NEURO VITAL SIGNS ASSESSMENT

It is the process of evaluating the level of consciousness using a tool (GCS/NVS scale). It
is a key component in the acre of neurologic patient which help detect the presence of
neurological disease or injury.

Purposes:
1. To assess patient’s level of consciousness.
2. To establish baseline data to compare subsequent assessment findings.
3. To detect the presence of neurological disease or disorder.
4. To determine the type of care to provided.

Materials Needed:

1. Percussion hammer
2. Wisps of cotton to asses light touch sensation
3. Sterile safety pin for tactile discrimination

Expected Behavior Rationale

Assessment
1. Review physician’s order for neurovital Ensure correct monitoring of patient.
signs/GCS monitoring.

2. Assess reason for NVS/GCS monitoring. Determines the need for monitoring.

3. Gather both subjective and objective data To provide baseline information abot
about the patient’s previous/present health patient’s neurologic status.
state.

4. Assess patient’s level of consciousness To determine level of assistance needed.

and ability to cooperate.

Planning
5. Gather all the materials/equipment To prevent delay of the procedure and to
needed. save time and effort.

6. Plan the need for assistance. Another person’s support during the
procedure may facilitate ease of procedure.

Implementation To ensure procedure is done correctly to the

7. Prior to performing the procedure, patient.
introduce self and verify the client’s Explaining the procedure will alleviate
identity using agency protocol. Explain to anxiety and gain cooperate from the patient.
the client what you are going to do, why it
is necessary, and how he or she can
participate. Discuss how the results will be
used in planning further
care or treatments and provide for client
privacy all throughout the examination.
8. Perform hand hygiene and observe other Reduces transmission of microorganism and
appropriate infection prevention protect hands from chemical irritant.
procedures.
1. Check vital signs. Evaluation of the client’s vital signs should
be conducted, as current or progressive
injury to the brain and brain stem may make
vital signs unstable, which could reduce
neurologic responses.
2. Inquire if the client has any history To provide baseline data. Allows to define
of the following: presence of pain in the patient’s problem and along with the
the head, back, or extremities, as result of physical examination, it will assists
well as onset and aggravating and in formulating an etiologic and/or
alleviating factors; disorientation to pathologic diagnosis.
time, place, or person; speech
disorder; loss of consciousness,
fainting, convulsions, trauma,
tingling or numbness, tremors or
tics, limping, paralysis,
uncontrolled muscle movements,
loss of memory, mood swings; or
problems with smell, vision, taste,
touch, or hearing.

Language This will assess if the speech delivered at a

3. If the client displays difficulty normal rate and volume, or is it pressured,
speaking: slow and accented. It also described the
• Point to common objects, and ask the enunciation quality, tempo and whether it is
client to name them. loud, quiet or impoverished.
• Ask the client to read some words and to
match the printed and written words with
pictures.
• Ask the client to respond to simple verbal
and written commands
(e.g., “point to your toes” or “raise your
left arm”).

Orientation
4. Determine the client’s orientation to Checks degree of mental orientation and
time, place, and person by tactful establishes alertness by evaluating for
questioning. Ask the client the time sleepiness, disinterest or distractibility.
of day, date, day of the week,
duration of illness, city and state of
residence, and names of family
members.
Memory This will provide early detection of
5. Listen for lapses in memory. Ask dementia
the client about difficulty with
memory. If problems are apparent,
three categories of memory are
tested: immediate recall, recent
memory, and remote memory.

To Assess Immediate Recall

• Ask the client to repeat a series of three
digits (e.g., 7–4–3), spoken slowly.
• Gradually increase the number of digits
(e.g., 7–4–3–5, 7–4–3–5–6, and 7–4–3–5
6–7–2) until the client fails to repeat the
series correctly.
• Start again with a series of three digits,
but this time ask the client to repeat them
backward. The average person can repeat a
series of five to eight digits in sequence and
four to six digits in reverse order.

To Assess Recent Memory

• Ask the client to recall the recent events
of the day, such as how the client got to the
clinic. This information must be validated,
however.
• Ask the client to recall information given
early in the interview (e.g., the name of a
doctor).
• Provide the client with three facts to
recall (e.g., a color, an object, and an
address) or a three-digit number, and ask
the client to repeat all three. Later in the
interview, ask the client to recall all three
items.

To Assess Remote Memory

• Ask the client to describe a previous
illness or surgery (e.g., 5 years ago) or a
birthday or anniversary. Generally
remote memory will be intact until late in
neurologic pathology. It is least useful in
assessing acute neurologic problems.
Attention Span and Calculation This will determine the amount of time
6. Test the ability to concentrate or spent concentrating on a task before
maintain attention span by asking becoming distracted.
the client to recite the alphabet or to
count backward from 100. Test the
ability to calculate by asking the
client to subtract 7 or 3
progressively from 100 (i.e., 100,
93, 86, 79, or 100, 97, 94, 91), a
task that is referred to as serial
sevens or serial threes. Normally,
an adult can complete the serial
sevens test in about 90 seconds with
three or fewer errors. Because
educational level, language, or
cultural differences affect
calculating ability, this test may be
inappropriate for some people.
Level of Consciousness Evaluation of LOC is the most important
7. Apply the Glasgow Coma Scale: part of the neuro exam, as a change is
eye response, motor response, and usually the first indication of a declining
verbal response. An assessment status. The GCS is a valuable tool for
totaling 15 points indicates the recording the conscious state of a person.
client is alert and completely
oriented. A comatose client scores 7
or less.
8. Check client’s pupil size, shape and The PERRLA (Pupils Equal, Round, React
equality. Turn the penlight on and to Light and Accommodation) is a useful
position it lateral to the eye on the tool to use. A change in pupillary response,
same plane. Slowly bring it over to such as unequal or dilated pupils can
shine directly on the pupil and provide a warning sign of increasing
observe for the reaction of pupil to intracranial pressure (ICP).
light.
Cranial Nerves It will provides information regarding the
9. For the specific functions and transmission of motor and sensory
assessment methods of each cranial messages, primarily to the head and neck
nerve. Test each nerve which are
not evaluated in another component
of the health assessment.
Reflexes Provides clues to the integrity of deep and
10. Test reflexes using a percussion superficial reflexes
hammer, comparing one side of the
body with the other to evaluate the
symmetry of response.
0 No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximal activity (hyperactive)

Plantar (Babinski) Reflex The plantar, or

Babinski, reflex is superficial. It may be
absent in adults without pathology or
overridden by voluntary control.
• Use a moderately sharp object, such as
the handle of the percussion hammer, a
key, or an applicator stick.
• Stroke the lateral border of the sole of the
client’s foot, starting at the heel, continuing
to the ball of the foot, and then proceeding
across the ball of the foot toward the
big toe.
• Observe the response. Normally, all five
toes bend downward; this reaction is
negative Babinski. In an abnormal
(positive) Babinski response, the toes
spread outward and the big toe moves
upward.
Motor Function Assessment of gait can provide important
11. Gross Motor and Balance Tests information to guide the focus of the rest of
the exam and can obviate the need for
WALKING GAIT specific testing.
Ask the client to walk across the room and
back, and assess the client’s gait. Assesses cerebellar and developmental
status as well as musculoskeletal structure
ROMBERG TEST and function.
Ask the client to stand with feet together
and arms resting at the sides, first with eyes Checks that the posture and gait are erect,
open, then closed. Stand close during this balanced, smooth, and aligned to the
test. developmental milestone.

Rationale: This prevents the client from

falling.

STANDING ON ONE FOOT WITH

EYES CLOSED
Ask the client to close the eyes and stand
on one foot. Repeat on the other foot. Stand
close to the client during this test.

HEEL-TOE WALKING
Ask the client to walk a straight line,
placing the heel of one foot directly in front
of the toes of the other foot.

TOE OR HEEL WALKING

Ask the client to walk several steps on the
toes and then on the heels.

12. Fine Motor Tests for the Upper This will evaluate if the hands develop
Extremities dexterity and strength.

FINGER-TO-NOSE TEST
Ask the client to abduct and extend the
arms at shoulder height and then rapidly
touch the nose alternately with one index
finger and then the other. The client repeats
the test with the eyes closed if the test is
performed easily.

ALTERNATING SUPINATION AND

PRONATION OF HANDS ON KNEES
Ask the client to pat both knees with the
palms of both hands and then with the
backs of the hands alternately at an ever-
increasing rate.

FINGER-TO-NOSE AND TO
THE NURSE’S FINGER
Ask the client to touch the nose and then
your index finger, held at a distance of
about 45 cm (18 in.), at a rapid and
increasing rate.

FINGERS-TO-FINGERS
Ask the client to spread the arms broadly at
shoulder height and then bring the fingers
together at the midline, first with the eyes
open and then closed, first slowly and then
rapidly.

FINGERS-TO-THUMB (SAME HAND)

Ask the client to touch each finger of one
hand to the thumb of the same hand as
rapidly as possible.

13. Fine Motor Tests for the Lower The ability to perform these tasks requires
Extremities properly functioning pyramidal
Ask the client to lie supine and to perform (corticospinal) and extrapyramidal tracts,
these tests. sensation and coordination.

HEEL DOWN OPPOSITE SHIN

Ask the client to place the heel of one foot
just below the opposite knee and run the
heel down the shin to the foot. Repeat with
the other foot. The client may also use a
sitting position for this test.

TOE OR BALL OF FOOT TO THE

NURSE’S FINGER
Ask the client to touch your finger with the
large toe of each foot.

14. Light-Touch Sensation Provides information regarding integrity of

the spinothalamic tract, posterior columns
Compare the light-touch sensation of of the spinal cord and parietal lobes of the
symmetric areas of the body. Rationale: brain.
Sensitivity to touch varies among different
skin areas. This will evaluate the presence of
anesthesia, hypoesthesia and hyperesthesia
* Ask the client to close the eyes and to
respond by saying “yes” or “now”
whenever the client feels the cotton wisp
touching the skin. With a wisp of cotton,
lightly touch one specific spot and then the
same spot on the other side of the body.
• Test areas on the forehead, cheek, hand,
lower arm, abdomen, foot, and lower leg.
Check a distal area of the limb first (i.e.,
the hand before the arm and the foot before
the leg). The sensory nerve may be
• If areas of sensory dysfunction are found, assumed to be intact if sensation is
determine the boundaries of sensation by felt at its most distal part.
testing responses about every 2.5 cm (1 in.)
in the area. Make a sketch of the sensory
loss area for recording purposes.
15. Pain Sensation This will evaluate if the client has analgesia,
Assess pain sensation as follows: hypoalgesia or hyperalgesia.
• Ask the client to close the eyes and to say
“sharp,” “dull,” or “don’t know” when the
sharp or dull end of a safety pin is felt.
• Alternately, use the sharp and dull end
to lightly prick designated anatomic
areas at random (e.g., hand, forearm, foot,
lower leg, abdomen). Note: The face is not
tested in this manner.
• Allow at least 2 seconds between each
test to prevent summation effects of stimuli
(i.e., several successive stimuli perceived
as one stimulus).
16. Position or Kinesthetic Sensation This will evaluate the ability to sense motion
of a joint or limb.
Commonly, the middle fingers and the
large toes are tested for the kinesthetic
sensation (sense of position).

• To test the fingers, support the client’s

arm and hand with one hand. To test the
toes, place the client’s heels on the
examining table.
• Ask the client to close the eyes.
• Grasp a middle finger or a big toe firmly
between your thumb and index finger, and
exert the same pressure on both sides of the
finger or toe while moving it.
• Move the finger or toe until it is up,
down, or straight out, and ask the client to
identify the position.
• Use a series of brisk, gentle up-anddown
movements before bringing the finger or
toe suddenly to rest in one of the three
positions.
Evaluation
17. Client relates history in logical,
sequential manner. Questions are
answered appropriately and without
distraction. Client is able to easily
and accurately recall history and
facts.
18. Explain findings to the client within
the nurse’s scope of practice and
function.
19. Tidies up the area and returns all
the borrowed materials.
20. Document findings in the client
record using printed or electronic
forms or checklists supplemented
by narrative notes when
appropriate. Describe any abnormal
findings in objective terms, for
example, “When asked to count
backwards by threes, client made
seven errors and completed the task
in 4 minutes.”
RETURN DEMONSTRATION EVALUATION TOOL FOR
NEURO VITAL SIGNS ASSESSMENT

Name: _______________________________________ Grade: _____________

Time started: _________Time ended: _______Date of RD:_____________________

AREA OF EVALUATION RATING

5 4 3 2 1 0 COMMENT
S
SKILLS (35%)
Assessment
1. Reviews physician’s order for neurovital
signs/GCS monitoring.
2. Assesses reason for NVS/GCS
monitoring.
3. Gathers both subjective and objective
data about the patient’s previous/present
health state.
4. Assesses patient’s level of consciousness
and ability to cooperate.
Planning
5. Gathers all the materials/equipment
needed.
6. Plans the need for assistance.

Implementation
7. Introduces self and verify the client’s
identity. Explains to the client about the
procedure and discusses how the results will
be used in planning further care or
treatments.
8. Provides client privacy.

9. Performs hand hygiene.

10. Checks vital signs.

11. Asks for any history of any neurological

problems.
12. Assesses any difficulty in speaking.

13. Assesses the client’s orientation to time,

place, and person.
14. Assesses any lapses in memory.

15. Tests the ability to concentrate or

maintain attention span.
16. Assesses LOC using Glasgow Coma
Scale.
17. Checks client’s pupil size, shape and
equality.
18. Assesses any problem in cranial nerves.

19. Tests reflexes.

20. Assesses gross motor and balance test

21. Tests fine motor for the upper

extremities.
22. Tests fine motor for the lower
extremities.
23. Tests light touch sensation.

24. Assesses pain sensation.

25. Assesses position or kinesthetic

sensation.
Evaluation
26. Client relates in logical, sequential
manner.

27. Questions are answered appropriately

and without distraction.

28. Client is able to easily and accurately

recall history and facts.

29. Explain findings to the client within the

nurse’s scope of practice and function.
30. Cleans the area and returns borrowed
materials.
31. Documents findings in the client record.

KNOWLEDGE (15%)
1. Gives rationale of the procedure
2. Explain the elements and mechanics of
the procedure
3. Knows the elements of nursing process as
applied
4. States principles applied in procedure

ATTITUDE (10%)
1. Is well groomed
2. Wears the prescribed, neat and clean
uniform
3. Arrives on time for the RD
4. Speaks to CI and client tactfully
5. Minimizes use of energy, time and effort
6. Utilizes supplies efficiently
7. Considers client safety, privacy and
comfort
8. Is well organized
9. Keeps working area clean at all times
10. Gives high value for aesthetics

Comments:
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CI’s signature: _________________________________________________