NEUROLOGIC ASSESSMENT

NAME: DATE:
YEAR & SECTION: RATING:

GRADING CRITERIA
Score Description
1 The student performed the item correctly and completely.
0 The student performed the skill incompletely and incurred mistakes or did not
perform the skill at all.

ASSESSMENT SCORE REMARKS

1. Check order, wash hand, identify patient, explain
procedure.
2. Gather needed equipment. (Annotated Mini-Mental
State Examination (optional). Pencil, Paper, cotton -
tipped applicators, newsprint to read, ophthalmoscope,
paper clip, penlight, snellen chart, sterile cotton ball,
soap, tongue depressor, tuning fork, reflex hammer)
3. Provide privacy.
4. Note if the patient is in distress, if so keep your
assessment and focus.
5. Review or take V/S (if not already done during gen.
survey).
6. Assess for risk factors for neurological disorders
(smoking, alcohol intake, recreational drugs, daily diet,
prolonged exposure to chemicals, sports activity,
frequent lifting of heavy objects).
7. Determine patient's medication history.
PLANNING
8. Think about expected and unexpected outcomes.
9. Prepare the patient and the needed equipment.
IMPLEMENTATION
ASSESS MENTAL STATUS AND LEVEL OF CONSCIOUSNESS:
10. Inspect level of consciousness. Call the client's name
and note the response.
11. Inspect posture and body movement (tense, nervous,
fidgety and restless behavior).
12. Inspect dress, grooming and hygiene (note: cleanliness
and attire).
13. Inspect facial expressions.
14. Inspect speech, (tone, clarity, pace of speech)
 15. Inspect mood, feelings and expressions. Ask the client
"How are you feeling today?" and "What are your plans
for the future?"
16. Inspect thought processes and perceptions. Inspect for
clarity, content and perception by inquiring about client's
thoughts and perceptions expressed.
17. Observe cognitive abilities (orientation, concentration,
recent memory, remote memory, abstract reasoning,
judgment).
18. Perform the Mini-Mental State Examination if time is
limited and a quick standard measure is needed to
evaluate or reevaluate cognitive function.
ASSESS CRANIAL NERVES:
19. Test CN I (olfactory), for all assessments of the CN,
have the client sit in a comfortable position at your eye
level. Ask the client to clear the nose to remove any
mucus then to close eyes, occlude one nostril and
identify a scented object that you are holding such as
soap, coffee or vanilla, Repeat procedure for the other
nostril.
20. Test CN II (optic). Test distant and near visual acuity.
Test visual fields for peripheral vision. Use an
ophthalmoscope to view the retina and optic disc of
each eye.
21. Assess CN III (oculomotor), IV (trochlear) and VI
(abducens). Inspect margins of the eyelids of each eye.
Assess movements and pupillary response to light and
accommodation in both eyes.
22. Assess CN V (trigeminal). Test motor function by asking
the client to clench the teeth while you palpate the
temporal and masseter muscles for contraction Test
sensory function with the use of a paper clip.
23. Test CN VII (facial). Test motor function, ask the clients
to smile, frown and wrinkle forehead, show teeth, puff
out cheeks, purse lips, raise eyebrows, close eyes
tightly against resistance.
24. Test CN VIII (acoustic/vestibulocochlear). Test the
client's hearing ability in each ear and perform the
Weber and Rinne tests to assess the cochlear (auditory)
component.
25. Test CN IX (glossopharyngeal) and X (vagus). Test
motor function (gag reflex, ability to swallow and voice
quality)
 26. Test CN XI (spinal accessory) Ask the client to shrug the
shoulders against resistance to assess the trapezius
muscle. Ask the client to turn the head against
resistance, first to the right then to the left, to assess the
sternocleidomastoid muscle.
27. Test CN XII (hypoglossal) To assess strength and
mobility of the tongue, ask the client to protrude tongue,
move it to each side against the resistance of a tongue
depressor, then put it back in the mouth.
ASSESS MOTOR AND CEREBELLAR SYSTEMS:
28. Assess condition and movement of muscles. Assess the
shape and symmetry of all muscle groups.
29. Evaluate balance. To assess gait, ask the client to walk
naturally across the room. Note posture, freedom of
movement, symmetry, rhythm and balance.
30. Assess coordination. Demonstrate the finger-to-nose
test to assess accuracy of the movements then ask the
client to extend and hold arms out to the side with eyes
open.

31. Assess light touch, pain and temperature sensations.

For each test, ask clients to close both eyes and tell you
what they feel and where they feel it.
32. Test vibratory sensation. Strike a low-pitched tuning fork
on the heel of your hand and hold the base on a bony
surface of the fingers or big toe. Ask the client to
indicate what he feels. Repeat on the other side.
33. Test sensitivity to position. Ask the client to close both
eyes. Then move the client's toes or finger up or down.
Ask the client to tell you the direction it is moved.
Repeat on the other side.
34. Assess tactile discrimination (fine touch). With the
patient's eyes closed test for stereognosis, point
localization, graphesthesia, two-point discrimination and
test extinction.
ASSESS REFLEXES:
35. Test deep tendon reflexes. Position the client in a
comfortable sitting position. Use the reflex hammer to
elicit reflexes.
36. Test Achilles reflex. With the client's leg still hanging
freely, dorsiflex the foot. Tap the Achilles tendon with the
reflex hammer. Repeat on the other side.
 37. Test superficial reflexes. Assess plantar reflex. With the
end of the reflex hammer, stroke the lateral aspect of the
sole from the heel to the ball of the foot, cursing medially
across the ball. Repeat on the other side.
ASSESS MENINGEAL IRRITATION OR INFLAMMATION
38. If you suspect the client has meningeal irritation of
inflammation from infection or subarachnoid
hemorrhage, assess the client's neck mobility.
39. Test for Brudzinski's sign. As you flex the neck, watch
the hips and knees in reaction to your maneuver.
40. Test for Kemig's sign. Flex the client's leg at both the hip
and the knee, then straighten the knee.
EVALUATION
41. Observe throughout the procedure for evidence of pain
and distress.
42. Compare current findings with previous assessments.
43. Ask the patient if there is anything else they would like
to discuss.
RECORDING AND REPORTING
44. Record vital signs.
45. Document all findings.

a. Subjective
b. Objective
46. Report all abnormalities to the health team.
TOTAL SCORE (46)

Overall Remarks
Signature of Instructor
over Printed Name:
Date:
Signature of Student
over Printed Name:
Date:
 NURSING HISTORY WORKSHEET

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