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    Retdem Neuro

    Uploaded by

    Charlize Pare
    The nurse will perform a full head-to-toe assessment of a patient, including: general appearance and mental status; neurological, sensory, and motor function; and neurovascular status. The assessment involves observation, patient questioning, and physical exams of cranial nerves, sensation, coordination, and extremities. Findings will be documented in the patient's record.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Retdem Neuro

    Uploaded by

    Charlize Pare
    30 views3 pages
    The nurse will perform a full head-to-toe assessment of a patient, including: general appearance and mental status; neurological, sensory, and motor function; and neurovascular status. The assessment involves observation, patient questioning, and physical exams of cranial nerves, sensation, coordination, and extremities. Findings will be documented in the patient's record.

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    retdem neuro

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    The nurse will perform a full head-to-toe assessment of a patient, including: general appearance and mental status; neurological, sensory, and motor function; and neurovascular status. The assessment involves observation, patient questioning, and physical exams of cranial nerves, sensation, coordination, and extremities. Findings will be documented in the patient's record.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    30 views3 pages

    Retdem Neuro

    Uploaded by

    Charlize Pare
    The nurse will perform a full head-to-toe assessment of a patient, including: general appearance and mental status; neurological, sensory, and motor function; and neurovascular status. The assessment involves observation, patient questioning, and physical exams of cranial nerves, sensation, coordination, and extremities. Findings will be documented in the patient's record.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Before I start, I will perform hand hygiene to deter the spread of microorganisms and prevent

    healthcare associated infections.

    1. Hi po good afternoon, ma’am. How are you po? I am nurse cha and I will be your nurse po for today.

    2. Can you please state your name and your birthday po.

    3. I will be also closing the curtains to give you privacy

    4. At this moment I will be assessing your appearance and mental status, neurological system, and
    neurovascular status

    5. Now I will be assessing the patient’s General Appearance, Manner, and Attitude

    a. Physical appearance (height, weight, appropriate for age) (What is your height and weight po?)

    b. Grooming (Can I assess your skin po and nails)

    c. Personal hygiene habits (do you have personal hygiene habits po?)

    d. Posture (Can you please stand up)

    e. Signs of distress (facial expression, posture)

    f. Speech: quantity, pace, volume, clarity

    g. Relevance, content, and organization of responses

    6. Next is I will assess the patient’s expressive Aspects of Behavior

    a. Now I will assess for the General motor activity

    b. Purposeful movements, gestures, and gait (Now can you please walk po)

    7. Now I will assess the Thought Processes and Perceptions

    a. The Coherency, logic, and relevance

    b. Reality orientation

    c. Perceptions

    (Do you know where you are and the date today?) (Can you tell me po when Is your birthday)

    8. Next is I will assess for the patient’s mood

    a. Variability in mood

    b. Abnormal euphoria

    c. Presence of depression

    (How are you feeling today. Can you share your plans for your future)

    9. Now I will assess your Vision (SNELLEN CHART STAND up and all you need to do is to read the letters
    that I point out)
    10. Next is I will assess your Hearing ability

    11. Now I will assess your Tasting ability

    12. Next is I will assess your ability to feel

    13. Now I will assess your smelling ability

    14. Discard Gloves and hand hygiene

    15. Lastly, I will report the findings and document the data on client’s record

    Neurological System

    1. Before I start would it be okay if I ask you several questions

    a. Presence of pain in the head, back, or extremities

    b. Disorientation to time, place, or person

    c. Speech disorder

    d. History of loss of consciousness, fainting, convulsions, trauma, tingling or numbness, tremors or tics,
    limping, paralysis, uncontrolled muscle movements, loss of memory, mood swings, or problems with
    smell, vision, taste, touch, or hearing

    2. *Asked the client to read some words and to match the printed and written words with pictures.
    *Asked the client to respond to simple verbal and written commands. (I will show you some pictures and
    tell me what it is)

    3. Now I will determine the client’s orientation to time, place, and person (Can you please state the time
    right now) (What is the date today) (What city are we in right now) (Can you please state the name of
    your family members) (What is your reason for seeing health care provider)

    4. Are you having difficulty with your memory

    5. Now I will test the patient’s ability to concentrate or maintain attention span (Can you please count
    backward from 10) (Can you please subtract 3 from 10)

    6. Now I will Test for CN I (olfactory): (Can you please close your eyes, occlude one nostril and identify
    the scent)

    7. Now I will test for CN II (optic); (Can you please read this part)

    8. Now I will test for CN III (oculomotor), CN IV (trochlear), and CN VI (abducens): (Assess extraocular
    movements and use penlight for pupillary reaction)

    9. Now I will test for CN V (trigeminal): (Can you please clench your teeth – palpate temporal and
    masseter muscle) (Now can you please close your eyes and identify if it is sharp or dull – forehead,
    cheeks, and chin)

    10. Now I will test for CN VII (facial): (Can you please smile, frown, show your teeth, puff out cheeks,
    purse lips, and raise eyebrows) (can you please close your eyes tightly against resistance)
    11. Now I will test for CN VIII (acoustic/vestibulocochlear): (Perform Weber and Rinne’s test)

    12. Now I will test for CN IX (glossopharyngeal) and X (vagus): (Can you please open your mouth and say
    “ahh” – use tongue depressor)

    13. Now I will Test for CN XI (spinal accessory): (can you please shrug your shoulders against the
    resistance, ask client to move head to the right or left against the resistance) (Now I will assess the
    sternocleidomastoid muscle.)

    14. Now I will Test for CN XII (hypoglossal): (Can you please protrude your tongue, and move it to each
    side against the resistance – use tongue depressor)

    15. Discard Gloves and hand hygiene

    16. Lastly, I will report the findings and document the data on client’s record

    Neurovascular Status

    1. Now I will Assess the extremity distal to the injury for color and temperature

    2. Next is I will Assess the capillary refill time (Pinch the nail)

    3. Now I will Assess the extremity for pain and sensation.

    4. Next is I will TEST the PRIMARY SENSATIONS: (Wisp of cotton and paper clip (sharp or dull))

    5. Now I will TEST the CORTICAL AND DISCRIMINATORY SENSATION: (Can you please identify what is
    placed in your hand) (Can you please identify the area being touched)

    6. Next is I will TEST FOR CEREBELLAR SYSTEM: (*Show finger to nose test) (Can you please do this)
    (TEST RAPID ALTERNATING MOVEMENTS WITH THE USE OF PALMS.) (Client rapidly turns palms up and
    down.)

    7. Discard Gloves and hand hygiene

    8. Lastly, I will report the findings and document the data on client’s record

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