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    Assessment of Neurologic System

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    jlinuel' St
    The document describes a student nurse conducting a neurologic assessment on a patient. The assessment includes introducing oneself to the patient, performing hand hygiene, assessing the patient's mental status, cranial nerves, motor function, gross motor skills and balance. The student tests each cranial nerve, assesses fine motor skills of the hands and balance by having the patient walk, stand on one foot, and do heel-toe walking. The patient is able to answer all questions appropriately and perform all physical tasks as requested without issues.

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    Assessment of Neurologic System

    Uploaded by

    jlinuel' St
    63 views35 pages
    The document describes a student nurse conducting a neurologic assessment on a patient. The assessment includes introducing oneself to the patient, performing hand hygiene, assessing the patient's mental status, cranial nerves, motor function, gross motor skills and balance. The student tests each cranial nerve, assesses fine motor skills of the hands and balance by having the patient walk, stand on one foot, and do heel-toe walking. The patient is able to answer all questions appropriately and perform all physical tasks as requested without issues.

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    The document describes a student nurse conducting a neurologic assessment on a patient. The assessment includes introducing oneself to the patient, performing hand hygiene, assessing the patient's mental status, cranial nerves, motor function, gross motor skills and balance. The student tests each cranial nerve, assesses fine motor skills of the hands and balance by having the patient walk, stand on one foot, and do heel-toe walking. The patient is able to answer all questions appropriately and perform all physical tasks as requested without issues.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    63 views35 pages

    Assessment of Neurologic System

    Uploaded by

    jlinuel' St
    The document describes a student nurse conducting a neurologic assessment on a patient. The assessment includes introducing oneself to the patient, performing hand hygiene, assessing the patient's mental status, cranial nerves, motor function, gross motor skills and balance. The student tests each cranial nerve, assesses fine motor skills of the hands and balance by having the patient walk, stand on one foot, and do heel-toe walking. The patient is able to answer all questions appropriately and perform all physical tasks as requested without issues.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 35

    NEUROLOGIC SYSTEM

    RETURN
    DEMONSTRATION
    Introduction

    Good Afternoon Doc. Nika, I am John


    Linuel Tulliao, a student nurse from WU-
    P and for today’s return demonstration, I
    will be performing the assessment of
    neurologic system. So maam can I
    proceed now?
    Goal
    The goal of this assessment is to assess
    the function of cranial nerves and detect
    any abnormalities.
    Introduce yourself
    The first thing we’re going to do is to
    introduce yourself, and verify the client’s
    identity. Identifying the patient ensures
    the right patient receives the intervention
    and helps prevent errors.
    Hand Hygiene

    Next is to perform hand hygiene and


    observe other appropriate infection
    prevention procedures.We should also
    wear some PPEs in order to prevent the
    spread of microorganisms.
    Client Privacy
    We should provide client privacy by
    closing the curtains, doors, or windows.
    Inquire
    Inquire if the client has any history of the following:
    Sir did you have a presence of pain in the head, back, and
    extremities, as well as onset and aggravating and alleviating
    factors, problems in speech,  loss of consciousness, fainting,
    convulsion, 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.
    Mental Status
    Level of Consciousness:
    Opens eyes spontaneously oriented
    Cognitive Function
    I have here some few questions that you’re
    going to answer.
    Sir can you tell what is today’s date? When is
    your birthday? What did you have for lunch?
    Patient is able to answer questions regarding
    recent, remote and intermediate memory.
    Cranial Nerves

    CN I (Olfactory):
    Can you close your eyes and identify
    different mild aromas?
    Cranial Nerves

    CN II (Optic):
    Can you read Snellen’s chart, and I’m
    going to check your visual fields by
    confrontation.
    Can you cover your left eye?
    How about your right eye?
    Cranial Nerves

    CN III and IV (Oculomotor and Trochlear):


    I’m going to assess six ocular movements
    and pupil reaction. Can you stare at the tip
    of this pen and follow its movements?
    Cranial Nerves

    CN V (Trigeminal):
    a.     Can you look upward, I’m going to lightly touch lateral
    sclera of eye with sterile gauze to elicit blink reflex.
    b.     To test light sensation, Can you close your eyes and
    I’m going to touch your forehead and paranasal sinuses by
    using a wisp of cotton.
    c.     To test deep sensation, I’ll use alternation blunt and
    sharp ends of a safety pin over the same area.
    Cranial Nerves

    CN VI (Abducens):
    I’m going to assess direction of gaze.
    (We’ve already done this a while ago)
    Cranial Nerves

    CN VII (Facial):
    Can you smile, raise your eyebrows,
    frown, puff out your cheeks, close your
    eyes tightly. Can you identify various
    taste placed on tip and sides of tongue.
    Cranial Nerves

    CN VIII (Auditory):
    We’re going to do a whisper test, I’ll whisper
    some words and you’re going to repeat it. Can
    you cover your left ears, your right ears. Now,
    we’re going to use the tuning fork and please
    tell me if you hear the vibrations.
    Cranial Nerves

    CN IX (Glossopharyngeal):
    I’m going to apply tastes on posterior tongue
    for identification. Can you move your
    tongue from side to side and up and down.
    Cranial Nerves

    CN X (Vagus):
    I’m going to assess your speech for
    hoarseness. Can you please speak and say
    your name?
    Cranial Nerves

    CN XI (Accessory):
    Can you shrug your shoulders? Now, I’m going to
    apply some force and can you please resist it? and
    can you turn your head to the right and I’m going
    to apply some force again then you’re going to
    resist it. Can you turn your head to the left?
    Cranial Nerves

    CN XII (Hypoglossal):
    Can you stick your tongue out or protrude it at
    midline, then move it side to side
    Can you say “light, tight, dynamite,” and I’m
    gonna note that lingual speech (sounds of
    letters l, t, d, n) if it is clear and distinct.
    Motor Function
    Fine Motor Test for the Upper Extremities
    Motor Function

    Finger-to-nose Test
    Can you repeatedly and rhythmically
    touches your nose using your finger?
    Motor Function

    Finger-to-nose-and-to- the nurse’s finger


    Can you repeatedly touch you nose and my
    finger using your finger? Performs with
    coordination and rapidly able to perform with
    ease.
    Motor Function

    Fingers to fingers
    Can you repeatedly touch your finger?
    Performs with accuracy and rapidly
    Motor Function

    Fingers to thumb (Opposition)


    Can you touch each finger with your
    thumb with each of your hand rapidly?
    Motor Function
    Heel Down Opposite Shin
    Can you place the heel of one foot just
    below the opposite knee and run the heel
    down the shin to the foot. Repeat it with
    the other foot. You may also use a sitting
    position for this test.
    Gross Motor and Balance Tests

    Walking Gait
    Can you stand and walk without support?
    Gross Motor and Balance Tests

    Romberg Test
    Sways and able to maintain upright
    posture and foot stance
    Gross Motor and Balance Tests

    Standing on One Foot with Closed Eyes


    Can you please stand on one foot with
    your eyes closed?
    Able to maintain stance for 5 seconds
    Gross Motor and Balance Tests

    Heel-toe Walking
    Can you walk with your other foot’s heel
    on top of your foot’s toe?
    The patient was able to maintain heel-to-
    toe walking around a straight line.
    Gross Motor and Balance Tests

    Toe or Heel Walking


    Can you walk with your toes? How about
    your heels?
    able to walk several steps on toes or heels
    Secure patient’s comfort and
    safety.
    Document all the findings
    Dispose PPEs
    Now, I’m going to dispose my gloves and
    put another spray of alcohol to prevent
    the spread of microorganisms.
    Thank you
    Thank you sir for cooperating and thank
    you Maam Nika for listening and for your
    time.

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