ARELLANO UNIVERSITY

COLLEGE OF NURSING
1058 Taft Avenue, Pasay City

EVALUATION TOOL

PHYSICAL ASSESSMENT 4 (Neurological Exam)

NAME: _____________________________________________________ DATE: ____________________ SCORE: _____________

SCORE
CRITERIA
4 3 2 1
I. ATTITUDE – 10%
1. Report on time
2. Wears complete prescribed uniform
3. Neat and well-groomed
4. Observes proper decorum
5. Acknowledges criticism/ suggestions cheerfully
6. Shows mastery of the activity
TOTAL = 24
II. KNOWLEDGE – 20%
1. States objectives of the activity
2. Uses appropriate terms
3. States steps of the procedure in correct order
4. Explains rationale of the steps
TOTAL = 16

III. SKILLS COMPETENCY – 70%

A. ASSESSMENT

1. Performs hand washing before the procedure

2. Preparation of the equipment
a. Cotton
b. Newspaper/magazine
c. Paper clip
d. Coffee/soap/perfume
e. Penlight
f. Snellen chart (if any)
g. Glass of water
h. Tongue depressor
3. Preparation of the Environment
a. Prepares an assessment room that is quiet, well lighted and well ventilated
B. PLANNING
1. Plans proper positioning of the client
2. Plans for proper draping of the client
C. IMPLEMENTATION
a. Preparation of the Client
1. Greets and identifies client, introduces self
2. Explains the purpose of the activity, what will be done and what instruments will be used.
3. Ask the client to use comfort room before the physical assessment
4. Position the client comfortably during the physical assessment
5. Prepares client properly and avoids unnecessary exposure
b. Concern for Client
1. Handles client gently
2. Relays results to the client
3. Speaks in client’s level of understanding
4. Expresses self readily and appropriately
c. Communication Skills
1. Uses appropriate terms, grammar is correct
2. Speaks in client’s level of understanding
3. Expresses self readily and appropriately
 SCORE
CRITERIA
4 3 2 1
CRANIAL NERVE ASSESSMENT

Cranial Nerve 1-Olfactory

Ask the client to clear the nose to remove any mucus then to close eyes, occlude one nostril, and identify
a scented object that you are holding such as soap, coffee or vanilla. Repeat procedure for other nostril.

Cranial Nerve II- Optic

Use a Snellen chart to assess vision in each eye

Ask client to read a newspaper or magazine paragraph to assess near vision (14 inches distance)

Assess visual field of each eye by confrontation

Cranial Nerves III (Oculomotor), IV (Trochlear) and VI (Abducens)

Inspect eyelids of each eye

Assess extraocular movement

Assess pupillary response to light and accommodation in both eyes (Use penlight)
Cranial Nerve V- Trigeminal

Teat motor function. Ask client to clench the teeth while you palpate the temporal and masseter muscle.

Test sensory function. Tell the client” I am going to touch your forehead, cheeks, and chin with the sharp
or dull side of a paper clip. Please close your eyes and tell me if you feel a sharp or dull sensation. Also tell
me where you feel it”. Vary the sharp and dull stimulus in the facial areas and compare sides. Repeat test
for light touch with a wisp of cotton.

Test the corneal reflex. Ask the client to look away and up while you lightly touch the cornea with a fine
wisp of cotton. Repeat on the other side.
Cranial nerve VII- Facial

Test motor function. Ask the client to:

a. Smile
b. Frown and wrinkle forehead
c. Show teeth
d. Puff out cheeks
e. Purse lip
f. Raise eyebrows
g. Close eyes tightly
Cranial nerve VIII- Acoustic/vestibulo-cochlear)

Test the client’s hearing ability in each ear (Whisper words to client from 1 to 2 feet.

To assess the cochlear (auditory component of cranial nerve VIII, perform weber and Rinnes test (This may
not be performed due to unavailability of tuning fork)
Cranial nerve IX- Glossopharyngeal and Cranial nerve X- Vagus

Test motor function. Ask the client to open mouth and say “ah” while you use a tongue depressor on the
client’s tongue

Test the gag reflex by touching the posterior pharynx with the tongue depressor. Warn the client that you
are going to do this and that the test may feel a little uncomfortable.

Check the client’s ability to swallow by giving the client a drink of water. Also note the client’s voice
quality if there is hoarseness.
Cranial Nerve XI- Spinal Accessory

Ask the client to shrug shoulders against resistance to assess the trapezius muscle

Ask the client to turn the head against resistance, first to the right then to the left, to assess the
sternocleidomastoid muscle.
Cranial nerve XII- Hypoglossal

To assess strength and mobility of the tongue, ask the client to protrude tongue, move it to each side
against the resistance of a tongue depressor.
 MOTOR AND CEREBELLAR SYSTEM
A. Ask client to walk naturally across the room (Note posture, freedom of movement, symmetry,
rhythm and balance
B. Ask the client to walk in heel-to-toe fashion (the nurse should stand close to the client in case
client loses balance)
C. Perform the Romberg test. Ask the client to stand erect with arms at side and feet together.
Note any unsteadiness and swaying. Then with the client in the same position, ask the client to
close the eyes for 20 seconds. Again, note any imbalance or swaying.
D. Perform the finger-to-nose test
E. Ask the client to put the palms of both hands down on both legs, then turn the pals up, then turn
the palms down again. Ask the client to increase the speed.
F. Perform the heel-to-shin test

AFTER CARE
1. Arrange articles properly and systematically
2. Throw wastes or used articles in the trash can
a. EVALUATION
1. ACCURACY IN RECORDING
A. Neat and legible
B. Accurate
C. comprehensive
TOTAL

GRADING SYSTEM: ATTITUDE 10%

KNOWLEDGE 20%
SKILLS 70%

RATE THE STUDENT FROM 1-4 WHERE;

4 – Very Satisfactory exhibits competency independently
3 – Satisfactory exhibits competency with minimal supervision
2 – Fair exhibits competency fairly with close supervision
1 – Needs Improvement did not exhibit competency

FORMULA FOR GETTING THE GRADE PERCETAGE:

ATTITUDE (PERFECT SCORE: __) Grade Percentage = raw score x 60 + 40 x 10%
Perfect score
KNOWLEDGE (PERFECT SCORE: __) Grade Percentage = raw score x 60 + 40 x 20%
Perfect score
SKILLS (PERFECT SCORE: __) Grade Percentage = raw score x 60 + 40 x 70%
Perfect score
FINAL GRADE = ATTITUDE + KNOWLEDGE + SKILLS

REMARKS / SUGGESTIONS:

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Clinical/ Instructor’s Signature over Printed Name & Date Student’s Signature over Printed Name & Date