Which elements of the patients primary sensory function would the nurse assess?

The nervous system is a very complex system which is vital to the functioning of the human body. The nervous system is comprised of the central nervous system (CNS) and peripheral nervous system (PNS).

There are 31 pairs of spinal nerves and 12 pairs of cranial nerves. Below are some tips for performing a Nursing Health Assessment of the Nervous System.

For more information about performing a nursing health assessment read the article Tips for A Better Nursing Health Assessment.

This will help you proceed through an assessment including the nervous system as you move from head-to-toe. This article contains 5 tips for Performing a Nursing Health Assessment of the Nervous System.

Comprehensive Assessment of the Nervous System vs. A Hospital Recheck.

A comprehensive or complete nursing health assessment of the nervous system is done when a neurological concern or dysfunction is suspected.

A basic check or recheck of the nervous system can be done during a normal head-to-toe assessment. During a health assessment of the nervous system, you will assess the cranial nerves, motor function, sensory function, and reflexes.

These tips cover all the basics for a comprehensive or complete nursing health assessment of the nervous system.

You will use the techniques of observation, inspection, palpation and other techniques and methods to gather information about specific neurological functions.

Tip #1 – Gather Information about the Patient’s History, Activities of Daily Living (ADLs) and Mental Status.

Assess Patients history. This information will help guide your assessment.

1. Have you ever had a head or back injury?
2. Have you ever been diagnosed with a neurological illness?
3. If yes, what was the problem?
4. When were you diagnosed?
5. What treatment did you receive?
6. Was the treatment helpful?
7. Are the symptoms you are having now a recurrence of this problem?

Asses the patient’s ADL’s. Ask the following questions.

1. Has there been a change in your ability to carry out daily activities?
2. Describe the changes.
3. How long have you noticed these changes?
4. Did you notice the symptoms gradually or all of a sudden?

Observe the following

1. Patient”s hygiene.
2. Note the patient’s grooming.
3. Observe the patient’s posture.
4. Pay close attention to the patient’s body language.
5. Note the patient’s facial expression.
6. Listen to the patient’s speech. In listening to the patient’s speech, listen to the loudness or softness of their voice. Note the rate of speech. Observe the ability to speak clearly and the ability to pronounce words.
7. Can the patient respond to questions with ease?
8. Does the patient follow directions?

Assess the patient’s mental status.

1. Assess the patient’s orientation to date, time, and place.
2. Note the patient’s level of alertness.
3. Assess the patient’s memory by asking them their name, date of birth and age. Ask them about their education and a description of their job.
4. Observe the patient’s body language and the way they communicate.
5. Further, assess the patient’s ability to calculate simple mathematical problems.
6. Assess the patient’s ability to think abstractly.
7. Observe the patient’s emotional state.
8. Assess the patient’s perception and thought process. The patient should be able to respond logically and their answers should be relevant.
9. Note the patient’s ability to make judgments.

Tip #2 – Gather Information on Chief Complaints or Symptoms.

A nursing health assessment of the nervous system involves assessment of the chief complaint and common symptom.

Common symptoms of the nervous system include headaches, dizziness, vertigo, generalized weakness, numbness, seizures, and tremors.

Headaches

Assess for headaches out of the norm. For complaints of headaches, ask the patient the following question.

1. When did the headaches start?
2. How often do the headaches occur?
3. What is the location of the headache? Have the patient point to the area of their head that hurts.
4. Are the headaches always in the same area?
5. How long do the headaches normally last?
6. Is the pain constant or intermittent?
7. What do you think causes your headaches?
8. Are the headaches associated with any other symptoms such as a change in vision or weakness?
9. Do you have a history of migraine headaches?
10. On a scale of 0-10, how severe are your headaches?

Dizziness and Vertigo

Distinguish between dizziness and vertigo. A patient experiencing dizziness may feel light-headed or faint.

A patient experiencing vertigo will have the perception that the room is spinning. Ask the patient the following questions.

1. Do you feel light-headed?
2. Do you ever feel faint? Have the patient describe the fainting.
3. Have you ever felt as if the room is spinning?
4. If yes, when does this occur?
5. Does the fainting occur with any specific activity?
6. Does the fainting occur with a change in position?

Weakness

When assessing weakness in a patient determine if it is generalized or localized. Distinguish between weakness and paralysis.

Weakness is a problem or decreased ability to move a body part.

Paralysis is a loss of motor function. For complaints of weakness, ask the patient the following question.

1. Does the weakness occur with any particular movement or is there an inability to move a body part or a particular side of the body.
2. Did the weakness develop slowly or come on all of a sudden?
3. Has there been an increased or decreased and the severity?
4. Which body part is involved?
5. Does the weakness affect one side of the body or both sides of the body?
6. Are there any other associated symptoms with the weakness?

Numbness or tingling

Paraesthesia is an abnormal sensation of burning and tingling. Ask the patient the following questions.

1. Do you have any numbness or tingling to any part of the body?
2. Does the sensation feel like pins and needles?
3. When did this start?
4. Where are the numbness and tingling located?
5. Does it occur with activity?

Tremors

Tremors are involuntary shaking or trembling of a body part. Ask the patient the following questions.

1. Do you have any shakes or tremors anywhere in your body?
2. Where are the tremors located?
3. When did they start?
4. Do they get worse when you are anxious?
5. Are they worst at rest?
6. Are the tremors relieved with rest or activity?
7. Do they affect your activities of daily living?

Seizures

A seizure is a disorder caused by a sudden excessive electrical discharge in the cerebral cortex. Attempt to get a complete description of the seizure activity. Ask the patient the following question.

1. Have you ever had a seizure?
2. If yes, when did they start?
3. How often do they occur?
4. Do you have any type of warning signs before your seizures?
5. Do the seizures normally affect both sides of your body or just one side?
6. Does your muscle tone tense up or is it limp?
7. Do you lose consciousness during seizures? If so how long?
8. During a seizure, do you have any eyelid fluttering, eye-rolling, or lip-smacking?
9. Are you ever incontinent during a seizure?
10. Do you ever experience any confusion weakness headaches are muscle aches following the seizure?
11. Do you spend time sleeping following a seizure?
12. Have you noticed that there are certain things that bring on your seizures?
13. Are you on any medications?
14. Do the seizures affect your ability to work?
15. Do your seizures affect your ability to perform activities of daily living?

A complete nursing health assessment of the nervous system includes an assessment of the cranial nerves. A thorough assessment of the cranial nerves can be lengthy. For that reason, it is not included in this article but you can click here for our article Assessment of the Cranial Nerves.

Tip # 3 – Assessment of the Motor Function

Assessment of motor function includes the neurological aspect of motor functions.

These functions are directly related to the activity of the cerebellum. This includes coordination, smoothness of movement, and equilibrium.

First, assess the patient’s gait and balance.

1. During this procedure, you are observing the patients posture.
2. Note any stiffness or difficulty with movement.
3. Note the pace the patient is walking.
4. Are their steps even?
5. Watch the arm swing of the patient to see if there is coordination.
6. Note the position the arms assume when walking. And, watch to see if the patient can maintain their balance.
7. Ask the patient to walk across the room and returned.
8. Describe the following method to the patient. Walk heel-to-toe, by placing the heel of one foot (right or left) in front of the toes of the other foot, then the heel of the opposite foot in front of the toes of the other foot.
9. Ask the patient to look straight ahead and not at the floor.
10. Have the patient continue walking in this manner for several yards.
11. Next, ask the patient to walk on his or her toes.
12. Then, ask the patient to walk on their heels.

Next, perform the Romberg test.

The Romberg test assesses equilibrium. For this test stand near the patient and be prepared to support them if they lose their balance.

1. Ask the patient to stand with feet together and arms at their side.
2. Begin with their eye open, then have them close their eyes.
3. Wait for about 20 seconds.
4. The patient should be able to maintain this position with only a little swaying.
5. This is documented as negative Romberg and is normal.

Perform the finger to nose test.

The finger to nose procedure test coordination and equilibrium. During this procedure, you are observing the movements of the arm. How smooth are the patient’s movements? What is the point of contact of the finger? Does the finger touch the nose, or is another part of the face touched?

1. Ask the patient to extend both arms out from the sides of the body.
2. Have the patient keep both eyes open.
3. Ask the patient to touch the tip of the nose with the right index finger and then return the right arm to an extended position.
4. Next, ask the patient to touch the tip of the nose with the left index finger and then return the left arm to an extended position.
5. Repeat the procedure several times.
6. Now, have the patient repeat both movements with both eyes closed.
7. Also, the patient can also perform this procedure by touching the nurse finger first then their nose. Do this with each hand.

Next, perform the rapid alternating movement test.

The test assesses coordination. Observe the patient’s hands as they perform the procedure. Is the rhythm, continuous? Are the movements smooth or clumsy?

1. Ask the patient to sit with the hand’s palms down and pat the thigh.
2. Next, have them turn their hand palms up and pat their thigh with the back of the hand.
3. Ask them to return the hands to palm down position.
4. Now, have the patient alternate the movement as they increase the speed.
5. If you suspect any deficits you can test one side at a time.
6. Additionally, ask the patient to touch the thumb to each finger with increasing speed.
7. It would help if you demonstrate these procedures for the patient.

Next, perform the heel to shin test.

During this procedure observe the smoothness of the action. The patient’s heel should follow a straight line and not fall off the leg.

1. Place the patient in a supine position.
2. Have the patient place the heel of the right foot below the left knee.
3. Now, ask the patient to slide the right heel along the shin bone down to the ankle.
4. Have the patient repeat the procedure on the opposite leg.

Tip #4 – Assessment of the Sensory Nerves

There are several sensations used to test the sensory system. The sensations which are used include pain, light touch, hot and cold, sharp and dull, and vibration, stereognosis, graphesthesia, and two-point discrimination.

Assessing for pain.

1. To assess for pain use a pinprick.
2. Break a tongue blade forming a fractured end with a point and a dull end on the rounded side.
3. Lightly apply the sharp point or the dull end to the patient’s body in random, unpredictable order.
4. Ask the person to say “sharp” or “dull”, depending on the sensation felt.
5. Give at least two seconds between each stimulus.

Assess a patient’s ability to identify light touch.

1. Using a wisp of cotton, touch various parts of the body, including feet, hands, arms, legs, abdomen, and face.
2. Touch at a random location and use random time intervals.
3. Instruct the patient to say “now” when the stimulus is felt.

Assess the patient’s ability to distinguish temperature.

1. Perform this test only if the patient demonstrates an absence or decrease in pain sensation.
2. Touch the patient with a test tube containing warm or cold water.
3. Have the client describe the temperature. (Hot or cold)
4. Be sure to test corresponding body parts.

Assess the patient’s ability to feel vibrations.

1. This procedure requires a tuning fork.
2. While holding the tuning fork by the handle, gently strike the fork on the palm of your hand. This will start the tuning fork vibrating.
3. Place it on a bony part of the body, such as the toes, ankle, knee, iliac crest, fingers, sternum, wrist, or elbows.
4. Ask the patient to say “now” when the vibration is perceived and “now” again when it is no longer felt.
5. If the patient’s perception is accurate when you test the most distal body parts, end the test at this time.
6. If the patient’s perception is not accurate proceed to test a point proximal to those points that are diminished.

Test stereognosis.

Sterognosis is the ability to identify an object without seeing it.

1. Instruct the patient to close both eyes.
2. Place an object in the patient’s right hand. Objects such as keys, coin, cotton balls can be used.
3. Ask the patient to identify it.
4. Placed a different object in the left hand.
5. Ask the patient to identify it.
6. The objects you use must be familiar and safe to hold.
7. Test more than one object and test each object independently.

Test graphesthesia.

Graphesthesia is the ability to perceive writing on the skin.

1. Instruct patient to keep both eyes closed.
2. You may use the wooden end of a cotton applicator as a pen.
3. Trace a number such as 5 into the palm of the patient’s right hand.
4. Be sure the number faces the patient.
5. Ask the patient to identify the number.
6. Repeat in the left hand using a different number such as 3 or 2.
7. Ask the patient to identify the number.

Perform the two-point discrimination test.

This test assesses a patient’s ability to discriminate between two points.

1. During this test, you will simultaneously touch the patient with two stimuli over a given area at the same time.
2. You may use the unpadded end of two cotton applicators.
3. Vary the distance between the two points you are stimulating.
4. The level of discrimination will vary depending on the location. The more distal the location, the more sensitive the discrimination.
5. Ask the patient to say “now” when the two points of stimuli are first perceived.
6. You will note the smallest distance between the points at which the patient can perceive two different stimuli.

Assess kinesthesia.

Kinesthesia is a person’s ability to perceive the passive movement of the extremities.

1. Ask the patient to close both eyes.
2. Grasp the patient’s great toe.
3. First, move the joint into dorsiflexion.
4. Continue to move the joint into plantar flexion, and abduction.
5. Ask the client to identify the movement by saying “up”, “down”, etc.

Tip # 5 – Assess the Reflexes

Assessment of the reflexes requires the use of a reflex hammer. Remember, that this is a complete neurological assessment. You will not see this done a lot in hospital settings. However, this is practiced in the nursing lab and usually makes great test questions.

Some Practice is needed to properly handle the reflex hammer. When using the reflex hammer use just enough force to get a response. Compare the right and left sides. The responses should be equal. Grade the response on a 4-point scale listed below.

Assess the biceps reflex.

1. Support the patient’s lower arm with your non-dominant hand.
2. Hold the reflex hammer in your dominant hand.
3. The patient’s arm needs to be slightly flexed at the elbow with palm up.
4. Compress the bicep tendon with the thumb of your non-dominant hand.
5. Using the pointed side of the reflex hammer, briskly tap your thumb.
6. Observe for a contraction of the biceps muscle and slight flexion of the forearm.

Assess the triceps muscle reflex.

1. Support the patient’s arm just above the elbow with your non-dominant hand.
2. Have the patient to let you support their arm. They should let their arm go limp.
3. Hold the reflex hammer in your dominant hand.
4. Briskly tap the tendon just above the olecranon process with the pointed end of the reflex hammer.
5. Observe for a contraction of the triceps muscle with the extension of the lower arm.

Assess the brachioradialis reflex.

1. Position the patient’s arm so the elbow is flexed and the hand is resting on the patient’s lap
2. Have the palm in a semi pronated position.
3. Hold the patient’s thumb.
4. Using the flat end of the reflex hammer, briskly strike the tendon toward the radius side about 2 or 3 in about the wrist.
5. Observe for flexion of the lower arm and supination of the hand.

Assess the quadriceps reflex.

1. Position the patient in a sitting position.
2. Allow the lower leg to dangle.
3. Briskly strike the tendon just below the patella with the flat end of the reflex hammer.
4. Observe for extension of the lower leg and contraction of the quadriceps muscle.

Test the Achilles tendon reflex.

1. Position the patient so that the knee is flexed and the hip is externally rotated.
2. Dorsiflex the foot of the leg being tested.
3. Hold the foot slightly in the non-dominant hand.
4. Strike the Achilles tendon with the flat end of the reflex hammer.
5. Observe for plantar flexion of the foot.

Assess plantar reflex.

1. Position of the leg with a slight degree of external rotation at the hip.
2. Stimulate the sole of the foot from the heel to the ball of the foot on the lateral aspect.
3. Continue the stimulation across the ball of the foot to the big toe.
4. Observed for plantar flexion, in which the toes curl.
5. It may be necessary to hold a patient’s ankle to prevent movement.

Assess abdominal reflexes upper and lower.

1. Place the patient in a supine position with the knee slightly bent
2. Using an applicator or tongue blade.
3. Stroke the abdomen from the side toward the umbilicus.
4. Observe muscular contractions and movement of the umbilicus is toward the stimulus.
5. Repeat this procedure in the other three quadrants of the abdomen.

In conclusion, the tips above will help you with a nursing health assessment of the nervous system. A comprehensive or complete nursing health assessment of the nervous system is done when a neurological concern or dysfunction is suspected.

A basic check or recheck of the nervous system can be done during a normal head-to-toe assessment. Don’t forget to read the Assessment of the Cranial Nerves to complete the comprehensive nervous system assessment.

Reference

Bickley LS., Szilagyi PG., (2017). Bates Guide to Physical Examination and History Taking. 12th ed. Philadelphia, PA. Wolters Kluwer/Lippincott Williams & Wilkins.
Jarvis C., (2017). Physical Examination & Health Assessment. St Louis, MO. Elsevier Inc.
Mosby’s Medical Dictionary (2017). 10th ed. St Louis, MO. Elsevier Inc.

Disclaimer: The information contained on this site is not intended or implied to be a substitution for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained is provided for educational purposes only. You assume full responsibility for how you chose to use this information.

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