NEUROLOGIC ASSESSMENT

DEFINITION

• The initial neurological assessment is a comprehensive examination covering several critical

areas of assessment, including level of consciousness (LOC), orientation, speech, facial
symmetry, motor and sensory function and reflex activity. Assessment of cranial nerve function,
cerebellar function an d reflex activity are covered in a comprehensive neurological assessment.
• Glasgow Coma Scale- (GCS) is a valuable tool for recording the conscious state of a person, and
is based on three patient responses: Eye opening, motor response, and verbal response. The
total score will range from 3 (coma) to 15 (fully conscious, alert and oriented). A score of 7 or
lower usually indicates coma.

PURPOSES
• To assess the nervous system function.
• To determine the highest level of functional ability.
• To detect neurological disease or injury in the patient, monitor its progression to determine the
type of care to be provided.
• To monitor the patient's response to the interventions.
• To identify teaching needs.
• To evaluate patient outcomes

MATERIALS/EQUIPMENT

• Neurological Observation Record

• Pen
• Penlight
• Thermometer
• Sterile Cotton tipped applicator or cotton ball
• Cotton wisp
• Snellen’s Chart
• Test tubes
• Safety pin
• Reflex hammer

PROCEDURE RATIONALE Able to Able to Unable

Perform Perform to
with
(2) assistance perform

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 (1) (0)
Assessment To ensure that the data to be
1. Check for any medical condition that gathered will be accurate and to
may affect the accuracy of the intervene any condition that
assessment. needs to be attended

2. Check patient’s vital signs as current or Ensuring that the patient will be
progressive injury to the brain and stable first allowing it to facilitate
brain stem may make vital signs in the assessment. Also, to gather
unstable, which could reduce a more accurate data.
neurologic responses. It is best to

conduct the neuro assessment at

a time when vital signs are
relatively stable. To make patient comfortable and
3. Assess that the environment is to ensure that it will not interfere
conducive for the conduct of upon the assessment proper.
the procedure.
Planning To readily perform procedure
4. Gather equipment.
Implementation
5. Explain the procedure to the patient To allay patient’s anxiety and to
even if unresponsive. encourage patient’s participation

6. Wash hands and provide privacy. To make patient comfortable and

prevent spread of microbes

7. Assess the level of consciousness using

the Glasgow Coma Scale. a. Assess Eye This assessment will determine
Opening the patient’s state of
consciousness.
Eye Opening
4 Spontaneous
3 To voice
2 To pain
1 None (No response)
i. Spontaneous (4): Observe the
patient’s eyes. A patient that has
This will allow determine the eye
eyes that are opening spontaneously
response of the patient upon
receives a 4. ii. Voice (3): Supply
eliciting some stimulus. And to
vocal stimulus by asking the patient
determine whether to what
loudly and clearly to open their eyes.
extent of the stimulus that the
If the patient responds by opening
patient will response, allowing it
their eyes they receive a 3.
to be specific so that the data will
iii. Pain (2): Elicit a pain response by
be accurate.
pushing down behind the ear
anterior to the mastoid process. You
can also push down on the patient’s

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 finger nail bed. If the patient then
opens their eyes they receive a score
of 2. iv. None (1): If there is not any
response to pain the patient
receives a score of 1.
b. Assess Verbal Response. In assessing the patient’s verbal
Verbal Response response, this will help determine
the patient’s ability to respond
5 Orientated to time & place
and determine its consciousness
4 Confused speech by asking the patient questions
3 Inappropriate words that will also help determine
2 Incomprehensible sounds their orientation.
1 None
i. Orientated (5): Ascertain whether
the patient is orientated to time
and place. Patients’ that respond
appropriately receive a 5. Ask the

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 patient questions which you
know the answer to, such as;
‘What day is it today’? and ‘Do
you know where you are at the
moment?’.
ii. Confused (4): If the patient
appears slightly confused and/or
disorientated during conversation
they receive a 4.
iii. Inappropriate speech (3): If the
patient has random or muddled
speech without exchange of
information during conversation
they receive a 3.
iv. Incomprehensible (2): If the
patient is making sounds but is
unable to formulate words they
receive a 2.
v. None (1): A patient that is unable
to produce sounds receives a 1.
This does not refer to aphasia due
to any cause, such as airway
obstruction or laryngeal injury.
c. Assess Motor Response.
Motor Response
6 Obeys command
5 Localizes to pain
4 Withdraws to pain
3 Decorticate
2 Decerebrate
1 None
i. Obeys Commands (6): A patient
who responds to you and does
what you ask receives a 6. In
order to assess this, shake the
persons hand upon arrival or ask
them ‘can I hold your wrist to
take your pulse’?
ii. Localizes to pain (5): Elicit a pain
response through the techniques
previously mentioned. If the
patient purposefully attempts to
remove the stimulus they receive
a 5. E.g. the patient pushes your
hand away if you elicit nail bed
pressure.
iii. Withdraws to pain (4): Elicit a

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 pain response through
techniques previously
mentioned. If the patient pulls
away from the

stimulus they receive a 4.

iv. Abnormal Flexion (Decorticate) This will allow the nurse to
(3): Elicit a pain response through determine the need of any
techniques previously mentioned. intervention and hep rule out
If the patient’s arms move toward any neurological problems in the
their chest, their fingers and patient that will need to be
wrists flex on their chest and they checked and evaluated
point their toes, then they are
said to have decorticate posturing
and receive a 3. This posture is
indicative of head injury and a
patient may present in this
position prior to any painful
stimuli.
v. Abnormal Extension This indicates that despite the
(Decerebrate) (2): Elicit a pain stimulus given to the patient, no
response through techniques response has been noticed
previously mentioned. If the
patient’s arms and legs extend,
their wrists rotate away from
their body and they point their
toes, then they are said to have
decerebrate posturing and To further evaluate patient’s
receive a 2. This posture is also mental and neurologic status.
indicative of head injury and a
patient may present in this
position prior to any painful
stimuli.
vi. No Response (1): A patient that
does not have a motor response
receives a 1.
d. Add the numbers from each section
(eye opening, best verbal & best
motor response) and document in
the “total” section of the record. A
score of 3 is lowest and 15 are
highest. A score of 7 or less
indicates coma.
GCS < 8 – 9 = Severe brain injury/
dysfunction
GCS 8 or 9 – 12 = Moderate brain
injury/ dysfunction
GCS ≥ 13 = Minor brain injury/
dysfunction

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8. If patient is alert or awake enough to
answer questions, assess level of
orientation to person, place, and time:
e.g. Ask: What is your name? Where
are you right now? What year is it?
Who is the person in the room?

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9. Assess pupils and eye movement
a. Ask the patient to open his eye. This will allow the nurse to
b. If he doesn’t respond, lift his upper determine any deviation from a
eyelids. normal eye, size, shape and for
c. Inspect each pupil’s size and shape, equality.
and compare for equality. This will help determine the
d. Note if the pupils are positioned in, position of the eyes
or deviate from the midline.
e. Test direct light response
This will also help asses the eye
i. Hold each eyelid open in turn,
condition of the patient
keeping the other eye covered. ii.
whether both eyes have
Swing a penlight from the patient’s
constricted when light was
ear toward the midline of the face. elicited on the patient’s eyes.
iii. Shine the light directly into the
eye. Normally, the pupil constricts
immediately. When remove the
penlight, the pupil should dilate
immediately. iv. Wait about 20
seconds before testing the other
pupil. This will help determine
f. Test consensual light response. whether the patient would be
i. Hold both eyelids open, but shine able to focus on a certain object
light into one eye only. ii. Watch for and have the eyes converge
constriction in the other pupil, which while doing it.
indicates proper nerve function of
the optic chiasm.
iii. Brighten the room and have the This will help determine if the
conscious patient open his eyes. patient has blink reflec which
iv. Observe the eyelids for ptosis or helps in protecting the eyes
drooping. from foreign objects that may
go into his eyes.
v. Check ocular movements.
vi. Watch for involuntary jerking or
oscillating eye movements.
(nystagmus)
g. Check eye accommodation.
i. Hold up one finger midline to the
patient’s face and several feet away.
ii. Have the patient focus on your
finger.
iii. Gradually move your finger
toward his nose while he focuses
on your finger. This should cause
his eyes to converge and both
pupils constrict equally.
iv. Test the corneal reflex by
touching a wisp of cotton ball to
the cornea. This normally causes

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 an immediate blink effect.
v. Repeat for the other eye. To check the condition of the
vi. Hold the patient’s eyelids open. other eyes
vii. Quickly turn patient’s head to
one side, then the other. If his
eyes move in the opposite
direction from the side to which
you turn the head, the reflex is
intact.
10. Assess cranial nerves. This will assess the patient’s
a. Cranial Nerve I – Olfactory Nerve optic nerve by determining its
i. Check first for the patency of the visual acuity, its ability to
nose constrict its eyes when the light
was elicited to him.
ii. Instruct to close the eyes
iii. Occlude one nostrils at a time iv.
This will help check for any
Hold familiar substance and asks presence of eye abnormalities
for the identification such as nystagmus
v. Repeat with the other nostrils
b. Cranial Nerve II – Optic Nerve
i. Check the visual acuity with the
use of the Snellen chart ii. Check To help know any damage to
for visual field by confrontation these cranial nerves by allowing
test the patient to determine its
iii. Check for pupillary reflex- direct sensation to pain, hot and cold
and consensual objects.
c. Cranial Nerves III, IV, & VI
i. Have patient “follow your finger
with their eyes without moving
their head”.
ii. Move your finger side to side,
then up and down (in an “H”
pattern)
iii. Look for failure of movement and
nystagmus
d. Cranial Nerve V & VII
i. To test for pain, touch, &
temperature, gently touch
patient’s face with clean safety
pin & hot and cold objects
ii. To check corneal reflex, gently
use a cotton wisp on the patient’s
cornea.
iii. To test for motor function, have
the patient clench their teeth and
move their jaw side to side.
e. Cranial Nerve VII
i. Sensory portion- Prepare salt,
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 sugar, vinegar and quinine. Place
each substance in the anterior
two thirds of the tongue, rinsing

the mouth with water

ii. Motor portion- Ask the client to To check for the facial symmetry
make facial expressions, ask to
forcefully close the eyelids To determine eye abnormalities
f. Cranial Nerve VIII
i. Observe for nystagmus and To check if patient has a hearing
disturbed balance loss or any problems in patient’s
ii. Test patient’s hearing acuity. ability to hear
Whisper numbers in each ear,
while occluding the other; ask the
client to repeat.
iii. If deafness is suspected, perform
Weber and Rinne tuning fork test
g. Cranial Nerve IX & X
i. Observe ability to cough,
swallow, and talk.
ii. Test motor function: Ask patient
to open mouth and say “ah”
while you depress the tongue
with a tongue blade. Observe soft
palate and uvula. Soft palate and
uvula should rise medially.
h. Cranial Nerve XI
i. Press down the patient’s shoulder
while he attempts to shrug against
resistance.
i. Cranial Nerve XII
i. Ask patient to protrude the tongue
and note for symmetry

11. Assess muscle strength

a. In a patient who obeys commands: To check for the lower
extremities and other abnormal
i. Assess the patient’s ability to
reflexes in the patient
move limbs against gravity and
To ensure that even if the
resistance in response to a
patient does not respond, there
command. ii. Assess and document
has still been observation of the
each limb separately. iii. Observe for
patient’s muscle strength.
differences from side to side.
iv. Arms: Assess for straight arm lift,
elbow flexion and extension.
v. Legs: Assess for leg extension,
plantar flexion and dorsiflexion.
b. If the patient does not respond to
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 commands, assess/document
symmetry and strength of each
unrestrained limb movement based
on assessment of motor function for
GCS (i.e. by observing patient’s
spontaneous movements

or patient’s response to central

pain). To have a proper documentation
c. Document the best response of each about it
limb separately on the
Neurological Observation Record.
Scale for Muscle Strength:
Grade Description
5 Limb moves against full resistance.
4 Limb moves against moderate
resistance, but strength is diminished.
Limb may move against minimal
resistance or against gravity, e.g., if the
3
patient lifts the arm off a surface and it
immediately drops back.
Limb moves on a horizontal surface
2 To check if patient doesn’t have
with the inability to lift against gravity.
1 Limb or muscle flickers.
any abnormalities in the
cerebellum
0 No movement is observed.

To check its ability to follow the

12. Assess cerebellar function
fingers which can help rule out
a. Upper extremities
other neurologic problems
i. If patient is in bed, hold up your
finger and have patient quickly
and repeatedly move his finger To further assess the patient
back and forth from your finger
to his nose.
ii. Then have patient alternately
touch their nose with their right
and left index fingers. iii. Have
patient repeat these tasks with
their eyes closed.
iv. Movements should be precise and
smooth.
b. Lower extremities
i. Have patient bend their leg and
slide that heel along the opposite
shin, from the knee to the ankle. ii.
This movement, too, should be
accurate, smooth, and without
tremors.
c. If patient is able to stand, you can
assess their balance using the

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 Romberg test.
i. Have patient stand with their feet
together, arms at their sides, and
eyes open; he should be able to
stand upright with no swaying. ii. If
patient can do that, have them close
their eyes and stand the same way.
Observe for 1 full minute.

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 i. Because the examiner is trying to To ensure that the patient will
elicit whether the patient falls be safe throughout the
when the eyes are closed, it is procedure
advisable to stand ready to catch
the falling patient. For large
subjects, a strong assistant is To rule out abnormalities
recommended.
ii. Romberg's test is positive if the
patient sways or falls while the To assess it properly, ensuring
patient's eyes are closed, that no part will be missed in
indicating proprioceptive or doing it
vestibular dysfunction
13. Evaluate sensation. To determine ability to
a. Ask the patient to close the eyes distinguish between hot and
while testing. cold
a. Evaluate symmetric areas of the
body.
To determine the ability to
b. Begin with the feet and move up
discriminate objects through
the body to the face, comparing one
tactile stimulation
side with the other. Assess
To check any reflex in the biceps
sensation to light touch using your
fingertips or wisp of cotton.
c. Use of test tubes with cold and
warm water to test temperature
sensation. To check if patient has a reflex
d. Test superficial pain sensation with when a slight force will be given
a clean, unused safety pin. Also, test through the hammer.
sensation using a dull object. The
patient should be able to distinguish
sharp from dull.
a. Ask to identify objects placed on
the hands.
14. Assess Deep Tendon Reflexes
a. Biceps- Patient’s arm should be
flexed slightly with the palm facing
up. Hold arm with your thumb in
the antecubital space over the
biceps tendon. Strike your thumb
with the hammer; the arm should
flex slightly.
b. Triceps- Patient's arm should be
flexed 90 degrees. Support the arm
and strike it just above the elbow,
between the epicondyles;

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 the arm should extend at the
elbow. To determine presence of reflex
c. Brachioradialis- Patient's arm should in the brachioradialis
be flexed slightly and resting on the
lap with the palm facing down.
Strike the outer forearm about two
inches above the wrist; the palm To ensure that patient responds
should turn upward as the forearm to this part of the procedure
rotates laterally.
d. Patellar- With the patient's legs To check if the patient will
dangling (if possible), place your present the expected result in
hand on one thigh and strike the leg this reflex assessment
just below the kneecap; the leg
should extend at the knee.
e. Achilles tendon- With patient's foot
in slight dorsiflexion, lightly strike
the back of the ankle, just above the
heel; the foot should plantar flex.
f. Rate according to the following
scale:
Rating Reflex Response To help determine any abnormal
+5 Sustained clonus. reaction to a patient, and mostly,
+4 Non-sustained clonus (repetitive done to coma patients. This will
vibratory movements)
help nurses determine any
+3 Brisk
abnormal findings and intervene
+2 Normal
when needed.
+1 Rare, or seen only with reinforcement.
0 Absent reflex

15. Assess superficial reflex.

a. Plantar reflex is the only superficial
reflex that’s commonly assessed
and should be tested in comatose
patients, and those with suspected
injury to lumbar 5-5 or sacral 1-2
areas of the spinal cord.
b. Stimulate the sole of the foot with a
tongue blade or the handle of a
reflex hammer.
c. Begin at the heel & move up the
foot, in a continuous motion, along
the outer aspect of the sole and
then across the ball to the base of
the big toe.
d. Normal response is plantar flexion
(curling under) of the toes.
e. Extension of the big toe (Babinski’s
sign) is abnormal, except in

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 children younger than 2 years.
16. Assess brainstem reflexes.
a. Oculocephalic/doll’s eye reflex To check for the presence of this
i. Turn patient’s head briskly from reflex
side to side- the eyes should
move to the left while head is
turned to the right, and vice
versa. To check if patient has the ability
ii. If this reflex is absent, there will to determine area of the body
be no eye movement. which is affected
b. Oculovestibular reflex (ice caloric or
cold caloric reflex)
To prevent spread of microbes
i. Physician will instill at least 20 mL
To make patient relax
of ice water into patient’s ear. ii.
To prevent cross contamination
With intact brain stem, eyes will
move laterally toward affected ear.
iii. With severe brain stem injury, gaze
will remain at midline.
17. Restore or discard all equipment.
18. Place patient in a comfortable position.
19. Wash hands.

Evaluation
20. Evaluate client’s tolerance and reaction To determine any reactions
to the procedure. needed for an intervention or
21. Evaluate accuracy of results. may indicate complications
22. Compare findings to those of previous
examinations.
Documentation
23. Document all relevant information: To have a legal finding
a. Record the date and time of
assessment.
b. List positive findings first followed
by significant negative findings for
each component.

Rating Scale:
Excellent : 96- 100%
Very Satisfactory : 90-95%
Very Good : 85-89% Good : 80-84%
Fair : 75-79%
Poor : 74 & below

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