6.10 Neurological Assessment

Now that we have reviewed tests included in a neurological exam, let’s review components of a routine neurological assessment typically performed by registered nurses. The neurological assessment begins by collecting subjective data followed by a physical examination.

Subjective Assessment

Subjective data collection guides the focus of the physical examination. Collect data from the patient using effective communication and pay particular attention to what the patient is reporting, including current symptoms and any history of neurological illness. Ask follow-up questions related to symptoms such as confusion, headache, vertigo, seizures, recent injury or fall, weakness, numbness, tingling, difficulty swallowing (called dysphagia) or speaking (called dysphasia), or lack of coordination of body movements.[1]

See Table 6.10a for sample interview questions to use during the subjective assessment

Table 6.10a Interview Questions Related to Subjective Assessment of Neurological System

Interview Questions Follow-up
Are you experiencing any current neurological concerns such as headache, dizziness, weakness, numbness, tingling, tremors, loss of balance, or decreased coordination?

Have you experienced any difficulty swallowing or speaking?

Have you experienced any recent falls?

If the patient is seeking care for an acute neurological problem, use the PQRSTU method to further evaluate their chief complaint. The PQRSTU method is described in the “Health History” chapter.

Note: If critical findings of an acute neurological event are actively occurring, such as signs of a stroke, obtain emergency assistance according to agency policy.

Have you ever experienced a neurological condition such as a stroke, transient ischemic attack, seizure, or head injury? Describe the condition(s), date(s), and treatment(s).
Are you currently taking any medications, herbs, or supplements for a neurological condition? Please describe.

Life Span Considerations


At birth, the neurologic system is not fully developed. The brain is still developing, and the newborn’s anterior fontanelle doesn’t close until approximately 18 months of age. The sensory and motor systems gradually develop in the first year of life. The newborn’s sensory system responds to stimuli by crying or moving body parts. Initial motor activity is primitive in the form of newborn reflexes. Additional information about newborn reflexes is provided in the “Assessing Reflexes” section. As the newborn develops, so do the motor and sensory integration. Specific questions to ask parents or caregivers of infants include the following:

  • Have you noticed your infant sleeping excessively or having difficulty arousing?
  • Has your infant had difficulty feeding, sucking, or swallowing?


Depending on the child’s age and developmental level, they may answer questions independently or the child’s parent/guardian may provide information. Specific questions for children include the following:

  • Have you ever had a head injury or a concussion?
  • Do you experience headaches? If so, how often?
  • Have you had a seizure or convulsion?
  • Have you noticed if your child has any problems with walking or balance?
  • Have you noticed if your child experiences episodes of not being aware of their environment?

Older Adults

The aging adult experiences a general slowing in nerve conduction, resulting in a slowed motor and sensory interaction. Fine coordination, balance, and reflex activity may be impaired. There may also be a gradual decrease in cerebral blood flow and oxygen use that can cause dizziness and loss of balance. Examples of specific subjective questions for the older adult include the following:

  • Have you ever had a head injury or recent fall?
  • Do you experience any shaking or tremors of your hands? If so, do they occur more with rest or activity?
  • Have you had any weakness, numbness, or tingling in any of your extremities?
  • Have you noticed a problem with balance or coordination?
  • Do you ever feel lightheaded or dizzy? If so, does it occur with activity or change in position?
Image showing drawing of stethoscope inside circle shapeEducate older adults to change positions slowly, especially when standing up from a lying or sitting position. Light-headedness and loss of balance during these activities increase the risk for falls.

Objective Assessment

The physical examination of the neurological system includes assessment of both the central and peripheral nervous systems. A routine neurological exam usually starts by assessing the patient’s mental status followed by evaluation of sensory function and motor function. Comprehensive neurological exams may further evaluate cranial nerve function and deep tendon reflexes. The nurse must be knowledgeable of what is normal or expected for the patient’s age, development, and condition to analyze the meaning of the data that are being collected.


Nurses begin assessing a patient’s overall neurological status by observing their general appearance, posture, ability to walk, and personal hygiene in the first few minutes of nurse-patient interaction. For additional information about obtaining an overall impression of a patient’s status while performing an assessment, see the “General Survey” chapter.

Level of orientation is assessed and other standardized tools to evaluate a patient’s mental status may be used, such as the Glasgow Coma Scale (GCS), NIH Stroke Scale, or Mini-Mental State Exam (MMSE). Read more information about these tools under the “Assessing Mental Status” section earlier in this chapter.

The nurse also assesses a patient’s cerebellar function by observing their gait and balance. See the “Assessing Cerebellar Function” section earlier in chapter for more information.


Auscultation refers to the action of listening to sounds from the heart, lungs, or other organs with a stethoscope as a part of physical examination. Auscultation is not typically performed by registered nurses during a routine neurological assessment. However, advanced practice nurses and other health care providers may auscultate the carotid arteries for the presence of a swishing sound called a bruit. Bruits suggest interference with cerebral blood flow that can cause neurological deficits.


Palpation during a physical examination typically refers to the use of touch to evaluate organs for size, location, or tenderness, but palpation during the neurologic physical exam involves using touch to assess sensory function and motor function. Refer to sections on “Assessing Sensory Function,” “Assessing Motor Strength,” “Assessing Cranial Nerves,” and “Assessing Reflexes” earlier in this chapter for additional information on how to perform these tests.

See Table 6.10b for a summary of expected and unexpected findings when performing an adult neurological assessment.

Table 6.10b Expected Versus Unexpected Findings on Adult Neurological Assessment

Assessment Expected Findings Unexpected Findings (Document and notify provider if new finding*)
Inspection Alert and oriented to person, place, and time

Symmetrical facial expressions

Clear and appropriate speech

Ability to follow instructions

PERRLA (Pupils are equal, round, and reactive to light and accommodation)

Cranial nerves all intact

Negative Romberg test

Sensory function present

Cortical functioning (indicated by stereognosis) intact

Good balance

Coordinated gait with equal arm swing

Finger-to-nose, rapid alternating arm movements, and heel-to-shin performance intact

Negative pronator drift test

Motor strength in upper and lower extremities equal bilaterally

Deep tendon reflexes intact

Not alert and oriented to person, place, and/or time

Asymmetrical facial expressions

Garbled speech

Inability to follow directions

Pupils unequal in size or reactivity

Deficits in one or more cranial nerve assessments

Positive Romberg test

Sensory function impaired in one or more areas

Stereognosis not intact

Poor balance

Shuffled or asymmetrical gait with unequal arm swing

Unable to complete finger-to-nose, alternating arm movement, or heel-to-shin tests

Positive pronator drift test

Unequal strength of upper and/or lower extremities

One or more deep tendon reflexes are not reactive



Critical findings to report immediately and/or obtain emergency assistance: Change in mental status, pupil responsiveness, facial drooping, slurred words or inability to speak, or sudden unilateral loss of motor strength



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