St.

Paul University Surigao

St. Paul University System
8400 Surigao City, Philippines

Name of Student: Date:

Year Level:

PROCEDURE CHECKLIST
Neurologic Health Assessment

ILO: The student will practice beginning nursing skills in promoting healthy physiologic responses
to health / illness.

Key:
3 : Correctly and confidently performed the skill
2 : Able to perform skill; requires moderate reinforcement
1 : Skill not preformed correctly; needs re-demonstration

3 2 1
1. Prior to performing the procedure, introduce self and verify
the client’s identity using agency protocol. Explain to the
client what you are going to do, why it is necessary, and how
he or she can participate. Discuss how the results will be
used in planning further care or treatments.
2. Perform hand hygiene and observe other appropriate
infection prevention procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
presence of pain in the head, back, or extremities, as well as
onset and aggravating and alleviating factors; disorientation
to time, place, or person; speech disorder; loss of
consciousness, fainting, convulsions, trauma, tingling or
numbness, tremors or tics, limping, paralysis, uncontrolled
muscle movements, loss of memory, mood swings; or
problems with smell, vision, taste, touch, or hearing.
EVALUATION OF MENTAL STATUS
LANGUAGE
5. If the client displays difficulty speaking:
• Point to common objects, and ask the client to name them.
• Ask the client to read some words and to match the printed
and written words with pictures.
• Ask the client to respond to simple verbal and written
commands (e.g., “point to your toes” or “raise your left arm”).

ORIENTATION
6. Determine the client’s orientation to time, place, and
person by tactful questioning. Ask the client the time of day,
date, day of the week, duration of illness, city and state of
residence, and names of family members. Ask the client why
he or she is seeing a health care provider.“Why” questions
may elicit a more accurate clinical picture of the client’s
orientation status than questions directed to time, place, and
person. To evaluate the response, you must know the correct
answer. If the client cannot answer these questions
accurately, also include assessment of the self by asking the
client to state his or her full name.
MEMORY
7. 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, and
remote memory.
To Assess Immediate Recall
• Ask the client to repeat a series of three digits, spoken
slowly.
• Gradually increase the number of 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 repeat them backward. The average person can
repeat a series of five to eight digits in sequence and four to
six digits in reverse order.
 St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines

8. To Assess Recent Memory

• Ask the client to recall the recent events of the day, such as
how the client got to the clinic. This information must be
validated, however.
• Ask the client to recall information given early in the
interview (e.g., the name of a doctor).
• Provide the client with three facts to recall or a three-digit
number, and ask the client to repeat all three. Later in the
interview, ask the client to recall all three items.
9. To Assess Remote Memory
• Ask the client to describe a previous illness or surgery or a
birthday or anniversary. Generally remote memory will be
intact until late in neurologic pathology. It is least useful in
assessing acute neurologic problems.
ATTENTION SPAN AND CALCULATION
10. Test the ability to concentrate or maintain attention span
by asking the client to recite the alphabet or to count
backward from 100.
Test the ability to calculate by asking the client to subtract 7
or 3 progressively from 100 also known as Serial Sevens or
Serial Threes.
LEVEL OF CONSCIOUSNESS
11. Assess the Glasgow Coma Scale:
EYE RESPONSE:
 Spontaneous – 4
 To sound or verbal command- 3
 To pain or pressure – 2
 No response – 1
12. MOTOR RESPONSE:
 To verbal command – 6
 To localized pain – 5
 Withdrawal from pain – 4
 Flexes abnormally (Decorticate Posturing) – 3
 Extends abnormally (Decerebrate Posturing) – 2
 No response – 1
13. VERBAL RESPONSE:
 Oriented, Converses – 5
 Disoriented, Converses – 4
 Uses inappropriate words – 3
 Makes incomprehensible sounds – 2
 No response – 1
CRANIAL NERVES
14. CN I–check patency of nostrils, checks one nostril at a
time for client’s ability to identify the smell of common
substances.
15. CN II–test visual acuity and visual fields.
16. CN III, IV, and VI–
a. Test EOMs by having the client move the eyes through the
6 cardinal fields of gaze with the head held steady.
b. Test pupillary reaction to light and accommodation.
17. CN V, motor function–have client move his jaw from side
to side, clenching his jaw, and biting down on a tongue blade.
18. CN V, sensory function– have the client close his eyes
and identify when nurse is touching his face at the forehead,
cheeks, and chin bilaterally—first with the finger and then
with a toothpick.
19. Test corneal reflex by touching the cornea with a wisp of
cotton or puffing air from a syringe over the cornea.
20. CN VII, motor function–have the client make faces, such
as smile, frown or whistle.
21. CN VII, taste–test taste on the anterior portion of the
tongue by placing sweet (sugar), salty (salt), or sour (lemon)
substance on tip of tongue.
 St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines

22. CN VIII–Uses:
a. Watch-tick test for hearing.
b. Weber and Rinne test for air and bone conduction.
c. Romberg test for balance (if not already done).
23. CN IX and X–observe ability to talk, swallow, and cough.
24. CN IX and X, motor function–ask client to say “ah” while
depressing tongue with a tongue blade and observing the
soft palate and uvula to rise.
25. CN IX and X, sensory function–touch the back of pharynx
with tongue blade to induce a gag reflex.
26. CN IX and X, taste (sweet, salty, sour)–tests on posterior
portion of tongue.
27. CN XI (if not assessed with musculoskeletal exam):
a. Place hands on client’s shoulders and has client shrug
his shoulders against resistance.
b. Have client turn his head from side to side against
resistance.
28. CN XII–have the client:
a. Say “d, l, n, t.”
b. Protrude the tongue and move it from side to side.
29. Test each of the following deep tendon reflexes: biceps,
triceps, brachioradialis, patellar, and Achilles.
30. Test plantar superficial reflex (Babinski Reflex) with
thumbnail or pointed object. Strokes sole of foot in an arc
from the lateral heel to medially across the ball of the foot.
31. REFLEXES
Test reflexes using a percussion hammer, comparing one
side of the body with the other to evaluate the symmetry of
response.
0 No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximal activity (hyperactive)
32. BICEPS REFLEX
Support the patient's forearm by resting it on the forearm of
the examiner, with the arm midway between flexion and
extension. Tap briskly. The forearm should flex at the elbow.
33. TRICEPS REFLEX
With the elbow in flexion, tap the triceps tendon, just proximal
to the elbow, with a reflex hammer. The arm could also be
abducted at the shoulder for this maneuver. There should be
a reflex contraction of the triceps muscle (elbow extension).
34. BRACHIORADIALIS REFLEX
Tap the brachioradialis muscle tendon at its point of insertion
onto the styloid process of the radius. A normal reflex would
produce flexion and supination of the forearm.
35. PATELLAR REFLEX
Slightly lift up the leg under the knee and tap the patellar
tendon with a reflex hammer. There should be a reflex
contraction of the quadriceps muscle (knee extension). If
performed in a sitting position, have the legs dangle over the
edge of the chair or table.
36. ACHILLES REFLEX
Slightly externally rotate at the hip, and gently dorsiflex the
foot, tapping the Achilles tendon with a reflex hammer. There
should be a reflex contraction of the gastrocnemius muscle
(plantar flexion).
GROSS MOTOR AND BALANCE TESTS
37. WALKING GAIT
Ask the client to walk across the room and back, and assess
the client’s gait.
38. ROMBERG TEST
Ask the client to stand with feet together and arms resting at
the sides, first with eyes open, then closed. Stand close
 St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines

during this test.

39. STANDING ON ONE FOOT WITH EYES CLOSED
Ask the client to close the eyes and stand on one foot.
Repeat on the other foot. Stand close to the client during this
test.
40. 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.
41. TOE OR HEEL WALKING
Ask the client to walk several steps on the toes and then on
the heels.
FINE MOTOR TESTS FOR THE UPPER EXTREMITIES
42. FINGER-TO-NOSE TEST
Ask the client to abduct and extend the arms at shoulder
height and then rapidly touch the nose alternately with one
index finger and then the other. The client repeats the test
with the eyes closed if the test is performed easily.
43. ALTERNATING SUPINATION AND PRONATION OF
HANDS ON KNEES
Ask the client to pat both knees with the palms of both hands
and then with the backs of the hands alternately at an ever-
increasing rate.
44. FINGER-TO-NOSE AND TO THE NURSE’S FINGER
Ask the client to touch the nose and then your index finger,
held at a distance of about 45 cm (18 in.), at a rapid and
increasing rate.
45. FINGERS-TO-FINGERS
Ask the client to spread the arms broadly at shoulder height
and then bring the fingers together at the midline, first with
the eyes open and then closed, first slowly and then rapidly
46. FINGERS-TO-THUMB (SAME HAND)
Ask the client to touch each finger of one hand to the thumb
of the same hand as rapidly as possible.
47. FINE MOTOR TESTS FOR THE LOWER EXTREMITIES
Ask the client to lie supine and to perform these tests.
48. HEEL DOWN OPPOSITE SHIN
Ask the client to place the heel of one foot just below the
opposite knee and run the heel down the shin to the foot.
Repeat with the other foot. The client may also use a sitting
position for this test.
49. TOE OR BALL OF FOOT TO THE NURSE’S FINGER
Ask the client to touch your finger with the large toe of each
foot.
50. LIGHT-TOUCH SENSATION
Compare the light-touch sensation of symmetric areas of the
body.
• Ask the client to close the eyes and 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 and
then the same spot on the other side of the body.
• Test areas on the forehead, cheek, hand, lower arm,
abdomen, foot, and lower leg. Check a distal area of the limb
first (i.e., the hand before the arm and the foot before the
leg).
• If areas of sensory dysfunction are found, determine the
boundaries of sensation by testing responses about every
2.5 cm (1 in.) in the area. Make a sketch of the sensory loss
area for recording purposes.
51. PAIN SENSATION
Assess pain sensation as follows:
• Ask the client to close the eyes and to say “sharp,” “dull,” or
“don’t know” when the sharp or dull end of a safety pin is felt.
• Alternately, use the sharp and dull end to lightly prick
designated anatomic areas at random (e.g., hand, forearm,
foot, lower leg, abdomen). Note: The face is not tested in this
 St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines

manner.
• Allow at least 2 seconds between each test to prevent
summation effects of stimuli (i.e., several successive stimuli
perceived as one stimulus).
52. POSITION OR KINESTHETIC SENSATION
Commonly, the middle fingers and the large toes are tested
for the kinesthetic sensation (sense of position).
• To test the fingers, support the client’s arm and hand with
one hand. To test the toes, place the client’s heels on the
examining table.
• Ask the client to close the eyes.
• Grasp a middle finger or a big toe firmly between your
thumb and index finger, and 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,
and ask the client to identify the position.
• Use a series of brisk, gentle up-and-down movements
before bringing the finger or toe suddenly to rest in one of the
three positions.
53. Document findings in the client record using printed or
electronic forms or checklists supplemented by narrative
notes when appropriate. Describe any abnormal findings in
objective terms, for example, “When asked to count
backwards by threes, client made seven errors and
completed the task in 4 minutes.” Report deviations from
expected or normal findings to the primary care provider.

( ____ x 3) + ( ____ x 2) + ( ____ x 1)

X 100 =
(Total # of items ____ x 3)

SOURCE:
Berman, A. &. (2012). Kozier & Erb's Fundamentals of Nursing, 9th Ed. New Jersey: Pearson.

Student shall be graded based on the following observations.

Fullname ad
Grade/ signature of
Qualitative description of student’s performance
Remarks clinical
instructor/Date
Very satisfactory performance. Student showed
basic competency in performing the procedure,
Competen showed mastery in understanding the rationale
90-99
t behind all the actions, and was able to execute all
the steps on his/her first attempt of return
demonstration.
Satisfactory performance. Student showed basic
competency in performing the procedure, showed
Partially
mastery in understanding the rationale behind all
Competen 80-89
the actions, and was able to execute 80% of all
t
the steps on his/her first attempt of return
demonstration.
 St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines

Performance that needs improvement. Student No grade.

failed to show basic competency in performing Student shall be
the procedure, showed less mastery in given another
Not yet
understanding the rationale behind all the actions chance until
Competen
and was only able to execute less than 80% of all he/she shows
t
the steps on his/her first attempt of return competency and
demonstration. mastery in skills
and knowledge.
2nd attempt 90
3rd attempt 85
4th attempt 80
5th attempt 75

Remarks:

STRENGTHS AREAS FOR IMPROVEMENT

Rated by: __________________