shrug  shoulder against resistance and evaluate strength of Trapezius muscle.
Have patient turn head to one side against resistance and evaluate strength and observe contracting sternomastoid muscle

This nerve tests the bulkحجم and power of the tongue. The examiner looks for tongue protrusion and/or abnormal movements
Positioning Ask the patient to shut his eyes. Grasp the side of the toe between index finger and thumb.
Move the digit up or down and ask the patient to tell you the direction of movement