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02.03 Neuro Assessment

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Overview

  1. Heavily based on interviewing the patient
  2. Also involves direct or indirect assessment of cranial nerves

Nursing Points

General

  1. Neuro assessment begins when you first walk in the room – during your general assessment
  2. To determine alertness:
    1. Start by just walking in the room – if they open their eyes, that’s considered “spontaneous” eye opening
    2. If they don’t – call their name 2 or 3 times – if they open their eyes, it’s to “voice”
    3. If they still haven’t roused – gently shake and progressively increase noxious or painful stimuli until they arouse – “to pain”
  3. Supplies needed
    1. Pen light
    2. Alcohol swab
    3. Reflex hammer
    4. Cotton-tipped applicator
    5. Snellen chart if available
    6. Cup of water

Assessment

  1. Mental Status
    1. Level of Consciousness
      1. Normal
      2. Confused
      3. Delirious
      4. Somnolent
      5. Obtunded
      6. Stuporous
      7. Comatose
    2. Glasgow Coma Scale
      1. Eye opening
        1. 4 = spontaneous
        2. 3 = to voice
        3. 2 = to pain
        4. 1 = no response
      2. Vocalization
        1. 5 = oriented
        2. 4 = confused
        3. 3 = inappropriate
        4. 2 = incomprehensible
        5. 1 = no response
      3. Motor response
        1. 6 = follows commands
        2. 5 = localizes to pain
        3. 4 = withdraws from pain
        4. 3 = abnormal flexion
        5. 2 = abnormal extension
        6. 1 = no response
      4. *NOTE*
        1. Much of this information is obtained throughout the rest of your assessment, NOT as an individual assessment
    3. Orientation
      1. Person
        1. “Can you tell me your name?”
        2. Can be assessed when gathering 2 patient identifiers
      2. Place
        1. “Where are we right now?” OR “What city are we in?”
      3. Time
        1. “Can you tell me what month it is?”
        2. Asking the full date may be difficult for anyone
      4. Situation
        1. “What brings you into the clinic/hospital?”
        2. This also helps assess recent memory
    4. Thought process / Attention span
      1. Are they following your line of questioning?
      2. Are they paying attention?
      3. Are their responses scattered?
      4. Logical thought process questions:
        1. Will a stone float on water?
        2. Are there fish in the sea?
        3. Can you use a hammer to cut wood?
    5. Memory/Judgment
      1. Ask questions you can easily verify
      2. Common knowledge:
        1. What must you do to water to make it boil?
        2. When is Memorial Day?
        3. What are the four seasons of the year?
      3. Personal remote memory:
        1. Kids’ birthdays
        2. Their birthday
      4. Judgment
        1. Are they making safe/good decisions while hospitalized?
    6. Destructive thoughts
      1. “Are you having any thoughts of hurting yourself or anyone else?”
  2. Cranial Nerve Testing
    1. I – rarely tested, can ask patient if they have any difficulty identifyingsmells
      1. Have them identify known smells (alcohol rub, coffee)
    2. II, IV, and VI
      1. Visual Acuity – use a Snellen chart 20 feet away if possible. Otherwise have the patient read a sign on the wall
        1. Allow them to use corrective lenses if they have them
      2. PERRLA = Pupils Equal, Round, Reactive to Light and Accommodation
        1. Shine pen light in eyes bilaterally to assess constriction
        2. Should be equal bilaterally
        3. Right pupil should also contract when light shines in left pupil and vice versa (accommodation)
        4. Make note of pupil size
      3. Extraocular movements (EOM)
        1. Ask pt to follow finger in 6 cardinal positions
    3. V – motor and sensory function
      1. Palpate masseter muscles while patient clenches jaw
        1. Can also assess for TMJ at this point – clicking or pain
      2. Have pt close their eyes, lightly touch cheek, forehead, chin and ask pt to tell you when they feel it and if it’s the same bilaterally
    4. VII – facial motor function
      1. Have patient smile, frown, close eyes tightly, raise eyebrows, and show teeth
      2. Look for symmetry of movement
    5. VIII – hearing
      1. Lightly rub fingers about a foot from patient’s ears and move closer until they can hear
      2. Whisper test – whisper a 2-syllable word about 2 feet from the patient and see if they can hear it
    6. IX, X, XII – tongue
      1. Swallow/gag reflex
        1. If patient can swallow safely, nerves are intact
      2. Open mouth and say “Ah”- uvula should rise midline
      3. Stick out tongue – should be midline
    7. XI –
      1. Shrug shoulders against resistance
      2. Turn head left and right against resistance
  3. Sensory / Reflexes
    1. Use a cotton-tipped applicator with the wood split to test sharp and dull on 4 extremities
      1. Show the patient “sharp” and “dull” first, then ask them to close their eyes and tell you what they feel
      2. Compare side to side
    2. Use reflex hammer to test reflexes:
      1. Bicep
      2. Tricep
      3. Patellar
      4. Achilles
      5. Graded:
        1. 0 = no response
        2. 1 = diminished
        3. 2 = normal
        4. 3 = brisk
        5. 4 = hyperactive
    3. Babinski reflex – pull the handle of the reflex hammer up and across the foot (like an upside down J)
      1. Should see toes curl
      2. If toes flare out, that’s a bad sign (positive babinski)
  4. Balance / Coordination
    1. Assess gait by having patient walk 5 feet away and back
      1. Should be smooth and effortless
    2. Romberg test
      1. Have the patient stand with feet together, close eyes, and hold for 20 seconds
      2. Should be able to stay balanced without falling
      3. Some sway is normal
    3. Finger to nose test
      1. Have the patient touch your finger, then their nose, repeatedly as you move your finger – in approximately 5-6 positions.
      2. Should be able to easily bring their hand back to their nose from any position
      3. Have them repeat with both hand

Nursing Concepts

  1. There are MANY things that could cause barriers to this assessment
    1. Use alternative assessments when needed
    2. Document objectively
      1. “Unable to assess” is appropriate

Patient Education

  1. Purpose for each assessment and good instructions on how to perform

Reference Links

Study Tools

Video Transcript

In this video we’re going to review how to do a full neurological assessment. There are quite a few things involved, including level of consciousness, memory, and cranial nerve testing. We’re going to show you the most efficient way to get all of these things done in a coordinated fashion. Supplies you’ll need for this assessment – a pen light, an alcohol swab, a reflex hammer, a cotton-tipped applicator, and a Snellen chart if you have one available.

The neuro assessment begins the moment you walk in the room and you start assessing whether the patient is awake and alert. If they aren’t, start by calling their name – if that doesn’t work, give them a gentle shake. If they’re truly just asleep, that should wake them up.

If not, increase the noxious stimuli until you get a response, or you may have to start some other assessments if they won’t wake up.

The next thing is you need to check for orientation to person, place, and time. Ask the patient their name, what month it is, and where they are. I usually don’t ask for a full date because half the time I don’t even know what the date is! As with your general assessment, you also want to be looking at their overall mood and affect and listening to the quality of their speech while you talk to them.

At this point let the patient know you’re going to ask a bunch of silly questions to assess their memory and thought processes. You can find examples of these in your outlines, but it might include things like “does a stone float on water?” or “what are the four seasons of the year?”. This helps you to see how their attention span is, how is their judgment? Are they following your line of questioning?

Once you’ve done your interview questions and you’re confident they’ll be able to follow the rest of your instructions… you’ll move on to the cranial nerve testing. First is cranial nerve 1, the olfactory nerve – have the patient close their eyes and ask them to identify a common smell. The best and most available option you have is an alcohol swab, just open the package and wave it a few inches from their nose.

Next we’ll test cranial nerves 2, 4, and 6 – These are all about the eyes. You’ll want to have the patient cover one eye at a time and read a Snellen chart if you have it, or just a sign on the wall opposite the bed.

Then we’ll do our pupil exam – we’re looking at PERRLA – pupils round, reactive to light and accommodation. Grab your pen light and shine it into the patient’s eyes one at a time. I usually ask the patient to look right at my nose.

When you shine the light, you’re looking for the pupil to constrict. They should be equal on both sides and react quickly. You should ALSO see the opposite pupil react when you shine a light in the other eye. That’s the “accommodation” part of PERRLA.

Then you’ll do your 6 cardinal movements to check extraocular movements. Just ask the patient to follow your finger with just their eyes.

Now you can move on to the cranial nerves of the face. I usually start with cranial nerve 7 – the facial nerve. Ask the patient to smile, frown, raise their eyebrows, close their eyes tight, and show their teeth – all the while you’re looking for symmetry from side to side.

Then I do cranial nerve 5 – Palpate the jaw while the patient clenches their teeth – you can even assess TMJ at this point by feeling for any clicking when they open and close their mouth and asking if there’s any tenderness.
Then just lightly touch both sides of their forehead, cheeks, and chin and make sure the patient feels it equally on both sides.

Then we test the cranial nerves related to the tongue and swallowing – Have the patient swallow a sip of water to make sure they have no issues, then have them open their mouth, stick out their tongue and say “ah” – you should see the tongue midline, and the uvula should rise midline and well.

Last is cranial nerve 11 – have the patient shrug their shoulders and turn their head side to side against resistance. And that’s it for the cranial nerves.

We’re almost done! Next is sensory – many times I’ll just ask the patient if they have any numbness or tingling, but to specifically assess this, we’re going to get a cotton tipped applicator and break a bit of the wood off. Now you’ll have one sharp side and one dull side. Don’t push hard, but show the patient on their arm which one is sharp and which one is dull.
Then have the patient close their eyes and simply work side to side on the arms and legs telling you whether they feel sharp or dull – just mix it up, don’t be predictable!

Now you can quickly assess reflexes. Grab your reflex hammer and test the triceps and biceps reflexes on both arms. Then we need to check the patellar and achilles reflexes on the legs. You may have to have the patient sit on the side of the bed, but that’s okay, because we’re about to get them out of bed anyways! We’ll also check for a babinski reflex – remember we should see the toes curl – if they don’t, that’s not a good sign!

The very last thing we are going to check is balance and coordination. If the patient is able and there’s no reason they can’t, have them stand up at the side of the bed with their feet together. Then they’ll close their eyes and hold that position for 20 seconds. This is called the Romberg test. They should be able to stand without falling the whole time. A little bit of sway is totally normal.

Now I have the patient do the finger to nose test. They should touch your finger, then their nose, back and forth as you move their finger. This tests for ataxia or uncoordination. It should be smooth and simple and sometimes patients can have a lot of fun with it!

Then the very last thing you have to test is their gait. Just have them walk about 5 feet away from you and back. Their gait should be smooth and effortless with no sway. If they regularly use any kind of cane or walker, make sure you let them use it when they walk!

Now, even in a perfectly healthy patient, some of these assessments might be difficult to do, either because of medications the patient is on, lack of equipment, or some other barrier. That’s okay – just make sure you use any alternatives you can and document everything objectively.

So that’s a full neurological exam. I hope that was helpful. Now, go out and be your best selves today. And, as always, happy nursing!

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