ASSESSING THE NEUROLOGIC,

MUSCULOSKELETAL, AND PERIPHERAL

VASCULAR SYSTEMS
THE EXPECTED OUTCOME TO ACHIEVE IN PERFORMING AN
EXAMINATION OF THE NEUROLOGIC, MUSCULOSKELETAL,
AND PERIPHERAL VASCULAR SYSTEMS IS THAT THE
ASSESSMENTS ARE COMPLETED WITHOUT CAUSING THE
PATIENT TO EXPERIENCE ANXIETY OR DISCOMFORT, THE
FINDINGS ARE DOCUMENTED, AND THE APPROPRIATE
REFERRAL IS MADE TO OTHER HEALTHCARE PROFESSIONALS,
AS NEEDED, FOR FURTHER EVALUATION. OTHER SPECIFIC
OUTCOMES WILL BE FORMULATED, DEPENDING ON THE
IDENTIFIED NURSING DIAGNOSIS.
Numbness, tingling, tremors
Seizures / convulsion
Headaches
Dizziness
Trauma (head/spine)
Infections in brain
Stroke
Changes in ability to hear, see, smell or taste
Loss of ability to control bladder and bowel
Smoking
Chronic alcohol use
Diabetes mellitus
Prescription and over the counter
Perform hand hygiene and put on PPE, if
indicated.

Hand hygiene and PPE prevent the spread of

microorganisms.
PPE is required based on transmission
precautions
2. Identify the patient.

Identifying the patient ensures the right patient

receives the intervention
and helps prevent errors.
3. Close curtains around bed and close the door to
the room, if possible. Explain the purpose of the
neurologic, musculoskeletal, and peripheral vascular
examinations and what you are going to do. Answer
any questions

This ensures the patient’s privacy. Explanation

relieves anxiety
and facilitates cooperation.
4. Help the patient undress, if needed, and provide a
patient gown. Assist the patient to a supine position.
Use the bath blanket to cover any exposed area other
than the one being assessed

Having the patient wear a gown facilitates

examination of the cardiovascular
system. Use of a bath blanket provides for comfort
and warmth.
5. Begin with a survey of the patient’s overall
hygiene and physical appearance

This provides initial impressions of the patient.

Hygiene and appearance can provide clues about the
patient’s mental state and comfort level
6. (sitting position) Assess the patient’s mental
status.
a. Evaluate the patient’s orientation to person, place,
and time.
(ask name, where his house is, date and time)
b. Evaluate level of consciousness. c. Assess memory
(immediate recall and past memory).
d. Assess abstract reasoning by asking the patient to
explain a proverb, such as “The early bird catches the
worm.”
6. Assess the patient’s mental status.
a. Evaluate the patient’s orientation to person, place,
and time.
This helps identify the patient’s level of awareness.
(ask name, where his house is, date and time)
b. Evaluate level of consciousness.
The patient should be awake and alert. Patients with altered level of
consciousness may be lethargic, stuporous, or comatose (Glasgow
coma scale)
c. Assess memory (immediate recall and past
memory).
d. Assess abstract reasoning by asking the patient to
explain a proverb, such as “The early bird catches
the worm.”
If intellectual ability is impaired, the patient usually gives a
literal interpretation or repeats the phrase.

e. Evaluate the patient’s ability to understand spoken and

written word. Receptive aphasia (repeat what I say and
total it all) expressive aphasia (any na babasahin)
This helps assess for aphasia
Test cranial nerve (CN) function.
a. Ask the patient identify the smell of different
substances, Repeat with other nostril. tests the function of CN
I (olfactory nerve).
b. Test visual acuity & pupillary constriction. CN II &
III (optic and oculomotor nerves).
c. six cardinal positions of gaze.
d. smile, frown, wrinkle forehead, & puff out cheeks
e. Test hearing.
f. Test the gag reflex
g. Place your hands on the patient’s shoulders against
resistance. Then place your hand on the patient’s left
cheek, then the right cheek, and have the patient push
against it. 8. Inspect the ability of the patient to move
9. Inspect the upper extremities. Observe for skin
color, presence of lesions, rashes, and muscle mass.
Palpate for skin temperature, texture, and presence of
masses

Examination of the upper extremities provides

information about
the circulatory, integumentary, and musculoskeletal
systems.
10. (sitting position) Ask patient to extend arms
forward and then rapidly turn palms up and down.
This maneuver tests proprioception and cerebellar function.
(demonstrate and let him copy)
A. Extend arms forwardly then turn palms up and
down repeat it as fast as he can
B. Thumb opposition. Touch each finger to thumb
and increase speed. Repeat in other side.

Patient has good cerebellar function

C. Finger to nose test. Assess accuracy of
movements..

‘touch tip of nose then touch tip of my finger. Back

and forth’ (move finger to diff positions) then other
side
11. Ask patient to flex upper arm and to resist
examiner’s opposing force. (punong braso)

This technique assesses the muscle strength of the

upper extremities.
12. Inspect and palpate the hands, fingers, wrists
(Figure 3), and
elbow joints.

Inspection and palpation provide information about

abnormalities, tenderness, and range of motion.

Fingers are equally similar in both hands

Wrist has no tenderness
Elbow joints properly extend and flex
13. Palpate the radial and brachial pulses

Pulse palpation evaluates the neurovascular status of

the upper extremities

radial = thumb
Brachial = loob ng siko

Pulse is present and is 2+ ( slightly diminished but

detectable)
14. Have the patient squeeze two of your fingers

This maneuver tests the muscle strength of the hands.

15. Ask the patient to close his eyes. Using your
finger or
applicator, trace a one-digit number on the patient’s
palm and
ask him or her to identify the number. Repeat on the
other
This test evaluates tactile
hand with a different number
discrimination,
(use other side of percussion hammer)
specifically graphesthesia
16. Ask the patient to close his or her eyes. Place a
familiar
object, such as a key, in the patient’s hand and ask
him or her
to identify the object. Repeat using another object for
the
other hand.

This test evaluates tactile discrimination, specifically

stereognosis
17. In a supine position, examine the lower
extremities (legs and feet for color, varicosities,
edema and muscle mass

Information about peripheral vascular function

Color is relatively equal, no vein distensions, edema

18. Test pitting edema in the pretibial area by
pressing fingers into the skin of the that area. If there
is a mark left after lifting the finger, pitting edema is
present.

This reveals information about excess interstitial

fluid. Refer to a “pitting edema scale” in assessing
the amount of edema: 1 about 2 mm deep to 4 about
8 mm deep.
19. Palpate for pulses and skin temperature at the
posterior tibial, dorsalis pedis, and popliteal areas

Pulses and skin temperature provide information

about the patient’s peripheral vascular status.
20. Have the patient perform the straight leg test with
one leg at a time (Figure 6).
This test checks for vertebral disk problems.
Abscences of pain and tenderness
21. Ask the patient to move one leg laterally with the
knee straight to test abduction and medially to test
adduction of the hips
This maneuver assesses ROM and provides
information about joint problems.
A (paghiwalayin ang 2 binti)
B. (ipapasok niya legs niya)
22. assess motor strength of the upper and lower
legs.
Ask the patient to raise the thigh against the
resistance of your hand ; next have the patient push
outward against the resistance of your hand; then
have the patient pull backward against the resistance
of your hand. Repeat on the opposite side.
These measures assess motor strength of the upper
C. then have the patient pull backward against the resistance of
your hand

and lower legs.

Testing motor strength of upper leg. Patient attempts
to raise thigh against nurse’s resistance
23. Assess the patient’s deep tendon
reflexes (DTR).
evaluate the brachioradialis, biceps, triceps,
patellar,and Achilles’ DTR, respectively
a. Support the arm and let wrist hang
freely. Use flat side of reflex hammer to
asses tendon 2” above wrist
b. Place your fingers at the elbow area
with the thumb over the antecubital area
and tap with a reflex hammer; repeat on
c. (Tricep reflex)Place hand on bicep
area and let forearm hang freely tap
with a pointed part of reflex hammer;
repeat on the other side

d. (patellar reflex)Tap the tendon just

below the patella with a reflex
hammer; repeat on the other side

e. Tap over the Achilles’ tendon area

24. Babinski reflex
Stroke the sole of the patient’s from
the heel to toe with the end of a
reflex hammer handle or any hard
object such as a key; repeat on the
other side
negative Babinski reflex
Plantar flexion of all the toes is
considered a normal finding in an
individual 18 months of age and
25. Ask patient to dorsiflex and then plantarflex both
feet against opposing resistance (Figure 14).
(dorsiflex is tapak or tulak ng paa)
(plantarflex is I aangat mo yung paa lang)
These measures test foot strength and ROM

pushes the balls of the feet against resistance of the nurse’s attempts to pull against nurse’s resistance
hands
25b. Dorsiflex the patient’s leg and ask if there is
pain
Measures negativity or positivity of Homan’s sign
which may reveal Deep pain thrombosis
25c. Assessing Brudzinki’s sign. Flex neck and
observe hip and knee reaction upon flexion (no pain)
(normal=negative brudsinki’s sign)

25d. For assessment of Kernig’s sign. Dominant

hand supporting the sole of feet and NonDH
supporting the tighs, straighthen the the knee. Ask for
pain

May reveal Meningitis

26. assist the patient to a standing position. Observe
the patient as he or she walks with a regular
gait(normal lakad), on the toes, on the heels, and then
heel to toe(straight line and toe touching heel).

This procedure evaluates cerebellar and motor

function
27. In assessing Romberg’s test; ask the patient to
stand straight
with feet together, first with eyes open then closed
and arms at side or at front. Wait 20 seconds and
observe if swaying and ability to maintain balance.
Be alert to prevent patient fall or injury related to
losing balance during this assessment
This checks cerebellar functioning, evaluates balance,
equilibrium, and coordination. Slight swaying is normal,
but patient should be able to maintain balance.
28. Assist the patient to a comfortable position.
This ensures the patient’s comfort.
29. Remove PPE, if used. Perform hand hygiene.
Continue with assessments of specific body systems,
as appropriate, or indicated. Initiate appropriate
referral to other healthcare practitioners for further
evaluation, as indicated.
Removing PPE properly reduces the risk for infection transmission and
contamination of other items. Hand hygiene prevents the spread of
microorganisms. Additional assessments should be completed, as
indicated, to evaluate the patient’s health status. Intervention by other
healthcare providers may be indicated to evaluate and treat the patient’s
health status
Documentation

Paient alert, oriented, cognitively appropriate. CNS

intact, Sensation intact
DTR 2 positive.
Full ROM on all joints
Muscled soft, firm, non tender and no atrophy.
Pain is present due to biking the day before.
Cerebellum functioning is working properly, can
maintain balance and has coordination