Neurological and Stroke Assessment

A scale used to assess the level of consciousness and evaluate for brain injury.

CN III (Oculomotor), CN IV (Trochlear), and CN VI (Abducens) control eye movement and pupil response.

CN IX (Glossopharyngeal) is responsible for the gag reflex.

Use a tongue depressor to stimulate the gag reflex. If absent, check for pharyngeal sensation.

CN IX is responsible for the posterior tongue, tonsils, pharynx, taste, and pharyngeal muscles.

CN IX (glossopharyngeal) is for taste, posterior tongue, and pharynx, while CN X (vagus) is for the heart, lungs, and digestive system.

CN XII (Hypoglossal) controls the tongue's midline position and side-to-side movement.

CN V (Trigeminal) controls chewing.

CN VII (Facial) controls facial expressions (smiling, frowning, puffing cheeks).

CN II (Optic) is the nerve for vision.

The cerebellum is responsible for balance and coordination.

The cerebrum is divided into four lobes: frontal, parietal, temporal, and occipital, each with specific functions.

Controls emotions, cognition, personality, and Broca's area (speech production).

Processes and integrates sensory information.

Processes smells, sounds, and language.

Processes visual information.

The ability to see, hear, smell, touch, and sense other things, like pain.

Movement, strength, range of motion (ROM), and walking (gait).

Mental status, orientation, and memory.

Begin the assessment as soon as you enter the room.

Sudden, unilateral muscle weakness, slurred speech, facial droop, and aphasia (difficulty speaking or understanding).

The onset of symptoms is often sudden.

These symptoms are urgent because residual deficits may develop.

Unilateral symptoms are more concerning for a stroke.

Do a thorough neurological assessment.

Deficits manifest on the opposite side of the body from the affected brain area.

Inward posturing of the body.

Outward posturing of the body.

A test of balance and coordination, where patient stands with eyes closed.

Nurse should stand beside the patient with one arm in front and one behind to prevent falls.

Instruct the patient to close their eyes.

Swaying or falling, or the need to use arms to maintain balance.

Maintaining posture without swaying or using arms for support.

A negative Romberg test is considered normal.

A scale to assess mental status, evaluating for brain injury severity (mild, moderate, or severe).

Cranial nerves 3, 4, and 6 control eye movement and pupil response.

Cranial nerve 9 (Glossopharyngeal) controls the gag reflex.

Use a tongue depressor to assess responsiveness and then assess pharyngeal sensation if no gag response.

Controls taste, posterior tongue sensations, tonsils, pharynx, and pharyngeal movement.

CN IX (glossopharyngeal): taste, posterior tongue, pharynx; CN X (vagus): heart, lungs, digestive system.

Cranial nerve 12 (Hypoglossal) controls tongue movement (midline & side-to-side).

Cranial nerve 5 (Trigeminal) is responsible for chewing.

Cranial nerve 7 (Facial) controls facial expressions (smile, frown, etc.).

Cranial nerve 2 (Optic) controls vision.

The cerebellum is responsible for balance and coordination.

The cerebrum is divided into four lobes: frontal, parietal, temporal, and occipital, each with different functions.

Controls emotions, cognition, personality, and Broca's area for speech.

Processes and integrates sensory information.

Processes smells, sounds, and language.

Processes visual information.

The ability to see, hear, smell, touch, and feel.

Movement, strength, range of motion, and walking.

Mental status, orientation, and memory.

Begin the assessment as soon as you enter the room.

Sudden, unilateral muscle weakness, slurred speech, facial droop, and aphasia.

The onset of symptoms is often sudden.

Urgent; residual deficits may develop if not addressed quickly.

Unilateral symptoms (one side) are more concerning for a stroke.

Thorough neurological assessment is needed.

Deficits manifest on the opposite side of the body from the affected brain area.

Inward posturing (arms flexed toward the chest).

Outward posturing (arms and legs extended).

A test assessing balance and coordination with eyes closed.

Swaying or falling, or using arms to maintain balance.

Maintains posture without swaying or using arms.

Scale assessing brain injury severity (mild, moderate, or severe) through mental status evaluation.

Cranial nerves 3 (Oculomotor), 4 (Trochlear), and 6 (Abducens) control eye movement and pupil response.

Cranial nerve 9 (Glossopharyngeal) controls the gag reflex.

Use a tongue depressor to assess gag response; if absent, check pharyngeal sensation.

Controls taste, posterior tongue sensation, tonsils, pharynx, and pharyngeal movement.

CN IX (glossopharyngeal): taste, throat; CN X (vagus): broader body functions (heart, lungs, digestion).

Cranial nerve 12 (Hypoglossal) controls tongue movement (midline & side-to-side).

Cranial nerve 5 (Trigeminal) controls chewing.

Cranial nerve 7 (Facial) controls facial expressions (smile, frown, etc.).

Cranial nerve 2 (Optic) controls vision.

Controls balance and coordination.

The cerebrum has four lobes: frontal, parietal, temporal, and occipital, each with specialized functions.

Controls emotions, cognition, and personality; also includes Broca's area for speech.

Processes and integrates sensory information.

Processes sounds, smells, and language.

Processes visual information.

The ability to see, hear, smell, taste, and touch.

Movement, strength, range of motion (ROM), and gait.

Mental status, orientation, and memory.

Start the assessment as soon as you enter the room.

Sudden, unilateral symptoms like weakness, slurred speech, facial droop, or aphasia.

The onset of stroke symptoms is usually sudden.

Stroke symptoms need immediate attention to prevent lasting damage.

Symptoms affecting one side of the body, more concerning for stroke.

A thorough neurological assessment is crucial in stroke situations.

Deficits from a stroke typically appear on the opposite side of the body from the affected brain area.

Inward posturing, with arms flexed towards the body.

Outward posturing, with arms and legs extended.

A test for balance and coordination performed with eyes closed.

Swaying or falling during the Romberg test indicates poor balance and coordination.

Maintaining balance without swaying or using supports during the Romberg test.

Maintaining balance during Romberg test.

A weak pulse in the extremities, often a +1 reading.

A sensation of pins and needles or a loss of feeling.

A condition characterized by decreased bone density, increasing risk of fractures.

A spinal deformity causing a "hunchback" appearance.

A spinal deformity with abnormal lateral curvature, causing uneven shoulders/hips.

An increased curvature of the lumbar spine, often called an "arched" lower back.

"Wear and tear" arthritis caused by breakdown of joint cartilage.

Bony growths on the distal interphalangeal (DIP) joints, specifically in osteoarthritis, ONLY seen in osteoarthiritis.

An autoimmune arthritis affecting the joints and other body parts.

Bony growths in the proximal interphalangeal (PIP) joints, seeing in both osteo and rheumatoid conditions.

Symptoms appearing quickly are usually a higher priority.

The presence of movement restrictions or impairments prior to any treatment or intervention.

The sequence of steps in a physical assessment, typically: Inspection, Palpation, ROM assessment, and Strength assessment

Evaluating the patient's ability to exert force against resistance.

Evaluating the extent of movement a patient can produce in their joints.

Possible indication of a fracture needing immediate stabilization.

Muscle mass tends to decrease with age, increasing the risk of falls.

Provides relief from chronic musculoskeletal pain.

Potential for pain and stiffness.

Bending a joint (e.g., elbow, knee).

Straightening a joint.

Moving a limb away from the midline of the body.

Moving a limb toward the midline of the body.

Moving the foot upward, toes towards the ceiling.

Pointing the foot downward.

Inability to contract muscle without gravity.

Able to contract muscle slightly.

Able to move joint without gravity.

Able to move joint against gravity.

Able to move joint against gravity with some resistance.

Able to move joint fully against full resistance.

Characterized by shuffling steps, slow and short steps, and lack of arm swing.

Uncoordinated and unsteady gait/movements.

Uncoordinated, unsteady movements suggestive of lower extremity weakness.

A critical evaluation comprising pain, paralysis, paresthesia, pallor, and pulselessness.

A warm extremity with a weak distal pulse (+1) is a possible sign of inflammation, and the weak pulse may indicate a circulatory issue.

A sensation of pins and needles or loss of feeling, a concerning symptom possibly related to nerve damage or other issues.

A condition where bones lose density, increasing the risk of fractures, often associated with height loss.

A spinal deformity causing a "hunchback" appearance, commonly seen in older adults due to postural changes.

A spinal deformity characterized by abnormal lateral curvature, causing asymmetry and uneven shoulders/hips.

An increased curvature of the lumbar spine, often referred to as an "arched" lower back, potentially seen during pregnancy.

A type of arthritis resulting from wear and tear on joints, causing pain and stiffness.

Bony growths on the DIP joints, are a sign of osteoarthritis appearing only in those joints.

An autoimmune type of arthritis.

Bony growths on the PIP joints and often seen in both Osteoarthritis and Rheumatoid Arthritis.

Inspect, palpate, assess range of motion, assess strength.

Range of motion (ROM) is assessed before strength.

May indicate a fracture; immobilize the extremity immediately.

Muscle mass naturally decreases with age.

Chronic musculoskeletal pain.

Potential for pain or stiffness.

Bending a joint (e.g., elbow, knee).

Straightening a joint.

Moving a limb away from the midline of the body.

Moving a limb toward the body's midline.

Moving the foot upward at the ankle.

Moving the ankle downwards.

No muscle contraction.

Slight muscle contraction.

Muscle movement against gravity.

Movement against gravity with some resistance.

Full range of motion with some resistance.

Full range of motion with full resistance.

Shuffling, slow steps, no arm swing.

Uncoordinated, unsteady movements and gait.

Indicates weakness of lower extremities and may indicate a problem with the cerebellum.

5 P's: Pain, Paralysis, Paresthesia, Pallor, Pulselessness