Shadow Health Neurological Assessment: How to Perform and Document It (Including Cranial Nerves)

Why the neurological assessment matters

The nervous system controls thinking, movement, sensation, balance and the body’s automatic functions. A careful neurological assessment helps nurses detect conditions such as stroke, head injury, seizures, infections, peripheral neuropathy and dementia, and it gives a baseline to compare against when a patient’s condition changes (Jarvis & Eckhardt, 2024). In Shadow Health, the neurological assessment is often completed in the same week as the musculoskeletal exam, and the two together make up the Shadow Health musculoskeletal and neurological assignments. Movement problems can come from either system, so understanding both helps you reason about weakness, numbness, falls and gait problems. See the companion Shadow Health Musculoskeletal Assessment guide.

Part 1: Subjective data for the neurological exam

Ask about:

• Headaches: OLDCARTS, especially sudden, severe or “worst ever” headaches
• Dizziness and vertigo: lightheadedness vs. spinning, triggers, falls
• Seizures or fainting: frequency, warning signs, what happened before and after
• Weakness, numbness or tingling: location, one side or both, sudden or gradual
• Coordination and gait: clumsiness, dropping objects, tripping, tremor
• Speech and swallowing: slurred speech, word-finding problems, choking
• Vision, hearing, taste and smell changes
• Memory, mood and cognition: confusion, forgetfulness, personality changes
• History and risk factors: head injury, stroke, hypertension, diabetes, alcohol use, toxic exposures, medications, family history of neurological disease

Part 2: How to perform a neurological assessment

A complete neurological exam has five parts (Jarvis & Eckhardt, 2024):

1. Mental status

• Level of consciousness: alert, lethargic, obtunded, stuporous or comatose; use the Glasgow Coma Scale for patients with altered consciousness (eye opening 1–4, verbal response 1–5, motor response 1–6; total 3–15).
• Orientation: person, place, time and situation.
• Appearance and behavior, speech, mood and affect.
• Cognition: attention, memory and judgment; screening tools such as the Mini-Cog or Montreal Cognitive Assessment when indicated.

Shadow Health cranial nerve assessment

A popular way to remember the names is the phrase “On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops.” Facial droop that spares the forehead suggests a central lesion such as a stroke, while weakness of the whole side of the face, including the forehead, suggests a peripheral facial nerve problem such as Bell’s palsy.

3. Motor system

• Inspect muscle size and symmetry; note atrophy, tremor, fasciculations or abnormal movements.
• Assess tone (flaccid, normal, spastic or rigid) with passive movement.
• Test strength on the 0–5 scale in all major groups and compare sides.
• Pronator drift: the patient holds both arms out, palms up, eyes closed for 20–30 seconds; downward drift or pronation suggests subtle weakness.

4. Sensory system

• With the patient’s eyes closed, test light touch (cotton), pain (sharp vs. dull), vibration (tuning fork on bony prominences) and position sense (moving a finger or toe up or down), comparing sides and moving from distal to proximal.
• Test monofilament sensation on the feet of patients with diabetes.
• Cortical sensation: stereognosis (identifying an object by touch), graphesthesia (a number drawn on the palm) and two-point discrimination.

5. Reflexes

Test deep tendon reflexes (biceps, triceps, brachioradialis, patellar and Achilles) and grade them (Ball et al., 2023):

Test the plantar reflex: stroke the sole of the foot. Normal in adults is toes curling down; toes fanning upward (a positive Babinski sign) suggests a problem in the brain or spinal cord.

Cerebellar function, coordination and gait

• Finger-to-nose and heel-to-shin tests
• Rapid alternating movements, such as flipping the hands quickly
• Romberg test: stand with feet together, eyes open then closed; loss of balance with eyes closed suggests a sensory or position-sense problem
• Gait: normal walking, heel walking, toe walking and tandem (heel-to-toe) walking

Practice case: neurological assessment

Original practice case for learning; not taken from Shadow Health and not an answer key.

Clinical reasoning

• Cues: symmetric distal sensory loss, absent vibration, reduced ankle reflexes, mild ankle weakness, positive Romberg, poorly controlled diabetes, alcohol use, recent trips.
• Analysis: findings fit diabetic peripheral neuropathy, which increases the risk of falls and foot ulcers. The gradual, symmetrical pattern and normal cranial nerves argue against an acute stroke.
• Actions: report findings; teach daily foot inspection, proper footwear and never walking barefoot; refer for podiatry and physical therapy for balance training; reinforce glucose control and alcohol reduction; assess home fall hazards.

How to document a neurological assessment

• Document mental status first, then cranial nerves, motor, sensory, reflexes, coordination and gait.
• Be specific about the location and pattern of abnormal findings and compare sides.
• Use standard scales: Glasgow Coma Scale, 0–5 strength, 0–4+ reflexes.
• Include pertinent negatives, such as no facial droop, no drift and no speech changes.

Sample documentation

Red flags to report immediately

• Sudden facial droop, arm or leg weakness, speech difficulty or vision loss (possible stroke; remember BE FAST: balance, eyes, face, arm, speech, time)
• Sudden, severe “worst ever” headache, or headache with fever and neck stiffness
• Decreasing level of consciousness or new confusion
• New seizure
• Unequal or nonreactive pupils after head injury
• New loss of bladder or bowel control with back pain or leg weakness

Common mistakes in the Shadow Health neurological exam

• Skipping cranial nerves or testing them incompletely
• Testing sensation without having the patient close their eyes
• Not comparing right and left sides
• Forgetting coordination, Romberg and gait
• Documenting “neuro intact” without describing what was tested

Neurological assessment across the lifespan

• Infants and young children: assess developmental milestones, primitive reflexes (such as rooting, Moro and grasp, which should disappear at expected ages), head circumference and fontanels.
• Older adults: slower reaction time, mildly reduced vibration sense in the feet and slightly decreased ankle reflexes can be normal with aging, but new confusion, focal weakness or sudden change are never normal and must be reported. Screen for delirium, dementia and fall risk.
• Patients with altered consciousness: use the Glasgow Coma Scale, pupil checks and motor response, and reassess frequently to detect deterioration.

Frequently asked questions

Continue the series: Shadow Health DCE: Complete Student Guide, Shadow Health Focused Exams and Shadow Health Neurological Reflection examples.

Deep-dive Shadow Health guides

• Shadow Health Focused Exam: Chest Pain and Cardiovascular Assessment
• Shadow Health Focused Exam: Cough and Respiratory Assessment
• Shadow Health Focused Exam: Abdominal Pain and Abdominal Assessment
• Shadow Health Special Populations Focused Exams
• Shadow Health Documentation: How to Document Your Assessment

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.