Critical Neurologic Dysfunction Nursing Assessment Checklist Form
Complete this checklist to assess and document key neurologic functions for patients with suspected or confirmed critical neurologic dysfunction. Use the options and notes provided for each item.
Level of Consciousness
*
Alert
Drowsy
Stuporous
Unresponsive
Pupil Size and Reactivity
*
Equal & Reactive
Unequal
Non-Reactive
Motor Function
*
Normal
Weakness
Paralysis
Speech Assessment
*
Clear
Slurred
Aphasic
Orientation
*
Oriented x4
Disoriented
Unresponsive
Seizure Activity Observed
*
No
Yes
Pain Level (0 = No Pain, 10 = Worst Pain)
*
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Cranial Nerve Function
*
Normal
Abnormal
Not Assessed
Vital Signs Within Expected Range
*
Yes
No
Additional Notes or Observations
Submit Assessment
Should be Empty: