Republic of the Philippines

TARLACSTATEUNIVERSITY
COLLEGE OFSCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines
Tel.no.: 4931865 Fax: (045) 982-0110 website: www.tsu.edu.ph
___________________________________________________________________________________________________________

Performance Evaluation Checklist

NEUROLOGICAL ASSESSMENT

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________

Numerical Interpretation of grades:

2- Outstanding
1- Satisfactory
0- Needs improvement/Repeat performance

SCORE
PROCEDURES 2 1 0 Remarks

1. Beginning examination
Prepare Equipment
Examination gloves (for infectious patient )
Cotton tipped applicator
Newsprint to read
Paper clip
Penlight
Snellen’s chart
Sterile cotton balls
Substance to smell or taste (soap, salt ,sugar ,lemon juice,
coffee, vanilla )
Tongue depressor
Tuning fork
Object to feel (coins or key)
Reflex hammer

2.W ash hands

Introduce yourself
Permission and if there is pain
Expose patient appropriately
R eposition patient
MENTAL STATUS ASSESSMENT
3. Physical Appearance and Behavior
Posture , Movements ,Gait and Balance .
Ask client to walk normally on a bare foot
Test tandem gait by asking the patient to walk a straight
line while touching the heel of one foot to the toe of the
other with each step. Heel to toes Fashion
Turns should also be observed closely
The Client's ability to rise from a chair with or without
assistance should also be recorded.
Perform Romberg’s test
Ask the client to stand erect with arms at the side and feet
together .Note any unsteadiness and swaying .
Then with same body position and feet together ,ask client
to close eyes for 20 seconds .Again note for imbalance
and swaying
4. Assess Coordination
Demonstrate the finger to nose test to assess accuracy of
movement then ask the client to extend and hold arms out
to the side with eyes open .Say touch the tip of your nose
first with your right index finger for 3x.Next ask the client to
repeat movement with eyes close.
Ask the client to put palms of both hands down on both
legs then turn the palms up,then turn the palms down
again and repeat with increase speed

5 Assess Sensory Function

Assess light ,touch ,pain and temperature sensations
Ask client to close both eyes and tell you what the
client feel and where he/she feel . Scatter the stimulus
over the distal ,proximal parts of all extremities and the
trunk to cover most of the dermatomes.
Test light sensation
Use a wisp of cotton to touch the client
To test pain sensation
Use blunt and sharp ends of a paper clip or safety pin.
To test temperature sensation use test tube filled with
hot or cold water .
6 Level of Consciousness –Glasgow Comma Scale
7 Cognitive Abilities , Mentation and Orientation
To determine orientation,
Ask detailed questions about your Client's name,
where he is, and the date.
Obtain as much information as you can from the
question;
Example, asks the date, the month and year.
(Keep in mind that hospitalized client often know the
month but not the date or day of the week.)
Evaluate your client's knowledge of date and time
carefully; patients who are confused may still
answer correctly enough that a disorder goes
unnoticed.(alternate your questions with each
assessment.)
It's important to note that when you're assessing
orientation you're also evaluating your client's
speech
8 Memory ASSESSMENT
Memory is divided into three abilities:
1. Immediate memory,
To assess immediate memory, give your client 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.
2. Short-term memory
To assess short-term memory, ask your client to
describe something that happened in the last few
days.
Example : 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.
3. remote memory.
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.

CRANIAL NERVES ASSESSMENT

9 Olfactory Nerve (CN I) - Ask your client to identify at
least two common substances such as coffee and
cinnamon. Make sure his nostrils are patent before
performing this test.
10 Optic Nerve (CN II)
Visual Field & Visual Acuity Test visual acuity with a
Snellen chart
Ask the client to read a newspaper or magazine paragraph
to assess near vision
View the retina and optic disc of each eye
11. CN III (oculomotor), CN IV (trochlear), and CN VI
(abducens).
Inspect margins of eyelids of each eye
Assess extraocular movement
If nystagmus (rhythmic oscillation of the eyes )determine
the direction of the fast and slow phases of movement
Assess pupillary response to light and accommodation in
both eyes.
12 Trigeminal Nerve (CN V)
To assess the sensory component of the trigeminal
nerve, ask your client to close his eyes and then touch
him with a wisp of cotton on his forehead, cheek, and
jaw on each side (see photo at left). Next, test pain
perception by touching the tip of a safety pin to the same
three areas. Ask him to describe and compare both
sensations.
To test the motor component, ask him to clench his teeth
while you palpate the temporal and masseter muscles .
Note the strength of the muscle contraction; it should be
equal bilaterally. If your client isn't alert, test his corneal
reflex by lightly touching the cornea with a fine wisp of
cotton. Look for the normal reaction of blinking of the
eyes. (Note: Corneal reflex testing isn't done on an alert
patient.)
13. Facial Nerve (CN VII –Test motor function
Ask client to smile, frown and wrinkle forehead
Show teeth puff out cheeks
Raise eye brows
Close eyes tightly against resistance
14 Acoustic Nerve (CN VIII) Sense of Hearing
To assess this nerve,
Weber's test—strike a tuning fork lightly against your hand
and place the vibrating fork on your patient's forehead at
the midline or on the top of his head
Rinne’s test—strike the tuning fork against your hand and
place the vibrating fork over his mastoid process
15 Glossopharyngeal Nerve (CN IX) and Vagus Nerves
(CN X)
Test these nerves together because their innervation
overlaps in the pharynx. Listen to your patient's
voice. Then check his gag reflex by touching the tip
of a tongue blade against his posterior pharynx and
asking him to open wide and say "ah." Watch for
symmetrical upward movement of the soft palate
and uvula and for the midline position of the uvula
16 Spinal Accessory Nerve (CN XI)
Assess this nerve by testing the strength of the
sternocleidomastoid muscles and the upper portion of
the trapezius muscle.
Ask the client to turn head against resistance ,first to the
right then to the left
17 Hypoglossal Nerve (CN XII)
Observe your patient's tongue for symmetry. His
tongue should be midline without tremors or muscle
twitching.
Test tongue strength by asking him to push his tongue
against his cheek as you apply resistance
18 Assessing Motor Function
When 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.
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.
When assessing the ability to move on command, the patient
must be awake, willing to cooperate, and able to understand
what you are asking her.
With the patient in bed, assess motor strength bilaterally:
Have the patient flex and extend her arm against your hand,
squeeze your fingers, lift her leg while you press down on her
thigh, hold her leg straight and lift it against gravity, and flex
and extend her foot against your hand. Grade each extremity
using a motor scale like the one below.4
+5 - full ROM, full strength
+4 - full ROM, less than normal strength
+3 - can raise extremity but not against resistance
+2 - can move extremity but not lift it
+1 - slight movement
0 - no movement
Score :

Shown to me :

______________________________
Signature over Printed Nam
Student

Shown by:

__________________________
Signature over Printed Name
Clinical Instructor
Noted:

______________________
Program Chairperson

Prof. Mary Jane N. Rigor_

Dean

References :
Berman, Audrey Et al (2008) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process and
Practice Eight Edition; Pearson Education South Asia Pte Ltd

Kozier, Barbara Et al (2004) Fundamentals of Nursing: Concepts, Process, and Practice

Seventh Edition; Pearson: Prentice Hall

Marieb,Elaine N. Et al. (2011) Essentials of Human Anatomy and Physiology 10th edition;
Singapore: Pearson Education South Asia