Ateneo de Zamboanga University

COLLEGE OF NURSING
PERFORMANCE EVALUATION CHECKLIST

NAME: _____________________________________ DATE PERFORMED: _________________

YEAR & SECTION: ______________

ASSESSING THE NEUROLOGICAL SYSTEM

Legend (Rating Criteria):
5 – Expert (student performs all tasks proficiently and independently).
4 – Competent (student performs efficiently in an effective and efficient
manner).
3 – Progress Acceptable (performance is usually effective and but not always).
2 – Needs Improvement (progress in performance is too slow to judge
satisfactorily; task performance is not most of the time).
1 – Progress Unacceptable (no progress in performance has been
demonstrated, and or performance is consistently ineffective and inefficient).

PREPARATION 1 2 3 4 5
1. Assemble equipment:
• Sugar, salt, lemon juice, quinine flavors
• Percussion hammer
• Tongue depressors (one broken diagonally, for
testing pain sensation)
• Wisps of cotton, to assess light touch sensation
• Test tubes of hot and cold water, for skin
temperature assessment (optional)
• Pins or needles for tactile discrimination
PROCEDURE
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it
is necessary, and how the client can cooperate.
2. Perform hand hygiene and observe other appropriate
infection control procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
• Presence of pain in the head, back, or
extremities, as well as onset and aggravating and
alleviating factors
• Disorientation to time, place, or person
• Speech disorders
• Any history of loss of consciousness, fainting,
convulsions, trauma, tingling or numbness,
tremors or tics, limping, paralysis, uncontrolled
muscle movements, loss of memory, or mood
swings
• Problems with smell, vision, taste, touch, or
hearing
Language
5. If the client displays difficulty speaking:
Point to common objects, and ask the client to name
them.
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
6. Determine the client’s orientation to time, place, and
person by tactful questioning.
Ask the client the city and state of residence, time of
day, date, day of the week, duration of illness, and
names of family members.
More direct questioning might be necessary for some
people—e.g., “Where are you now?” “What day is it
today?”
Memory
7. Listen for lapses in memory.
Ask 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 5–8

digits in sequence, and 4–6 digits in reverse
order.
To assess recent memory:

• Ask the client to recall the recent events of the

day, such as how he 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, 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.
Attention Span and Calculation
8. Test the ability to concentrate or attention span by
asking 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.
 Level of Consciousness
9. Apply the Glasgow Coma Scale:
Eye response, motor response and verbal response
Cranial Nerves
10. Test the cranial nerves.
Cranial Nerve I—Olfactory
Ask client to close eyes and identify different mild
aromas, such as coffee and vanilla.
Cranial Nerve II—Optic
Ask the client to read Snellen’s chart; check visual
fields by confrontation, and conduct an
ophthalmoscopic examination.
Cranial Nerve III—Oculomotor
Assess six ocular movements and pupil reaction.
Cranial Nerve IV—Trochlear
Assess six ocular movements.
Cranial Nerve V—Trigeminal
While client looks upward, lightly touch the lateral
sclera of the eye to elicit the blink reflex. To test light
sensation, have the client close eyes, and wipe a
wisp of cotton over client’s forehead and paranasal
sinuses. To test deep sensation, use alternating
blunt and sharp ends of a safety pin over same area.
Cranial Nerve VI—Abducens
Assess directions of gaze.
Cranial Nerve VII—Facial
Ask the client to smile, raise the eyebrows, frown,
puff out cheeks, and close eyes tightly. Ask the client
to identify various tastes placed on the tip and sides
of tongue—sugar, salt—and to identify areas of
taste.
Cranial Nerve VIII—Auditory
Assess the client’s ability to hear the spoken word
and the vibrations of a tuning fork.
Cranial Nerve IX—Glossopharyngeal
Apply tastes on the posterior tongue for
identification. Ask the client to move tongue from
side to side and up and down.
Cranial Nerve X—Vagus
Assessed with CN IX; assess the client’s speech for
hoarseness.
Cranial Nerve XI—Accessory
Ask the client to shrug shoulders against resistance
from your hands and to turn head to the side against
resistance from your hand. Repeat for the other side.
Cranial Nerve XII—Hypoglossal
Ask the client to protrude tongue at midline, then
move it side to side.
Reflexes
11. Test reflexes using a percussion hammer, comparing
one side of the body with the other to evaluate the
symmetry of response.
Biceps Reflex
The biceps reflex tests the spinal cord level C-5, C-6.
Partially flex the client’s arm at the elbow, and rest
the forearm over the thighs, placing the palm of the
hand down.
Place the thumb of your nondominant hand
horizontally over the biceps tendon.
 Deliver a blow (slight downward thrust) with the
percussion hammer to your thumb.
Observe the normal slight flexion of the elbow, and
feel the biceps’s contraction through your thumb.
Triceps Reflex
The triceps reflex tests the spinal cord level C-7, C-8.
Flex the client’s arm at the elbow, and support it in
the palm of your nondominant hand.
Palpate the triceps tendon about 2–5 cm (1–2
inches) above the elbow.
Deliver a blow with the percussion hammer directly
to the tendon.
Observe for the normal slight extension of the elbow.
Brachioradialis Reflex
The brachioradialis reflex tests
the spinal cord level C-3, C-6.
Rest the client’s arm in a relaxed position on your
forearm or on the client’s own leg.
Deliver a blow with the percussion hammer directly
on the radius 2–5 cm (1–2 inches) above the wrist or
the styloid process, the bony prominence on the
thumb side of the wrist.
Observe the normal flexion and supination of the
forearm. The fingers of the hand might also extend
slightly.
Patellar Reflex
The patellar reflex tests the spinal cord level L-2. L-3, L-4.
Ask the client to sit on the edge of the examining
table so that legs hang freely.
Locate the patellar tendon directly below the patella.
Deliver a blow with the percussion hammer directly
to the tendon.
Observe the normal extension or kicking out of the
leg as the quadriceps muscle contracts.
If no response occurs, and you suspect the client is
not relaxed, ask the client to interlock fingers and
pull.
Achilles Reflex
The Achilles reflex tests the spinal cord level S-1, S-2.
With the client in the same position as for the patellar
reflex test, slightly dorsiflex the client’s ankle by
supporting the foot lightly in your hand.
Deliver a blow with the percussion hammer directly
to the Achilles tendon just above the heel.
Observe and feel the normal plantar flexion
(downward jerk) of the foot.
Plantar (Babinski’s) Reflex
The plantar or Babinski’s reflex is superficial. It might 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 the dull end of a
pin or 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’s. In an
abnormal Babinski response, the toes spread
outward and the big toe moves upward.
 Motor Function
Assessment

12. Gross Motor and Balance Tests

Walking Gait
Ask the client to walk across the room and back, and
assess the client’s gait.
Romberg’s Test
Ask the client to stand with feet together and arms
resting at the sides, first with eyes open, then closed.
Standing On One Foot With Eyes Closed
Ask the client to close eyes and stand on one foot,
then the other. 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.
13. Fine Motor Tests for the Upper Extremities
Finger-to-Nose Test
Ask the client to abduct and extend arms at shoulder
height and rapidly touch nose alternately with one
index finger and then the other. Have the client
repeat the test with 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 hands,
alternately, at an ever-increasing rate.
Finger to Nose and to the Nurse’s Finger
Ask the client to touch nose and then your index
finger, held at a distance at about 45 cm (18 inches),
at a rapid and increasing rate.
Fingers to Fingers
Ask the client to spread arms broadly at shoulder
height and then bring fingers together at the midline,
first with 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.
14. Fine Motor Tests for the Lower Extremities
Ask the client to lie supine and to perform these
tests:
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
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.
15. Light-Touch Sensation
Compare the light-touch sensation of symmetric
areas of the body.
 Ask the client to close eyes and to respond by saying
“yes” or “now” whenever the client feels the cotton
wisp touching 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.
Ask the client to point to the spot where the touch
was felt.
If areas of sensory dysfunction are found, determine
the boundaries of sensation by testing responses
approximately every 2.5 cm (1 inch) in the area.
Make a sketch of the sensory loss area for recording
purposes.
16. Pain Sensation
Assess pain sensation as follows:
Ask the client to close his eyes and to say “sharp,”
“dull,” or “don’t know” when the sharp or dull end of
the broken tongue depressor is felt.
Alternately, use the sharp and dull end of the sterile
pin or needle to lightly prick designated anatomic
areas at random. The face is not tested in this
manner.
Allow at least two seconds between each test.

17. Temperature Sensation

Touch skin areas with test tubes filled with hot or
cold water.
Have the client respond say saying “hot,” “cold,” or
“don’t know.”
18. Position or Kinesthetic Sensation
Commonly, the middle fingers and the large toes are
tested for the kinesthetic sensation.
To test the fingers, support the client’s arm with one
hand and hold the client’s palm in the other. To test
the toes, place the client’s heels on the examining
table.
Ask the client to close 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 up-and-down movements
before bringing the finger or toe suddenly to rest in
one of the three positions.
19. Tactile Discrimination

For all tests, the client’s eyes need to be closed:

One- and Two-Point Discrimination
Alternately stimulate the skin with two pins
simultaneously and then with one pin. Ask whether
the client feels one or two pinpricks.
 Stereognosis
Place familiar objects—such as a key, paper clip, or
coin—in the client’s hand, and ask the client to
identify them.

If the client has a motor impairment of the hand and

is unable to manipulate an object, write a number or
letter on the client’s palm, using a blunt instrument,
and ask the client to identify it.
Extinction Phenomenon
Simultaneously stimulate two symmetric areas of the
body, such as the thighs, the cheeks, or the hands.
20. Document findings in the client record.

TOTAL

________________________
Clinical Instructor
(Sign over printed name)