HEALTH

ASSESSMENT

Nursing process:
Introduction: The nursing process enables you to organize and deliver appropriate nursing care to a client.
To successfully apply the nursing process, you need to integrate elements of critical thinking to make
judgments and take reasoned action. The nursing process is used to identify, diagnose and treat human
responses to health and illness (American Nursing Association, 1995). The process includes five steps:
assessment, nursing diagnosis, planning, implementation, evaluation.
Purpose of nursing process: To establish a database about the client’s response to health concerns or
illness or the ability to manage health care needs. Activities:
Establish a database

• Obtain health history

• Conduct physical assessment
• Review client records
• Review literature
• Consult support persons
• Consult health professionals
Update data as needed
Organize data
Validate data
Communicate/document data

HEALTH ASSESSMENTS
Introduction:
Nursing assessment includes two steps. First, collect and verify data from a primary source (the client) and
secondary sources (family, health professionals). Then analyze those data as a basis for developing
nursing diagnoses and an individualized plan of. Nursing care. The purpose of the assessment is to
establish a database about the client's perceived needs, health problems, and responses to these
problems. in addition, the data reveal related experiences, health practices, goals, values, lifestyle e, and
expectations from the health care system.
An assessment must be relevant to a client's particular health problem. You apply critical thinking to
determine what is relevant to include in your client's assessment.
For example, if a woman comes to an urgent care setting because of a possible ankle fracture, you
consider the implications of a musculoskeletal injury, associated pain, and immobility to focus your
assessment. You do not need her childbirth or surgical history.
Your assessment will focus on the ankle injury and its effects on the client. Definition:
Assessment is a continuous process carried out during all phase of the nursing process. For example, in
the evaluation phase, assessment is done to determine the outcomes of the nursing strategies and to
evaluate goal achievement. All phases of nursing process depend on the accurate and complete collection
data (information). Purpose:
To establish a database (all the information about the client):

• Nursing health history.

• Physical assessment.
• The physician’s history & physical exanimation  Results of laboratory & diagnostic tests.
• Material from other health personnel.

Types of Assessment:
a. Initial comprehensive assessment
An initial assessment, also called an admission assessment, is performed when the client enters a health
care from a health care agency. The purpose is to evaluate the client's health status to identify functional
health patterns that problematic, and to provide an indepth, comprehensive database, which is critical for
evaluating changes in the client's health status in subsequent assessments.
b. Problem-focused assessment
A problem focus assessment collects data about a problem that has already been identified. This type of
assessment has a narrower scope and a shorter timeframe than the initial assessment. In focus
assessments, nurse determines whether the Problems still exists and whether the status of the problem
has changed (i.e. improved, worsened, or resolved). This Assessment also includes the appraisal of any
new, overlooked, or misdiagnosed problems. Intensive care units, may perform focus assessment every
few minutes.
c. Emergency assessment
Emergency assessment takes place in life- threatening situations in which the preservation of life is the top
priority. Time is of the essence in rapid identification of and intervention for the client's health problems.
Often the client's difficulties involve airway, breathing and circulatory problems (the ABCs). Abrupt changes
in self-concept (suicidal thoughts) or roles or relationships (social conflict leading to violent acts) can also
initiate an emergency. Emergency assessment focuses on essential health patterns and is not
comprehensive.
d. Time-lapsed assessment or ongoing assessment
Time lapsed reassessment, another type of assessment, takes place after the initial assessment to
evaluate any changes in the client’s functional health. Nurses perform time-lapsed reassessment when
substantial periods of time have elapsed between assessments (e. g., periodic output patient clinic visits,
home health visits, and health and development screenings). Steps of assessment:
1. Collection of data
 Subjective data
 Objective data
2. Validation of data
 3. Organization of data
4. Recording/documentation of data
Collection of data
Data collection includes the gathering of subjective and objective data from or about your client.
Subjective data are your clients ‘perceptions about their health problems, only clients can provide this kind
of information.
For example, a client's report of headache pain is a subjective finding. Only the client can provide
information about its frequency, duration, location, and intensity. Subjective data usually include Feelings of
anxiety, physical discomfort, or mental stress. Subjective data are more difficult to measure
Objective data is based on an accepted standard, such as a thermometer, on which the Fahrenheit or
Celsius scale is the standard unit of measure for body temperature. For example, when assessing
headache pain, you further assess your client for areas of stress and lifestyle issues. During the
assessment you obtain data about your client’s job related stressors and lack of exercise that may
contribute to frequent headaches. You only minimally assess areas like skin condition and nutrition,
because they do not relate to the client’s headache.
Methods of data collection
Interview: an interview is a planned communication or a conversation with a purpose, for example, to give
information, identify problems with mutual concern, evaluate change, teach, provide support, or provide
counselling or therapy.
The first step in establishing a database is to collect subjective information by interviewing the client. An
interview is an organized conversation with the client to obtain the client's health history and information
about the current illness. During the interview you have the opportunity to
1. Introduce yourself to the client, explain your role, and the role of others
during care.

2. Establish a therapeutic relationship with the client

3. Gain insight about the client's concerns and v[worries

4. Determine the client's goals and expectations of the 5. 0btain cues about which Parts of
the data collection phase require in-depth investigation

Preparation of the environment

To prepare for physical examinations, ensure that the environment is private, quite, comfortable, and well
lighted.

An examination is may be conducted in a special room in an office clinic.

Preparation of equipment:
Assemble all necessary equipment before beginning. Arrange equipment in order of sue to facilitate
examination.
Preparation of the client:
The client is prepared physically and psychologically for the physical examination. Before beginning the
examination, the nurse instructs the client to empty the bladder. If clvine specimen is needed the client is
instructed in the technique for collection at this time. An empty the bladder facilitates examination of the
omega, genital and rectum.
Draping
Physical preparation also includes instructing the client to dress according to the type and extent of
examination to be conducted. A hospital gowns cloths provide privacy.

Positioning
During the examination the client is assisted in assuming different positions – like. The client is kept in
these positions only as long as required and is draped to patient unnecessary exposure.
Positions as follows:
1. Sitting position. 2. Supine position. 3. Dorsal recumbent position. 4. Lithotomy position. 5. Prone position.
6. Knee chest position.
Preparation of the examiner:
The nurse begins the physical examination on meting the client by focusing on the client’s appearance,
movements, position and reaction to the assessment process. A mental plan (check list) is helpful.
SEQUENCE OF EXAMINATION:
The importance of organizing the physical examination systematically follows.
Definition: The physical examination is performed after the history interview. Physical examination skills
require use of eyes, ears and Senses of touch and Smell. Repeated Practice reinforces integration of these
skills. Learn the techniques and correct use of equipment as well as how to discriminate “Normal” from
“abnormal” findings. Physical examinations is used in many settings. Health fairs, screening-clinics,
Physicians’ offices, independent practice clinics, health care and hospitals are some examples.
Purpose: The Purpose of physical examination is to differentiate normal form abnormal physical findings. A
foundation of basic anatomy (Structure) and physiology (function0 is key to developing skill, expertise, and
an appreciation for the wide range of findings that are considered normal. In addition to collecting base line
data, use assessment skills to make clinical Judgements about health status and to evaluate the
effectiveness of health care interventions.
Levels of Physical Examinations:
Physical examinations are available, depending on client need.
(1) A screening physical examination is an organized, superficial check of major body systems for
detecting abnormalities or possible findings.
 (2) If a problem is detected the examination focuses on a regional or branching examination, which is
an in depth assessment of a specific body system.
(3) A complete physical examination which includes ancillary procedures such as xray studies and
clinical laboratory tests, etc.
Accuracy of Physical Examination:
The Physical examination helps to validate data collected during the health history interview. As with the
health history, strike to collect accurate, through data. If you encounter difficulty with an assessment
technique or question the accuracy of a findings, consult with colleagues.
Physical examination and the Nursing Process:
An accurate data base is essential for formulating individualized nursing diagnosis. It may be misleading to
diagnose a problem on the basis of one assessment finding. A complete assessment is necessary before
data can be grouped and a cause determined. The initial physical assessment is the baseline for the
client’s functional ability. Physical assessment is also used as intervention (e.g. monitoring lung sounds) to
evaluate changes in the client’s physical condition and to determine whether expected outcomes have been
achieved.
TECHNIQUES OF PHYSICAL EXAMINATION:
Four primary techniques are used in physical assessment inspection, palpation, percussion and
auscultation. These techniques are enhancing the data collected by observations of ears, eyes, and senses
of touch and smell and are use as indicated during the examination of each body region.  Inspection
Inspection is the systematic, deliberate visual examination of the entire client or a region. Inspection yields
information about size, shape, colour, texture, symmetry, position and deformities.
During Inspection, compare observations with the known parameters of normal finding in clients of age,
sex, race and ethnicity.
Inspection is enhanced with special instruments such as a penlight, otoscope, ophthalmoscope, and
various speculum. That permits visual access to body cavities. Others equipment includes tongue blades, a
marking pen, a ruler, a tape-measure, skin fold callipers and eye charts.
 Palpation:
Palpation is the use of touch. During palpation, exert varying amounts of pressure to determine information
about masses, pulsation, organ size, tenderness or pain swelling and moisture, in addition use palpation to
asset masses for position, size, shape, consistency and nobility.
Technique: Use the most sensitive parts of your hands and fingers to palpate specific characters. E.g.: The
finger tips to palpate pulses, lymph nodes and breast tissue. Back of the hand and fingers are used to
discriminate changes in skin temperature.
Levels of Palpation:
Light Palpation: It depresses the underlying tissue approximately 1 to 2 cm. After the palpation use deep
palpation to determine size and condition of underlying structures, such as abdominal organs.
Deep palpation: It depress the underlying tissue approximately 4 to 5cm.
Bimanual palpation: Place hand sensing hand lightly on the client’s skin and place the other hand over the
sensing hand to apply pressure.
 Percussion:
Percussion is a technique to asses tissue density by sound produced from striking the skin. With this step
which is usually the 3rd technique in physical assessment 3 to 5 cm of tissue depth care be examined. If the
body structure containing air, fluid, & solids produces various sounds depending on their density.
Methods:
1) Direct: It involves striking the body surface with either one or Two Fingers or the first.
2) Indirect: Is placed firmly on the body’s surface.
 Auscultation:
It is the listening to internal body sounds to assess normal sounds and detect abnormal sounds.
Types:
Pitch: Is the number or frequency of sound wake cycles per second, by varying the frequency one may alter
the pitch.
1) Intensity: The amplitude of a sound wake, the greater the amplitude, the louder the sound. The lower
the amplitude, the softer the sound.
2) Duration: The length of time a sound endures: It may be long, medium or short.
3) Quality: A description of a sound’s character, such as “gurgling”, “blowing”, “whistling”, a) “snaping”.

Neurological examination
Introduction
Neurological assessment is an important part of the patient assessment. Disorder of the nervous system
are seen in all age groups. Neurological assessment enables students to perform a comprehensive
assessment including history taking, physical examination, assessment of cranial nerves, assessment of
sensory functions and reflexes.
A good knowledge of the anatomy and physiology of the nervous system is crucial in performing or effective
assessment of the nervous system. In neurological examination it is important for the clinicians to
understand the communication key.
Definition
A Neurological examination is focused on finding out whether there are lesions in the central and peripheral
nervous systems or there is another diffuse process that is troubling the patient.
Used both as a screening tool and investigative tool.

It is a systematic examination that surveys the functioning of nerves delivering sensory information to the
brain and carrying motor commands ( Peripheral nervous system) and impulses back to the brain for
processing and coordinating ( central nervous system )
PURPOSE
To identify the presence of any neurological dysfunction , screening for the presence of discrete
abnormalities in patients at risk for the development of neurological disorders.
INDICATION
It is a part of routine physical examination
Trauma or injury which may involve possible impairment the nervous system . for example- head injury,
spinal injury
Neurological disorder
Other disorder which have a clinical presentation in the form of headaches , altered consciousness ,
numbness and tingling in arms and legs , decreased movements of extremities, change in balance or
coordination etc
Mental health disorder
COMPONENTS OF NEUROLOGICAL EXAMINATIONS
1- Level of consciousness
2- Mental status examination
3- Special cerebral functions

4- Cranial nerve functions

5- Motor functions
6- Sensory functions
7- Cerebellar functions
8- Reflexes

GENERAL INSTRUCTIONS

1. Wash hands thoroughly before touching the patients

2. Warm hands by rubbing hands together before examining patients
3. Ensure privacy, dignity and comfort of the patient
4. Expose only the necessary area that needs to be exposed for the examination
5. When assessing for the first time , ensure that a comprehensive examination is done.
6. Explain the procedure to the patient and explain how long the procedure may take . obtain verbal
consent.
7. Ensure that assessment is conducted in a well lit area that ensure privacy
8. Encourage patient to empty bladder so that examination is done comfortably
9. Proceed in a systematic and organized manner

S no ITEMS S no ITEMS

1 Vitals tray 12Wooden Spatula

2 Sphygmanometer Snellens chart
3 Stethoscope Pen and paper to record
4 Tunning fork findings
5 Knee hammer Safety oins
6 Coffee powder/talcum powder Cotton tiped applicatiors
7 Test tubes wiyh hot and cold water Measuring tapes
 8 Opthalmoscope A coin
9 Wisk of cottons Eye occulator
10 Torch Eye drops/ dialting drops
11 Sugar/salt

NEUROLOGICAL HISTORY TAKING

Assessment begins with focused history taking of the patient .
History taking include:
A) General information - age , gender and occupation of the patients
B) Chief Complaints :- nature of symptoms, onset, characterstics,prescipitating factors and
releiving factors
C) Past Medical History - birth defect of the brain , spinal cord injuries, brain aneurysim, brain
injury, cereberal palsy
D) Deug history
E) Family history
F) Social history
G) All recent diagnostic test pertaining to the neurological system including radiological studies.

NEUROLOGICAL ASSESSMENT
1Level of consciousness
Mental status examination
Special cereberal functions
Cranial nerve functions
Motor functions
Sensory functions
Cereberall functions
Reflexes

ASSESSEMNT OF LEVEL OF CONSCIOUSNESS

Assessment of level of consciousness include following category
 consciousness : patient is alert, attentive and follows command
 If sleeping, awakens promptly to external stimulation and remains attentive.
 Lethargic :- patient is drowsy but wakes up and follows commands but is slow to respond and
sometimes inattentive.
 Obtunded :- Patient is difficult to arouse and needs constant stimulation to follow command . goes back
to sleep almost immediately between stimulation.
 Stupors :- patient wakes up to vigorous and continuous stimulation and respond to painful stimuli by
withdrawing. Patient typically doesn’t follow commands.
 Comatose:- patient has no response when to noxious [Link] reflexive movement is seen.
Nurses responsibility is to recognise a change in mental status from what it was before and identify the time
of occurance. Is the symptoms is indicative of stroke , then time of occurance is of utmost impotance for
therapeutic meausres to be started.
Use of tool - GCS

2- COMPONENT OF MSE

 General appearance and behaviour

 Speecht
 Moods and affect
 Thought
 Perception
 Cognitive functions
 Insight

ASSESSMNET OF SPECIAL CEREBERAL FUNCTIONS

 Agnosia :- inability to recognise through senses , inability to process sensory information
Example:- loss of ability to recognise objects, persons sounds,shapes, smells while the specific sense is
not defective nor is there any significant memory loss

Damage to brain:- especially occipitotemporal border

 Apraxia:- loss of ability to exexute or carry out skilled movements and gesture , despita having the
physical ability and desire to perform them.
 Inability to communicate

4 :- CRANIAL NERVE ASSESSMENT

There are 12 pairs of cranial nerve. The cranial nerves are classified into sensory, motor or both.
Assessment of cranial nerves depend on the patients diagnosis, patient cooperation and level of
consciousness.
The I (olfactory), II (optic), and VIII (vestibulocochlear) nerves are entirely sensory. Cranial nerves III
(oculomotor), IV (trochlear), VI (abducens), XI (accessory), and XII (hypoglossal) are classified as motor,
although they do contain proprioceptive afferent fibers. Cranial nerves V (trigeminal), VII (facial), IX
(glossopharyngeal), and X (vagus) are mixed. All cranial nerves except the olfactory nerves are connected
to the brain stem (medulla, pons, mesencephalon), and all are distributed in the head and neck except the
vagus, which also supplies structures in the thorax and abdomen.
Cranial nerve function is commonly assessed as part of a general physical examination of the head, eyes,
ears, nose, throat, and neck by physicians. More comprehensive examination of cranial nerve functions is
usually done by specialists such as neurologists, ophthalmologists, optometrists, and audiologists

Olfactory nerve - CN-I

Testing Sense of Smell -
This tested separately in each nostril, after confirming the patency of the nostrils, and with the eyes closed.
oil, clove oil, soap, etc. can be used. Irritating and pungent substances like ammonia are avoided as
trigeminal nerve is also stimulated.
There is a strong relationship between the sense of smell and taste, which combine to give a perception of
flavour, Normal olfaction is therefore necessary to appreciate taste.
Anatomy
The olfactory nerve begins in the form of about 20 branches on each side of upper nasal cavity from the
bipolar cells located in the olfactory epithelium (the first-order neurons). These branches pierce the
cribriform plate of the ethmoid bone and synapse with the mitral and tuft cells. The axons of these cells
(mainly mitral cells) continue in the olfactory bulb and tract and lie in the olfactory groove in the basifrontal
region. The olfactory tract divides into medial and lateral olfactory striae. The primary olfactory cortex is
located in the medial temporal lobe (hippocampus).
Purpose of the test
. To determine whether any impairment of the sense of smell is unilateral or bilateral, and whether it is due
to local nasal disease or to a neural lesion.
Method of testing
. Small bottles containing essences of very familiar odours are required. These must indeed be familiar.
Asafoetida and even musk are sometimes advised, but are useless. Coffee, almonds, chocolate, oil of
lemon and peppermint are amongst the many that are suitable.
• Local acute or chronic inflammatory nasal disease; heavy smoking.
• Head injury*- usually thought due to tearing of olfactory fila-ments. The trauma may be surprisingly slight
and often occipital.
• Intracranial tumours, most commonly inferior frontal, malignant or benign, compressing the olfactory bulb
or tract.
• Atrophy* of the olfactory bulbs.
• Chronic meningeal inflammation (e.g. syphilis) or infiltration (e.g. sarcoidosis).
• Parkinson's disease.

OPTIC NERVE:-CN-II
Check central and peripheral vision . CN II has purely sensory function. Assessment of the optic nerve
involves the following step
1- Inspection :- inspect the eye for foreign bodies, cataract, inflammation or other obvious
abnormalities
2- Visual acuity :-in this snellen chart is used for the assessment of vision.
It can be wall mounted or hand held
Method :- patient is asked to read the letters or numbers on the lowest line that the patient can read with 50
% accuracy is recorded.
The eyes should be tested individually and then together.
Each line has a fraction written next to it . 20/20 means normal vision. 20/400 means that patient vision 20
feet from an object is equivalent to that of a normal person of the same object from 400 feet.
If the chart is handheld , it is to be positioned 14 inches away from the eye.
If the chart is not availabe then - hold 5 fingers in front of the patients 6 inches away from eye - Ask patient
to identify how many fingers he/she can see.
3- VISUAL FIELD TESTING:- it involve testing the peripheral vision
METHOD:- the examiner should be nose to nose with the patient, separated by approximately 8-12 inches.
Each eye is checked separately, the examiner closes one eye and the patient closes the opposite.
The open eyes should then be starting directly at one another
Instruct the patient to look at your nose.
Move your index fingers to check the superior and inferior fields one at a time.
Ask the patient to note any movement in the peripheral visual fields and indicate that to you.
3) Assess Pupil
Assess the size, shapes , symmetery , reactiveness of both pupils.
A change in size, shape and reactivity - early sign of brain injury, increased ICP
POSSIBLE abnormal findings
Trauma to orbit or eyeball
Fracture of optic foramen
Diabetic retinopathy
Laceration or blood clots in brains temporal,periorbital or occipital lobes and increased ICP

OCCULOMOTOR NERVE- CRANIAL NERVE III

This nervE control pupillary constriction and elevation of upper lid
Method:- Dim room light as necessary.
Ask patient to look into distance to avoid effect of accommodation.
Shine bright light obliquely into each pupil.
size and shape of pupil is noted.

CRANIAL NERVE IV AND V AND VI

Oculomotor, Trochlear, Abducens Nerves

Because these nerves help move the eye , they are tested together.
TROCHLEAR- Supplies the superior oblique muscles
Abducent- lateral rectus muscle
occulomotor- medial,superior,inferior recti and inferior oblique muscles
Visual inspection-
Look at ocular alignment at rest (primary gaze), Does the reflection of light hit at same location in each
eye? Is one eye deviated in, out, up and down?
Observe for ptosis (lid droopiness).

6 cardinal directions of gaze-

Stand 3-6 feet in front of patient.
Ask patient to follow you finger with the eyes without moving the head, keep head fix, making an X OR 4 or
rectangle shape in front of patient , making sure that your fingers moves far enough out /in and down and
up so that you are able to see all appropriate eye movements
Move your finger in the six cardinal direction and observe whether movements are full in each eye.
observation
Dis-conjugate gaze - vestibulocerebellar problems
CN III Oculomotor: moves
eyes in all directions except
outward and down & in; opens
eyelid; constricts pupil
CN IV Trochlear:
moves eyes
down and in….
CN VI Abducens: moves eyes outward

EOM’s:
(extraoccular movement)
assessment of eye
movement in all directions ( III, IV VI)

Convergence-
Ask patient to follow your finger with the eyes without moving the head. Hold lids up necessary.
Move your finger toward bridge of patient’s nose and observe eye movements.
Drooping of eyes(ptosis)/pupillary abnormality/eye muscle weakness

TRIGEMINAL NERVE CRANIAL NERVE - 5

HAS two components: Sensory part and Motor part
Facial sensation- sensory part
Use sharp end of a broken cotton swab or a pin to test pain sensation on forehead, check and jaw of each
side of face.(3 division)
Ask patient to tell you whether it feels about the same on both sides.
Eyes should be closed.
Motor part:-

b Temporalis and Masseter strength -

Ask patient to open mouth and clench teeth.
Palpate temporalis and masseter muscles just above the mandibular angle.
pupillary abnormalities, and eye muscle weakness.
The sensory component of the trigeminal nerve (CN V) is tested by having the patient identify light touch
(cotton) and pinprick in each of the three divisions (ophthalmic, maxillary, and mandibular) of the nerve on
both sides of the face. The patient's eyes should be closed during this part of the examination. The motor
component is tested by asking the patient to clench the teeth and palpating the masseter muscles just
above the mandibular angle. The corneal reflex test evaluates CN V and CN VII simultaneously, It involves
applying a cotton wisp strand to the cornea. The sensory component of this reflex (corneal sensation) is
innervated by the ophthalmic division of CN V. The motor component (eye blink) is innervated by the facial
nerve (CN VII). This reflex is not normally tested in patients who are awake and alert because other tests
evaluate these two nerves. However, for patients with a decreased level of consciousness, the corneal
reflex test provides an opportu nity to evaluate the integrity of the brainstem at the level of the pons
because the fibers of CN V and CN VII have connections in this area.

Facial nerve :- Facial nerve. The facial nerve (CN VII) innervates the muscles of facial expression. Its
function is tested by asking the patient to raise the eyebrows, close the eyes tightly, purse the lips, draw
back the corners of the mouth in an exaggerated smile, and frown. The examiner should note any
asymmetry in the facial movements because they can indicate damage to the facial nerve.
Although taste discrimination of salt and sugar in the anterior two thirds of the tongue is a function of this
nerve, it is not routinely tested unless a peripheral nerve lesion is suspected.

Procedure to test motor component of the facial nerve:

 Ask your patient to:

o  smile
o  lift their eyebrows
o  frown
o  close their eyes tightly
 o  pucker their lips
o  wrinkle the forehead

Vestibulocochlear nerve (CN VIII)

The vestibulocochlear nerve is a sensory nerve that conveys sound information and balance (Acoustic
nerve. The cochlear portion of the acoustic (vestibulocochlear) nerve (CN VIII) is tested by having the
patient close the eyes and indicate when a ticking watch or the rustling of the examiner's fingertips is heard
as the stimulus is brought closer to the ear. Each ear is tested individually, and the distance from the
patient's ear to the sound source when first heard is recorded. This test identifies only gross deficits in
hearing. For more precise assessment of hearing, an audiometer is used . The vestibular portion of this
nerve is not routinely tested unless the patient complains of dizziness, vertigo, or unsteadiness or has
auditory dysfunction. If this is the case, caloric testing, which is beyond the scope of routine testing, may be
done.

equilibrium).

Materials: tuning fork

1. Rinne Test.

This test is used to identify impairment in the conduction of sound though the external and middle ear, to
the sensory areas of the inner ear. It is done by comparing air conduction with bone conduction.

 Strike a tuning fork against the palm of your hand (never strike the tuning fork against a hard
surface)
 Place its handle on the subject’s mastoid process.
 When the subject no longer hears the sound, move the prongs (they should still be vibrating) to the
opening of the external auditory meatus (be careful not to touch it). Normally, the hum will be heard
again; if not, conduction impairment is suspected.
 Record your results in the worksheet.
 Repeat on the other side of the head.
 Figure 9. Placement of the tuning fork behind
next to the ear (not touching the subject) and then with the base of the tuning fork touching the subject on
the bone behind the ear.

2. Weber Test.

This is another test used to identify defects in conduction. The Weber Test is only useful if there is an
asymmetrical hearing loss. If hearing is symmetrical, the patient perceives the sound in the middle of their
head.

 Strike a tuning fork against the palm of your hand and place the handle against the middle of the
subject’s forehead.
 Ask the subject on which side, if any, the sound seems louder.
 Record your results.

Figure 10. Placement of the base of the

tuning fork touching the middle of the subject’s forehead for the Weber Test.

3. Romberg Test.
The Romberg test evaluates a subject’s ability to maintain balance and equilibrium, using proprioceptors
and the vestibular apparatus (utricle and saccule) without the aid of vision. Impairment of the dorsal white
column of the spinal cord (transmits information from proprioceptors to the brain), the vestibular apparatus,
the basal ganglia or the cerebellum can be detected during this test. Note: If equilibrium impairment exists,
the subject may topple over. Have at least one person standing by to stabilize the subject if this happens.

Procedure:

 Have the subject stand near the wall with the tape on it.
 Have the student stand so you can see at least one set of lines on each side the subject’s body,
parallel to it.
 Have the subject stand in place, feet together, with their eyes open, staring straight ahead for 30
seconds. Note any swaying movements, using the lines on the board as a reference.
 Repeat the test, this time with the subject’s eyes closed. Again, note the degree of side-to-side
movement.
 Repeat the test again (steps in bold above) with the subject standing perpendicular to the wall (the
left shoulder is near the wall, but not touching it)

4. Auditory Frequency Test.

Determine the subject’s range of hearing by listening to a spectrum of sounds from YouTube. Use the
headphones, but please make sure the volume is turned to 30 (right side lower task bar), or higher
frequency sounds will be unpleasant.

Use the spectrum to determine the low and high frequency values for your hearing.

Put on the headphones. Open the “Week5_20Hz to 20 kHz” file from the P-drive. Click pause to record
when you start hearing and when you stop hearing the sounds

Glossopharyngeal and vagus nerves. The glossopharyngeal and vagus nerves are tested together because
both innervate the pharynx. The glossopharyngeal nerve (CN [X) is primarily sensory. In the gag reflex
(bilateral contraction of the palatal muscles initiated by stroking or touching either side of the posterior
pharynx or soft palate with a tongue blade), the sensory component is mediated by CN IX and the major
motor component by the vagus nerve (CN X). It is important to assess the gag reflex in patients who have a
decreased level of consciousness, a brainstem lesion, or a disease involving the throat musculature. If the
reflex is weak or absent, the patient is in danger of aspirating food or secretions. The strength and
efficiency of swallowing are important to test in these patients for the same reason. Another test for the
awake, cooperative patient is to have the patient phonate by saying "ah" and to note the bilateral symmetry
of elevation of the soft palate. Any asymmetry can indicate weakness or paralysis.
Swallowing is also assessed by lightly holding the examiner's hands on either side of the patients throat
and asking to swallow. Any asymmetry is noted.

Spinal accessory nerve. The spinal accessory nerve (CN XI) is tested by asking the patient to shrug the
shoulders against resistance and to turn the head to either side against resistance. There should be smooth
contraction of the sternomastoid and trapezius muscles. Symmetry, atrophy, or fasciculation of the muscle
should also be noted.
· Have your lab partner stare straight ahead.
· Place your hand on their right cheek.
· Have them turn their head to the right against the resistance of your hand.
· Repeat this procedure on the left side.
· For each side, assess the strength of the muscle contraction using a scale of 1 (very weak) to 4 (very
strong).
· Observe whether there are any differences in the strength of the muscle contraction between the two
sides.
· Record your observations.
· Have your lab partner sit up straight on the lab stool.
· Place your hands on their shoulders.
· Ask them to shrug their shoulders against resistance.
· Assess the strength of the contraction using the scale mentioned above.
· Compare the strength of the contraction between the two sides
· Record your observations

Hypoglossal nerve. The hypoglossal nerve (CN XII) is tested by asking the patient to protrude the tongue. It
should protrude in the midline. The patient should also be able to push the tongue to either side against the
resistance of a tongue blade. Again, any asymmetry, atrophy, or fasciculation should be noted.

Hypoglossal nerve (CN XII)

The hypoglossal nerve is a motor nerve to the intrinsic muscles of the tongue.

Procedure:

 Ask your lab partner to protrude their tongue in the midline.

 Look for any deviations to the right or left.
 The tongue should not deviate from the midline.
 Record your observations.

Motor system:-. The motor system examination includes assessment of bulk, tone, and power of the major
muscle groups of the body, as well as assessment of balance and coordination. The examiner tests
strength by asking the patient to push and pull against the resistance of the examiner's arm as it opposes
flexion and extension of the patient's muscle. The patient should be asked to offer resistance at the
shoulder, elbow, wrist, hips, knees, and ankles. The patient's grip strength can also be tested.
Mild weakness of the upper extremities may be tested by having the patient extend both arms forward at
shoulder height with palms up while the eyes are closed. Mild weakness of the arm is demonstrated by
downward drifting of the arm or pronation of the palm (pronator drift). Any weakness or asymmetry of
strength between the same muscle groups of the right and left side should be noted.
Tone is tested by passively moving the limbs through their range of motion; there should be a slight
resistance to these movements. Abnormal tone is described as hypotonia (flaccidity) or hypertonia
(spasticity). Involuntary movements (e.g., tics, tremor, myoclonus [spasm of muscles], athetosis [slow,
writhing, involuntary movements of extremities], chorea [involuntary, purposeless, rapid motions], dystonia
[impairment of muscle tone))should be noted.
Cerebellar function is tested by assessing balance and coordination. A good screening test for both balance
and muscle strength is to observe the patient's stature (posture while standing) and gait. The examiner
should note the pace and rhythm of the gait and observe the arm swing. (The arms should move
symmetrically and in the opposite direction of the leg on the same side.) The patient's ability to ambulate is
a key factor in determining the amount of nursing care that is needed and the risk of injury from falling. A
patient with cerebellar disease may have an ataxic or staggering gait, in which the feet are placed wide
apart and the steps are unsteady.
Coordination can be easily tested in several ways. The finger-to-nose test involves having the patient
alternately touch the nose with the index finger, then touch the examiner's finger. The examiner repositions
the finger while the patient is touching the nose so that the patient must adjust to a new distance each time
the examiner's finger is touched. These movements should be performed smoothly and accurately. Other
tests include asking the patient to pronate and supinate both hands rapidly and to do a shallow knee bend,
first on one leg and then on the other.
Dysarthria or slurred speech should be noted because it is a sign of incoordination of the speech muscles.
The heel-to-shin test involves having the patient place one hee on the opposite shin below the knee and
moving the heel down the shin to the ankle. This is repeated for the other leg. These movements should
flow smoothly without jerking or hesitation.

Sensory system. Several modalities are tested in the somatic sensory examination. Each modality is
carried by a specific ascending pathway in the spinal cord before it reaches the sensory cortex.
There are some general guidelines for performing the sensory examination. The patient should always
have the eyes closed to avoid visual clues. The examiner should avoid giving verbal cues such as, "Is this
sharp?" The sensory stimulus should be applied in such a way that the patient does not expect it; that is,
the examiner should avoid rhythmic application of the stimulus. In the routine neurologic examination,
sensory testing of the four extremities is sufficient. However, if a disturbance in sensory function of the skin
is identified, the boundaries of that dysfunction should be carefully delineated.

Light touch. Light touch is usually tested first. The examiner gently strokes a cotton wisp over each of the
four extremities and asks the patient to indicate when the stimulus is felt by saying
"touch." (The sensory examination of the trigeminal nerve may be delayed until this time because the same
material for testing sensation is used.)

Pain and temperature. Pain is tested by touching the skin with the sharp end of a pin. This stimulus is
irregularly alternated with a simple touch stimulus with the dull end of the pin to determine whether the
patient can distinguish the two stimuli. Extinction or inhibition is assessed by simultaneously stimulating
opposite sides of the body symmetrically with either a pain or a touch stimulus. Normally, the simultaneous
stimuli are perceived (sensed); perception of only one may indicate a parietal lobe lesion.
The sensation of temperature is tested by applying tubes of warm and cold water to the skin and asking the
patient to identify the stimuli with the eyes closed. If pain sensation is intact, assessment of temperature
sensation may be omitted because both sensations are carried by the same ascending pathways.

Vibration sense. Vibration sense is assessed by applying a vibrating C128 tuning fork to the fingernails and
the bony prominences of the hands, legs, and feet with the patient's eyes closed.
The examiner asks the patient if the vibration or "buzz" is felt.
The examiner then asks the patient to indicate when the vibration ceases. The examiner stops the vibration
with the hand as desired.

Position sense. Position sense is assessed by placing the thumb and forefinger on either side of the
patient's forefinger or great toe and gently moving the finger up or down. The patient is asked to indicate
the direction in which the digit is moved.
Another test of position sense of the lower extremities is the Romberg test. The patient is asked to stand
with the feet together and then close his or her eyes. If the patient is able to maintain balance with the eyes
open but sways or falls with the eyes closed (i.e., a positive Romberg test), this may indicate disease in the
posterior columns of the spinal cord. It is important that the nurse be aware of patient safety during this test.

Cortical sensory functions. Several tests evaluate cortical integration of sensory perceptions (which occurs
in the parietal lobes). Two-point discrimination is assessed by placing the two points of a calibrated
compass on the tips of the fingers and toes.
The minimum recognizable separation is 4 to 5 mm in the fingertips and a greater degree of separation
elsewhere. This test is important in diagnosing diseases of the sensory cortex and peripheral nervous
system.

Graphesthesia (ability do feel writing on skin ) is tested by having the patient identify numbers traced on the
palm of the hands. Stereognosis (ability to perceive the form and nature of objects) is tested by having the
patient identify the size and shape of easily recognized objects (e.g., coins, keys, a safety pin) placed in the
hands. Sensory extinction or inattention is evaluated by touching both sides of the body simultaneously. An
abnormal response occurs when the patient perceives the stimulus only on one side. The other stimulus is
"extinguished."

Reflexes. Tendons attached to skeletal muscles have receptors that are sensitive to stretch. A reflex
contraction of the skeletal muscle occurs when the tendon is stretched. A simple muscle stretch reflex is
initiated by briskly tapping the tendon of a stretched muscle, usually with a reflex hammer. The response
(muscle contraction of the corresponding muscle) is measured as follows: 0/5 absent, 1/5 weak response,
2/5 normal re-sponse, 3/5 exaggerated response, 4/5 hyperreflexia with clonus.
Clonus, an abnormal response, is a continued rhythmic contraction of the muscle with continuous
application of the stimulus.
In general, the biceps, triceps, brachioradialis, and patellar and Achilles tendon reflexes are tested. The
examiner elicits the biceps reflex by placing the thumb over the biceps tendon in the antecubital space and
striking the thumb with a hammer. The patient should have the arms partially flexed at the elbow with the
palms up. The normal response is flexion of the arm at the elbow or contraction of the biceps muscle that
can be felt by the examiner's thumb.
The triceps reflex is elicited by striking the triceps tend above the elbow while the patient's arm is flexed.
The normal response is extension of the arm or visible contraction of the tricep.
The brachioradialis reflex is elicited by striking the radius 3 to 5 cm above the wrist while the patient's arm
is relaxed. The normal response is flexion and supination at the elbow or visible contraction of the
brachioradialis muscle.
The patellar reflex is elicited by striking the patellar tendon just below the patella. The patient can be sitting
or lying as long as the leg being tested hangs freely. The normal response is ex tension of the leg with
contraction of the quadriceps.
The Achilles tendon reflex is elicited by striking the Achilles tendon while the patient's leg is flexed at the
knee and the foot i dorsiflexed at the ankle. The normal response is plantar flexion a the ankle.
 Innervated by (including cranial
Muscle Effect of Contraction
nerve number):
 Superior rectus Eye rotates to look up Oculomotor nerve (III)
Medial rectus Eye rotates to look medially Oculomotor (III)
Inferior rectus Eye rotates to look down Oculomotor (III)
Lateral rectus Eye rotates to look laterally Abducens (VI)
Superior oblique Medial rotation Trochlear (IV)

Inferior oblique Lateral rotation Oculomotor (III)

Innervated by (including cranial

Muscle Effect of Contraction
nerve number):
Superior rectus Eye rotates to look up Oculomotor nerve (III)
Medial rectus Eye rotates to look medially Oculomotor (III)
Inferior rectus Eye rotates to look down Oculomotor (III)
Lateral rectus Eye rotates to look laterally Abducens (VI)
Superior oblique Medial rotation Trochlear (IV)
Inferior oblique Lateral rotation Oculomotor (III)
igure 6. Muscles controlled by the accessory nerve.
BIBILIOGRAPHY

1. Black J.M., Hawks JH, Keene AM. Medical surgical Nursing. Clinical management for positive out
comes. 6th ed. Pennsylvania: Saunders; 2003 P-163.
2. Kozier B, Erb G, Blais K, Wilkinson JM. Fundamentals of Nursing, concepts, process, and practice.
5th ed. Addison – wisely 1995. P-466.
3. BT Basavanthappa Medical-Surgical Nursing, 1st ed. New Delhi; 2005 P-22.
4. BT Basavanthappa Fundamentals of Nursing 1st ed., New Delhi; 2002 P-204.

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