UNIVERSITY OF THE EAST

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER INC.

Aurora Boulevard, Quezon City

College of Nursing

Performance Evaluation Tool

Systematic Comprehensive Assessment of Neurological System
Name: ______________________________________________Date: ______________________
Year/Section/Grp #:___________________________________ Grade: _____________________
Given a simulated administration of a nursing procedure, the student demonstrates
the skill that will be rated as:
3 – Performed the correct procedure consistently self directed efficient and
effective
2 – Performed procedures efficient and effective with minimal supervision
1 – Performed the procedures efficient and effective with frequent
supervision

Key Areas of
Responsibility Core Competency and Indicators 3 2 1 Remarks
A. Communication Core Competency 1: Establishes
rapport with patients, significant
others and members of the health
team
1. Introduce self and verify the
identity of the patient
2. Explain and instruct the client
about the procedure (what, why
and how)
3. Reassure the client about the
safety of the procedure and the
environment
B. Safe and Core Competency 3: Promotes safety
quality nursing and comfort and privacy of patients
care 4. Prepare the immediate
environment by providing drapes,
closing the doors and windows.
5. Instruct the client to void prior to
the procedure (offers urinal/bed
pan)
Core Competency 7.3: implements
planned nursing care to achieve
identified outcomes

Assessment of the Cerebral Function

(Mental Function)
6. Don hand washing prior the
procedure
7. Determine the level of
consciousness
8. Compute for the GCS score
(Glasgow’s Coma Scale)
9. Determine the client’s orientation
(time, person, place)
10.Inquire about client’s history and
verified it with the relatives or
significant others
11.Check for lapses in memory
(immediate recall, recent and
remote memory)
12.Test the ability to concentrate and
calculate
13.Inspect for appropriateness of
mood/affect for the situation

Assessment for functions of Cranial

Nerves
14.Cranial Nerve I – Olfactory
15.Cranial Nerve II – Optic
a. Determine visual acuity (use of
Snellen’s chart )
b. Check visual field
(confrontation)
16.Cranial Nerve III/IV/VI –
Oculomotor/ Trochlear/Abducens
a. Perform six extraocular
movements (CN III, IV and VI)
b. Perform Convergence test (CN
IV)
c. Check for papillary reaction to
light (direct and sensorineural
reaction)
d. Check for papillary reaction to
accomodation
17.Cranial Nerve V – Trigeminal
a. Elicit corneal reflex
b. Palpate for contraction of
temporal and masseter
muscles
c. Test sensation over the face
(ophthalmic, maxillary,
mandibular)
18.Cranial Nerve VII/IX/X/XII – Facial/
glossopharyngeal/vagus/hypogloss
al
a. Ask client to perform gestures
(CN VII)
b. Ask client to protrude tongue
(CN XII)
c. Ask client to move tongue from
side to side and up and down
(CN IX)
d. Ask client to say “Ah” and
observe for rise of soft palate
and uvula (CN X)
e. Elicit gag reflex (CN IX)
f. Perform taste test (CN VII/IX)
19.Cranial Nerve VIII –
Vestibulocochlear
a. Assess hearing
b. Perform Weber test
c. Perform Rinne test
20.Cranial Nerve XI – Accessory
a. Palpate for strength of
trapezius and
sternocleidomastoid muscles

Assessment for Reflexes

21.Check for Biceps reflex (C-5, C-6)
22.Check for Triceps reflex (C-7, C-8)
23.Check for Patellar reflex (L-2, L-3,
L-4)
24.Check for plantar reflex

Assessment of Motor Function

25.Palpate for symmetry of muscle
tone and mass
26.Palpate for muscle strength of
upper and lower extremities
 27.Ask the client to perform alternate
pronation and supination of hands
28.Ask client to perform rotation of
ankle (clockwise/counterclockwise)

Assessment of Cerebellar Function

(Coordination and Gait)
29.Test upper extremities for
coordination
a. Finger to thumb
b. Finger to finger
c. Finger to nose
30.Test lower extremities for
coordination
a. Heels down opposite shin
31.Balance
a. Walking Gait
b. Heel to toe walking
c. Romberg test

Assessment of Sensory Function

32.Pain sensation (sharp/dull)
33.Stereogenesis
Core Competency 7.4: Evaluates
progress towards expected outcomes
34.Assess the response of the client
towards the procedure
35.Don hand washing after the
procedure
C. Resource 36.Prepares and organizes
Management appropriate equipment for the
procedure
37.Performs after care of the
equipment and proper waste
disposal
D. Records Core Competency 1: Maintains
Management accurate and updated documentation
of patient care
38.Records the gathered assessment
findings with the client’s reaction
toward the procedure

1.00 168
1.25 167-158
1.50 157-148
1.75 147-138
2.00 137-128
2.25 127-118
2.50 117-108
2.75 107-101
3.00 100
99 and
4.00 below

_______________________________ ________________________________
Signature over printed name of student
Signature of Evaluator