Learn how to do a complete neuro nurse assessment. This will teach you everything you need too know, even if you are a new nurse.
As a neuro nurse, assessments are a very important part of your job. This is everything you need to look for and record as you do them.
How To Do A Neuro Nurse Assessment
You assessments will change depending on whether the patient is awake or asleep. For the purposes of this training, I’m going to share how to do an assessment on someone who is awake and can follow commands.
1. Observe How The Patient Is Acting
The first thing that you want to check on your patient as you walk into the room is to just observe how the patient is acting. Are they eating their food? Are they watching TV? Notice whether they are able to move their extremities or not (things like moving around in bed or playing on their smartphone will give you that information).
Don’t just notice whether they can move their extremities, but can they do it appropriately? Does it look normal when they eat their food or move their hands?
Before you even interact with them you can gather a lot of useful information.
If they are able to have a normal conversation with someone, that tells us their speech is doing great. Speech issues are very common in stroke and neurological injuries, so pay attention to that as well.
2. Assess Their Level of Alertness
When you chat with them, their level of alertness and level of consciousness are both very important.
When neuro changes occur, they first appear in levels of consciousness. It is very subtle and they happen over a longer period of time. It’s not like vital sign changes that can flip on a dime.
Even though it can happen – people can have acute neuro changes – that is the exception and not the rule.
Neuro changes are slow and subtle over a long period of time. That is why it is so crucial at the beginning of your shift you get a very good assessment.
When you walk into the room, note where they fall in the different levels of consciousness:
- Awake and alert
If they are unresponsive or stuporous, they should probably be in an ICU or step-down environment.
3. Ask Orientation Questions
After you begin interacting with the patient and noting their level of consciousness, you will ask them your orientation questions.
Here is how you can phrase it: “I am going to be asking you some questions that are really basic and straightforward, but I want to get an idea of how your orientation is.”
If they are having speech difficulties, you can turn these questions into a yes/no answer.
Ask them these questions:
- What is your name?
- Where are you right now?
- Why did you come into the hospital? – This can be as basic as “I had a stroke,” as long as I know they understand basically what happened.
- What is the month and/or year? – This helps me understand if they can orient to the current time period. Refrain from asking what day of the week it is, because even us night-shift nurses forget what day they are on!
4. Look At Their Pupils and Eyes
The next thing we are going to do is look at their pupils and their eyes. This is the first part as we work from the head down.
You will need a pen light for this step. Using this pen light, assess each eye individually.
Do not sweep in front of their eye. It is difficult to quantify a pupillary change when you sweep from the side because as you get closer to their eye, their pupil will start constricting.
Instead, tell the patient to look at your nose and then take a pen light and turn it on right in front of their eye. You will be watching for multiple things at once:
- Shape – irregular, oval, circular
- Size – the size it was when I started and then what it shrunk down to
- Time – how quickly the pupil responds to the light. Is it brisk, non-reactive, sluggish, or is it hippus (where it gets smaller then bigger again)?
Another thing you should know before you do this step is whether they have had cataract surgery or some other eye surgery that might change how their pupils look.
5. Check Extraocular Movements
After we look at their pupils, we will check their extraocular movements. You need to make sure that their eye can move in all of the directions.
This is a very simple check. All you need to do is say, “watch my finger with both eyes.” Then move your finger all the way up, all the way down, and do across both sides.
Another one you can do is you can just draw a big circle around their head with your finger.
This one checks cranial nerves 3, 4, and 6.
6. Assess Their Visual Field
The next thing you will check is their visual field. Here is what you will do.
Hold one hand up to one of their eyes. Then, ask the patient to look at your nose. Holding your fingers outside of their field of vision, ask them to tell you when they can see your fingers wiggling. Begin to bend your elbow and slowly bring your fingers into their peripheral vision.
Imagine a big cross on one side and try to do this to all four fields of vision for each side.
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You can wiggle fingers or you can ask them to tell you how many fingers you are holding up in each field of vision.
That is assessing cranial nerve 2.
7. Check Facial Symmetry
When you check facial symmetry, you are assessing cranial nerves 5 and 7.
Throughout this entire interaction, I’m watching their entire face. Does one side move easier or more than the other one?
Another way to check it is to ask them to close their eyes really tight and then open their eyes and raise their eyebrows really high. Ask them to smile really big, and stick out their tongue.
8. Do A Motor Assessment
After we assessed everything on their face and head, it’s time to move down to their arms and hands.
For this test, ask them to grip your two fingers. Do not give them your entire hand. If they have a hard time following directions or don’t have full control of their hands they could hurt you by grabbing your knuckles too tightly.
Hold your index and middle fingers out and ask them to grab your two fingers. Then, ask them to squeeze. Note if they have equal strength.
Then ask them to push your hands away and pull you closer to them and notice the strength in their arms as well.
Then do a drift check.
Ask the patient to closer their eyes and hold their arms up in front of them like they are holding a pizza box. Count to 10 out loud. Watch their arms. Their arms should stay up in the air in their original position.
If they have a drift, one or both arms will begin to drift down over 10 seconds.
Some patients might not be able to hold their arms up at all. Others might have a very slow drift. Others might pronate and then go down.
Take notes how their arms react over the 10 seconds because each means something different. So if you noticed that the patient has a drift, quantify and describe how much of a drift it was and what it looked like.
9. Check Leg Function
Then finally we check their legs. To do this, put your hands under their feet and ask them to push down like they are pushing on a gas pedal, note whether they have equal strength.
Move your hands to the top of their feet and check the same thing – equal strength – and ask them to push against your hands. This is called checking dorci plantar flexion.
Next, do a drift check for their feet. Tell them to keep their leg straight and lift it up off the bed. Then, count to 5. Show them your fingers as you count up to 5. Then, let them put that leg down and do the same to the next leg.
Do a plantar stroke. This is where you take a pen and go up the side of their foot so you can see if their toes fan.
10. Sensory Check
The last thing you need to do is a sensory check.
Ask the patient to close their eyes. Then, ask them to tell you if they feel you touching them on their right side, left side, or both. Lightly press on different areas of their face, arms, and legs.
Some charts will ask you to distinguish between dull and sharp. I have found through charting and hospital policy and after talking to neurosurgeons and neurologists that during my routine neuro check getting out something to distinguish between sharp and dull wasn’t necessary.
Ask at your hospital whether you truly need to check sharp or dull sensory every four hours.
After the sensory check, your neuro nurse assessment is complete!
Neuro Nurse Assessment Video
Be Thorough With Your Neuro Nurse Assessment
When you do a neuro nurse assessment, be thorough with your notes. Document everything. Never try to rely on your memory. The next nurse or physician should be able to get all the information they need from your charts and notes.
You will refer to your first assessment throughout the day, so make sure it is spot on.
A neuro assessment is a critical skill for any nurse (not just neuro ICU nurses) This goes beyond simple neuro checks. If you’re interested in improving this nursing skill, this article is for you. This is a short and sweet explanation of a nursing assessment of an unconscious neuro patient. Always refer to your hospital’s policies and procedures to guide your practice.
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