Complete Neurological Assessment Guide

What is a Neurological Assessment?

A neurological assessment is a systematic examination used to evaluate a patient’s neurological function. It helps nurses identify changes in consciousness, cognition, pupil response, motor function, sensation and other neurological signs that may indicate deterioration or neurological impairment.

Neurological Assessment Sequence

A structured approach helps ensure important neurological findings are not missed. A neurological assessment may include the following components.

1. General observation and initial impression
2. Level of consciousness
3. Glasgow Coma Scale (GCS)
4. Pupillary assessment (PERRLA)
5. Upper and lower limb motor strength
6. Sensory assessment
7. Additional neurological observations
8. Documentation and escalation of abnormal findings

1. General observation and initial impression

Begin the neurological assessment by observing the patient before performing specific tests. The initial impression can provide important information about the patient’s neurological status and may help identify changes that require further assessment.

What to observe

• Level of alertness and general responsiveness
• Appearance, behaviour and interaction
• Speech clarity and ability to communicate
• Facial symmetry
• Posture, movement and gait, where appropriate
• Obvious weakness, tremor or involuntary movements
• Signs of confusion, agitation or unusual behaviour

2. Level of Consciousness

Assess the patient’s level of consciousness and responsiveness. Observe whether the patient is alert and appropriately responsive, or whether there is reduced consciousness, drowsiness, confusion or unresponsiveness. Changes from the patient’s baseline neurological status are particularly important to recognise.

3. Glasgow Coma Scale (GCS)

The Glasgow Coma Scale (GCS) provides a structured method for assessing a patient’s level of consciousness. It evaluates three components: eye opening, verbal response and motor response. The findings from each component are documented individually and combined to give a total score ranging from 3 to 15. [4]

GCS Components

Component	Response	Score
Eye	Spontaneous	4
	To sound	3
	To pressure	2
	None	1
Verbal	Orientated	5
	Confused	4
	Words	3
	Sounds	2
	None	1
Motor	Obey commands	6
	Localising	5
	Normal flexion	4
	Abnormal Flexion	3
	Extension	2
	None	1

Source:[4] Glasgow Coma Scale

4. Pupillary Assessment (PERRLA)

Pupillary assessment is an important component of a neurological assessment. Changes in pupil size, symmetry or response to light may indicate changes in neurological function. Assess both pupils systematically and compare findings bilaterally. [1]

PERRLA

PERRLA is a commonly used mnemonic referring to pupils that are equal, round and reactive to light and accommodation. Terminology and the extent of pupillary assessment may vary between clinical settings.

• Pupils equal – compare pupil size bilaterally.
• Round – observe pupil shape.
• Reactive to light – assess the pupillary response to light.
• Accommodation – assess the response to changing focus, where clinically appropriate. [1]

How to Assess the Pupils

Pupillary assessment forms part of neurological observations in Australian healthcare settings. Assess both pupils systematically and compare their size, shape, symmetry and response to light. Findings should be documented and compared with the patient’s baseline and previous neurological observations.

1. Observe both pupils – Inspect the pupils for size, shape and symmetry before introducing a light source.
2. Measure pupil size – Estimate and document the diameter of each pupil in millimetres using the organisation’s approved neurological observation chart or pupil gauge.
3. Compare the pupils – Determine whether the pupils are equal in size and note any difference between the left and right pupil.
4. Assess direct light response – Shine a penlight from the side toward one pupil and observe whether that pupil constricts.
5. Assess consensual light response – Observe the opposite pupil for constriction when light is directed into the other eye.
6. Repeat on the opposite eye – Compare the response of both pupils.
7. Document the findings – Record pupil size and reaction according to the health service’s neurological observation chart and local policy.
8. Escalate abnormal or new findings – Report unexpected changes such as newly unequal pupils, a change in pupil size or an abnormal response to light according to local clinical deterioration and escalation procedures.

5. Upper and Lower Limb Motor Strength

Assessment of limb movement and strength helps identify motor weakness, asymmetry and changes in neurological function. Assess the upper and lower limbs bilaterally and compare one side with the other. Observe for differences in movement, strength, posture and muscle tone. [1]

Upper Limb Assessment

Ask the patient to move both arms and compare movement between the left and right sides. Assess strength against resistance where appropriate and observe for weakness or asymmetry.

• Ask the patient to raise both arms.
• Observe and compare movement on both sides.
• Assess hand grip strength bilaterally.
• Ask the patient to push and pull against resistance, where appropriate.
• Compare the strength of the left and right upper limbs.
• Observe for weakness, asymmetry, abnormal movement or changes in muscle tone.

Lower Limb Assessment

Assess movement and strength of both lower limbs and compare findings bilaterally.

• Ask the patient to lift or move each leg as appropriate.
• Assess the ability to push against resistance with the lower limbs.
• Assess ankle movement, such as dorsiflexion and plantar flexion, where appropriate.
• Compare strength and movement between the left and right sides.
• Observe for weakness, asymmetry or abnormal movement.

6. Sensory Assessment

Sensory assessment helps identify changes in the patient’s ability to detect and interpret sensation. Assess sensation bilaterally and compare corresponding areas on the left and right sides of the body. Consider the patient’s baseline neurological status and report new or unexpected sensory changes.

Assessing Light Touch

Explain the assessment to the patient and ask them to close their eyes, where appropriate. Using a light touch, assess corresponding areas on both sides of the body and ask the patient whether the sensation feels the same.

• Compare the left and right sides.
• Assess both upper and lower limbs, where clinically appropriate.
• Ask whether sensation feels normal, reduced, absent or different between sides.
• Note any reported numbness, tingling or altered sensation.
• Document any sensory changes and escalate new or concerning findings according to local policy.

7. Additional Neurological Observations

In addition to consciousness, pupils, motor function and sensation, observe for other changes that may indicate altered neurological function. The extent of assessment will depend on the patient’s presentation, clinical setting and local healthcare service procedures. [1]

Additional Findings to Observe

• Speech and communication – observe for new slurred speech, difficulty speaking or difficulty understanding instructions.
• Facial symmetry – observe the face and smile for new asymmetry or facial droop.
• Behaviour and cognition – note new confusion, agitation, unusual behaviour or changes from the patient’s baseline.
• Gait and balance – where it is safe and clinically appropriate, observe walking, balance and stability.
• Coordination – observe for new difficulty coordinating movements where clinically indicated.
• Posture and muscle tone – observe for abnormal positioning, posturing or changes in tone.
• Visual symptoms – ask about or observe for new visual disturbances where relevant.
• Vital signs – consider neurological findings together with the patient’s overall physiological observations and clinical condition.

8. Documentation and Escalation of Abnormal Findings

Accurate documentation and timely escalation are essential components of neurological assessment. Record neurological findings clearly, compare them with previous observations and the patient’s known baseline, and identify changes or trends that may indicate deterioration. Abnormal or concerning findings should be escalated according to the healthcare service’s local recognition and response procedures. [3]

What Should Be Documented?

• Level of consciousness and relevant GCS components and total score
• Pupil size, equality and reactivity
• Upper and lower limb movement and strength
• Relevant sensory findings
• Changes in speech, behaviour, cognition, gait, balance or coordination, where assessed
• Relevant vital signs and other clinical observations
• Any change from the patient’s baseline or previous assessment
• Actions taken, including escalation, communication and reassessment

When Should Findings Be Escalated?

Escalate care when neurological findings indicate deterioration, meet the healthcare service’s escalation criteria, or cause clinical concern. The urgency and escalation pathway will depend on the patient’s condition and the organisation’s local recognition and response system. [3]

• A new or worsening change in level of consciousness
• A decrease or unexpected change in GCS
• New changes in pupil size, equality or reactivity
• New weakness or asymmetry in limb movement
• New or worsening sensory changes
• New confusion, behaviour change or altered mental state
• New abnormalities involving speech, balance, coordination or neurological function
• Any neurological change that causes clinical concern

References

[1] Agency for Clinical Innovation. (2023). Neurological assessment. NSW Health, Emergency Care Assessment and Treatment (ECAT).

[2] Agency for Clinical Innovation. (2026). Neurovascular assessment: Clinical practice guide. NSW Health.

[3] Australian Commission on Safety and Quality in Health Care. (2021). National Safety and Quality Health Service Standards (2nd ed.). Australian Commission on Safety and Quality in Health Care.

[4] Glasgow Coma Scale. (n.d.). What is the Glasgow Coma Scale? University of Glasgow.

[5] Queensland Health. (2026). AVPU: Assessment tool for conscious state. Queensland Government.