LESSON PLAN

ON
NEUROLOGICAL ASSESSMENT

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 LESSON PLAN

Name of the teacher : Kiran Rani

Course: PHD Scholar

Name of the topic : Neurological assessment

Group : Nursing students

Number : 500

Time : 45 monutes

Date : December 2021

Venue : Colleges of Nursing, Moga

Teaching method : Vedio ( Lecture cum discussion ,Demonstration)

A.V aids: Charts, Handouts, Blackboard, Roller boards and flash cards)

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GENERAL OBJECTIVES

After the completion of the class, the nursing students will be acquired knowledge regarding neurological assessment and apply this
knowledge in their clinical practices and identify the person with neurological disorders while clinical experience or in society.

SPECIFIC OBJECTIVES

After the completion of the class the nursing students will be able to:

 define neurological assessment

 enlist the purpose of neurological assessment
 narrate article required for neurological assessment
 mention components of neurological assessment
 illustrate LOC
 describe cranial nerve assessment
 explain motor system examination
 discuss reflex assessment
 Explain sensory assessment
 summarize menigeal irritation assessment

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TIME SPECIFIC CONTENT TEACHER & AUDIO EVALUATION
OBJECTIVE LEANERS ACTIVITY VISUAL
AIDS
1mt To establish Self introduction: Good Morning, Myself Kiran Rani, PHD Teacher establish Verbally
rapport with Scholar in Desh Bhagat University,Mandi Gobindgarh. Today we self rapport with
the group will discuss about Neurological Assessment. students

1mt To assess -What do u know about Neurological Assessment Teacher assess

previous -How many cranial Nerves in Nervous system previous Verbally
knowledge of -Why Neurological assessment is important knowledge of
the students students

5mts To define Neurological Assessment

neurological A neurological examination is the assessment of sensory neuron
assessment and motor responses, especially reflexes, to determine whether the Defining and Vedio what is
nervous system is impaired. This typically includes a physical Explaining (LCD) neurological
examination and a review of the patient's medical history,[1] but assessment
not deeper investigation such as neuroimaging.

5mts To enlist the Purpose What are the

purpose of  Evaluate the function of the nervous system Listening and Vedio purpose of
neurological  Detect nervous system dysfunction explaining (LCD) neurological
assessment  Monitor response to treatment assessment

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  Evaluate patient outcomes
 Identify teaching needs
 Determine highest level of functional ability

To narrate Article required Lecture cum Vedio Which articles

5mts article  Stethoscope Discussion or are required
required for  Gloves Handout for
neurological  tongue depressors s neurological
assessment  a reflex hammer assessment
 a tuning fork
5mts To mention Components of Neurological examination Listening Vedio What are the
components  History and Or Roller components of
of  Physical Exam Explaining Board neurological
neurological  History assessment
assessment  Precipitating Events
 Family History
 Medical Surgical History

Physical Neurological Examination

Components
 Vital Signs
 Consciousness

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  Glasgow Coma Scale
 Motor Function
 Sensory Function
 Cranial Nerve Function
 Reflexes

Glasgow Coma Scale

Quick and easy way to describe baseline LOC Tests
 Eye Opening
 Verbal
 Motor Response
Highest score possible: 15
Lowest score possible 3

To LOSS OF CONSCIOUSNESS (LOC)

5mts illustrate A change in LOC is the earliest & MOST sensitive indication of a Listening Vedio What do you
LOC change in the patients’ neuro status! and (LCD) know about
Sedation should be stopped or decreased for an accurate Explaining LOC
assessment Types of LOC
 Full Consciousness: Alert, awake, responds appropriately
to stimuli, follows commands.
 Confusion: Disoriented, short attention span, agitated,

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 restless, may have hallucinations.
 Lethargic: Drowsy, delayed response to stimuli, slow in
speech and mental process, & may drift off to sleep during
exam.
 Obtunded: Able to arouse with stimulation very drowsy.
Response is minimally maintained. Indifference to
external stimuli exists.
 Stuporous: Minimal spontaneous movement. Verbal
responses are minimal & incomprehensible. Requires
vigorous stimuli to elicit a response.
 Comatose: Awareness & arousal are absent. No response
to verbal or painful stimuli.

CRANIAL NERVE EXAMINATION How we

8mts To describe Cranial Nerve Nerve Type Function Lecture cum (vedio) assess cranial
about cranial Olfactory Nerve Olfaction (Sensory) The patient is discussion LCD nerve
nerve (I) exposed to aromatic and
substances (e.g.,
examination Blackboard
coffee) and asked to
identify the odor.
Optic Nerve (II) Vision (Sensory) The patient is asked
to identify
objects/letters from
predefined distances.

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 Visual field The examiner wags a
finger towards the
patient's visual field
from all sides
Oculomotor nerve Eye Movement Patients are asked to
(III), trochlear (Motor) follow a finger
moving up, down,
nerve (IV),
laterally, and
abducens diagonally with they
nerve(VI) eyes. Observe if
paresis, nystagmus,
or alterations of
smooth pursuit
appear

Visual The physician moves

accomodation a finger towards the
patient. If visual
accommodation is
intact, the finger is
clearly visualized by
the patient at all
times.

Eyelid Ptosis The patient is asked

to open and close the
eyes.
Trigeminal Nerve Facial sensation The examiner lightly

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(V) touches three distinct
facial areas (the
forehead, cheek, and
jaw). Normally, light
touch should be felt
by the patient in all
three areas. If this is
not the case, tests for
abnormalities of
other sensory
modalities (e.g.,
pain, temperature)
should be performed.
Muscle function The patient is asked
(muscles of to open and close
his/her mouth; at the
mastication)
same time, the
examiner palpates
the masseter muscle.

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Facial Nerve Motor function If motor function is
(VII) (muscles of intact, the patient
should be able to
expression)
perform the
following: Forehead
wrinkling Closing
the eyes tightly Nose
wrinkling Inflate the
cheeks Smiling
(showing teeth)
Whistling
Taste If the sense is intact,
the patient should be
able to taste sweet,
salty, and sour
food/drinks

Vestibulocochle Hearing Basic hearing test:

normally, the patient
ar Nerve (VIII)
should be able to
hear two fingers
rubbing together
before the external
acoustic meatus (ear
canal). The Weber
test and Rinne test
allow sensorineural
hearing loss to be
differentiated from
conductive hearing

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 loss (see ENT
diagnostic testing).

Glossopharynge Palatal movement The physician

performs a visual
al nerve (IX) and
inspection of the
vagus nerve (X) uvula and soft
palate: asymmetry
and uvula
deviationindicate
impaired
innervations.
Sense of taste The patient patient is
given a bitter
substance to taste: no
sense of taste
indicates impaired
innervation.
vocalization In case of lesion, the
patient would have
hoarseness or bovine
cough.
Accessory Nerve Trapezius muscle Trapezius muscle:
the patient's shoulder
(XI) and
is elevated against
sternocleidomasto id resistance
Sternocleidomastoid
muscle (motor
muscle: the patient's
function) head is rotated
against resistance

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 Hypoglossal Tongue muscles The tongue should
be pressed against
Nerve (XII) (motor function)
the cheek from the
inside, while the
examiner tests the
strength by pushing
from the outside.
Hypoglossal nerve
paralysis: when the
patients stick out the
tongue, it moves
towards the impaired
side

THE MOTOR SYSTEM EXAMINATION What do u

The motor system evaluation is divided into the following:
Listening and Vedio know about
body positioning, involuntary movements, muscle tone and
10mts To explain Explaining ( LCD ) motor system
muscle strength.
about motor examination
Upper motor neuron lesions are characterized by weakness,
system
spasticity, hyperreflexia, primitive reflexes and the Babinski sign.
examination
Primitive reflexes include the grasp, suck and snout reflexes.
Lower motor neuron lesions are characterized by weakness,
hypotonia, hyporeflexia, atrophy and fasciculations.
Examination of Motor System
Aim: To assess the functional status of the motor system of the
given subject. Steps of motor system assessment

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 Bulk of muscle
 Tone of muscle
 Strength of muscle
 Co-ordination of movements
 Gait
 Involuntary movements
Bulk of Muscle:
By just observing the subject, any significant difference in the
bulk of muscle between both sides of the body can be
assessed. A tape is used to measure the circumference of the
limb at the same distance from a nonmovable bony
prominence, on both sides. The size or bulk of voluntary
muscle varies with age, sex, body build, state of nutrition and
muscular exercise.
Abnormalities include:
(a) Atrophy: In atrophy or wasting, the muscle becomes small
in size. This can occur due to disuse, neurological disorders,
joint injury or joint diseases.
(b) Hypertrophy: Here the bulk of the muscle increases eg,
muscular dystrophies. In pseudomuscular dystrophy due to
pathological changes in the muscles, the muscle bulk
increases, but these enlarged muscles are weak inspite of their

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size.
Tone of Muscle
The mild degree of tension or partial state of contraction found
in normal healthy muscle is referred to as muscle tone. The
tone is assessed by asking the subject to relax completely and
then passively moving the joints of motor system examination
Listener listen, discuss and clarify the doubts motor system
examination the upper and lower extremities. The resistance
offered by the muscle during passive movement represents the
degree of muscle tone. Abnormalities:
Hypertonia: Increase in muscle tone.
a) Spasticity - Seen in upper motor neuron lesions. The muscle
tone is increased and is of clasp knife’ type. As the joint is
passively flexed or extended, there is increased resistance to
begin with, but as the movement is continued the resistance
suddenly decreases.
b) Rigidity
i) Lead pipe rigidity - Characteristic feature of extrapyramidal
lesions. Resistance is felt uniformly through out the
movement. Here both agonists and antagonists muscles
contract.
ii) Cog-wheel rigidity - Here the agonists and antagonists

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muscles contract alternately and regularly during the passive
movement. As there is alternate increase and decrease in
resistance the passive movement will be jerky, like the
movements of a cog wheel. This is seen in extrapyram idal
diseases.
iii) Decorticate and Decerebrate rigidity-In decorticate
position the upper limb is flexed and the lower limb extended -
due to cerebral cortical lesions. In decerebrate rigidity there is
extension of all limbs with internal rotation of the upper limb
and plantar flexion of the feet.
(2) Hypotonia: Decrease in muscle tone. There is decreased
resistance to passive movement there is increased range of
movements in the limbs. This is seen in lower motor neuron
lesion and cerebellar lesions.
Strength of the muscle (Power):
The patient tries to contract the muscle against resistance
offered by the examiner (active method). Assessment:
inspection and palpation of muscle groups
Findings
 Fasciculation: involuntary, asynchronous contraction of
muscle fascicles within a single motor unit; usually
benign but can signify a lower motor neuron lesion

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 Tenderness
 Abnormal movements (e.g., tremor, tic, myoclonus)
 Abnormal posture
 Atrophy or hypertrophy (examined bilaterally)
 Muscle groups are measured to compare specific
differences in size.
 In neurologic disorders, the small hand muscles are often
affected by atrophy.
Power (strength) of the Muscles:
Definition: maximal effort a patient is able to exert from an
individual muscle or group of muscles
Assessment The patient is asked to flex and extend
extremities against resistance Muscle power tests should be
performed bilaterally for comparison Muscle power grading
0 = no contraction (paresis)
1 = flicker or trace of contraction
2 = active movement, with gravity eliminated
3 = active movement against gravity
4 = active movement against gravity and resistance
5 = normal power
Muscle Co-ordeination
Definition: ability to coordinate movements

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Assessment Finger-to-nose test: A test for appendicular Educator
ataxia in which the examiner holds up a finger and the patient described motor
is asked to touch his or her nose and the examiner's finger as system
quickly an alternation as possible. The examiner can move the examination
finger to accentuate the deficits. Patient's with cerebellar
lesions will exhibit dysmetria and/or overshoot the target. Listener listen,
Heel-knee-shin test: Rapid alternating movement test: A discuss and
group of tests for dysdiadochokinesia characterized by clarify the doubts
performing rapidly alternating movements. One of these tests
involves asking patients to tap their laps alternately with the
palm and the back of their hand. Deficits in this task suggest a
cerebellar lesion
Findings
 Dysmetria
 Dysdiadochokinesia
 Gait assessment
 Evidence for vestibular disorders, sensory or cerebellar
ataxia (see “Diagnostics” in cerebellar syndromes)
Assessment
Observation of casual gait: The patient is asked to walk a few
steps forwards and backwards.
Normal gait: steady, natural arm swing

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Abnormal gait: broad-based or unsteady gait, short-stepping
gait Balance test: The patient is asked to place one foot
directly in front of the other as if walking on a tightrope
Foot drop test: The patient is asked to walk on their heels
(impossible in the case of deep fibular nerve lesions)
Walking on tiptoes (impossible in the case of tibial nerve
lesions) Romberg test
Test for assessing ataxia (vestibular, sensory, or cerebellar
ataxia) May help to distinguish between sensory and
cerebellar ataxia.
The patient is asked to stand with both feet together, raise the
arms, and close the eyes.
Positive Romberg: closing the eyes impairs coordination
(patient starts swaying, or swaying increases), which is
indicative of sensory ataxia.
Negative Romberg
Closing the eyes does not affect patient's balance (patient's
swaying does not increase).
Uncontrollable swaying, even with eyes open, is indicative of
cerebellar ataxia.
An increased tendency to fall sideways after closing the eyes
indicates a vestibular disorder.

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 Trendelenburg sign
Tests for neurological insufficiency of the gluteus medius and
gluteus minimus muscles, which are innervated by the
superior gluteal nerve The patient is asked to stand on one leg.
Physiological: when standing on one leg, the pelvis remains
level (no compensatory movements of the upper body) →
Negative Trendelenburg sign
Pathological: pelvic drop towards the unimpaired,
unsupported side → Positive Trendelenburg sign

REFLEX ASSESSMENT How we assess

Tendon Reflex reflexes
5 mts Definition: stretch, monosynaptic reflexes Listening and (Vedio)
To Assessment Explaining LCD
Discuss about During reflex testing, the patient should be relaxed (at least
reflex the muscles involved in the reflex test should be relaxed). (→
assessment also see: radiculopathy)
Elderly patients may have reduced or absent lower deep
tendon reflexes due to normal aging-related changes in
muscles and tendon
Biceps reflex
First, the examiner places his/her thumb on the patient's

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biceps tendon, then the examiner strikes his/her thumb with a
reflex hammer and observes the patient's forearm movement.
Triceps reflex
The examiner holds the patient's arm (forearm hanging
loosely at a right angle) and taps the triceps tendon with a
reflex hammer to induce an extension in the elbow joint.
Knee reflex
Striking the tendon just below the patella (leg is slightly bent)
induces knee extension.
Ankle reflex
Striking the Achilles tendon with a reflex hammer elicits a
jerking of the foot towards its plantar surface. Alternatively,
the reflex is triggered by tapping the ball of a foot from the
plantar side. Adductor reflex
 Tapping the tendon above the medial condyle of femur
elicits the adductor reflex.
 Superficial reflexes
 Definition: polysynaptic reflexes elicited by
stimulation of the skin
 Superficial reflexes are divided into two subgroups:
 Physiological reflexes
 Pathological superficial reflexes: in case of central

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 motor neuron damage, the reflex response decreases.

Abdominal reflex
 Abdominal reflexes are tested with the patient lying
down. The anterior abdominal wall is lightly stroked
with a spatula from lateral to medial (bilaterally) in
following areas:
 below the coastal arch
 around the umbilicus
 above the inguinal ligament
 A normal response is a contraction of the abdominal
muscles, while the absence of contractions is indicative
of nerve root damage.
Anal reflex
Stroking the skin around the anus with a spatula elicits the
anal reflex, which results in a contraction of the anal
sphincter muscles. Cremasteric reflex
The reflex is elicited by stroking the medial, inner part of the
thigh. A normal response is a contraction of the cremaster
muscle that pulls up the testis on the same side of the body.
Primitive reflexes
Brief description: Reflexes that are normal in newborns and

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 infants, but not in adults, where they may appear in case of
diffuse brain injury due to lack of common inhibiting factors
Sucking reflex
Stroking the mouth induces sucking activity.
Palmar grasp reflex
Stroking the palms elicits finger flexion.
Palmomental reflex
Stroking the ipsilateral thenar eminence from proximal to
distal induces a short involuntary contraction of the mentalis
muscle.

SIGNS OF MENIGEAL OR NERVE ROOT How assess

IRRITATION meningeal
5 mts To Definition: triad of nuchal rigidity , headache, and Listening and (Vedio) irritation
Discuss about photophobia, associated with irritation of the inflamed Expaining LCD
menigeal meninges and/or spinal nerves
irritation Examination: The examiner passively flexes the neck of the
assessment patient lying in the supine position.
Causes: subarachnoid hemorrhage (SAH), bacterial
meningitis, etc. Kernig sign: in a supine patient, painful
passive extension of the knee when the thigh is flexed at the
hip (knee at a 90° angle) Brudzinski sign: Involuntary lifting

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 of the legs provoked by passive flexion of the neck in a
patient in supine position Lifting of the legs reduces pain
associated with tension of the irritated meninges and,
especially, the lumbosacral spinal nerves during neck flexion

SENSORY ASSESSMENT
Light touch How do
Dorsal columns sensory
4 mts To To test for symmetry of touch sensation, the examiner Listening and (Vedio) assessment
explain about touches the patient's body at different locations bilaterally. Explaining LCD
sensory In cases of suspected radicular lesions, the particular
assessment dermatome should be examined individually.
In cases of suspected peripheral nerve lesions, diagnostics
should involve checking the areas innervated by the
corresponding sensory nerves.
Finding
Paresthesia
Dysesthesia
Allodynia

Pain and temperature

Spinothalamic tract

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 Implements such as a broken spatula can be used to test pain
sensation bilaterally (e.g., by gently prodding the patient with
the object). Temperature sensation is tested using two objects
of different temperatures (e.g., two test tubes with cold and
warm water).
Finding
Decreased (hypoalgesia) or increased (hyperalgesia) Educator
sensitivity to nociceptive stimuli Proprioception (joint described reflex
position) assessment
Dorsal columns
To test proprioception, the most distal joint of the big toe or Listener listen,
the distal interphalangeal joint of the thumb are held by its discuss and
sides and moved up and down. clarify the doubts
The patient should be able to identify the positional change
with eyes closed.
Finding:
Abnormalities of proprioception suggest and peripheral
polyneuropathy or myelopathy.

Summarize the topic Topic is

1mint To So, Today we discussed about the neurological assessment ,their summarized
Summarize we discussed definition, purpose, components, cranial nerves, Listening cum Verbally

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the topic motor assessment, reflex assessment and sensory assessment. discussion

RECAPTULIZATION
Q What is neurological assessment?
Q What are the purposes of neurological assessment?
Q What are the components of neurological assessment?
Q What do you know about components of neurological
assessment?
Q What do you know about motor system examination?

REFERENCES
1. Brunner & Siddartha’s Medical Surgical Nursing, 10th
edition, Lippincott Williams and willikins, 1904-1908.
2. Chintamani, medical &surgical nursing, Elsevier, 1466-
1469.
3. Kozier, Fundamentals of nursing, 7th edition, 640-650.
4. Suresh Sharma k. Nursing research and statistics, 90-94. 4.
Joyce M. block et al. medical surgical clinical management
for positive outcomes 7th edition, 2005, 1189-1192
5. Dewitt Susan C. Essentials of medical surgical nursing 4th
edition, Philadelphia, w.b sunders company, 1998, 882-890.
6. Phipps, medical surgical nursing a nursing process

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approach 7th edition, 265-230.
7. Linton introduction to medical surgical nursing 1th edition,
465-479.

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