COLLEGE OF HEALTH AND SCIENCES

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Procedure Checklist

NEUROLOGICAL ASSESSMENT

Name:______________________________________ Date:___________________________

Group: __________________________________ Score: _______________________

Grading criteria:
SCORE DESCRIPTION
1 The student performed the skill completely and correctly
0 The student performed the skill incompletely and incorrectly or did not
perform the item at all.

Goal: The assessment are completed without causing the patient experience anxiety or
discomfort, the finding are documented and the appropriate referral is made to other healthcare
professional as needed for further evaluation
Performance Skill Additional Information Score Remarks
1. Prepare the equipment to be used For comprehensive
 Penlight neurological exam
 Snellen chart
 Tongue depressor
 Cotton applicator
 Percussion hammer
 Object to touch, such as coins or
paper clips
 Substances to smell, such as
vanilla, mint or coffee
 Substance taste such as sugar,
salt or lemon
2. Perform hand hygiene and put PPE, if Hand hygiene and PPE
indicated. prevent the spread of
microorganism. PPE is
required based on
transmission
precautions.
3. Introduce self and identify the patient Ensure that the right
using 2 identifiers procedure is done at
the right patient.
4. Close curtains around bed and close Provide clients privacy
the door to the room, if possible

5. Explain the purpose and the Encourage the patient

procedure of the neurologic participation and
examinations. Answer any questions. decrease anxiety
6. Help the patient undress, if needed Provide client privacy
and provide a patient gown. Assist the and comfort
patient to a supine position. Use the
bath blanket to cover any exposed area
other than the one being assessed

7. Begin with a survey of the patient’s To check any defects

overall hygiene and physical may affect assessment
appearance.
8. Assess patient mental status
a) Orientation to person, place and
time.
b) Assess memory (immediate
recall and past memory

c) Assess abstract reasoning by

asking the patient to explain a
proverb such as “ The early bird
catches the worm”

d) Evaluate the patient ability to

understand spoken and written
word.

9. Test cranial nerve (CN) function.

a) Ask the patient to close the eyes
occlude one nostril and then
identify the smell of different
substances such as coffee,
chocolate, or alcohol. Repeat
with other nostril.
b) Test visual acuity and pupillary
constriction.

c) Move the patient eyes though the

six cardinal position of gaze.

d) As the patient to smile, frown,

wrinkle forehead, and puff out
cheeks.

e) Test hearing
f) Test the gag reflex by touching Explain the patient that
the posterior pharynx with the this may be
tongue depressor. uncomfortable.
9. Assess level of consciousness and The GCS score are No
orientation, using Glassgow Coma used to indicate the score
Scale flow chart, if appropriate. The flow severity of the head
chart will promote your assessment and injuries and coma levels
guide you to your patient step by step. as described below:
 If GCS score is ≥
13, then tha
(score individually) patient has mild
head injury
 If GCS score is
 (9-12), then the
patient has
moderate head
injury
 GCS score ≤ 8
then the patient
has severe head
injury, and
considered to be
in coma (Juliet &
Claranne 2001)
a) Assess eye opening using the Note that there is a
flow chart and record the score special condition when
the patient eye are
closed because of a
facial injury or a swilling
then you document (C)
and the score cannot
be measured for this
category
b) Assess the best verbal response Some patient with
using flow chart and record the endotracheal/
score. tracheostomy tube may
be unable to respond
verbally. Document (T)
on GCS chart.
Language barrier and
hearing problem must
be consider in this step.
c) Assess the Best Motor Response To assess for pain, use
using flow chart and record the pain stimulus for
score. Immediate report any drop GCS. Do not omit the
in the motor response to the assessment assuming
medical team that the patient is
sleeping.
10. Continue GCS assessment until it is Ask for second option
discontinued by the medical team when you are in doubt
11. (Optional) Complete Mini-Mental
State Examination (MMSE), if indicated.
12. Assess for PERRLA
13. Assess motor strength and
sensation
 Hand grasps
 Upper body strength/ resistance
 Lower body strength/ resistance
 Sensation extremities
12. Assess coordination and balance. Ask the patient to walk
a. Assess gait for smoothness, using assistive device if
coordination, and arm swing. needed
b. As appropriate, assess the
patient ability to tandem walk
(heel to toe), walk on tiptoes,
walk on heels.
c. Assess cerebellar functioning
using:
  Romberg test
 Pronator drift
 Rapid alternating hand
movement
 Fingertip-to-nose
 Heel-to-shin tests
13. Assist the patient to a comfortable To allay anxiety and
position, ask if they have any questions, encourage verbalization
and thank them for their time. of feelings.
14. Ensure five safety measures when
leaving the patients room:
 CALL LIGHT: With reach
 BED: Low and locked (in lowest
position and brakes on)
 SIDE RAILS: Secured
 TABLE: Within reach
 ROOM: Risk-free for falls (scan
room and clear any obstacles)
15. Remove and discard PPE properly, Proper PPE disposal
if used and Perform hand hygiene and Hand Hygiene
prevents the spread of
microorganisms
16. Document the assessment findings Documentation
and report any concerns according to provides evidence of
agency policy. care and medico-legal
requirements of nursing
practice
Total Score: (30 or 31 including no. 11)
Sources:
Lynn, P.B. (2014). Taylor Clinical Nursing Skills. Lippincott Williams and Wilkins Quraan, H.A.
AbuRuz, M.E. (2015). Simplifying Glassgow Coma Scale Use for Nurses. Iternational Journal of
Advanced Nursing Studies

Evaluated by: Conforme:

_________________________________ ___________________________________
Signature over Printed Name of Instructor Signature over Printed Name of Student