Of all the assessments you conduct on your patients, neurological assessment is probably the most nuanced and challenging to master. For example, hospitals that are “Stroke certified” require their nurses get training on using the NIH stroke scale on an annual basis… it’s that important AND it’s definitely not easy.
In this article you’ll learn the basics of neurological assessment so you can feel more confident at the bedside and when taking nursing school exams.
The Glasgow Coma Scale
The most basic neurological assessment you’ll conduct is the determining the patient’s level of consciousness using the Glasgow Coma Scale. This scoring tool looks at how keenly or appropriately the patient responds in three key areas – eye opening, verbal, and motor.
Eye response – If the patient opens his eyes spontaneously, he scores the maximum number of points, which is 4. If you have to speak to the patient to get him to open his eyes, that’s a score of three. This is common if the patient was asleep when you went in to assess him in the morning. If the patient only opens his eyes to painful stimuli, this is a score of two. Common sources of painful stimuli are pressing a pen against the nail bed, performing a sternal rub, or squeezing the trapezius muscle. A score of one is earned if the patient has no eye opening to any stimulation.
Verbal response – For this section you’ll score the patient based on their verbal response to your questions. These questions are asked to elicit the patient’s orientation to person, place and time.
- “What is your name?”
- “Where are you right now?”
- “What day is it?”
If the patient is oriented to all of these elements, they get the maximum five points. If they’re confused on any element, that docks them a point, so they only get four points. If they use inappropriate words that don’t really make sense or don’t relate to what you’re asking, that’s a score of 3. If they just make sounds that don’t sound like words, that’s a score of two. And no response at all is a score of 1.
Motor response – To test the patient’s motor response, you want to see if they can obey commands or follow directions. This can be a very structured request such as, “Show me two fingers” or, you can make note of their ability to follow commands as you perform other assessments. For example, as you are wrapping the blood pressure cuff around their arm you could say, “Can you hold your left arm up please?” I find this approach works fine with patients who are alert and not overtly confused, but for anyone who has impaired level of consciousness, you will want to ask them to perform very basic tasks. For example, the NIH stroke scale item that assesses this is to ask the patient to close their eyes tightly and then open them again.
A lot of times, people will ask patients who are sedated or neurologically impaired to squeeze their hand. While this can be an assessment for motor response, note that in very neurologically damaged patients, the grasp reflex may actually be what is causing the patient to squeeze your hand. That’s why saying, “Show me two fingers” is a more appropriate test of motor response.
If the patient follows your instructions, they get all the possible points, which is six. If they localize to pain, this is a score of 5. A common example of localizing to pain occurs when you take their blood pressure. The squeeze of the cuff hurts, so they may reach toward it with their other hand. Or, when you performed that sternal rub to assess eye opening, they reached up toward your hand. Maybe you’re removing tape from their IV, and they try to push you away.
A patient who withdraws from painful stimuli scores a 4. For example, let’s say you performed nail bed pressure and they pulled their hand away. That’s a score of 4. Note that nail bed pressure is VERY painful, so please use other sources of painful stimuli first. If you get no response from a trapezius pinch, for example, then try nail bed pressure.
And then we have the two most ominous motor responses, decorticate posturing and decerebrate posturing. Decorticate posturing is abnormal flexion where the individual is stiff, has arms bent against the chest with clenched fists, and the legs are held out straight with the feet turning inward. It is a sign of significant brain injury and earns the patient three points on the Glasgow Coma Scale.
Even more ominous is decerebrate posturing, which is abnormal extension. In this response, the individual holds the arms and legs out straight, arches the head and neck, the toes are pointed downward and the hands are often bent outward at the wrists. Decerebrate posturing earns the individual a score of two and is a sign of the very severe neurological injury.
And, if the patient has absolutely no motor response to even the most painful stimulation, they receive a score of 1 in this area.
Overall, the best score one can get with the GCS is 15. If the score is 8 or less we are very concerned about this patient, and a score of three essentially means there is no neurological response.
Levels of Consciousness
Another way to assess your patient’s neurological status is to describe their level of consciousness which ranges from alert to comatose.
- Alert – This patient is awake and responsive to you and the environment.
- Example: Bob is sitting up in bed, texting with his granddaughter. When you ask him a question he answers appropriately and he follows all your commands.
- Confused – This patient is not oriented to one of the key elements of person, place, time or situation.
- Example: Sheila is sitting in the chair, eating breakfast. She follows all your commands, but when you ask her where she is she says, “I’m at my kids’ school waiting for the concert to start.”
- Somnolent – This patient is sleepy. It’s important to note that patients get sleepy, especially at night or when taking sedating medications.
- Example: Karin was up all night and is yawning through your morning assessment. She can’t wait for you to finish so she can get to sleep.
- Lethargic – A patient who is lethargic has marked drowsiness or is asleep. They can be roused without much difficulty, but when left undisturbed will go back to sleep.
- Example: Jessie just had his appendix removed and is in the PACU. He will rouse when you call his name and rub his shoulder. When awake, he will respond to you and answer your questions, possibly a little slowly. When you sit down to chart, he drifts back to sleep.
- Obtunded – This patient is difficult to rouse and is drowsy or blunted even when awake. His verbal responses indicate he is confused or he mumbles. He quickly goes back to sleep when undisturbed.
- Example: Lou has COPD and you suspect he’s becoming hypercapnic. With a loud voice and vigorous stimulation, Lou will rouse briefly. He mumbles at you and protests slightly when you place the BIPAP mask on him, but doesn’t have much energy to put up a fight. He quickly falls asleep once you stop adjusting the BIPAP mask.
- Stuporous – This patient is very difficult to rouse and requires vigorous and repeated painful stimulation. The patient is not very responsive to his environment when roused and as soon as the stimulation is stopped, the patient goes back to the unconscious state.
- Example: Your patient took an overdose of opioids. While one coworker performs assisted ventilation, you perform a vigorous sternal rub as you wait for the naloxone to arrive. The patient groans and limply reaches toward your hand, but nothing more.
- Comatose – This patient has no response to any stimulation.
- Example: Chelsea has suffered a traumatic brain injury. She exhibits no response to repeated painful stimulation. Her GCS is 3.
Cranial Nerve Assessment
For a more detailed assessment, you’ll assess the cranial nerves. This will come into play when you need a more pinpointed assessment of potential neurological deficits, beyond the patient’s level of consciousness. A great example of this is when the patient has a neurological injury or who has had a neurological intervention and we want to monitor the effectiveness of that intervention.
- CN I (olfactory nerve) – Ask the patient to smell a familiar odor. In the hospital, some options you can usually get your hands on are coffee and possibly food items that have a distinctive smell such as lemon and orange. Peppermint is another good choice if your hospital utilizes essential oils. If the patient can’t identify the odor or even says, “I don’t smell anything” this is a sign of neurological impairment.
- CN II (optic nerve) – Test visual acuity by having the patient read a Snellen chart if available. A handheld version can be utilized and held about 14 inches away. At the bedside, you probably don’t have a Snellen chart available. So what I often do is ask the patient to read the clock or the whiteboard. PRO TIP! Be sure to ask the patient if they wear glasses first!
- CN III (oculomotor nerve) – Shine your penlight and look for pupillary reaction. Also, ask your patient to move their eyes up, down, side to side and diagonally – you’re assessing the motor function of the eye. And bonus…this also tests for CN IV (trochlear) and CN VI (abducens), so you can knock three out with one assessment. Time management for the win!
If the pupils are not reactive, this could mean a couple of different things. Pinpoint, nonreactive pupils are often present in opioid overdose. As the opioid wears off, reassess. Sluggish pupils (meaning they constrict slowly) can also occur with sedatives and opioids.
A pupil that is fixed and dilated is usually a very ominous and late sign of neurological damage. If this is your first clue something is going on with your patient, there’s a really good possibility earlier clues were missed.
- CN V (trigeminal nerve) – To test the sensory function of this nerve, you can lightly touch the patient’s face with a wisp of cotton or a tissue in three key places while his eyes are closed – the forehead, the jaw and the cheek. You also want to ensure the patient can differentiate between blunt and sharp, so you can touch in the same three areas with something blunt and something sharp like a pin (be careful not to pierce the skin). In addition, test the patient’s ability to differentiate between warm and cold. You can put a few ice cubes in a glove and use that for your cold test, and you can use a heel warmer for the warm test.To test motor function of the trigeminal nerve, ask the patient to clench his jaw and open his mouth.
- CN VII (facial nerve) – The facial nerve has both a sensory and motor function, so you’ll do two assessments. To test the sensory function, have your patient taste a familiar flavor such as sugar or lemon with the anterior section of the tongue. To test motor function, have the patient raise their eyebrows, close eyes tightly and give a big smile. You’re looking for symmetry in all areas of the face.
- CN VIII (acoustic nerve) – The official test for this involves a tuning fork but I can pretty much guarantee you won’t have a tuning fork available in the clinical in-patient setting. A quick way to test the sensory function of this nerve is to rub your fingers together near each ear to determine if the patient can hear the sound. Since this nerve also plays a role in equilibrium, perform the Romberg test. To perform this test, have the patient stand still with their eyes open for thirty seconds, then with eyes closed for 30 seconds. If they lose their balance, this is a positive Romberg test and could mean the acoustic nerve is not functioning optimally.
- CN IX (glossopharyngeal nerve) – This is another nerve that has motor and sensory functions. To test the motor function, assess the patient’s ability to swallow or their gag reflex. This also tells us about CN X (vagus nerve) as they both are involved in the gag reflex.To test the sensory function of the glossopharyngeal nerve, you can place a familiar flavor on the posterior portion of the tongue.
- CN X (vagus nerve) – The vagus nerve is also both sensory and motor and we mainly test its motor function by testing the pharynx. A quick way to assess the function is to ask the patient to swallow and speak. Hoarseness is a sign the nerve is impaired.
- CN XI (accessory nerve) – The accessory nerve innervates the trapezius and sternocleidomastoid. Place your hands on the patient’s shoulders and ask them to shrug their shoulders upward. Both shoulders should move upward with equal force. To test the sternocleidomastroid, place a hand against one cheek and have them turn their head against resistance, then repeat with the other side.
- CN XII (hypoglossal nerve) – To test the motor function of the hypoglossal nerve, ask your patient to stick their tongue straight out and then ask them to move it side to side. If the patient’s tongue deviates to one side, this is a sign of neurological injury.
Whew! I know the cranial nerves are a LOT to learn! If you want to go through some drills and PodQuizzes for all the cranial nerve names, functions and assessments, then check out my study-on-the-go podcast, Study Sesh.
General neurological assessment
Assessing your patient for general neurological impairment doesn’t usually involve testing every cranial nerve as was outlined above. However, you will still conduct key assessments that can tell you if your patient is deteriorating or improving neurologically.
The key components of a general neurological assessment are:
- Assess level of consciousness (you’ll often use the GCS for this)
- Ask the patient to raise their eyebrows and smile. PROTIP: Say, “Smile and show me your teeth,” so you get the biggest smile possible. With this assessment you are looking for facial symmetry and signs of any facial droop.
- Shine a penlight into the patient’s pupils to assess for equal pupil size and reaction. Note that changes to the patient’s pupils is a late sign of neurological injury.
- Test upper extremity strength by having the patient squeeze your hands with theirs and push/pull against resistance. You can also have them hold their arms up against gravity for a count of 10. You’re looking for equal and normal strength on both sides.
- Test lower extremity strength by assessing dorsiflexion and plantarflexion. For plantarflexion, ask the patient to push their feet into your hands (say, “Step on the gas.”). For dorsiflexion, have them pull their toes toward their face. Another test is to have them hold each leg up off the bed for a count of five. Make note of weakness or inability to perform these movements.
- Test for pronator drift by asking the patient to hold their arms out in front with palms upward and then close their eyes. If one arm pronates and drifts downward, this is a poor neurological sign.
- Assess the patient’s speech. Slurred speech, difficulty understanding speech, inappropriate words or difficulty speaking are all signs of neurological injury.
- Assess for numbness/tingling. While I’m assessing pulses, I ask the patient “Which hand/foot am I touching?” and “Do you have any numbness or tingling in your hands or feet?”
If you see any abnormalities in any of these areas, then you will want to dive deeper into assessing those specific cranial nerves and, of course, let the MD know.
The NIH Stroke Scale
If your facility takes care of stroke patients, then you will most likely be using the NIH Stroke Scale to assess the severity of stroke. The exam covers 15 different assessments that provide valuable information about the severity and effect of a stroke. A very standard use of the NIH stroke scale is to conduct an assessment prior to giving tPA and then regularly afterwards to assess if the patient is improving or deteriorating. Typical protocols have you administering the NIH exam every fifteen minutes for a period of time, then every thirty minutes, then hourly for a 24 hour period. It involves ICU-level care and also leads to sleep deprivation for your already exhausted patient.
The NIH stroke scale tool includes assessments such as:
- Asking the patient to state their age and the month
- Asking the patient to follow two commands such as making a fist and closing their eyes tightly
- Asking the patient to name common objects (glove, key, feather)
- Asking the patient to read words and phrases (or repeat them after you if they cannot read or have visual acuity issues)
- Assessing sensation and movement bilaterally
If you want to see more detail about this in-depth test, you can view the components here.
Neurological Assessment Best Practices
Neurological assessment can be challenging for a variety of reasons. Not only are there so many factors that come into play, but changes can be quite subtle. The more neurological assessments you conduct, the better you’ll get at picking up on abnormalities and changes. If you are ever concerned about a patient’s neurological status, CALL THE MD. You’d rather embarrass yourself than risk not speaking up for your patient. I promise.
Here are some key tips for performing a neurological assessment:
- Do a neuro assessment WITH the nurse who is giving you report. You want to make sure the things they saw earlier are the things you are seeing now. If there is a change, this is an excellent time to catch it. You want to avoid having to call the nurse later and say, “Did Joe’s tongue deviate to the side when you assessed him earlier?” By doing the assessment together, you would know the answer to this question.
- If conducting assessments in the middle of the night (and you definitely will), try to give the patient a moment to “wake up” before diving in. You don’t want the patient to score lower than they should just because they’re groggy.
- Don’t lead the patient to the right answer. For example, instead of saying, “Am I touching your right foot?” Say, “Which foot am I touching?”
- Sneak your basic neuro assessments in as much as you can. There is so much information you can obtain about a patient’s neurological status as you are interacting with them in other ways. This is often the first way I assess a patient who does not have a suspected or confirmed neurological injury, but I still want to know their general neurological status. For example:
- When you walk into the room, do they respond to you? Do they look up or speak to you? If so, this patient is alert! LOC is usually the very first thing I’ll take note of.
- Watch your patient take a drink. If they show no signs of difficulty swallowing (such as coughing or the water flowing out of their mouth) guess what? You’ve just assessed cranial nerve IX. Good job!
- When you ask your patient, “Where are you right now?” their response is going to tell you if they are oriented to place, but you can also assess for hoarseness (which could indicate a problem with cranial nerve X) or slurring (which is a sign of stroke).
- When you are looking for an IV site and ask the patient to make a fist, you’re also assessing their ability to follow commands.
- When your patient gets up to go to the bathroom, observe their gait. If they’re wobbly, it could simply be due to the medication they’re taking, or it could be a balance problem. This would be a clue to assess further.
- If you are performing neurological assessments for the purposes of assessing a known or suspected neurological injury, you will use a step-by-step systematic approach to ensure you don’t miss any clues. Develop a routine and stick to it. And yes, it’s perfectly acceptable to use a “cheat-sheet.”
- For an accurate neurological assessment of your critical patients, you want to give the patient what is called a “sedation holiday.” This is a period of time without sedating drugs. This gives the patient an opportunity to “wake up” so you can get the most accurate data possible.
- If your patient is intubated, notice if they gag and cough when performing suctioning. If not, this could indicate they have no gag reflex (either due to sedation or a neurological injury).
- Not sure you’re interpreting something correctly? Then get more eyes on the patient. Have a coworker or the charge nurse also assess the patient. And you always, always want to let the MD know about any unexpected findings.
Who is at risk for a neuro status change?
Knowing which patients are at higher risk for a change in neurological status amps up your awareness and helps you catch abnormalities early. So, what kind of patients might be at higher risk? Here are a few examples (please note this is not an exhaustive list, but is instead provided to get you thinking critically about your patients).
- Any patient with a current neurological injury or neurological condition. This may seem like a no-brainer, but the patient at highest risk for deterioration is the patient who already has a neurological impairment such as ischemic stroke, hemorrhagic stroke, subdural hematoma, blunt force trauma, encephalopathy, etc… Monitor these patients closely for changes both positive and negative.
- Anyone who has undergone a neurological surgery is going to require regular neuro checks. This includes craniotomy, shunt placement, removal of a mass, AVM repair, implantation of a deep brain stimulator, spinal surgery…basically any and all neurosurgeries of any kind.
- Patients who’ve had a carotid endarterectomy are going to undergo regular neuro assessments. A carotid endarterectomy is a procedure that removes plaque from the carotid arteries as a method of preventing stroke. However, the procedure itself does carry a slight risk of causing stroke. Bits of plaque or a blood clot can become dislodged and travel to the brain causing ischemic stroke. Studies show the risk of stroke after this procedure is about 2%, so patients undergoing a carotid endarterectomy are generally observed carefully in the ICU in the immediate post-operative period.
- Patients with atrial fibrillation are at higher risk for stroke, especially if untreated. This is because a thrombus can form in the heart that is ejected into systemic circulation and the cerebral vasculature.
- A patient with increased ICP can have significant neurological changes. You can read more about intracranial pressure here or listen to episode 5 here.
- Patients with advanced liver disease can have neurological changes due to hepatic encephalopathy. As you treat the elevated ammonia levels, your neuro assessment will typically improve.
- Sodium imbalances, especially hyponatremia, can cause drastic neuro changes in your patient. Common conditions that can lead to hyponatremia are water intoxication (often due to a psychological disorder), renal disease, diarrhea/vomiting, congestive heart failure, pituitary tumors and SIADH. Some medications can cause hyponatremia such as diuretics, SSRIs, antipsychotics and even NSAIDS. It’s important to note that MDMA (ecstasy) can cause hyponatremia as well.
- A patient with an elevated BP could have neurological changes due to the increased risk for hemorrhagic stroke. If this patient also has very low platelets, then not only do you need to address the hypertension, you want to make sure the MD knows and keep a very close eye on neurological status. This patient is at high risk for bleeding in the brain.
- Hypoglycemia can cause altered and depressed neurological function, depending on the severity. Some typical scenarios that lead to hypoglycemia are those patients with severe liver disease and patients taking hypoglycemic agents such as metformin or insulin.
- A patient with an infection is at risk for neurological changes, namely their level of consciousness and orientation. In fact, one of the key signs of urinary tract infection in the elderly is acute confusion.
- Patients with pH imbalances will often show decreased LOC. Two common examples are patients with COPD (respiratory acidosis) and end stage renal disease (metabolic acidosis).
I hope this overview of a very complex topic helps you feel a little more confident as you head to the bedside. The key takeaways are:
- Get a baseline neuro assessment whenever you can.
- Do a neuro assessment WITH the nurse you are receiving the patient from and the nurse you are handing the patient off to when transferring care.
- Never be afraid to ask for a second opinion.
- If you see something abnormal, go back and look at the chart. Sometimes patients have long-standing neurological deficits that weren’t relayed in report (not ideal, but it happens).
- Call the MD anytime there are changes or you are concerned about a patient.
Looking for more neurological topics? Here you go!
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