9 Focused Assessment- Neurological Examination

Learning Objectives

At the end of this chapter, the learner will:

  1. Obtain the health history of the neurological system.
  2. Assess the neurological system of the patient including the cranial nerves, sensory function, pain, temperature, and position sense of a patient.
  3. Document findings of the neurological exam.

I. Overview of the Neurological System

The assessment of the neurological system include examinations of mental status, level of consciousness and examinations of the neurological function. While details of the mental status assessment will be described in the next chapter, this chapter will begin with a review of the 12 pairs of cranial nerves and their functions. It will follow by a collection of some important terminologies of this system, and then continue with key assessment components for the system.

II. Anatomy and Physiology

Click the link below to review anatomy and physiology of the neurological system. In the assessment process, you will need to apply your knowledge of the 12 pairs of cranial nerves and their functions to the neurological system.



A more detailed review of neurological system is available at the link:

A & P Review.

III. Medical Terminology

The following are commonly used medical terminologies in the assessment of neurological system.

Affect observable behaviors that indicate a person’s feelings or emotions
Anxiety a feeling of uneasiness or discomfort experienced in varying degree
Apathy lack of emotional expression; indifference to stimuli or surroundings
Aphasia a neurological condition in which language function is absent or impaired
Cognitive functioning an intellectual process by which one becomes aware of, perceives, or comprehends ideas
Coherency conversation and behavior that conveys thoughts and feelings in a logical and relevant manner
Cerebrovascular Accident (CVA) a stroke; a blockage or the rupture of a blood vessel in the brain
Delirium a temporary state of confusion
Depression a mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things
Dementia impairment of intellectual functioning, memory, and judgment
Dysarthria speech disorder involving difficulty with articulating and pronunciation of specific sounds
difficulty in swallowing
Dysphasia difficulty with speech
Encephalitis inflammation of the brain
Hyperesthesia abnormally increased sensitivity to sensory stimuli such as touch or pain
Labile emotions unpredictable, rapid shifting of expression of feelings
Paralysis loss of muscle function and or sensation secondary to nervous impairment
Paraplegia a form of paralysis that affects in the lower half of the body
Paresis impaired muscle strength or weakness
Paresthesia abnormal sensation such as numbness, tingling, or burning
Quadriplegia a form of paralysis that affects all four extremities
Transient Ischemic Attack (TIA) A neurological event with the signs and symptoms of a stroke, but which go away within a short period of time
Temporomandibular joint (TMJ) the hinge joint between the temporal bone and the lower jaw
Terms to Classify Altered Level of Consciousness
Consciousness normal
Confusion disoriented; impaired thinking and difficulty following commands
Delirium a temporary state of confusion; restlessness, hallucination, sometimes delusions
Lethargy/Somnolence a state of severe drowsiness can be aroused by moderate stimuli
Obtundation decreased alertness, slowed psychomotor responses; similar to lethargy
Stupor responds only to intense and repeated stimuli; almost unconscious
Coma a profound or deep state of unconsciousness; may lack a gag reflex or a pupillary response

*Use Glasgow Coma Scale (GCS) to objectively assess the extent of impaired consciousness. GCS is described later in this chapter.

IV. Step by Step Assessment

  • Perform hand hygiene.
  • Check room for contact precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Assemble equipment prior to starting exam.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Apply principles of asepsis and safety.
  • Check vital signs.
Steps  Additional Information
  1. Obtain the health history related to mental status and the neurological system.
  2. Assess mental health status, alertness and orientation, level of consciousness (LOC) general appearance, and behavior.
  • Observe the patient’s appearance, attitude, activity (behavior), mood/affect.
  • Note hygiene, grooming, speech patterns, and facial expressions.
  • Observe gait and balance.
Ask relevant questions related to past or recent history of head injury, neurological illness, or symptoms, confusion, headache, vertigo, seizures, recent injury or fall, weakness, numbness, tingling, difficulty swallowing (dysphagia) or speaking (dysphasia), and lack of coordination of body movements.
3. Assess 12 cranial nerve functions.

(See chart below for more details).

CNI – Assess smell

CNII- Assess visual acuity by using Snellen chart. Normal vision is 20/20. The top number indicates the distance of the patient can see, and the bottom number indicates what a person with normal vision can see.

Snellen Chart
Snellen Chart
    • Assess peripheral vision: Ask the patient to cover one eye and the examiner cover the opposite eye. The examiner will move hand/fingers near the visual field. The patient and the examiner should see hand/fingers at the same time.

CNIII/IV/VI – assess extraocular eye movements with 6 cardinal directions of gaze. Ask the patient to keep the head still and only move eyes. Follow the examiner’s finger or an object to move in 6 directions.

Six cardinal directions for eye movements
Six Cardinal Directions
    • CN III -pupillary reaction – assessing pupils for size, shape, and reaction to light: Pupils Equal Round, Reactive to Light, and Accommodation (PERRLA)
    • Normal pupillary reflexes include direct reflex and consensual reflex.
Pupil's direct reaction to light.

CN V – assess jaw clench and sharp/dull sensation over three branches (forehead, cheek, and chin) bilaterally.

CN VII – ask the patient to raise eyebrows, smile, puff out cheeks, show teeth, squeeze eyes shut.

CN VIII – assess hearing by whispering or by lightly rubbing the examiner’s fingers next to ear.

CN IX /CN X – assess swallow, and check movement of soft palate and gag reflex.

CN XI – assess motor function of the spinal accessory nerve by asking the patient to shrug shoulders while the examiner applies pressure. Trapezius muscles should be strong and symmetric.

CN XII – assessing tongue movement

4. Assess motor strength and sensation.

  • Check arms and legs for strength and compare bilaterally.
  • Assess strength in the upper extremities by asking the patient to squeeze hands.
  • Assess strength in the lower extremities by asking the patient
    • to raise legs against the examiner’s hands;
    • the examiner places both hands on the patient’s inner thighs and asks the patient to bring legs together;
    • the examiner places both hands on the outer thighs and asks the patient to move legs apart;
    • the examiner places hands on the back of the patient’s feet and asks the patient to perform dorsiflexion;
    • the examiner places hands at the bottom of the patient’s feet and asks the patient to press down.
  • Assess extremities for sensation, numbness, tingling.
Unequal motor strength and unusual sensation may indicate underlying neurological disease or injury, such as stroke or head injury.

Assess grip strength
Assess Grip Strength
Assess strength and sensation of lower extremities
Assess strength and sensation
Assess strength in the lower extremities
Assess strength and sensation

Expected findings should be equal strength bilaterally, no pain/numbness/tingling sensation.

5. Report and document assessment findings and related health problems according to agency policy. Accurate and timely documentation and reporting promote patient safety.

Knowledge Check

Assess 12 Cranial Nerve Functions

Click all hyperlinks to access more details.

Mnemonic # Name Function (Sensory/Motor/Both) Assessment
On I Olfactory Smell (S)
Old II Optic Vision (S) Visual acuity 
Visual field 

Olympus’ III Oculomotor Eye movements (M)

Pupillary reaction and


Eye movements (CN III, IV, VI)

Towering IV Trochlear Eye movements (M)
Tops V Trigeminal Sensory/motor – face (B) Facial movement and sensation
A VI Abducens Eye movements (M)
Finn VII Facial Motor – face, taste (B) Facial motor function
And VIII Auditory (Vestibulocochlear) Hearing/balance (S) Hearing
German IX Glossopharyngeal Motor – throat, taste (B) Movement of the soft palate and gag reflex

(CNIX and X)

Viewed X Vagus Motor/sensory – viscera (autonomic) (B)
Some XI Spinal Accessory Motor – head and neck (M) Shrug shoulder
Hops XII Hypoglossal Motor – lower throat (M) Tongue
Cranial Nerves Assessment
Cranial Nerves Assessment

Copyrighted materials used with permission of the author, A. Chandrasekhar, Loyola University Medical Education Network.

Table adapted from Biga et al. Anatomy & Physiology. https://open.oregonstate.education/aandp/chapter/13-3-spinal-and-cranial-nerves/

Watch the cranial nerve assessment video below. In this video, the examiner uses ophthalmoscope to check the fundus of the eye (optic disc) which bedside nurses normally do not perform during head to toe or shift assessment.

Knowledge Check

Glasgow Coma Scale (GCS) Assessment

Glasgow Coma Scale is a scale to assess the level of consciousness of patients who have an acute brain injury or trauma in emergency situations. It contains assessment of three components: eye, verbal and motor responses. A fully awake person has the highest score of 15 and a person in deep coma receives the lowest score of 3.

Response Scale/Score

Best eye-opening response

Record “C” if eyes closed due to swelling.

Spontaneously (4)

To speech (3)

To pain (2)

No response (1)

Best motor response (to painful stimuli)

Press at fingernail bed and record best upper-limb response.

Obeys verbal command (6)

Localizes pain (5)

Flexion – withdrawal (4)

Flexion – abnormal (3)

Extension – abnormal (2)

No response (1)

Best verbal response

Record “E” if endotracheal tube is in place, and “T” if tracheostomy is in place.

Oriented x 3 (to person, time, and place) (5)

Conversation – confused (4)

Speech – inappropriate (3)

Sounds – incomprehensible (2)

No response (1)

 V. Documentation

A sample narrative documentation:

Alert and oriented (x4) to situation, person, place, and time. Behavior appropriate to situation and developmental age. Clear speech and follow verbal commands. Cranial nerves II to XII grossly intact. Pupils Equal, Round, React to Light and Accommodation (PERRLA). Active range of motion all extremities with symmetry strength. Peripheral sensation intact.

VI. Related Laboratory and Diagnostic Procedures/Findings

Depending on the patient’s signs and symptoms from physical examination, some diagnostic tests could be performed. For example, lumbar puncture (spinal tap) is to collect a sample of the patient’s spinal fluids to check if the patient has an infection in the brain or spinal cord or cancer in the brain. Imaging study such as magnetic resonance imaging (MRI) or computed tomography (CT) scan to diagnose a specific neurological disorder. Electroencephalogram (EEG) measures electrical activity in the brain that can be used to diagnose seizures, psychiatric disorders and other conditions of the brain.

A more detailed overview of different neurological diagnostic tests is available at: Neurological Diagnostic Tests and Procedures

VII. Learning Exercise

VIII. Attributions and References

  • Biga, L. M., Dawson, S., Harwell, A., Hopkins, R., Kaufmann, J., LeMaster, M., Matern, P., Morrison-Graham, K., Quick, D., & Runyeon, J. Anatomy & Physiology.  http://library.open.oregonstate.edu/aandp/chapter/13-3-spinal-and-cranial-nerves/#tbl-ch13_03
  • Chandrasekhar, A. (March 28, 2006 updated). Screening Physical Exam. http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/contents.htm
  • Doyle, G. R. & McCutcheon, J. A. Clinical Procedure for Safer Patient Care. https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/
  • Hacking, C. & Gaillard, F. Radiopaedia.org. https://radiopaedia.org/articles/olfactory-nerve?lang=us. Accessed July 20, 2019.
  • Michael Gibson, C.,  Bahekar, P., & Sharfaei, S. WikiDoc: Glasgow coma scale. https://www.wikidoc.org/index.php/Glasgow_coma_scale. Accessed July 20, 2019.
  • National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Neurological-Diagnostic-Tests-and-Procedures-Fact. Accessed July 20, 2019.
  • Orlando, G. (2006). Animation that illustrates the pupillary light reflex. Public domain via Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Eye_dilate.gif
  • Psychology Wiki https://psychology.wikia.org/wiki/Level_of_consciousness. Accessed 7/16/2021


Icon for the Creative Commons Attribution 4.0 International License

Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng; Michelle Agostini; and Raquel Bertiz is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

Share This Book