Evaluating the

neurologic status
of unconscious patients
Although overshadowed by CT and other
scanning methods, the neuro exam can help you
quickly gauge your patient’s condition.
By Elizabeth Anness, RN, CCRN, and Kelly Tirone, BSN, RN

ASSESSING THE NEUROLOGIC
STATUS of unconscious or coma-
tose patients can be a challenge be-
cause they can’t cooperate actively
with your examination. But once
you become proficient in perform-
ing this exam, you’ll be able to de-
tect early significant changes in a
patient’s condition—in some cases,
even before these show up on
more advanced diagnostic tests.
Subtle changes in findings may in-
dicate the need for further testing.
Before the advent of computed
tomography (CT) in the 1970s, the
neurologic examination was the
main tool used to monitor a patient’s
neurologic condition. Although it’s
still an integral assessment compo-
nent for critically ill patients, many
bedside nurses overlook or underuse
it. One reason may be that, unlike
CT scans and other diagnostic tools,
its results come in shades of gray,
not black and white.
Quicker and easier than you
might think
The neuro exam can be conducted
quickly and is easy to integrate into
your daily assessment. It starts the
moment you meet the patient. Per-
forming it early is crucial because
this helps you establish a baseline
for later comparison.
For accurate interpretation of as-
sessment findings, nurses on the off-
going and oncoming shifts should
evaluate the patient’s neurologic
status together during shift changes
or care transfers (as well as with
the medical team on rounds). Once
you’ve completed the initial assess-
ment, subsequent assessments
can be either basic or more
in-depth.
Two types of neuro
exams
The type of neuro exam
you conduct depends on
whether your patient can
follow commands. If she
can, your exam can be more
comprehensive and should in-
clude evaluation of:
• level of consciousness (LOC)
• pupils
• cranial nerves I through XII
• motor response
• sensation.
If your patient can’t follow com-
mands, you’ll be able to assess only
the pupils, eye opening, motor re-
sponse, and some of the cranial
nerves. Yet despite the relative brevi-
ty of this type of exam, it can yield a
significant amount of information.
First step: Evaluate ABCs and
vital signs
As with any patient, give top priori-
ty to assessing the ABCs—airway,
breathing, and circulation. Ask
yourself: Is the airway patent? If so,
is the patient able to maintain it?
Next, check vital signs: Are her res-
pirations adequate? Are her vital signs
stable? Is her blood pressure high
enough to perfuse the brain and other
vital organs? Be aware
that current or pro-
gressive injury to
the brain and
brain stem may
make vital signs
unstable, but this
situation can be
complex: Although
unstable vital signs
can reduce neurologic
response, brain injury itself
may cause unstable vital signs.
To appropriately assess the pa-
tient’s peak neurologic status, be sure
to evaluate oxygenation and circula-
tion. Ideally, you should conduct the
neuro exam when the patient’s blood
pressure, temperature, heart rate, and
heart rhythm are normal. Be aware
that a temporary decline in neurolog-
ic status caused by insufficient oxy-
genation or circulation still represents
a neurologic change—and leads to
permanent neurologic loss unless the
underlying problem is corrected.
Assess LOC, eye opening, and
motor response
Once you’ve established that your
patient is stable enough to assess,

8 American Nurse Today Volume 4, Number 4


begin the neuro exam itself. To de-
termine if the patient is unconscious
and unable to follow commands,
use the Glasgow Coma Scale (GCS)
to test eye opening, best motor re-
sponse, and best verbal response.
An unconscious patient is likely to
open her eyes only in response to
pain, if at all; obviously, you can’t
test her best verbal response at all.
To assess motor response using
the GCS, apply a painful or other
noxious stimulus to a central part of
the body; for instance, use trapezius
squeezing, supraorbital pressure, ear-
lobe pinching, or a sternal rub. (See
Testing your patient’s response to
pain.) Then watch for specific motor
responses, as specified in the GCS.
In an unconscious patient, the best
response is localization, in which
she reaches across the midline to-
ward the stimulus site as though try-
ing to stop the pain. In a semipur-
poseful (withdrawal) response, she
recoils as though attempting to with-
draw or escape from the pain.
A flexion motor response (decorti-
cate posturing) is marked by inward
flexion of the elbows, wrists, and
hands accompanied by extension and
plantarflexion of the feet. An exten-
sion motor response (decerebrate pos-
turing) is straightening or stiff exten-
sion of the arms, with wrists rotated
outward, knees and ankles rigidly
straight, and plantarflexion of the feet.
After assessing eye opening and
verbal and motor responses, assign
a GCS score. The best possible
score is 15, which indicates the pa-
tient is awake, oriented, and fol-
lowing commands. The lowest pos-
sible score is 3, which means the
patient doesn’t open the eyes and
has no motor or verbal response to
a central stimulus.
Usually, a GCS of 8 or less indi-
cates severe brain insult; the patient
may be unable to maintain an air-
way, may require airway protection
or even intubation, and may need
to go to the intensive care unit for
airway monitoring.
If the patient is intubated, write
Testing your patient’s response to pain
Testing response to a central painful stimulus is the most reliable way to evaluate
motor response in an unresponsive patient. If your patient doesn’t respond to a cen-
tral stimulus, you may want to use a peripheral stimulus. Be aware, though, that a
peripheral stimulus may elicit a reflex response, which isn’t a true indicator of a mo-
tor response. This chart lists both central and peripheral testing sites and methods.
Central testing
Trapezius squeeze: Firmly pinch or
grasp the trapezius muscle (as shown
in photo).
Earlobe: Pinch the earlobe.
Supraorbital: With your thumb, apply
firm pressure to the upper inner aspect
of the orbital wall. (Don’t use this
method if the patient has suspected
facial fractures.)
Sternum: Using your knuckle, rub the
sternum firmly or apply firm pressure
to it. (This method isn’t recommended
because it may cause bruising.)
the letter “T” (for endotracheal
tube) or “ETT” on the GCS form,
indicating the patient might be able
to verbalize if not intubated. If the
patient was sedated during the ex-
am, write the letter “S” (for seda-
tion), acknowledging that sedation
may have decreased the GCS score.
If your patient has a GCS score
of 8 or less, follow the steps below
to complete the neurologic assess-
ment of the unconscious patient.
Evaluate pupils
Pupil evaluation includes assessment
of pupil size, shape, and equality
Visualizing a keyhole pupil
A pupil with a keyhole shape (patient’s
left eye above) may indicate early com-
pression of cranial nerve III. It’s also seen
in diabetic patients and those who’ve un-
dergone eye surgery. Although a base-
line finding of a keyhole pupil usually is
benign, later development suggests neuro-
logic deterioration.
Peripheral testing
Nail bed: Using a penlight or similar item,
apply firm pressure to the nail bed for
10 to 30 seconds.
Inner arm or thigh: Pinch or twist the
sensitive tissues of the inner arm or thigh.
(Use caution if the patient has frail or
friable skin.)
before and after exposure to light.
Normally, pupils are equal in size
and about 2 to 6 mm in diameter,
but they may be as large as 9 mm.
Also, the pupils may be pinpoint,
small, large, or dilated. Normal pupil
shape is round; variations include ir-
regular, keyhole, and ovoid. (See
Visualizing a keyhole pupil.)
To assess the patient’s pupils,
hold both eyelids open and shine a
light into the eyes. The pupils
should constrict immediately and
equally bilaterally; after you remove
the light, they should immediately
dilate back to baseline. Document
the response: Is it brisk, sluggish,
nonreactive, or fixed? Immediately
report any changes from baseline.
In many cases, a change in pupil-
lary response, such as unequal or
dilated pupils, results from a pro-
gressive neurologic condition.
Fixed and dilated pupils are an
ominous sign that warrant immedi-
ate physician notification (unless
the patient’s pupils have just been
dilated chemically). For true
changes in pupillary response, ex-
pect the physician to order further
diagnostic tests, such as a CT scan.
April 2009 American Nurse Today 9
 Assessing cranial nerves in the unconscious patient
Each of the 12 pairs of cranial nerves (CNs) is assigned a name and Roman numeral. The nerves are numbered in descending order
from their origin points in the central nervous system. Three pairs are sensory, five are motor, and four have mixed sensory and
motor functions. In an unresponsive patient, you can assess only five CNs—III, V, VII, IX, and X—as described below. (Note: This
chart addresses CN testing in the unconscious patient only.)

Cranial nerve and function What to test for Testing method and normal response

III (Oculomotor): Motor Pupillary response Shine a light into patient’s eye to assess pupil size, shape,
equality, and reaction. (Normal response: see “Evaluate
pupils,” page 9.)

V (Trigeminal): Mixed motor Corneal reflex Hold eye open and gently touch sclera or lower eyelashes
and sensory with a sterile cotton swab, taking care not to touch cornea.
Normal response: forceful eye closure. Any movement is a
positive response; document it as strong or weak
accordingly.

VII (Acoustic): Mixed motor Facial grimace Observe for facial grimace after applying noxious
and sensory stimulus or touching a sterile cotton swab to inside of
nostril. Normal response: grimace of entire face; compare
results bilaterally for equal or nearly equal response.

IX (Glossopharyngeal): Coughing Touch back of pharynx, soft palate, or uvula with tongue
Mixed motor and sensory blade, cotton swab, or Yankaur suction catheter. Normal
response: coughing.

X (Vagus): Mixed motor Gag reflex Touch back of pharynx, soft palate, or uvula with tongue
and sensory blade, cotton swab, or Yankaur suction catheter. Normal
response: gagging.

Assess cranial nerves
Findings from cranial nerve (CN)
assessment can tell much about the
patient’s midbrain, pons, and
medullary functions. Although some
nurses find this assessment intimi-
dating, it’s not that difficult. (See
Assessing cranial nerves in the
unconscious patient.)
Physician’s examination
The oculocephalic (doll’s eye) and
oculovestibular (cold caloric) tests,
which reveal brain stem function,
are performed only by physicians
on patients who don’t respond to
the exam methods described above.
These tests aid prognosis of severe-
ly brain-injured patients.
The oculocephalic test evaluates
extraocular muscle movements
(controlled by CNs III and VI). The
examiner moves the patient’s head
from side to side forcefully and
quickly; in an abnormal response
(an ominous sign), the eyes remain
stationary. This exam is contraindi-
cated in patients with suspected
cervical spinal cord injury.
Oculovestibular testing also evalu-
ates CNs III and VI, along with CN
VIII. The physician instills iced saline
solution into the ear canal and ob-
serves for nystagmus (involuntary
rapid eye movements). In a normal
response, the eyes show conjugate
movement and nystagmus in the di-
rection of the irrigated ear, indicating
an intact brain stem. Absence of nys-
tagmus is an abnormal response sig-
nifying a decrease in consciousness
with severe brain stem injury. The
oculovestibular test is contraindicated
in patients with ruptured tympanic
membranes or otorrhea; results may
be false-positive in patients who are
on ototoxic drugs (including pheny-
toin) or who have Ménière’s disease.
Document and follow up on
findings
By following these guidelines, you
can quickly and easily perform a
neuro exam on the unconscious
patient. Establish your patient’s
baseline early, and make sure you
know how to differentiate normal
and abnormal neurologic findings.
Remember that changes can be
subtle and should be documented
and reported promptly. Most im-
portantly, use your nurse’s “sixth
sense”—that gut feeling most of us
have when something just isn’t
right. ✯
Selected references
Barker E. Neuroscience Nursing: A Spectrum
of Care. 3rd ed. St. Louis, MO: Elsevier/Mos-
by; 2008.
Hickey J. The Clinical Practice of Neurologi-
cal and Neurosurgical Nursing. 6th ed.
Philadelphia, PA: Lippincott Williams &
Wilkins; 2008.
Both authors work in the Neurosciences Intensive
Care Unit at Harborview Medical Center in Seattle,
Washington. Elizabeth Anness is a staff nurse; Kelly
Tirone is an assistant nurse manager.

10 American Nurse Today Volume 4, Number 4