Checklist

Assessing the Neurological System

S.NO STEPS YES NO
1 Assemble equipment and supplies:
Percussion hammer
Tongue depressors (one broken diagonally, for testing pain
sensation)
Wisps of cotton, to assess light touch sensation
Test tubes of hot and cold water, for skin temperature
assessment
(optional)
2 Explain to the client what you are going to do, why it is
necessary, and how he can cooperate.
3 Wash hands and observe other appropriate infection
control procedures.
4 Provide for client privacy.
5 Determine client’s history of the following:
Presence of pain in the head, back, or extremities, as well as
onset and aggravating and alleviating factors
Disorientation to time, place, or person
Speech disorders
Any history of loss of consciousness, fainting, convulsions,
trauma, tingling or numbness, tremors or tics, limping,
paralysis, uncontrolled muscle movements, loss of memory, or
mood swings
Alterations in smell, vision, taste, touch, or hearing
6 If the client displays difficulty speaking:
Point to common objects, and ask the client to name them.
Ask the client to read some words and to match the printed and
written words with pictures.
Ask the client to respond to simpleverbal and written
commands, e.g.“point to your toes” or “raise your left arm.”
7 Determine the client’s orientation to time, place, and
person by tactful questioning.
Ask the client the city and state of residence, time of day, date,
day of the week, duration of illness, and names of family
members.
More direct questioning may be necessary for some people,
e.g.,“Where are you now?” “What day is it today?”
8 Listen for lapses in memory.
*Ask the client about difficulty with memory. If problems are
apparent, three categories of memory are tested immediate
recall, recent memory, and remote memory.
To assess immediate recall:
>Ask the client to repeat a series of three digits—e.g., 7-4-3—
spoken slowly.
>Gradually increase the number of digits—e.g., 7-4-3-5, 7-4-3-
5-6, and 7-4-3-5-6-7-2—until the client fails to repeat the series
correctly.
>Start again with a series of three digits, but this time ask the
client to repeat them backward.
>The average person can repeat a series of five to eight digits
in sequence, and four to six digits in reverse order.
9 To assess recent memory:
>Ask the client to recall the recent events of the day, such as
how he got to the clinic. This information must be validated,
however.
>Ask the client to recall information given early in the interview,
e.g., the name of a doctor.
>Provide the client with three facts to recall—e.g., a color, an
object, an address, or a three-digit number—and ask the client
to repeat all three. Later in the interview, ask the client to
recall all three items.
10 To assess remote memory:
>Ask the client to describe a previous illness or surgery.
11 Attention Span and Calculation
*Test the ability to concentrate or attention span by asking the
client to recite the alphabet or to count backward from 100.
*Test the ability to calculate by asking the client to subtract 7 or
3 progressively from 100—i.e., 100, 93, 86, 79, or 100, 97, 94.
12 Level of Consciousness
Apply the Glasgow Coma Scale.
13 Test Cranial Nerves.
Cranial Nerve I—Olfactory
Ask client to close eyes and identify different mild aromas, such
as coffee, vanilla.
14 Cranial Nerve II—Optic
Ask client to read Snellen’s chart, check visual fields by
confrontation, and conduct an ophthalmoscopic examination.
15 Cranial Nerve III—Oculomotor
Assess six ocular movements and pupil reaction.
16 Cranial Nerve IV—Trochlear
Assess six ocular movements.
17 Cranial Nerve V—Trigeminal
While client looks upward, lightly touch lateral sclera of eye to
elicit blink reflex. To test light sensation, have client close eyes,
and wipe a wisp of cotton over client’s forehead and paranasal
sinuses. To test deep sensation, use alternating blunt and
sharp ends of a safety pin over same area.
18 Cranial Nerve VI—Abducens
Assess directions of gaze.
19 Cranial Nerve VII—Facial
Ask client to smile, raise the eyebrows, frown, puff out his
cheeks, close his eyes tightly. Ask client to identify various
tastes place on tip and sides of tongue—sugar, salt—and
identify areas of taste.
20 Cranial Nerve VIII—Auditory
Assess client’s ability to hear spoken word and vibrations of
tuning fork.
21 Cranial Nerve IX—Glossopharyngeal
Apply tastes on posterior tongue for identification. Ask client to
move tongue from side to side and up and down.
22 Cranial Nerve X—Vagus
Assessed with CN IX; assess client’s speech for hoarseness.
23 Cranial Nerve XI—Accessory
Ask client to shrug shoulders against resistance from your
hands and to turn his head to side against resistance from your
hand. Repeat for the other side.
24 Cranial Nerve XI—Accessory
Ask client to shrug shoulders against resistance from your
hands and to turn his head to side against resistance from your
hand. Repeat for the other side.
25 Test reflexes using a percussion hammer, comparing one
side of the body with the other to evaluate the
symmetry of response.
26 Biceps Reflex
The biceps reflex tests the spinal cord level C-5, C-6.
*Partially flex the client’s arm at the elbow, and rest the forearm
over the thighs, placing the palm of the hand down.
*Place the thumb of your nondominant hand horizontally over
the biceps tendon.
*Deliver a blow (slight downward thrust) with the percussion
hammer to your thumb.
*Observe the normal slight flexion of the elbow, and feel the
biceps’s contraction through your thumb.
27 Triceps Reflex
The triceps reflex tests the spinal cord level C-7, C-8.
*Flex the client’s arm at the elbow, and support it in the palm of
your nondominant hand.
*Palpate the triceps tendon about 2–5 cm (1–2 in) above the
elbow.
*Deliver a blow with the percussion hammer directly to the
tendon.
*Observe for the normal slight extension of the elbow
28 Brachioradialis Reflex
The brachioradialis reflex tests the spinal cord level C-3, C-6.
*Rest the client’s arm in a relaxed position on your forearm or
on the client’s own leg.
*Deliver a blow with the percussion hammer directly on the
radius 2–5 cm (1–2 in) above the wrist or the styloid process,
the bony prominence on the thumb side of the wrist.
*Observe the normal flexion and supination of the forearm. The
fingers of the hand may also extend slightly.
29 Patellar Reflex
The patellar reflex tests the spinal cord level L-2. L-3, L-4.
*Ask the client to sit on the edge of the examining table so that
his legs hang freely.
*Locate the patellar tendon directly below the patella.
*Deliver a blow with the percussion hammer directly to the
tendon.
*Observe the normal extension or kicking out of the leg as the
quadriceps muscle contracts.
*If no response occurs, and you suspect the client is not
relaxed, ask the client to interlock the fingers and
pull.
30 Achilles Reflex
The Achilles reflex tests the spinal cord level S-1, S-2.
*With the client in the same position as for the patellar reflex,
slightly dorsiflex the client’s ankle by supporting the foot lightly
in the hand.
*Deliver a blow with the percussion hammer directly to the
Achilles tendon just above the heel.
*Observe and feel the normal plantar flexion (downward jerk) of
the foot.
31 Plantar (Babinski’s) Reflex
The plantar or Babinski’s reflex is superficial. It may be absent
in adults without pathology, or overridden by voluntary control.
*Use a moderately sharp object, such as the handle of the
percussion hammer, a key, or the dull end of a
pin or applicator stick.
*Stroke the lateral border of the sole of the client’s foot, starting
at the heel, continuing to the ball of the foot, and then
proceeding across the ball of the foot toward the big toe.
*Observe the response. Normally, all five toes bend downward;
this reaction is negative Babinski’s. In an abnormal Babinski
response, the toes spread outward and the big toe moves
upward.
32 Gross Motor and Balance Tests
Walking Gait
Ask the client to walk across the room and back, and assess
the client’s gait.
33 Romberg’s Test
Ask the client to stand with feet together and arms resting at
the sides, first with eyes open, then closed.
34 Standing On One Foot With Eyes Closed
Ask the client to close his eyes and stand on one foot, then the
other. Stand close to the client during this test.
35 Heel–Toe Walking
Ask the client to walk a straight line, placing the heel of one foot
directly in front of the toes of the other foot
36 Toe or Heel Walking
Ask the client to walk several steps on the toes and then on the
heels.
37 Fine Motor Tests for the Upper Extremities
Finger-to-Nose Test
Ask the client to abduct and extend the arms at shoulder height
and rapidly touch the nose alternately with one index finger and
then the other. Have the client repeat the test with the eyes
closed if the test is performed easily.
38 Alternating Supination and Pronation of Hands on Knees
Ask the client to pat both knees with the palms of both hands
and then with the backs of the hands alternately at an ever-
increasing rate.
39 Finger to Nose and to the Nurse’s Finger
Ask the client to touch the nose and then your index finger,
held at a distance at about 45 cm (18 in), at a rapid and
increasing rate.
40 Fingers to Fingers
Ask the client to spread the arms broadly at shoulder height
and then bring the fingers together at the midline, first with the
eyes open and then closed, first slowly and then rapidly
41 Fine Motor Tests for the Lower Extremities
Ask the client to lie supine and to perform these tests:
42 Heel Down Opposite Shin
Ask the client to place the heel of one foot just below the
opposite knee and run the heel down the shin to the foot.
Repeat with the other foot. The client may also use a sitting
position for thistest.
Toe or Ball of Foot to the Nurse’sFinger
 Ask the client to touch your finger with the large toe of each
foot.
43 Light-Touch Sensation.
Compare the light-touch sensation of symmetric areas of the
body.
*Ask the client to close the eyes and to respond by saying “yes”
or “now” whenever the client feels the cotton wisp touching his
skin.
*With a wisp of cotton, lightly touch one specific spot and then
the same spot on the other side of the body.
*Test areas on the forehead, cheek, hand, lower arm,
abdomen, foot, and lower leg. Check a specific area of
the limb first.
*Ask the client to point to the spot where the touch was felt. If
areas of sensory dysfunction are found, determine the
boundaries of sensation by testing responses about
every 2.5 cm (1 in) in the area. Make a sketch of the sensory
loss area for recording purposes.
44 Pain Sensation
Assess pain sensation as follows:
*Ask the client to close his eyes and to say “sharp,” “dull,” or
“don’t know” when the sharp or dull end of the broken tongue
depressor is felt.
*Alternately, use the sharp and dull end of the sterile pin or
needle to lightly prick designated anatomic areas at random.
The face is not tested in this manner.
*Allow at least 2 seconds between each test.
45 Temperature Sensation
*Touch skin areas with test tubes filled with hot or cold water.
*Have the client respond say saying “hot,” “cold,” or “don’t
know.”
46 Tactile Discrimination
For all tests, the client’s eyes need to be closed:
One- and Two-Point Discrimination
Alternately stimulate the skin with two pins simultaneously and
then with one pin. Ask whether the client feels one or two
pinpricks.
Stereognosis
*Place familiar objects—such as a key, paper clip, or coin—in
the client’s hand, and ask the client to identify them.
*If the client has a motor impairment of the hand and is unable
to manipulate an object, write a number or letter on the client’s
palm, using a blunt instrument, and ask the client to identify it.
Extinction Phenomenon
Simultaneously stimulate two symmetric areas of the body,
such as the thighs, the cheeks, or the hands.
47 Document findings in the client record.

Assessing the Musculoskeletal System

S.NO STEPS YES NO

1 Assemble equipment and supplies:
Goniometer
2 Explain to the client what you are going to do, why it is
necessary, and How she can cooperate
3 Wash hands and observe other appropriate infection
control procedures.
4 Provide for client privacy.
Determine client’s history of the following:
History or presence of muscle pain: onset, location, character,
associated phenomena, and aggravating and alleviating factors
Any limitations to movement or inability to perform activities of
daily living
Previous sports injuries
Any loss of function without pain
5 Inspect the muscles for size.
Compare each muscle on one side of the body to the same
muscle on the other side. For any apparent discrepancies,
measure the muscles with a tape.
4 Inspect the muscles and tendons for contractures.
5 Inspect the muscles for fasciculations and tremors.
Inspect any tremors of the hands and arms by having the client
hold the arms out in front of the body.
6 Palpate muscles at rest to determine muscle tonicity.
7 Palpate muscles while the client is active and passive for
flaccidity, spasticity, and smoothness of movement.
8 Test muscle strength.
Compare the right side with left side.
10 *Inspect the skeleton for normal structure and deformities.
* Palpate the bones to locate any areas of edema or tenderness.
*Inspect the joint for swelling.
Palpate each joint for tenderness, smoothness of movement,
swelling, crepitation, and presence of nodules.
* Assess joint range of motion.
Ask the client to move selected body parts. If available, use a
goniometer to measure the angle of the joint in
degrees.
11 Document findings in the client record
Assessing the Eye Structures and Visual Acuity

S.NO STEPS YES NO

1 Assemble equipment and supplies:
Cotton tip applicator
Examination gloves
Millimeter ruler
Penlight
Snellen’s chart
2 Explain to the client what you are going to do, why it is
necessary, and how she can cooperate.
3 Wash hands and observe other appropriate infection
control procedures.
4 Provide for client privacy.
5 Determine client’s history of the following:
Family history of diabetes, hypertension, or blood dyscrasias
Eye disease, injury, or surgery
Last visit to an ophthalmologist
 Current use of eye medications
Use of contact lenses or eyeglasses
Hygienic practices for corrective lenses
Current symptoms of eye problems
6 External Eye Structures
* Inspect the eyebrows for hair distribution and alignment and for
skin quality and movement.
*Inspect the eyelashes for evenness of distribution and direction
of curl.
*Inspect the eyelids for surface characteristics, position in
relation to the cornea, ability to blink, and frequency of blinking.
Inspect the lower eyelids while the client’s eyes
are closed.
*Inspect the bulbar conjunctiva for color, texture, and the
presence of lesions.
7 *Inspect the palpebral conjunctiva by everting the lids.
* Evert the upper lids if a problem is suspected.
*Inspect and palpate the lacrimal gland.
*Inspect and palpate the lacrimal sac and nasolacrimal duct.
8 Inspect the cornea for clarity and texture.
Ask the client to look straight ahead .Hold a penlight at an
oblique angle to the eye, and move the light slowly across the
corneal surface.
9 Perform the corneal sensitivity (reflex) test to determine the
function of the fifth (trigeminal) cranial nerve.
Ask the client to keep both eyes open and look straight ahead.
Approach from behind and beside the client, and lightly touch
the cornea with a corner of the gauze.
10 Inspect the anterior chamber for transparency and depth.
Use the same oblique lighting used when testing the cornea.
*Inspect the pupils for color, shape, and symmetry of size.
* Assess each pupil’s direct and consensual reaction to light.
*Assess each pupil’s reaction to accommodation.
11 Assess six ocular movements to determine eye alignment
and coordination.
12 Assess near vision.
*Assess distance vision.
* Perform functional vision tests if the client is unable to see the
top line (20/200) of Snellen’s chart.
13 Document findings in the client record.

Assessing the ENT System

S.NO STEPS YES NO

1 Assemble equipment and supplies:
Otoscope with several sizes or ear specula
Nasal speculum
Flashlight/penlight
Examination gloves
Tongue depressor
2 x 2 gauze pads
Flashlight or penlight
2 Explain to the client what you are going to do, why it is
necessary, and how he can cooperate.
3 Wash hands and observe other appropriate infection
control procedures.
4 Provide for client privacy.
5 Determine client’s history of the following:
Family history of hearing problems or loss
Presence of any ear problems
Medication history, especially if there are complaints of ringing
in ears
Any hearing difficulty: its onset, factors contributing to it, and
how it interferes with activities of daily living
Use of a corrective hearing device: when and from whom it
was obtained Allergies
Difficulty breathing through the
nose
Sinus infections
Injuries to nose or face
Nosebleeds
Any medications taken
Any changes in sense of smell
6 Position the client comfortably, seated if possible.
7 Inspect the auricles for color,symmetry of size, and
position.
8 Palpate the auricles for texture, elasticity, and areas of
tenderness.
9 Using an otoscope, inspect the external ear canal for
cerumen, skin lesions, pus, and blood.
10 Inspect the tympanic membrane for color and gloss.
11 Assess client’s response to normal voice tones. If client
has difficulty hearing the normal voice, proceed with the
following tests.
Perform the watch tick test.
Have the client occlude one ear. Out of the client’s sight, place a
ticking watch 2–3 cm (1–2 in) from the unoccluded ear.
Ask what the client can hear. Repeat with the other ear.
Tuning Fork Tests
Perform Weber test.
Conduct Rinne test.
12 Inspect the external nose for any deviations in shape, size,
or color and flaring, or discharge from the nares.
* Lightly palpate the external nose to determine any areas of
tenderness, masses, and displacements of bone
and cartilage.
13 Determine patency of both nasal cavities.
Ask the client to close the mouth, exert pressure on one naris,
and breathe through the opposite naris. Repeat the procedure to
assess patency of the opposite naris.
14 Inspect the nasal cavities using a flashlight or a nasal speculum.
15 Observe for the presence of redness, swelling, growths, and
discharge.
16 Inspect the nasal septum between the nasal chambers.
17 Palpate the maxillary and frontal sinuses for tenderness.
18 Inspect the hard and soft palate for color, shape, texture,
and the presence of bony prominences.
Ask the client to open his mouth wide and tilt his head
backward. Then, depress tongue with a tongue blade as
necessary, and use a penlight for appropriate visualization.
19 Inspect the uvula for position and mobility while examining
the palates.
To observe the uvula, ask the client to say “ah” so that the soft
palate rises.
20 Inspect the tonsils for color, discharge, and size.
21 Elicit the gag reflex by pressing the posterior tongue with a
tongue depressor.
22 Document findings in the client record

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