Neurologic assessment doesn't just take place in neuro units and the ED. A patient who doesn't have a neurologic diagnosis may also require a neuro assessment; for example, a patient with pneumonia can develop neurologic changes due to hypoxia or a post-op patient may have a neurologic deficit due to blood loss. No matter what setting you work in, you'll have to perform a neurologic assessment at some point. The value of a solid neurologic assessment
can't be overstated—a small change in the assessment is indicative of a neurologic injury, and early intervention can prevent permanent damage. Performing a neurologic assessment sends many of us into a panic. Fortunately, it doesn't have to be that way. In this article, I'll review not only how to perform a solid neurologic assessment, but also how you can tailor your assessment to the situation. I'll also give you some helpful tips to make your assessment as smooth as
possible. A thorough neurologic assessment will include assessing mental status, cranial nerves, motor and sensory function, pupillary response, reflexes, the cerebellum, and vital signs. However, unless you work in a neuro unit, you won't typically need to perform a sensory and cerebellar assessment. Also, most vital sign changes are a sign of end-stage neurologic injury. Therefore, we'll look at assessment of
mental status, cranial nerves, motor function, and pupillary response. Although this isn't a comprehensive neurologic exam, it will yield valuable clinical information. Let's get started with mental status. Evaluating a patient's mental status includes level of consciousness (LOC), orientation, and memory. To assess LOC, you'll
use the Glasgow Coma Scale (see Glasgow Coma Scale). LOC is crucial to test because it's the first assessment to change when there's neurologic injury. You should always elicit your patient's best level of response for an accurate assessment of LOC. Begin with speaking your patient's name in a normal tone. If he doesn't respond, say his name again in a louder tone. (If your patient is hearing-impaired, you'll need to document this; it
shouldn't change his score.) If there's still no response, gently shake your patient. If you still can't get a reaction, you'll need to use painful stimulation. To do this, you can use one the following techniques: Glasgow Coma Scale
If these techniques elicit a reaction, it comes from the brain. But there's one more technique you'll need in your repertoire. The patient who requires painful stimuli isn't following commands; therefore, if he reacts to the painful stimuli with only one side of his body, you'll need to assess the nonreactive side. This can be done by pressing a pencil into the cuticle of one of your patient's fingers. The response you'll see will be purposeful, occurring when your patient pulls away from the pain; nonpurposeful, occurring when he moves in response to the pain but not in any meaningful way (including flexion posturing [arms bent up toward the trunk with legs extended] and extension posturing [arms extend down and legs extended], formerly called decorticate and decerebrate posturing); or no response at all. All painful stimuli should be applied for 15 to 30 seconds. To determine orientation, ask detailed questions about your patient's name, where he is, and the date. Obtain as much information as you can from the question; for example, when asking the date, also ask for the month and year. Keep in mind that hospitalized patients often know the month but not the date or day of the week. Evaluate your patient's knowledge of date and time carefully; patients who are confused may still answer correctly enough that a disorder goes unnoticed. I once had a patient who was clearly confused in conversation but confidently stated the name of the hospital each time I asked where we were. Halfway through my shift, I realized he was reading the hospital's name off his roommate's sheets, which were emblazoned with our logo. For the same reason, alternate your questions with each assessment. It's important to note that when you're assessing orientation, you're also evaluating your patient's speech. Memory is divided into three abilities: immediate memory, short-term memory, and remote memory. To assess immediate memory, give your patient three unrelated words to remember, such as pencil, grape, and car. Have him repeat the words and ask him to remember them. After 5 minutes, ask him to repeat the words back to you. To assess short-term memory, ask your patient to describe something that happened in the last few days. The classic example is to ask him what he had for breakfast, but you'll want to be able to verify his response. You may choose to ask about a recent significant news event or a recent holiday. Remote memory also commonly requires verification from another party. Wedding dates or children's birth dates are tests of remote memory but if you can't get confirmation, you can again try to use a news event. Assessing the cranial nervesThe next component of the neurologic assessment is cranial nerve testing. Test the cranial nerves as follows:
 Assessing motor functionWhen assessing motor function, you'll want to look at both sides of your patient's body simultaneously. On inspection, note any asymmetry of muscle; unilateral atrophy will often indicate weakness. To assess the upper extremities, have your patient raise his arms parallel to the floor or bed, and then have him resist when you try to push them down. You'll do the same for the lower extremities, having him raise his legs and resist when you push them down. You can also have him grasp your fingers in his fist, and then ask him to let go. If he can't let go on command, it's indicative of neurologic injury. Visualizing pupil size To test for pronator drift, have your patient close his eyes so he can't compensate and extend his arms, palms up, in front of him. Look for one arm to sway from its original position: a subtle indicator of weakness. Assessing pupillary responseNow, we'll move on to pupillary response. Along with eye motion, pupillary response is controlled by cranial nerves III, IV, and VI. Normal pupils are of the same size bilaterally, about 2 to 6 mm and round (see Visualizing pupil size). About 15% of people have one pupil up to 1 mm smaller than the other; this is a normal variant known as anisocoria. To check pupil reactivity, bring a small beam of light in from the outer canthus of one eye; the normal response is for both pupils to react equally and briskly. Keep in mind that medications, surgery, and blindness can affect pupil size, shape, and reactivity. The hallmark sign of severe neurologic injury is a change in pupil size and reactivity. Eye motion is tested by asking your patient to follow your finger as you trace the letter H in front of him. This is known as extraocular movement, or EOM. Document any inability to follow your finger. The focused assessmentAlthough a thorough neurologic assessment yields valuable information, at times you'll need to perform a focused neurologic assessment. You may have a patient with a neurologic diagnosis who develops a change. More likely, you may have a patient with another diagnosis who develops a neurologic deficit. In these cases, it isn't necessary to perform the entire assessment as previously described. Limit your examination to LOC, motor strength, and pupillary reactivity. You'll also want to include other assessments you feel may yield important data. For example, if your patient develops slurred speech, you'll want to include an examination of the cranial nerves involved with speech. Helpful tipsIn performing frequent neurologic assessments, I've found the following information to be helpful. Follow these steps to perform a successful neurologic assessment. Keep a cheat sheet. Remembering the function of each cranial nerve or the terminology to describe deficits is overwhelming. Consult your cheat sheet for accurate documentation or when discussing your findings with the healthcare provider, as well as to determine what additions you need if you perform a focused neurologic assessment. Explain the assessment to your patient and his family before you begin. Many people are frightened when they, or a loved one, develop a neurologic injury, so they can become frustrated when you ask them to do such seemingly silly things as sticking out their tongues. Explain to your patient upfront that you'll be asking him to answer a series of questions and perform commands that may seem frivolous but are important indicators of brain function. I also instruct family members not to answer questions for the patient, even if he seems to be struggling to respond. Peak performancePerforming a neurologic assessment can be scary. But if you take your time and use the proper resources, you can perform a solid neurologic assessment no matter what. Learn more about itBickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:671–689. Health Assessment Made Incredibly Visual! Philadelphia, PA: Lippincott Williams & Wilkins; 2007:177–189. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:2143–2152. Which assessments would the nurse perform during the neurologic examination of a patient?A thorough neurologic assessment will include assessing mental status, cranial nerves, motor and sensory function, pupillary response, reflexes, the cerebellum, and vital signs. However, unless you work in a neuro unit, you won't typically need to perform a sensory and cerebellar assessment.
Which tests should the NP perform to assess balance function in a patient quizlet?Which tests should the nurse perform to assess cerebellar function in a patient? The Romberg test is done to assess balance. The finger-to-nose test is done to assess upper limb coordination.
Which action would the nurse take to assess cranial nerve 2 in a patient?Cranial nerve II (optic)
Visual fields are evaluated with confrontation testing. Face the patient and ask them to cover one eye while you cover your eye on the same side.
What intervention does the nurse perform to test the Stereognosis of a patient?What intervention does the nurse perform to test the stereognosis of a patient? Ask the patient to identify an object placed in the hand without visual clues. The nurse asks a patient to bend the head forward and back, turn the head to either side, and to shrug the shoulders.
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