NG-315

🩺 Focused Neurological Assessment

What to check, in what order, and which single finding matters more than all the others.

⭐ The one rule

The level of consciousness drawn as a scale from alert down to comatose, and pupils drawn at their actual sizes in millimeters from pinpoint through normal to fixed and dilated, with the assessment order and the Cushing pattern. — Pupils drawn at their real millimeters, so a blown pupil is something you recognize rather than a number you recall. Swipe it sideways if it is cut off, or tap to open it full size.

Level of consciousness changes first. Before pupils, before vital signs, before motor changes. If you assess one thing on a neuro patient, assess whether they are as awake and oriented as they were an hour ago.

"Slightly more restless" or "harder to wake" is a neurological deterioration until proven otherwise. Do not wait for the next scheduled round.

👀 The assessment, in order

1LOC — alert? oriented to person, place, time?

2Pupils — PERRLA, size, symmetry, reaction

3Motor — strength, symmetry, drift

4Sensory — touch, pain, position

5Vitals — the Cushing pattern

Component	What you are looking for	Concerning
LOC	Alert → lethargic → obtunded → stuporous → comatose	Any downward move
Orientation	Person, place, time, situation	Lost in that order — time goes first
Pupils	Equal, round, reactive; 2–6 mm	New unilateral dilation — emergency
Motor	Equal grip, no pronator drift, moves all four	New one-sided weakness, posturing
Speech	Clear, appropriate	Slurred, aphasic, word-finding trouble
Vitals	Stable	Widening pulse pressure + bradycardia

📈 Glasgow Coma Scale

Eye opening (4)	Verbal (5)	Motor (6)
4 Spontaneous	5 Oriented	6 Obeys commands
3 To voice	4 Confused	5 Localizes pain
2 To pain	3 Inappropriate words	4 Withdraws from pain
1 None	2 Incomprehensible	3 Decorticate (flexion)
	1 None	2 Decerebrate (extension)
		1 None

Maximum 15. Minimum 3 — never zero, because the lowest score in each column is 1.

GCS ≤ 8 → intubate. The airway is not protected below that.

Best motor response is the most sensitive component for detecting change.

🧠 Posturing, decoded

	Decorticate	Decerebrate
Arms	Flexed in toward the core	Extended, rigid, palms out
Damage	Above the brainstem	Brainstem
Prognosis	Bad	Worse

deCORticate = toward the CORE

Moving from decorticate to decerebrate means the patient is deteriorating. Report it immediately.

🎯 NCLEX traps

LOC changes first — always
Orientation is lost time → place → person
GCS minimum is 3, not 0
A new blown pupil is an emergency
Decerebrate is worse than decorticate

Sources. Written from MedlinePlus, NIAMS, National Cancer Institute and OpenStax A&P 2e (CC BY 4.0).