Physical Assessment

Core Concepts

Start with history and observation

Before touching the patient, gather context. Ask about headache, dizziness, weakness, numbness, vision changes, difficulty speaking or swallowing, and when symptoms began. For a person with possible stroke, the last known well time is one of the most important pieces of information in the chart — document it exactly. Then simply observe: posture, facial symmetry, how the person moves, speech clarity, eye contact, and whether they seem to understand what is said. Much of the neurological exam is visible before any hands-on testing begins.

Level of consciousness and mental status

Level of consciousness (LOC) is the most sensitive indicator of neurological change. A common bedside screen is AVPU: is the person Alert, responding to Voice, responding only to Painful stimulus, or Unresponsive? More detailed is the Glasgow Coma Scale (GCS), which scores eye opening, verbal response, and motor response, with lower scores indicating deeper impairment. Orientation is usually assessed as person, place, time, and situation ("oriented ×4"). Also note speech and language: is speech slurred (dysarthria, a motor problem) or is the person struggling to find words or understand them (aphasia, a language problem)? These are different findings with different meanings.

Cranial nerve screening

Twelve pairs of cranial nerves emerge directly from the brain. Nurses commonly screen the ones that are quick to test and quick to change: pupil size, equality, and reactivity to light (CN III); eye movement in all directions (CN III, IV, VI); facial sensation (CN V); facial symmetry — smile, frown, raise eyebrows (CN VII); hearing (CN VIII); ability to swallow and speak (CN IX, X); and shoulder shrug with head turn (CN XI) plus tongue protrusion (CN XII). Full cranial nerve testing is often performed by providers, but the pupil check and facial symmetry check are core nursing skills that appear in almost every neuro assessment.

Motor function, coordination, and gait

Motor testing looks for weakness and asymmetry. Muscle strength is commonly graded 0 to 5, from no contraction (0) to full strength against resistance (5). Ask the person to squeeze your fingers, push and pull against your hands with arms and legs, and hold both arms straight out with palms up — a hand that slowly drifts downward suggests weakness (pronator drift). Coordination is tested with finger-to-nose and heel-to-shin movements, and balance with the Romberg test (standing with feet together, eyes closed) and by observing gait. Tremor, staggering, or falling to one side are important findings.

Sensory function

Sensory testing checks light touch, sharp/dull discrimination, and sometimes temperature, vibration, and position sense (proprioception). Sensation follows predictable maps: dermatomes are skin areas served by single spinal nerve roots (for example, the nipples around T4 and the umbilicus around T10), and peripheral nerves serve the hands and feet. Asking "does this feel the same on both sides?" while comparing left and right is the fastest way to detect a problem. Sensory testing is subjective — it depends on what the person reports — so a calm, consistent technique matters.

Reflexes

Reflex testing evaluates the integrity of spinal cord pathways. Common deep tendon reflexes (DTRs) include the biceps, triceps, patellar (knee), and Achilles. The plantar reflex (Babinski test) is a key finding: stroking the sole of the foot normally produces downward curling of the toes in adults, while upward fanning of the big toe can indicate upper motor neuron damage. Pupillary response to light is also a reflex — brisk, equal, reactive pupils are a reassuring sign, while sluggish or unequal pupils are a red flag.

The neuro check in practice

A "neuro check" is a focused set of the most sensitive tests — usually LOC, orientation, pupil response, and motor strength in arms and legs — repeated at a set frequency (for example, after surgery, head injury, or stroke). The frequency is ordered or set by institutional protocol and depends on how stable the person is. The golden rule: any change from baseline is reported immediately, with a time-stamped, objective description of what was seen. Assessment technique, documentation, and scope of practice vary by institution and by state or provincial regulations, so always follow local policy.

Common Confusions