Physical Assessment

Introduction to Neurological Physical Assessment

A neurological physical assessment is a systematic examination used by nurses to evaluate the integrity of the central and peripheral nervous systems. This evaluation helps detect early signs of neurological decline, localize site-specific lesions, and monitor the effectiveness of ongoing medical interventions. The examination integrates historical data with direct physical testing of function, reflexes, and sensation.

Baseline data collection is the primary objective when assessing a patient admitted to a medical-surgical or emergency ward in Nigerian hospitals. Subtle changes in neurological status often precede catastrophic clinical deterioration, making structured assessment vital for patient safety.

Mental Status and Cognitive Function Examination

Assessing mental status evaluates higher cortical functions, giving insight into cerebral hemisphere integrity. The nurse observes appearance, behavior, mood, and cognitive processes during routine interaction.

• Level of Consciousness: Determines wakefulness and arousal, ranging from alert to comatose.
• Orientation: Assesses awareness of person, place, time, and situation.
• Memory: Evaluates immediate recall, recent memory, and remote past events.
• Language: Tests naming, reading, writing, and comprehension during conversation.

A common clinical error is assuming an uncommunicative patient lacks cognitive capacity. Nurses must use alternative communication methods before concluding cognitive impairment.

Assessment of Cranial Nerves I through XII

Cranial nerve testing evaluates the twelve pairs of nerves emerging directly from the brain. Each nerve serves specific sensory, motor, or mixed functions primarily in the head and neck.

1. CN I (Olfactory): Test nasal patency and identify familiar scents with eyes closed.
2. CN II (Optic): Assess visual acuity using a Snellen chart and check visual fields.
3. CN III, IV, VI (Oculomotor, Trochlear, Abducens): Check pupillary reaction to light, accommodation, and extraocular eye movements.
4. CN V (Trigeminal): Test facial sensation to light touch across three divisions and motor function of jaw muscles.
5. CN VII (Facial): Observe symmetry during smiling, frowning, and puffing cheeks.
6. CN VIII (Vestibulocochlear): Evaluate hearing using the whisper test, Weber, and Rinne tests.
7. CN IX, X (Glossopharyngeal, Vagus): Assess gag reflex, swallowing, and vocal cord movement.
8. CN XI (Accessory): Test strength of sternocleidomastoid and trapezius muscles against resistance.
9. CN XII (Hypoglossal): Observe tongue movement and symmetry when protruded.

Motor System and Cerebellar Function Evaluation

Evaluating the motor system involves inspecting muscle bulk, testing tone, and grading strength on a standard zero to five scale. Involuntary movements, tremors, or fasciculations are noted during inspection.

Cerebellar testing assesses coordination, balance, and fine motor skills. The finger-to-nose test, heel-to-shin test, and rapid alternating movements evaluate limb coordination. Balance is tested using the Romberg test, where the patient stands with feet together and eyes closed, watching for excessive swaying.

Sensory System Testing and Pain Perception

Sensory examination maps the integrity of peripheral nerves, spinal tracts, and the sensory cortex. Testing is usually performed with the patient's eyes closed to prevent visual compensation.

• Light Touch: Tested using a wisp of cotton stroked across dermatomes.
• Pain and Temperature: Assessed using sharp and dull ends of a safety pin or broken cotton bud.
• Vibration: Evaluated by placing a vibrating tuning fork over bony prominences like the medial malleolus.
• Proprioception: Tested by moving the patient's big toe up or down and asking them to identify the direction.
• Cortical Sensory Functions: Includes stereognosis (identifying objects by touch) and graphaesthesia (identifying numbers drawn on the skin).

Deep Tendon and Superficial Reflex Assessment

Reflex testing evaluates the integrity of spinal reflex arcs. Deep tendon reflexes (DTRs) are elicited by striking a muscle tendon with a percussion hammer, while superficial reflexes involve stimulation of the skin or mucous membranes.

DTRs are graded on a scale from 0 to 4:

• 0: Absent reflex
• 1+: Diminished or hyporeactive
• 2+: Normal or average
• 3+: Brisker than average
• 4+: Hyperactive with clonus

Common reflexes tested include the biceps, triceps, brachioradialis, patellar, and achilles reflexes. The plantar reflex is a superficial reflex where stroking the lateral sole normally causes toes to curl downward; an upward extension of the big toe is known as the Babinski sign, indicating upper motor neuron disease.

Evaluating the Level of Consciousness Using the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is a standardized tool used to assess and document the level of consciousness in patients with head injuries or acute neurological insults. It evaluates three distinct behavioral responses:

• Eye Opening (E): Spontaneous, to speech, to pain, or none.
• Verbal Response (V): Oriented, confused, inappropriate words, incomprehensible sounds, or none.
• Motor Response (M): Obeys commands, localizes pain, withdraws from pain, abnormal flexion, abnormal extension, or none.

The total score ranges from 3 to 15. A lower score indicates severe neurological impairment, while a score of 15 represents a fully alert and oriented patient. Nurses must record individual component scores alongside the total sum to give a clear clinical picture.

Documentation and Nursing Responsibilities in Neurological Findings

Accurate and timely documentation of neurological assessments is a critical legal and clinical nursing responsibility. Vague descriptions like 'patient is resting quietly' are insufficient; nurses must record objective, measurable data including exact GCS scores, pupil sizes, and motor strength grades.

Trend monitoring is essential. If a patient's neurological score drops even by two points on the GCS, it warrants immediate notification of the attending physician or medical officer. Ensuring proper handoff communication during shift changes prevents missed warning signs of rising intracranial pressure or acute stroke progression.