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Neurological Checklist

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8 views

Neurological Checklist

Uploaded by

andrenesbethjm
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Chapter 25

Demographics

General Survey
Process Findings
Observe physical Development and sexual development
(appropriate for age)
Observe skin complexion
Observe dress and hygiene
Observe posture and gait
Observe body build
Observe consciousness level (alertness, orientation,
appropriateness)
Observe comfort level
Observe behaviour, facial expression, and speech

Vitals
Blood Pressure
Temperature
Pulse
Respiration
Pain Level
Height
Weight

History - Subjective Data: COLDSPA, Family History, Life

Style Practices

Assessing Peripheral Vascular System


Nursing Interview Guide to Collect Subjective Data From the Client

Questions Findings

Current Symptoms
Past History

Family History

Lifestyle and Health Practices

Preparation

1. Gather equipment, such as examination 4. Explain procedure to client.


gloves, pencil and paper, cotton-tipped
applicators, newsprint to read,
ophthalmoscope, paper clip, penlight, Snellen
chart, sterile cotton ball, substances to smell
and taste, tongue blade, tuning fork, tape
measure, cotton balls, objects to feel, test
tubes with hot and cold water, tuning fork
(low-pitched), and reflex hammer.

5. Find consent from patient


2. Introduce self to patient

3. Ask client to gown.


3. Identify the patient
Assessing Neurologic System

Physical Assessment Guide to Collect Objective Client Data

Questions Findings

Current Symptoms

Mental Status

1. Assess level of consciousness.

2. Observe appearance and behavior.

3. Observe mood, feelings, and expressions.

4. Observe thought processes and perceptions.

5. Observe cognitive abilities. (includeing cultural


and spiritual awareness)

Cranial Nerves

1. Test cranial nerve I—olfactory.(Sensory -


smell)

2. Test cranial nerve II—optic. (Sensory - vision)

3. Test cranial nerve III—oculomotor.(motor – eye


muscle movement & light reflex)

4. Test cranial nerve IV—trochlear. (motor – eye


muscle movement)

5. Test cranial nerve V—trigeminal. (Mixed –


masseter and jaw movement; facial sensation)

6. Test cranial nerve VI—abducens. (motor – eye


muscle movement)

7. Test cranial nerve VII—facial. (motor – eyelids


& mouth movement, facial expression, facial
muscle strength)

8. Test cranial nerve VIII—acoustic


(vestibulocochlear - sensory).

9. Test cranial nerve IX—glossopharyngeal.


(mixed – pharynx movement; ear canal &
drum, tongue, pharynx sensation including
taste)

10.Test cranial nerve X—vagus. (mixed – palate,


pharynx & larynx movements; pharynx &
larynx sensory)

11.Test cranial nerve XI—spinal accessory. (motor


– SCM and Trapexius muscles movement)

12.Test cranial nerve XII—hypoglossal. (motor –


tongue sysmetry and movement)

Motor and Cerebellar Systems

1. Test condition and movement of muscles. (to


be done in musculo-skeletal assessment)

2. Test balance. (gait, station, heel to toe, heel to


shin, Romberg test)

3. Test coordination. (rapid alternating


movements, point to point movement, point
location,.... found in the videos

Sensory System

1. Test light touch, pain, and temperature


sensations.

2. Test vibratory sensations.

3. Test position sensations.

4. Test tactile discrimination (fine touch –


dull/sharp), stereognosis and graphesthesia

Reflexes

1. Test deep tendon reflexes (biceps,


brachioradialis, triceps, patellar, Achilles, and
ankle clonus).

2. Test superficial reflexes (plantar, abdominal,


cremasteric).
3. Test for meningeal irritation/inflammation
(Brudzinski and Kernig signs if indicated).

Analysis of Data

1. Formulate nursing diagnoses (wellness, risk,


actual).

2. Formulate collaborative problems.

3. Make necessary referrals.

4. Nurses notes

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