Neurological Assessment
Autor: Jessica Baker • September 28, 2015 • Research Paper • 1,536 Words (7 Pages) • 771 Views
Beth-El College of Nursing and Health Sciences
NURS 3050 RN-BSN Health Assessment
Assessing Neurologic System
Nursing Interview Guide to Collect Subjective Data from the Client | |
Questions | Findings |
Current Symptoms | |
1. Headaches, numbness, or tingling? | Frequent headaches |
2. Seizure activity? | no |
3. Dizziness, lightheadedness, or problems with balance or coordination? | no |
4. Decrease in ability to smell or taste? | Only during time of sinus congestionno |
5. Ringing in ears? | |
6. Change in vision? | no |
7. Difficulty understanding when people are talking to you or when you talk to others? | no |
8. Difficulty swallowing? | no |
9. Loss of bowel or bladder control? | no |
10. Memory loss? | no |
11. Tremors? | no |
Past History | |
1. Head injury? | no |
2. Meningitis? | no |
3. Encephalitis? | no |
4. Spinal cord injury? | no |
5. Stroke? | no |
6. Treatment received? | no |
Family History | |
1. High blood pressure? | Yes maternal |
2. Stroke? | Yes grandmother paternal side |
3. Alzheimer disease? | no |
4. Epilepsy? | no |
5. Brain cancer? | no |
6. Huntington chorea? | no |
Lifestyle and Health Practices | |
1. Any prescription or nonprescription medications? | Tylenol or ibuprofen occasional |
2. Smoking? | Yes 10+ cigarettes daily |
3. Wearing of seat belts/protective headgear? | Sometimes not consistently |
4. Daily diet? | Eats at least 2 meals per day very inconsistent with breakfast |
5. Exposure to lead, insecticides, pollutants, chemicals? | Yes in hay industry and exposed to fertilizer |
6. Lifting of heavy objects? | Yes daily |
7. Frequent repetitive movements? | Yes daily |
8. Functioning/daily activities? | Drives semi truck, as well as tractors daily, able to complete all activities needed, |
Analysis of Data | |
1. Formulate nursing diagnoses (wellness, risk, actual). | Risk for injury r/t daily lifting of heavy objects as required by job |
2. Formulate collaborative problems. | Reduce smoking to improve whole body health, |
3. Make necessary referrals. | Seek medical help is any change in motor function begins to happen |
Physical Assessment Guide to Collect Objective Client Data | |
Questions | Findings |
Current Symptoms | |
1. Gather equipment, such as examination 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. | |
2. Explain the procedure to client. | |
3. Ask the client to put on a gown. | |
Mental Status | |
1. Assess level of consciousness. | Alert and oriented x3 |
2. Observe appearance and behavior. | Well kept, normal behavior for setting |
3. Observe mood, feelings, and expressions. | Smiling appropriately, happy appearing mood |
4. Observe thought processes and perceptions. | Does not really know what I am doing, will explain prior to any steps |
5. Observe cognitive abilities. | Reacts appropriately for 34 year old |
Cranial Nerves | |
1. Test cranial nerve I—olfactory. | Intact |
2. Test cranial nerve II—optic. | intact |
3. Test cranial nerve III—oculomotor. | intact |
4. Test cranial nerve IV—trochlear. | Intact, |
5. Test cranial nerve V—trigeminal. | In tact |
6. Test cranial nerve VI—abducens. | intact |
7. Test cranial nerve VII—facial. | intact |
8. Test cranial nerve VIII—acoustic (vestibulocochlear). | Decreased ability to hear whisper |
9. Test cranial nerve IX—glossopharyngeal. | intact |
10. Test cranial nerve X—vagus. | intact |
11. Test cranial nerve XI—spinal accessory. | intact |
12. Test cranial nerve XII—hypoglossal. | intact |
Motor and Cerebellar Systems | |
1. Test condition and movement of muscles. | Rom intact, |
2. Test balance. | Romberg negative |
3. Test coordination. | Able to do repetitive tasks with coordination |
Sensory System | |
1. Test light touch, pain, and temperature sensations. | Able to feel all |
2. Test vibratory sensations. | Decreased slightly |
3. Test position sensations. | intact |
4. Test tactile discrimination (fine touch). | intact |
Reflexes | |
1. Test deep tendon reflexes (biceps, brachioradialis, triceps, patellar, Achilles, and ankle clonus). | 1 |
2. Test superficial reflexes (plantar, abdominal, cremasteric). | 1 |
3. Test for meningeal irritation/inflammation (Brudzinski and Kernig signs if indicated). | Negative |
Analysis of Data | |
1. Formulate nursing diagnoses (wellness, risk, actual). | Risk for hearing loss aeb decreased ability to hear whisper |
2. Formulate collaborative problems. | Decreased wellness d/t hearing and smoking |
3. Make necessary referrals. | Refer patient to smoking cessation programs as well as audiologist for full hearing evaluation |
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