Saint Francis of Assisi College

COLLEGE OF NURSING
045 Admiral Village Talon III, Las Pinas City

NEUROLOGICAL ASSESSMENT

NAME OF STUDENT: _____________________ YEAR/SECTION: ___________ SCORE: ____________

Use the following criteria in evaluating the skill performance.

4 – Student was able to demonstrate the step correctly with rationale and without requiring guide questions
3 – Student was able to demonstrate the step correctly without requiring guide questions
2 – Student required guide questions to demonstrate the step correctly
1 – Student was not able to demonstrate the step correctly despite being given guide questions

PROCEDURE 4 3 2 1 REMARKS
1) Assemble equipment:
 Sugar, salt, lemon juice, quinine flavours
 Percussion hammer
 Tongue depressors (one broken diagonally for testing pain
sensation)
 Wisps of cotton, to assess light touch sensation
 Test tubes of hot & cold water, for skin temperature
assessment (optional)
 Pins or needles for tactile discrimination
2) Introduce yourself, & verify the client’s identity. Explain to the
client what you are going to do, why it is necessary, & how the
client can cooperate.
3) Perform hand hygiene & observe other appropriate infection control
procedures.
4) Provide for client’s privacy.
5) Inquire if the client has any history of the following:
 Presence of pain in the head, back, or extremities, as well as
onset & aggravating & alleviating factors
 Disorientation to time, place or person
 Speech disorders
 Any history of loss of consciousness, fainting, convulsions,
trauma, tingling or numbness, tremors or tics, limpoing,
paralysis, uncontrolled muscle movements, loss of memory, or
mood swings
 Problems with smell, vision, taste, touch or hearing
Language
6) If the client displays difficulty speaking:
 Point to common objects, & ask the client to name them
 Ask the client to read some words & to match the printed &
written words with pictures.
 Ask the client to respond to simple verbal & written commands
– e.g., “Point to your toes,” or “ Raise your left arm.”
Orientation
7) Determine the client’s orientation to time, place, & person by tactful
questioning.
 Ask the client the city & state of residence, time of day, date,
day of the week, duration of illness, and names of family
members.
 More direct questioning might be necessary for some people –
e.g.. “Where arre you now?”, “What day is today?”
Memory
8) Listen for lapses in memory. Ask the client about difficulty with
memory. If problems are apparent, three categories of memory are
tested: immediate recall, recent memory, & remote memory.
9) To assess immediate recall:
 Ask the client to repeat a series of three digits—(e.g., 1-4-3)—
spoken slowly.
 Gradually increase the number of digits (from 3 to 4 to 5 to 6
digits…) until the client fails to repeat the series correctly.
 Start again with a series of three digits, but this time ask the
client to recite it backwards
 The average person can repeat a series of 5-8 digits I
sequence, & 4-6 digits in reverse order.
10) To assess recent memory:
 Ask the client to recall the recent events of the day.
 Ask the client to recall information given early in the interview
 Provide the client with three facts to recall (a color, an object,
an address), and ask the client to recall all three.
11) To assess remote memory: Ask the client to describe a previous
 illness or surgery
Attention Span & Calculation
12) Test the ability to concentrate or attention span by asking the client
to recite the alphabet or to count backward from 100.
13) Test the ability to calculate by asking the client to subtract 7 or 3
progressively from 100 (e.g., 100, 93, 86, 79… or 100, 97, 94…)
Level of Consciousness
14) Apply the Glasgow Coma Scale. Assess for eye, verbal & motor
response
Cranial Nerves
15) Test the Cranial Nerves.
I. Cranial Nerve I – Olfactory
Ask client to close eyes and identify different mild aromas such as
coffee & vanilla
II. Cranial Nerve II – Optic
Ask the client to read Snellen’s chart; check visual fields of
confrontation & conduct an opthalmoscopic examination
III. Cranial Nerve III – Oculomotor
Assess the six oculomotor movements & pupil reaction
IV. Cranial Nerve IV - Trochlear
Assess six ocular movements
V. Cranial Nerve V – Trigeminal
While client looks upward, lightly touch the lateral sclera of the eye
to elicit the blink reflex. To test light sensation, have the client
close eyes, & wipe a wisp of cotton over client’s forehead
&paranasal sinuses. To test deep sensation, use alternating blunt &
sharp ends of a safety pin over the same area.
VI. Cranial Nerve VI – Abducens
Assess directions of gaze.
VII. Cranial Nerve VII – Facial
Ask the client to smile, raise the eyebrows, frown, puff out cheeks,
& close eyes tightly. Ask thre client to identify various tastes &
placed on the tip & sides of the tongue – sugar, salt - & to identify
areas of taste.
VIII. Cranial Nerve VIII – Auditory
Assess the client’s ability to hear the spoken word & the vibrations
of a tuning fork.
IX. Cranial Nerve IX – Glossopharyngeal
Apply tastes on the posterior tongue for identification. Ask the
client to move tongue from side to side and up & down.
X. Cranial Nerve X – Vagus
Assessed with CN IX; assess the client’s speech for hoarseness
XI. Cranial Nerve XI – Accessory
Ask the client to shrug shoulders against resistance from your
hands & to turn head to the side against resistance from your hand.
Repeat on the other side.
XII. Cranial Nerve XII – Hypoglossal
Ask the client to protrude tongue at midline, then move it side to
side.
Reflexes
16) Test reflexes using a percussion hammer, comparing one side of
the body with the other to evaluate the symmetry of response.
 Biceps reflex – tests the spinal cord levels C-5 , C-6
- Partially flex the client’s arm at the elbow, & rest the forearm
over the thighs, placing the palm of the hand down
- Place the thumb of your nondominant hand horizontally over
the biceps tendon.
- Deliver a blow (slightly downward thrust) with the percussion
hammer to your thumb.
- Observe the normal slight flexion of the elbow, & feel the
biceps contraction through your thumb.
 Triceps reflex – tests the spinal cord levels C-7, C-8
- Flex he client’s arm at the elbow & support it in the palm of
your nondominant hand.
- Palpate the triceps tendon about 2-5cm above the elbow.
Deliver a blow with the percussion hammer directly to the
tendon.
- Observe the normal slight extension of the elbow.
 Patellar Reflex – tests the spinal cord levels L-2, L-3, L-4
- Ask the client to sit on the edge of the examining table so that
the legs hang freely. Locate the patellar tendon directly below
the patella.
- Deliver a blow with the percussion hammer directly to the
tendon. Observe the normal extension or kicking out of the leg
as the quadriceps muscles contract.
- If no response occurs, and you suspect the client is not
relaxed, ask the client to interlock fingers & pull.
 Achilles Reflex – tests the spinal cord levels S-1, S-2
 -
With the client in the same position as the patellar tendon
reflex test, slightly dorsiflex the client’s ankle by supporting
the foot lightly in your hand.
- Deliver a blow with the percussion hammer directly to the
Achilles tendon
- Observe & feel the normal plantar flexion (downward jerk) of
the foot.
 Plantar (Babinski’s) Reflex – is superficial. It might be absent in
adults w/o pathology or overridden by voluntary control.
- Use a slightly sharp object such as the handle of the
percussion hammer, a key, or the dull end of a pin or
applicator stick.
- Stroke the lateral border of the sole of the client’s foot,
starting at the heel, continuing to the ball of the foot, & then
proceeding across the ball of the foot toward the big toe.
- Observe the response. Normally, all five toes bend downward;
this reaction is negative Babinski’s. In an abnormal Babinski’s
response, the toes spread outward & the big toe moves
upward.
Motor Function
 Gross Motor & Balance Tests
- Walking Gait. Ask the client to walk across the room & back,
and assess the client’s gait.
- Romberg’s Test. Ask the client to stand with feet together
&arms resting at the sides, first with eyes open, then closed.
- Standing on One Foot with Eyes Closed. Ask the client to close
the eyes & stand on one foot, then the other.
- Heel-Toe Walking. Ask the client to walk a straight line, placing
the heel of one foot directly in front of the toes of the other
foot.
- Toe or Heel Walking. Ask the client to walk several steps on
the toes & then on the heels.

 Fine Motor Test for the Upper Extremities

-Finger-to-Nose-Test. Ask the client to abduct & extend arms at
shoulder height & rapidly touch nose alternately with one
index finger & then the other. Have the client repeat the test
with eyes closed if the test is performed easily.
- Alternating Supination & Pronation of Hands on Knees. Ask the
client to pat of both hands & then with the backs of hands,
alternately, at an ever-increasing rate.
- Finger to Nose and to the Nurse’s Finger. Ask client to touch
nose & then to your index finger, held at a distance at about
45cm, at a rapid & increasing rate.
- Fingers to Fingers. Ask the client to spread arms broadly at
shoulder height & then bring fingers together at the midline,
first with eyes open & then closed, first slowly then rapidly.
- Fingers to Thumb (Same Hand). Ask the client to touch each
finger with one hand to the thumb of the same hand as rapidly
as possible.
 Fine Motor Test for the Lower Extremities. Ask the client to lie
supine & perform these tests:
- Heel Down Opposite Shin. Ask the client to place the heel of
one foot just below the opposite knee & run the heel down
from shin to foot. Repeat with the other foot. The client may
also use a sitting position for this test.
- Toe or Ball of Foot to the Nurse’s Finger. Ask the client to
touch your finger with the large toe of each foot.
17) Light-Touch Sensation
 Compare the light-touch sensation of symmetric areas of the
body
 Ask the client to close eyes & to respond by saying, “yes” or
“now” whenever the client feels the cotton wisp touching the
skin.
 With a wisp of cotton, lightly touch one specific spot & then the
same spot on the other side of the body.
 Test areas on the forehead, cheek, hand, lower arm, abdomen,
foot, & lower leg. Check a distal area of the limb first.
 Ask the client to point to the spot where the touch was felt.
 If areas of sensory dysfunction are found, determine the
boundaries of sensation by testing responses approx every
2.5cm in the area. make a sketch of the sensory loss area for
recording purposes.
Pain Sensation
18) Assess pain sensation as follows:
- Ask the client to close eyes & to say, “sharp,” “dull,” or “don’t
know” when the sharp or dull end of the broken tongue
depressor is felt.
 - Alternately, use the sharp & dull end of the sterile pin or
needle to lightly prick designated anatomic areas at random.
The face is not tested in this manner.
- Allow at least 2 seconds between each test.
19) Temperature Sensation
- Touch skin areas with test tubes filled with hot or cold water
- Have the client respond saying “hot,” “cold,” or “don’t know.”
20) Position or Kinesthetic Sensation
- Commonly, the middle fingers & the large toes are tested for
kinesthetic sensation. To test the fingers, support the client’s
arm with one hand & hold the client’s palm in the other. To
test the toes, place the client’s heels on the examining table.
- Ask the client to close eyes. Grasp a middle finger or a big toe
firmly between your thumb & index finger, & exert the same
pressure on both sides of the finger or toe while moving it.
- Move the finger or toe until it is up, down, or straight out, &
ask the client to identify the position.
- Use a series of brisk up-&-down movements before bringing
the finger or toe suddenly to rest in one or three positions.
21) Tactile Discrimination- for all tests, the client’s eyes must be closed
 One-and-Two Point Discrimination
- Alternately stimulate the skin with 2 pins simultaneously &
then with one pin. Ask whether the client feels one or two
pinpricks.
 Stereognosis
- Place familiar objects-such as a key, paper clip, or coin- in the
client’s hand, & ask the client to identify them.
- If the client has a motor impairment of the hand & is unable to
manipulate an object, write a number or letter on the client’s
palm, using a blunt instrument, & ask the client to identify it.
 Extinction Phenomenon
- Simultaneously stimulate 2 symmetric areas of the body, such
as the thighs, the cheeks, or the hands.
22) Document findings in the client’s record.

Comments:
______________________________________________________________________________________________
______________________________________________________________________________________________

____________________________ _________________________
Clinical Instructor Student