6.10 Neurological Assessment
Open Resources for Nursing (Open RN)
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
Newborn
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?
Children
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?
Educate 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.
Inspection
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
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
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 |
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology licensed under CC BY 4.0 ↵
Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with shear.
Health Care Settings
There are several levels of health care including primary, secondary, and tertiary care. Each of these levels focuses on different aspects of health care and is typically provided in different settings.
Primary Care
Primary care promotes wellness and prevents disease. This care includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations. Settings providing this type of health care include physician offices, public health clinics, school nursing, and community health nursing.
Secondary care
Secondary care occurs when a person has contracted an illness or injury and requires medical care. Secondary care is often referred to as acute care. Secondary care can range from uncomplicated care to repair a small laceration or treat a strep throat infection to more complicated emergent care such as treating a head injury sustained in an automobile accident. Whatever the problem, the client needs medical and nursing attention to return to a state of health and wellness. Secondary care is provided in settings such as physician offices, clinics, urgent care facilities, or hospitals. Specialized units include areas such as critical care, burn units, neurosurgery, cardiac surgery, and transplant services.
Tertiary Care
Tertiary care addresses the long-term effects from chronic illnesses or conditions with the purpose to restore a client's maximum physical and mental function. The goal of tertiary care is to achieve the highest level of functioning possible while managing the chronic illness. For example, a client who falls and fractures their hip will need secondary care to set the broken bones, but may need tertiary care to regain their strength and ability to walk even after the bones have healed. Clients with incurable diseases, such as dementia, may need specialized tertiary care to provide support they need for daily functioning. Tertiary care settings include rehabilitation units, assisted living facilities, adult day care, skilled nursing units, home care, and hospice centers.
Health Care Team
No matter the setting, quality health care requires a team of health care professionals collaboratively working together to deliver holistic, individualized care. Nursing students must be aware of the roles and contributions of various health care team members. The health care team consists of health care providers, nurses (licensed practical nurses, registered nurses, and advanced practice registered nurses), unlicensed assistive personnel, and a variety of interprofessional team members.
Health Care Providers
Providers are responsible for ordering diagnostic tests such as blood work and X-rays, diagnosing a client’s medical condition, developing a medical treatment plan, and prescribing medications. In a hospital setting, the medical treatment plan developed by a provider is communicated in the “History and Physical” component of the client's medical record with associated prescriptions (otherwise known as "orders"). Prescriptions or “orders” include diagnostic and laboratory tests, medications, and general parameters regarding the care that each client is to receive. Nurses should respectfully clarify prescriptions they have questions or concerns about to ensure safe client care. Providers typically visit hospitalized clients daily in what is referred to as "rounds." It is helpful for nurses and nursing students to attend provider rounds for their assigned clients to be aware of and provide input regarding the current medical treatment plan, seek clarification, or ask questions. This helps to ensure that the provider, nurse, and client have a clear understanding of the goals of care and minimizes the need for follow-up phone calls.
Nurses
There are three levels of nurses as defined by each state's Nurse Practice Act: Licensed Practical Nurse/Vocational Nurse (LPN/LVN), Registered Nurse (RN), and Advanced Practice Registered Nurse (APRN).
Licensed Practical/Vocational Nurses
The National Council of State Boards of Nursing (NCSBN) defines a licensed practical nurse (LPN) as, “An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by a state board of nursing to provide client care.”[1] In some states, the term licensed vocational nurse (LVN) is used. LPNs/LVNs typically work under the supervision of a registered nurse, advanced practice registered nurse, or physician.[2] LPNs provide "basic nursing care" and work with stable and/or chronically ill populations. Basic nursing care is defined by the Wisconsin Nurse Practice Act as “care that can be performed following a defined nursing procedure with minimal modification in which the responses of the client to the nursing care are predictable.”[3] LPNs/LVNs typically collect client assessment information, administer medications, and perform nursing procedures according to their scope of practice in that state. The Open RN Nursing Skills, 2e textbook discusses the skills and procedures that LPNs frequently perform in Wisconsin. See the following box for additional details about the scope of practice of the Licensed Practical Nurse in Wisconsin.
Registered Nurses
The NCSBN defines a Registered Nurse (RN) as “An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination and is licensed by a state board of nursing to provide client care.”[4] Registered Nurses (RNs) use the nursing process as a critical thinking model as they make decisions and use clinical judgment regarding client care. The nursing process is discussed in more detail in the “Nursing Process” chapter of this book. RNs may be delegated tasks from providers or may delegate tasks to LPNs and UAPs with supervision. See the following box for additional details about the scope of practice for Registered Nurses in the state of Wisconsin.
Advanced Practice Registered Nurses
Advanced Practice Registered Nurses (APRN) are defined by the NCSBN as an RN who has a graduate degree and advanced knowledge. There are four categories of Advanced Practice Registered Nurses: Certified Nurse-Midwife (CNM), Clinical Nurse Specialist (CNS), Certified Nurse Practitioner (CNP), and Certified Registered Nurse Anesthetist (CRNA). APRNs can diagnose illnesses and prescribe treatments and medications. Additional information about advanced nursing degrees and roles is provided in the box below.
Advanced Practice Nursing Roles[5]
Nurse Practitioners: Nurse practitioners (NPs) work in a variety of settings and complete physical examinations, diagnose and treat common acute illness and manage chronic illness, order laboratory and diagnostic tests, prescribe medications and other therapies, provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance, and refer clients to other health professionals and specialists as needed. In many states, NPs can function independently and manage their own clinics, whereas in other states physician supervision is required. NP certifications include, but are not limited to, Family Practice, Adult-Gerontology Primary Care and Acute Care, and Psychiatric/Mental Health.
To read more about NP certification, visit Nursing World's Our Certifications web page.
Clinical Nurse Specialists: Clinical Nurse Specialists (CNS) practice in a variety of health care environments and participate in mentoring other nurses, case management, research, designing and conducting quality improvement programs, and serving as educators and consultants. Specialty areas include, but are not limited to, Adult/Gerontology, Pediatrics, and Neonatal.
To read more about CNS certification, visit National Association of Clinical Nurse Specialist's What is a CNS? web page.
Certified Registered Nurse Anesthetists: Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia and related care before, during, and after surgical, therapeutic, diagnostic, and obstetrical procedures, as well as provide airway management during medical emergencies. CRNAs deliver more than 65 percent of all anesthetics to clients in the United States. Practice settings include operating rooms, dental offices, and outpatient surgical centers.
To read more about CRNA certification, visit National Board of Certification & Recertification for Nurse Anesthetist's website.
Certified Nurse Midwives: Certified Nurse Midwives provide gynecological exams, family planning advice, prenatal care, management of low-risk labor and delivery, and neonatal care. Practice settings include hospitals, birthing centers, community clinics, and client homes.
To read more about CNM certification, visit the American Midwifery Certification Board website.
Unlicensed Assistive Personnel
Unlicensed Assistive Personnel (UAP) are defined by the NCSBN as, “Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs), or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.”[6]
CNAs, PCAs, and PCTs in Wisconsin generally work in hospitals and long-term care facilities and assist clients with daily tasks such as bathing, dressing, feeding, and toileting. They may also collect client information such as vital signs, weight, and input/output as delegated by the nurse. The RN remains accountable that delegated tasks have been completed and documented by the UAP.
Interprofessional Team Members
Nurses, as the coordinator of a client’s care, continuously review the plan of care to ensure all contributions of the multidisciplinary team are moving the client toward expected outcomes and goals. The roles and contributions of interprofessional health care team members are further described in the following box.
Interprofessional Team Member Roles[7]
Dieticians: Dieticians assess, plan, implement, and evaluate interventions, including those relating to dietary needs of those clients who need regular or therapeutic diets. They also provide dietary education and work with other members of the health care team when a client has dietary needs secondary to physical disorders such as difficulty swallowing.
Occupational Therapists (OT): Occupational therapists assess, plan, implement, and evaluate interventions, including those that facilitate the client's ability to achieve their highest possible level of independence in their activities of daily living such as bathing, grooming, eating, and dressing. They also provide clients with adaptive devices such as long shoehorns so the client can put their shoes on, sock pulls so they can independently pull on socks, adaptive silverware to facilitate independent eating, grabbers so the client can pick items up from the floor, and special devices to manipulate buttoning so the person can dress and button their clothing independently. OTs assess the home for safety and the need for assistive devices when the client is discharged home. They may recommend modifications to the home environment such as ramps, grab rails, and handrails to ensure safety and independence. OTs practice in all health care environments, including the home, hospital, and rehabilitation centers.
Pharmacists: Pharmacists ensure the safe prescribing and dispensing of medication and are a vital resource for nurses with questions or concerns about medications they are administering to clients. Pharmacists ensure that clients not only get the correct medication and dosing, but also have the guidance they need to use the medication safely and effectively.
Physical Therapists (PT): Physical therapists are licensed health care professionals who assess, plan, implement, and evaluate interventions, including those related to the client's functional abilities in terms of their strength, mobility, balance, gait, coordination, and joint range of motion. They supervise prescribed exercise activities according to a client’s condition and also provide and teach clients how to use assistive aids like walkers and canes and how to perform exercise regimens. Physical therapists practice in all health care environments, including the home, hospital, and rehabilitation centers.
Podiatrists: Podiatrists provide care and services to clients who have foot problems. They often work with clients who have diabetes to clip toenails and provide foot care to prevent complications.
Prosthetists: Prosthetists design, fit, and supply the client with an artificial body part such as a leg or arm prosthesis. They adjust prosthesis to ensure proper fit, comfort, and functioning.
Psychologists and Psychiatrists: Psychologists and psychiatrists provide mental health and psychiatric services to clients with mental health disorders and provide psychological support to family members and significant others as indicated.
Respiratory Therapists: Respiratory therapists treat respiratory-related conditions in clients. Their specialized respiratory care includes managing oxygen therapy; drawing arterial blood gases; managing clients on specialized oxygenation devices such as mechanical ventilators, CPAP, and Bi-PAP machines; administering respiratory medications like inhalers and nebulizers; intubating clients; assisting with bronchoscopy and other respiratory-related diagnostic tests; performing pulmonary hygiene measures like chest physiotherapy; and serving an integral role in providing respiratory support.
Social Workers: Social workers counsel clients and provide psychological support, help set up community resources according to clients' financial needs, and serve as part of the team that ensures continuity of care after the person is discharged.
Speech Therapists: Speech therapists assess, diagnose, and treat communication and swallowing disorders. For example, speech therapists help clients with a disorder called expressive aphasia. They also assist clients with using word boards and other electronic devices to facilitate communication. They assess clients with swallowing disorders called dysphagia and treat them in collaboration with other members of the health care team including nurses, dieticians, and health care providers.
Ancillary Department Members: Nurses also work with ancillary departments such as laboratory and radiology departments.
- Clinical laboratory departments provide a wide range of laboratory procedures that aid health care providers to diagnose, treat, and manage clients. These laboratories are staffed by medical technologists who test biological specimens collected from clients. Examples of laboratory tests performed include blood tests, blood banking, cultures, urine tests, and histopathology (changes in tissues caused by disease).[8]
- Radiology departments use imaging to assist providers in diagnosing and treating diseases seen within the body. They perform diagnostic tests such as X-rays, CTs, MRIs, nuclear medicine, PET scans, and ultrasound scans.
Chain of Command
Nurses rarely make client decisions in isolation, but instead consult with other nurses and interprofessional team members. Concerns and questions about client care are typically communicated according to that agency's chain of command. In the military, chain of command refers to a hierarchy of reporting relationships – from the bottom to the top of an organization – regarding who must answer to whom. The chain of command not only establishes accountability, but also lays out lines of authority and decision-making power. The chain of command also applies to health care. For example, a registered nurse in a hospital may consult a “charge nurse,” who may consult the “nurse supervisor,” who may consult the “director of nursing,” who may consult the "vice president of nursing." In a long-term care facility, a licensed practical/vocational nurse typically consults the registered nurse/charge nurse, who may consult with the director of nursing. Nursing students should always consult with their nursing instructor regarding questions or concerns about client care before “going up the chain of command.”
Nurse Specialties
Registered nurses can obtain several types of certifications as a nurse specialist. Certification is the formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty. See the following box for descriptions of common nurse specialties.
Common Nurse Specialties
Critical Care Nurses provide care to clients with serious, complex, and acute illnesses or injuries that require very close monitoring and extensive medication protocols and therapies. Critical care nurses most often work in intensive care units of hospitals.
Public Health Nurses work to promote and protect the health of populations based on knowledge from nursing, social, and public health sciences. Public health nurses most often work in municipal and state health departments.
Home Health/Hospice Nurses provide a variety of nursing services for chronically ill clients and their caregivers in the home, including end-of-life care.
Occupational/Employee Health Nurses provide health screening, wellness programs and other health teaching, minor treatments, and disease/medication management services to people in the workplace. The focus is on promotion and restoration of health, prevention of illness and injury, and protection from work-related and environmental hazards.
Oncology Nurses care for clients with various types of cancer, administering chemotherapy and providing follow-up care, teaching, and monitoring. Oncology nurses work in hospitals, outpatient clinics, and clients’ homes.
Perioperative/Operating Room Nurses provide preoperative and postoperative care to clients undergoing anesthesia or assist with surgical procedures by selecting and handling instruments, controlling bleeding, and suturing incisions. These nurses work in hospitals and outpatient surgical centers.
Rehabilitation Nurses care for clients with temporary and permanent disabilities within inpatient and outpatient settings such as clinics and home health care.
Psychiatric/Mental Health Nurses specialize in mental and behavioral health problems and provide nursing care to individuals with psychiatric disorders. Psychiatric nurses work in hospitals, outpatient clinics, and private offices.
School Nurses provide health assessment, intervention, and follow-up to maintain school compliance with health care policies and ensure the health and safety of staff and students. They administer medications and refer students for additional services when hearing, vision, and other issues become inhibitors to successful learning.
Telenursing refers to providing nursing care remotely using information and communication technology. Nursing care may include client education, support, health assessment and evaluation, and triage. While telenursing is not a specialty, it is provided in several specialty areas such as Critical Care and Emergency Departments. It is also provided in outpatient environments and encourages increased client interactions, especially in underserved rural areas.[9]
Other common specialty areas include a life span approach across health care settings and include maternal-child, neonatal, pediatric, and gerontological nursing.[10]
This is the second edition of the Nursing Management & Professional Concepts nursing OER textbook that was developed specifically for prelicensure nursing students preparing to graduate and take the NCLEX-RN to obtain their nursing license. Content is based on the Wisconsin Technical College System (WTCS) statewide nursing curriculum for the Nursing Management & Professional Concepts course (543-114), the 2023 NCLEX-RN Test Plan,[11] and the Wisconsin Nurse Practice Act.[12] Here is a summary of updates made to the second edition.
This book introduces concepts related to nursing leadership and management, prioritization strategies, delegation and supervision, legal implications of nursing practice, ethical nursing practice, collaboration within the interprofessional team, health care economics, quality and evidence-based practice, advocacy, preparation for the RN role, and the avoidance of burnout with self-care. Several free, online, interactive learning activities are included in each chapter, including NCLEX Next Generation-style case studies that encourage students to develop clinical judgment while applying content to client-care situations. Additionally, the Appendix includes a "suite of patients” with suggested prompts for classroom discussion to assist students in applying concepts from the book to real patient-care situations.
The following video provides a quick overview of how to navigate the online version.
This e-book is free with CC BY 4.0 licensing and can be viewed online or downloaded as a PDF or in other formats for offline use. This book is part of the Open RN© Nursing OER textbook series, originally funded by a $2.5 million Open Textbook Pilot grant from the Department of Education with sustainability funded by WisTech Open. Read about other OER textbooks available on the Open RN and the WisTech Open websites.
