Nadine Salmon, MSN, BSN, IBCLC, Clinical Content Manager AMN Healthcare
A focused neurological assessment of your patient can make a difference between life and death, permanent disability or complete recovery. It is a key standard of care for all patients. Yet many nurses fear the neuro exam unnecessarily. RN.com offers you an easy and manageable guide to performing a neurological exam with ease!
The purpose of a neurological assessment is to detect neurological disease or injury in your patient, monitor its progression to determine the type of care you'll provide, and gauge the patient's response to your interventions (Noah, 2004). Performing a neurological assessment early is important in establishing a baseline for later comparison (Anness & Tirone, 2009).
The initial evaluation is usually a comprehensive examination covering several critical areas of assessment, including level of consciousness (LOC), orientation, speech, facial symmetry, motor and sensory function and reflex activity. Assessment of cranial nerve function, cerebellar function and reflex activity are covered in a comprehensive neurological assessment.
Before beginning a focused neurological assessment, evaluation of the patient’s vital signs should be conducted, as current or progressive injury to the brain and brain stem may make vital signs unstable, which could reduce neurologic responses. It is best to conduct the neuro assessment at a time when vital signs are relatively stable (Anness & Tirone, 2009).
Evaluation of LOC is the most important part of the neuro exam, as a change is usually the first indication of a declining status (Noah, 2004). The Glasgow Coma Scale (GCS) is a valuable tool for recording the conscious state of a person, and is based on three patient responses: Eye opening, motor and verbal response. The total score will range from 3 (coma) to 15 (fully conscious, alert and oriented). A score of 8 or lower usually indicates coma (CDC, 2013). Although the GCS was initially used to assess LOC after head injury, it was not designed to be used for patients who are intubated, as the verbal component of the score cannot be accurately assessed. In documenting the GCS score for intubated patients, a notation of the patient’s intubation can be included as a narrative note to facilitate accurate interpretation of the GCS scores (Matis & Birbilis, 2008).
In addition to performing the GCS, assessment of your patient’s pupil size, shape and equality before and after exposure to light is an integral part of a neurological exam. The PERRLA (Pupils Equal, Round, React to Light and Accommodation) acronym is a useful tool to use. A change in pupillary response, such as unequal or dilated pupils can provide a warning sign of increasing intracranial pressure (ICP) (Anness & Tirone, 2009).
A bedside neuro assessment almost always includes an evaluation of motor and sensory function, but requires the patient to be cooperative and oriented. To assess motor response in a comatose patient, apply a painful or other noxious stimulus to a central part of the body, such as trapezius muscle squeezing, or application of supraorbital pressure. Then observe for specific motor responses, as specified in the GCS, such as flexion (decorticate posturing) or extension motor responses (decerebrate posturing) (Anness & Tirone, 2009).
The Focused Neurological Assessment course is a part of the Assessment Series on RN.com. The course provides a comprehensive review of additional motor and sensory function tests, as well as cranial nerve testing.
Once an initial, thorough assessment is conducted (on admission or at the beginning of each shift), subsequent assessments should be problem-focused, zeroing-in on the parts of the nervous system affected by the patient's condition (Noah, 2004).
Although the comprehensive neurological exam can be complex, it is essential to the diagnosis and treatment of a wide variety of neurological conditions. With practice and repetition you will hone this essential, life-saving skill (Anness & Tirone, 2009).
The American Stroke Association (ASA) offers healthcare professionals a wide array of resources for assessing and managing stroke. Find National stroke guidelines, patient educational materials and NIH Stroke Scale Training online at the American Stroke Association. Other assessment tools include the National Institutes of Health (NIH) Stroke Scale (PDF) and The Internet Stroke Center’s Stroke Assessment Scales. Check your facility’s policies and procedures to identify the most appropriate tool to use on your particular unit.
American Stroke Association. (2013). Stroke Patient Education and Support. Retrieved from http://www.strokeassociation.org
Anness, E. & Tirone,K. (2009). Evaluating the neurologic status of unconscious patients. American Nurse Today, 4(4). Retrieved from http://www.americannursetoday.com/article.aspx?id=2548&fid=2446
Centers for Disease Control & Prevention [CDC]. (2013). Emergency Preparedness & Response: Glasgow Coma Scale. Retrieved from http://emergency.cdc.gov/masscasualties/gscale.asp
Matis, G. & Birbilis, T. (2008). The Glasgow Coma Scale – A brief review: Past, present, future. Retrieved from http://www.actaneurologica.be/acta/download/2008-3/01-matis%20et%20al.pdf
Noah, P. (2004). Neurological assessment: A refresher. Modern Medicine. Retrieved from http://www.modernmedicine.com/news/neurological-assessment-refresher
Walker, H. & Hurst, J. (1990). Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworth’s.
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