Performing a Full Neurological Assessment
- In this course we will learn about the components of a comprehensive neurological assessment, and why it is important for nurses to understand it in its entirety.
- You’ll also learn the basics of how to assess mental status, motor and sensory functions, and cranial nerves.
- You’ll leave this course with a broader understanding of how to complete a full neurological assessment.
Contact Hours Awarded: 1.5
MSN, RN, CNE
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The following course content
Assessment is a key component of nursing care. It not only informs the nurse of changes to the patient’s condition but allows the nurse to evaluate if interventions have been effective. When working with patients who have suffered injury or impairment to the neurological system, a complex neurological assessment is often needed to guide care. The purpose of this course is to provide guidance for nurses who are performing neurological assessments. We will identify the components of a neurological exam, discuss how the exam should be performed, and explore both normal and abnormal findings that may be seen.
Why a Neurological Assessment?
The neurological system is complex and affects every other system. The central nervous system (CNS) consists of the brain and spinal column. The brain is made up of the cerebrum (which includes the cerebral cortex), brain stem, and cerebellum. The peripheral nervous system (PNS) consists of the nerves, which are classified as cranial, spinal, peripheral, and association. Also included in the neurological system is the autonomic nervous system, which helps to regulate processes within the body using neurotransmitters. Because of how interconnected the neurological system is with other body systems, damage or injury to the neurological system can cause disruption in other body systems, resulting in altered or loss of function. Additionally, problems originating within the neurological system may present as symptoms within another system. For a nurse performing a neurological assessment, understanding that interconnectedness of the neurological system is important so that what might seem like a minor change in the musculoskeletal system or in vital signs is not missed as a neurological “red flag.”
While acute neurological patients are often cared for on specific units of a hospital, in reality, neurological patients are often cared for in a variety of units and in various settings. Patients with chronic neurological disorders often required comprehensive neurological assessments to monitor functioning. Additionally, just because a patient is being treated for a non-neurological problem does not rule out the possibility of an acute issue. Nurses caring for both patients with a neurological disorder as well as those caring for patients with a risk of developing one should be able to perform a comprehensive neurological exam.
Comprehensive Neurological Assessment
As with any assessment, it is important to gather information from the patient prior to conducting the initial assessment. This will help to establish the patient’s baseline or may help to identify other factors, which might impact assessment findings. If possible, the nurse should question the patient about past medical history, current medications, environmental risk factors, and current functional level, making a note of any information relevant to the neurological system.
Mental status is often one of the first aspects assessed during a comprehensive neurological assessment and provides information on cerebral functioning. Key components of a mental status exam include general appearance and behavior, cognition, and mood/affect.
Assessed by observing the patient. This assessment should include the level of consciousness, body posture, speech patterns, and even patient movement. Previous assessments should be compared if possible. If previous assessments are not available, family members may offer insight as to the normal posture or speech patterns of the patient.
The Glasgow Coma Scale is often used to assess the level of consciousness (LOC). It is typically used in patients with head injuries but may also have value in other situations where determining LOC needs to occur quickly. The scale looks at pupil size, verbal response, and motor response to determine a score. In patients who do not respond to verbal or touch stimuli, painful stimuli should be used to elicit a response. Common techniques include nail bed pressure, supraorbital pressure, trapezius grip, and a sternal rub (1). The score ranges from 3 to 15, and the higher the score the better. Patients with a score of less than 8 are usually in a comatose state.
Assessed by determining orientation and memory. The nurse should determine the patient’s orientation to time, place, person, and situation by asking the patient to identify the current date, where they are at, their full name, and what brought them to the hospital. Memory can be tested in a variety of ways. Most commonly, it might be asking the patient common knowledge questions or giving the patient three words or phrases and then asking them to repeat these several minutes later. It is important to note that questions asked to determine cognition should not be above the patient’s intellectual ability.
Mood and Affect
Assessed by observing the patient and asking questions regarding their mood. Both should be appropriate to the situation and should match. For example, a patient who states they are angry or sad but is smiling is abnormal.
Level of Consciousness Terminology
Alert, oriented, is able to pay attention and respond.
|Able to wake up but remains sleepy. Response to questions or commands is slow.
|Difficult to arouse and keep awake. Can be awoken repeatedly to provide one- or two-word answers.
|Requires repeated and often vigorous stimuli to awaken.
|Does not respond to any type of stimuli.
The nurse is caring for a patient who is in recovery following orthopedic surgery. Upon approaching the patient’s bedside, the nurse observes the patient is lying in bed, and their eyes are closed.
- What type of stimuli would the nurse use to determine if the patient is arousable?
- The patient arouses but seems slow to respond to questions. During the assessment, the patient falls asleep. How would the nurse document the patient’s condition?
- Based upon what is known about the patient, is this a normal finding?
Comprehensive Neurological Assessment (cont.)
Assessment of motor function evaluates for strength, tone, coordination, and symmetry of muscles. Testing of motor function is more easily completed if the patient is able to follow instructions or commands. When testing motor function during a neurological assessment, it should be done bilaterally and simultaneously in order to compare side to side. Muscle strength is graded on a scale from 0 to 5+, where 0 is no muscle contraction, 1+ is barely detectable, 2+ is active movement with assistance, 3+ is active movement without assistance, 4+ is active movement against some resistance, and 5+ is active movement with full resistance (5).
Begin the assessment by observing the upper extremities and shoulders for muscle atrophy, hypertrophy, asymmetrical development, fasciculations (twitching), myotonia (slowed relaxation), tremors, or other involuntary movements (6). Assess for strength by having the patient move arms independently and against resistance. Have the patient flex their arms, bending at the elbows, apply resistance to the lower arms and ask the patient to straighten their arms. The nurse should ask the patient to grasp two of their fingers and gently squeeze to assess for grip strength. Assess for pronator drift by asking the patient to close their eyes and to put arms out straight with palms up for 10 seconds (5). Downward drift is indicative of muscle weakness (5).
Begin by assessing the legs for muscle atrophy, hypertrophy, asymmetrical development, fasciculations (twitching), myotonia (slowed relaxation), tremors, or other involuntary movements (6). Have the patient move their legs independently and against resistance. Have the patient attempt to lift the leg while applying resistance on the thigh or lower leg. Have the patient hold the leg straight and attempt to lift it up against gravity. Test for foot strength by placing a hand on the patient’s foot and applying resistance as they flex and extend.
Normal patient posture is relaxed; however, in some patients, decorticate or decerebrate posturing may be present. Decorticate posturing occurs with damage to the corticospinal pathway (4). In decorticate posturing, the patient’s arms are folded in, hands are turned inwards, and both legs and feet are extended. Decerebrate posturing occurs with brainstem dysfunction (4). In decerebrate posturing, the patient’s body is rigid, arms are extended and turned out, both legs and feet are extended, and often spasms cause the body to arch.
The nurse is assessing a patient and determines the patient has muscle strength of 2+ in the left upper extremity and 4+ in the right upper extremity.
- What further assessments of motor function should the nurse make?
Comprehensive Neurological Assessment (cont.)
During a neurological assessment, peripheral or spinal nerve impairment can be determined by identifying a patient’s sensory function. Assessment of the sensory system includes tactile, superficial pain, temperature, vibration, and proprioception or body awareness (3). The patient needs to be alert and able to follow instructions in order to complete the assessment. In most cases, testing for sensory function should start at the feet and move up the body. The exam should occur with the patient’s eyes closed, and there should be pauses between stimulations to prevent it from being perceived as a longer stimulation (5).
Using a cotton ball, touch the patient on the foot and ask them to state where the sensation is felt (5). This can also be done using a finger and asking where the patient feels the touch (5).
Use a sharp object, such as a clean safety pin or a broken swab, and lightly touch the skin, asking the patient where the sensation is felt (5).
This is only tested if tactile and painful stimulation cannot be felt (3, 5). Use a warm or cold object, apply it to the skin and ask the patient which sensation is felt.
This is only tested if both the tactile and pain responses are weak or absent (5). To test for this, strike a tuning fork on the palm of the hand and, holding only the base of the fork, place one finger under one of the patient’s distal phalangeal joints and place the tuning fork on the top of the joint (6). Have the patient indicate when they start and stop feeling the vibration; they should stop feeling it the same time as the nurse stops feeling it through the bottom of the joint (6).
Testing proprioception is only necessary if other sensory findings were abnormal (5). Have the patient close their eyes and, starting at the most distal joint, move the toe or finger up and down a few degrees to determine if the patient can identify the movement (5, 6). If they cannot then move to the next proximal joint (5, 6).
The nurse is accessing sensory function in a patient. The patient is unable to identify either touch or pain.
- What further action should be taken by the nurse?
Comprehensive Neurological Assessment (cont.)
Cerebellar function is evaluated by looking at both coordination and balance. Testing of cerebellar function can only be completed if the patient is able to follow commands. The nurse should test upper extremities, lower extremities, and balance. Inability to do these activities smoothly or if the patient is unable to maintain their balance are abnormal findings, and the patient should be further evaluated for a problem in the cerebellum (4)
Have the patient perform rapid alternating movements and point-to-point testing (3). The patient should place the hand’s palm up and then palm down as quickly as possible (3). Then have the patient put their arms out to the side and touch the finger to the nose several times, with eyes open and then eyes closed (4).
Have the patient sit or lie down, then run the heel of one foot down the shin of the other leg. The patient should be able to do this smoothly with both legs.
In a patient who is mobile, this should be done by having the patient walk normally on heels, toes, and then heel-to-toe in a straight line; you should be observing the patient’s gait. Inability to maintain balance, swaying, or a staggering gait is an abnormal finding (7). A Romberg test is also commonly performed to test equilibrium. To complete this exam, the nurse should have the patient keep their eyes open and stand with their arms at their side and the feet together. Observe for swaying. Then ask the patient to close their eyes and again observe for swaying. If swaying only occurs when the eyes are closed, it is related to proprioception (7). However, if the patient is unable to balance regardless of if eyes are opened or closed, this lack of balance is more indicative of a problem in the cerebellum (4).
The nurse is caring for a patient with a spinal cord injury at the 2nd lumbar vertebrae.
- How might the nurse test this patient’s cerebellar function?
Comprehensive Neurological Assessment (cont.)
Cranial nerves (CN) are the only nerves branching from the brain instead of the spinal column. While abnormal findings in a CN assessment may indicate dysfunction within the brain, disorders affecting just the nerve or injury to the nerve may also result in abnormal findings.
Cranial Nerve Assessment
I – Olfactory
Assess the patency of nares first. Have the patient close the eyes, close one nare, and have them inhale an easily recognizable scent. Repeat on the other nare. Inability to smell the scent is an abnormal finding (5).
II – Optic
Test visual acuity using a Snellen chart or other visual acuity charts. If the patient typically wears corrective lenses, identify what the patient’s normal acuity is with and without correction if possible. Changes to the patient baseline should be considered abnormal (5).
III – Oculomotor
III, IV, and VI work together and are therefore tested together. Assess pupil size, shape, and symmetry, test for accommodation and convergence, and test cardinal gaze by having the patient follow a penlight or finger among all four quadrants, across the midline and towards the nose (5). Abnormal findings would include unequal size, shape, and reaction, presence of nystagmus, or inability to follow objects (5).
IV – Trochlear
VI – Abducens
V – Trigeminal
Using a cotton ball and a sharp object, touch the scalp, cheeks, and chin, asking the patient to identify if it is soft or sharp. Dull or absent sensation is an abnormal finding (5). Check for the corneal reflex by lightly touching a fluffed piece of cotton to the sclera of the eye. If the reflex is present (normal) the patient should blink.
VII – Facial
Check for symmetrical facial movement by having the patient smile, raise eyebrows, show teeth, puff out cheeks, and purse lips (5). You can also test for the ability to taste by applying sour, sweet, bitter, and salty solutions to one side of the tongue than the other (5, 6).
VIII – Vestibulocochlear
Assess for the ability to hear during normal conversation (5). Assess if the patient has a history of hearing loss and uses a hearing aid or has an implant. For patients without hearing aids, test for hearing can also be done by whispering or rubbing fingers together near the ear. If the patient is unable to hear, a Rinne or Weber test may be performed.
IX – Glossopharyngeal
Assess for difficulty with swallowing (5). If the patient does not have any known restrictions, offer a small sip of water and observe for inability to swallow, coughing, choking, or repeated swallowing. Difficulty swallowing is often seen in patients who have suffered from a stroke. Further neurological evaluation and possibly evaluation by a speech therapist are needed if the patient has any difficulty with swallowing.
X – Vagus
Have the patient stick out their tongue and check if it is midline (5). Also, check for a midline uvula and the presence of a gag reflex (5) using a tongue depressor.
XI – Accessory
Place a hand on one side of the patient’s chin and ask the patient to press against the resistance, then repeat on the other side (5). Also, apply resistance to the shoulders and ask the patient to shrug (5). Weakness or unequal strength are abnormal findings (5).
XII – Hypoglossal
Have the patient stick out their tongue and assess for symmetry (5).
Because CNs often work in conjunction with one another, additional assessments such as pupil response (CN II and III), corneal reflex (CN V and VII), and the gag reflex (CN IX and X) are performed. While these assessments are done as a full CN assessment, they can also be done independently. The nurse caring for these patients needs to be aware that abnormal findings in these assessments may be indicative of a single nerve or multiple nerve dysfunction.
It is also important to note the role of the vagus nerve (CN X) in regulating heart rate, respiratory rate, and vasomotor activity. Conditions affecting the vagus nerve, such as traumatic brain injury, can result in alterations in respiration, pulse, and blood pressure. Because of this, vital signs should also be a component of a complete assessment.
After completing a CN assessment on a patient, the nurse identifies the abnormal findings in CN VII, IX, and X.
- How does this finding impact the plan of care?
Comprehensive Neurological Assessment (cont.)
Reflexes are involuntary movements as a result of a stimulus. There are two types of reflexes that can be assessed, deep tendon reflexes (DTR) and superficial reflexes. DTRs are rated on a scale of 0-4+, with 0 being absent, 1+ is weak or hypoactive, 2+ is normal, 3+ is brisk, and 4+ is exaggerated or hyperactive (2). If a reflex is stimulated and clonus (uncontrollable shaking) occurs, it is also rated as a 4+ (2). Abnormal findings (absent, hypoactive, or hyperactive) may be indicative of a neurological disorder, and in some cases, may be the first sign of a degenerative neurological disorder (2).
DTRs are tested using a reflex hammer. The reflex occurs when the hammer strikes the tendon causing the muscle to contract. DTRs should be tested bilaterally.
Flex the arm at the elbow and ensure the palm is down. Place a thumb or finger over the bicep tendon. Strike the thumb or finger with the reflex hammer. The bicep should contract, and there should be flexion at the elbow.
Flex at the elbow and turn the palm towards the body. Find the tricep muscle and strike the tendon just above the elbow. The elbow should extend, and the tricep should contract.
The nurse should flex the arm at the elbow and rest the patient’s forearm on their arm. The brachioradialis tendon sits between 1-2 inches above the wrist on the thumb side. When the tendon is struck with the reflex hammer, the thumb will flex in, the elbow will flex, and the brachioradialis muscle will contract.
Sitting up, having the patient dangle their lower legs. Palpate for the patellar tendon just below the edge of the patella. When struck with a reflex hammer, the quadricep will flex, and the lower leg will extend.
With the patient sitting and legs dangling, palpate for the Achilles tendon on the back of the ankle. When the tendon is struck, the foot should plantarflex, and the large calf muscle (gastrocnemius) will flex.
Superficial reflexes are elicited by touching the skin or other surface (mucous membrane, cornea) of the body. The corneal and gag reflex are technically superficial reflexes but are tested as part of the cranial nerve assessment. While primitive reflexes are superficial reflexes, the only one typically assessed in adults is the plantar reflex. To elicit this reflex, a pointed object is stroked across the bottom of the foot. In adults, a normal finding is plantar flexion of the foot and toes. If the big toe extends and the toes splay, the patient has a positive Babinski sign. In patients over the age of 2, this often indicates some type of brain injury.
The nurse is reviewing a reflex assessment of a patient and observes DTRs of 1+ in both triceps and 2+ in both biceps.
- How does the nurse interpret this assessment?
The neurological system interacts with and impacts other body systems and being able to identify potential problems early allows the nurse to intervene, potentially preventing lasting neurological damage. While comprehensive neurological assessments are commonly performed by nurses working in acute neurological units, these are not the only places where patients with neurological disorders or injuries are cared for. Every nurse should be armed with the knowledge and skills to complete a neurological assessment.
References + Disclaimer
- Cook, N. F., Braine, M. E., & Trout, R. (2019). Nurses’ understanding and experience of applying painful stimuli when assessing components of the Glasgow Coma Scale. Journal of Clinical Nursing, 28, 3827-3839. https://doi.org/10.1111/jocn.15011
- Gilreath-Osoff, A. & Caple, C. (2018). Neurological assessment: Assessing reflexes. CINAHL Nursing.
- Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.). Wolters Kluwer.
- Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care (9th ed.). Elsevier.
- Jensen, S. (2019). Nursing health assessment: A best practice approach (3rd ed.). Wolters Kluwer.
- Newman, G. (2020). Neurological examination. https://www.merckmanuals.com/professional/neurologic-disorders/neurologic-examination/introduction-to-the-neurologic-examination
- Stanford Medicine. (2021). Introduction to cerebellar exam. https://stanfordmedicine25.stanford.edu/the25/cerebellar.html
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