Neuro Status

1+ images about Nclex neuro

RN/DREXEL Home Study Program
CE CENTER

CE credit is no longer available for this article. Expired July 2005

PATTY NOAH is the director of the neuro intensive care unit at Allegheny General Hospital in Pittsburgh.

Whether it's a brief check of neurological status or a comprehensive neuro exam, your assessment may uncover nervous system dysfunction before it's too late.

The neuro assessment is a key component in the care of the neurological patient. It can help you detect the presence of neurological disease or injury and monitor its progression, determine the type of care you'll provide, and gauge the patient's response to your interventions.

The initial assessment should be a comprehensive exam covering several critical areas: level of consciousness and mentation, cranial nerves, movement, sensation, cerebellar function, and reflexes. This initial exam will establish baseline data with which to compare subsequent assessment findings.

Once a thorough exam is done on admission or at the beginning of each shift, subsequent assessments should be problem-focused, zeroing in on the parts of the nervous system affected by the patient's condition. The patient's diagnosis and the acuity of her condition will determine how extensive your problem-focused assessments will be and how frequently you'll need to conduct them.

The single most important assessment

Evaluation of level of consciousness (LOC) and mentation are the most important parts of the neuro exam. A change in either is usually the first clue to a deteriorating condition.

The following terms are commonly used to describe a decreased LOC, so it helps to be familiar with them:

Full consciousness. The patient is alert, attentive, and follows commands. If asleep, she responds promptly to external stimulation and, once awake, remains attentive.1

Lethargy. The patient is drowsy but awakens—although not fully—to stimulation. She will answer questions and follow commands, but will do so slowly and inattentively.1

Obtundation. The patient is difficult to arouse and needs constant stimulation in order to follow a simple command. She may respond verbally with one or two words, but will drift back to sleep between stimulation.

Stupor. The patient arouses to vigorous and continuous stimulation; typically, a painful stimulus is required.1 She may moan briefly but does not follow commands. Her only response may be an attempt to withdraw from or remove the painful stimulus.

Coma. The patient does not respond to continuous or painful stimulation. She does not move—except, possibly, reflexively—and does not make any verbal sounds.

Since these and other terms used to categorize LOC are frequently used imprecisely, you'd be wise to avoid using them in your documentation.1, 2 Instead, describe how the patient responds to a given stimulus. For example, write: "Mrs. Jones moans briefly when sternum is gently rubbed, but does not follow commands." Bear in mind that recognizing and describing a change in LOC is more important than appropriately naming it.3

When assessing LOC, there are several tools you can choose from. With stroke patients, for instance, you may want to use the National Institutes of Health (NIH) Stroke Scale. (You can obtain a copy at Typically, though, it is the Glasgow Coma Scale (GCS) that comes to mind when one is assessing LOC. It's especially useful for evaluating patients during the acute stages of head injury.

A GCS score is based on three patient responses: eye opening, motor response, and verbal response. The patient receives a score for her best response in each of these areas, and the three scores are added together. The total score will range from 3 to 15; the higher the number, the better. A score of 8 or lower usually indicates coma.1, 2

If the patient is alert or awake enough to answer questions, you'll also assess mentation. Determine if she is oriented to person, place, and time by asking questions like: What is your name? Where are you right now? Why are you here? What year is it? Who is the president?

A comprehensive evaluation of mentation will include tests of higher intellectual function, as well. To test abstract reasoning, for example, you might ask the patient to interpret a well-known proverb.

Pupils are another important component of the neuro exam. Assessing them is especially important in a patient with impaired LOC. Like a change in LOC, a change in pupil size, shape, or reactivity can indicate increasing intracranial pressure (ICP) from a mass or fluid. You'll check pupils as part of the cranial nerve assessment, which is covered in the table at right.

Assessing for signs of motor dysfunction

A bedside neuro assessment almost always includes an evaluation of motor function. Since you'll be assessing the ability to move on command, the patient must be awake, willing to cooperate, and able to understand what you are asking her.

With the patient in bed, assess motor strength bilaterally: Have the patient flex and extend her arm against your hand, squeeze your fingers, lift her leg while you press down on her thigh, hold her leg straight and lift it against gravity, and flex and extend her foot against your hand. Grade each extremity using a motor scale like the one below.4

+5 - full ROM, full strength

+4 - full ROM, less than normal strength

+3 - can raise extremity but not against resistance

+2 - can move extremity but not lift it

+1 - slight movement

0 - no movement

As part of the motor assessment, also check for arm pronation or drift. Have the patient hold her arms out in front of her with her palms facing the ceiling. If you observe pronation—a turning inward—of the palm or the arm or the arm drifts downward, it means the limb is weak.

Assess motor response in an unconscious patient by applying a noxious stimulus and observing the patient's response to it. Another approach is central stimulation, such as sternal pressure. Central stimulation produces an overall body response and is more reliable than peripheral stimulation for this purpose. The reason: In an unconscious patient, peripheral stimulation, such as nail bed pressure, can elicit a reflex response, which is not a true indicator of motor activity.

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