Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Neurological Assessment

3.0 Nurses in all practice settings should conduct a neurological assessment on admission using a validated tool (such as, the Canadian Neurological Scale, National Institutes of Health Stroke Scale or Glasgow Coma Scale) and continue to monitor the client’s neurological status on an ongoing basis for any changes in:

  • Level of consciousness;   
  • Orientation;
  • Motor (strength, pronator drift, balance and coordination);
  • Pupils;
  • Speech/Language;
  • Vital signs (TPR, BP, SpO2); and
  • Blood glucose.

 
Cognition/Perception/Language
 3.1
Nurses in all practice settings should screen clients within 48 hours of the stroke client becoming awake and alert, using validated tools (such as, Montreal Cognitive Assessment [MoCA©], Modified Mini-Mental Status Examination, Line Bisection Test or Frenchay Aphasia Screening Test) for alterations in cognitive, perceptual and language function including:

  • Abstraction;
  • Arousal, alertness and orientation;
  • Attention;
  • Apraxia;
  • Language (comprehensive and expressive deficits);
  • Memory (immediate and delayed recall);
  • Spatial orientation, Unilateral Spatial Neglect (formally Extinction) & Visual Neglect.

 In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.

 
Neurological Assessment
3.2
Nurses in all practice settings should recognize that signs of decline in neurological status may be related to neurological or secondary medical complications. Clients with identified signs and symptoms of these complications should be referred to a trained healthcare professional for further assessment and management.