University of the East

Ramon Magsaysay Memorial Medical Center, Inc.

Aurora Boulevard, Quezon city

College of Nursing

Systematic Comprehensive Assessment of Neurologic System

(SCANS)

Components Content Procedure Normal Findings Deviations from

Normal
I. Mental Status a. Level of consciousness
(Cerebral • Eye response • Call the client’s name Alert: Responds to calling Lethargic: Opens eyes,
function) • Verbal response • Ask the about the patient’s and performs simple responds to question
condition (e.g. How are instructions then fall asleep
you?...)
• Motor response • Ask the client to perform Obtunded: Responds to
simple instruction (e.g. Make loud voice, responds
a fist, and then show palms) slowly with confusion

Stuporous: Awakens to
vigorous shake or
painful stimuli, then
goes back to sleep

Comatose: Unarousable
with eyes closed.

• Use Glasgow Coma • Compute for the total best See GCS Table See GCS Table
Scale GCS score of the patient
based on Eye response (4),
Verbal response (5), and
 Motor response (6)
Knows who he is and where Unable to express where
b. Orientation • Ask the patient: he lives, and can tell you the he or she is, time, and
• Time What is the date and time date. does not follow
• Place today? Where do you live? instructions
• Person Can you spell your first
name?

c. History • Perform interview to the

• Risk factors (Hx of patient. Inquire history of
trauma) unusual changes.
• Changes in mental
status • Confirm subjective data
• Presence of pain from patient to family
• Problems with members/ significant others.
speech
• Disorientation
• Problems with
senses
• Loss of
consciousness
• Sudden weakness
• Tingling sensation/
numbness
• Paralysis/
uncontrolled
movements

d. Memory Correctly answers the Inappropriate answer to

• Immediate recall • Ask the client to repeat a question about recent questions testing
sequence/phrase (e.g. 3-2-1) activities and can recall past memory and recall
• What is the previous events.
 • Recent memory meal? Ask the patient to recall
information given earlier in
the interview.

• Remote memory • What are the names of

your family members?
Reactions and responses Expresses feeling
e. Mood/Affect Observe patients responses were appropriate for the inappropriate to situation
• Expressions throughout the procedure. situation
• Feeling
• Non-verbal cues
Did not perform
• Behavior
Able to perform desired instruction. Answered
• Instruct the client to recite action with appropriate incorrectly to the
f. Attention
the alphabet or solve simple responses. question.
Span/Cognitive
abilities mathematical problem

II. Cranial Nerve a. Cranial Nerve I – • Hold scent under nostril Distinguished scent in each Unable to identify
Function Olfactory with the other occluded while nostril correctly correct odor
client’s eye closed.

b. Cranial Nerve II – • Use Snellen chart to check
Optic visual acuity. Each eye should
be tested separately. (Allow
the client to wear corrective
lenses or glasses)
20/20 (Client will be able to Missed any letters on
see objects within 20 feet 20/20 line or above.
that a normal person can see Client leans forward
at same distance) while reading.

• Assess visual fields by
confrontation. (Seat close to
the patient. Instruct the client
to look in the examiner’s eyes
then cover the eye not being
Client will be able to
identify objects at
peripheral vision equally
with an examiner having
normal vision.
Client does not report
seeing the object at the
same time as the
examiner.
 tested. The examiner shall do
the same. Bring two wagging
fingers in from the periphery
in a plane equidistant from
the patient and you) in all
quadrants of the visual field
and ask the patient to tell you
when he sees your wagging
fingers.)

c. Cranial Nerve III – • Assess six extraocular
Oculomotor movements. (Instruct client to
follow the tip of your penlight
and direct it to each of the 6
ocular points always starting
at the point of start.)
Both eyes move in a Failure to follow object
smooth, coordinated manner with one or both eyes
in all directions indicates muscle
weakness or cranial
nerve dysfunction.

• Convergence test. (try to Pupils converge and Pupils do not converge

direct the penlight toward the constricts as object moves or constrict. Unequal
nose of the patient) in towards the nose. pupil responses.

• Pupillary reaction to Reflections noted at same Reflections were seen at

Light. (Instruct the client to
place the fingers of one hand
in-line with the nose bridge
then look directly to the
examiner’s eyes. shine light to
each of the client’s eye in an
inverted-7 maneuver while
observing for papillary
constriction of the same eye
(direct reaction) and the other
eye (consensual reaction.
location on both eyes. different location on
Illuminated pupils and both eyes. Illuminated
opposite eye constricts eye (efferent nerve
simultaneously. defect) and opposite eye
of the illuminated
(afferent nerve defect)
failed to constrict
simultaneously.
 Note also the pupil size.)

• Pupillary reaction to Pupils dilates when looking Pupils do not constrict

accommodation. (instruct
patient to place 1 finger 10cm
from the nose. Then ask the
client to alternately look at a
distant object and the finger).
at a distant object and nor dilate.
constricts when focusing on
near objects.

d. Cranial Nerve IV – • Tested with CN III

Trochlear

e. Cranial Nerve V – • Assess corneal reflex Eye blinks bilaterally Absent blink of eyelids.
Trigeminal (touch the cornea lightly with
a wisp of cotton)

• Palpate for contraction of Muscle strength in the face Asymmetrical or no

temporal and massester should be present and muscle contraction.
muscle strength (place each should be symmetric.
thumb on both sides of the
patients temple and the rest of
the finger on the angle of the
jaw)

• Sensory function of Sensation should be present Unable to identify or

ophthalmic, maxillary and and symmetrical. Patient feel facial sensation
mandibular branch (pin test) was able to identify
characteristic of stimuli
f. Cranial Nerve VI –
• Tested with CN III
Abducens

g. Cranial Nerve VII – The facial muscles should Unable to perform facial
Facial • Instruct the client to look symmetric when the movements as
perform gestures (e.g. Smile,
 frown, raise eyebrows, tightly patient frowns, closes his instructed, or
close eyes) eyes, and smiles. movements
asymmetrical on one
side of the face.

h. Cranial Nerve XII – • Ask the client to stick out The tongue should be Asymmetrical tongue;
Hypoglossal the tongue and to move it symmetric and should not deviation to one side
from side to side and up and deviate. seen with unilateral
down. lesion.

i. Cranial Nerve X – Bilateral, symmetrical rise Unequal or absent rise of

Vagus • Ask client to open mouth of soft palate and uvula. soft palate and uvula
and say “Ahh” (observe the
reaction of soft palate and
uvula)
Gag reflex present Absent gag reflex
• Check for the gag reflex.
(Cranial Nerve VII – Identifies taste correctly Unable to taste or to
Facial ) • Perform taste test (apply identify taste correctly
tastes on the tip and sides of
the client’s tongue with eyes
closed. Then ask the client to
identify the taste)
j. Cranial Nerve VIII – Client was able to hear Client was unable to
Auditory/Acoustic/ • Assess hearing (ask the sound or watch tick on both hear sound or watch
Vesibulocochlear client to close eyes and ears. tick. Unequal response
determine on which ear did
he/she heard the sound)
Vibration heard equally in Vibratory sound
both ears lateralized to poor ear
• Weber test (place the
(conductive hearing
vibrating tuning fork on the
loss) or to good ear
forehead of the client with
(sensorineural hearing
eyes closed. Then ask the
 client on which ear did he/she loss)
heard the vibrations)
AC>BC BC>AC: conductive
• Rinne (ask the client to hearing loss. AC longer
notify the examiner if he/she than, but not twice as
can no longer hear the sound long as BC:
produced by tuning fork. First sensorineural hearing
place the tuning fork on the loss.
mastoid process, then remove
it and place it close to the
client’s ear after)

k. Cranial Nerve XI – Neck and shoulder muscle

spinal Accessory • Palpate strength of strength should be
Trapezius muscle (ask the symmetric.
client to shrug shoulders
against your hands. Assess
each and both of the
shoulders at a time) Neck and shoulder muscle
strength should be
• Palpate the strength of symmetric.
Sternocleidomastoid muscle
(ask the client to turn head
from side to side against your
hand)
III. Reflexes a. Biceps reflex (C-5, C- • Place partially flexed arm ++ (-) absent
6) of the client over the thigh (+) hyporeflexia
with palms down. Place the (+++) mild hyperreflexia
thumb above the biceps without clonus
tendon then deliver a blow (++++) hyperreflexia
with a use of reflex hammer. with clonus
b. Triceps reflex (C-7, C- • Support the flexed arm of
8) the client. Palpate for the
 triceps tendon about 2-5cm
above the elbow. Then deliver
a blow directly to the tendon
using reflex hammer.
c. Patellar reflex (L-2, L- • Instruct the client to sit on
3, L-4) the edge of the examining
table or chair so that the legs
hang freely. Palpate for the
patellar reflex directly below
the patella. Directly deliver a
blow to the tendon with the
use of reflex hammer.
d. Plantar (Babinski’s)
reflex • Use a moderately sharp
object to stroke on the
patient’s foot. Stroke the
lateral border of the sole
starting at the heel, to the ball
of the foot and to the big toe.
(Inverted letter “J)
IV. Motor a. Muscle condition • Palpate both upper Symmetrical muscle tone
Function • Muscle tone extremities at the same time. and mass.
• Muscle mass Start from the upper arm to
• Muscle Strength the wrist and ask the client to Muscle strength:
• Range of motion alternately open and close 0/5 – no contraction
hands while palpation. Note 1/5 – no visible contraction
for symmetry of both but with palpable muscle
extremities. movements
• Instruct client to raise both 2/5 – can partially move
hands to the front, then to the extremity against gravity
side and above the head. Ask 3/5 – can perform full ROM
the client to repeat the steps against gravity
with application of resistance. 4/5 – can move extremity
 • Palpate both lower against partial resistance
extremities at the same time. 5/5 can move extremity
Start from the thigh to the against full resistance
knees and to the ankle. Ask
the client to alternately flex
and extend foot while
palpating. Note for symmetry
b. Fine and Gross of both extremities. Client was able to perform Limited movement or no
motor movements as instructed movement at all.
• Alternating pronation and
supination of hands
• Alternating rotation of
feet (clockwise - counter
clockwise)
V. Coordination a. Coordination test
and Gait for the upper extremity
(Cerebellar • Finger to thumb • Ask client to touch each Client was able to perform
function) finger of one hand to the movements as instructed
thumb of the same hand as
rapidly as possible
• Finger to finger • Ask the client to spread Client was able to perform
arms broadly at shoulder and movements as instructed
then bring fingers at the
midline, first with eyes
opened then closed.
• Finger to nose test • Ask the client to Client was able to perform
alternately touch nose and movements as instructed
then your index finger rapidly
as possible while moving it to
other directions.
b. Coordination test
for the lower extremity
• Heels down • Ask client to place heel of Client was able to perform
 opposite shin one foot just below the movements as instructed
opposite knee and run heel
down the shin to foot.
c. Balance
• Walking Gait • Walk 10 steps in a straight Steady gait with opposite Unsteady gait.
line arm swing Uncoordinated arm
swing
• Heel-toe walking • Walk in a heel-to-toe Maintains balance while Unsteady walking
fashion walking

• Romberg’s test Slight swaying may occur, Client sways and moves
Stand with feet together. but the patient should not feet apart to prevent fall
fall.
VI. Sensory a. Light touch • Ask the client to close
Function sensation eyes and respond by saying
“yes” whenever light
sensation is felt.
• Ask the client to close
b. Pain sensation eyes and respond by saying
(dull/sharp) “dull”, “sharp” or “don’t
know” whenever pain
sensation is felt.
• Support client’s arm with
c. Kinesthetic one hand. Ask the client to
sensation close eyes then move and hold
the middle finger up, down,
left, and right, and ask client
to identify the position.
• Place familiar objects in
the client’s hand, then ask the
d. Tactile client to identify them.
discrimination
• Stereogenesis
Prepared by:

Christian Rodel Perez, MSN, RN

Level III Faculty