University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2022
Views:

462

Pages:

2
Author:

Carissa Thomas

Basic Health Assessment and Clinical Skills Neurological Assessment I Yes 1. 2. 3. 9. 10. 11. 13. 14. 15. 16. Identify the client (verbal) Wash hands (verbal) Maintain patient privacy (close curtain) Provide for proper lighting Assess mental status Level of consciousness Thought processes Appearance and behavior Speech Obtain history Provide for exposure of areas to be examined Test cranial nerves Cranial nerve I Olfactory (sensory) Smell (omit)(verbal) Cranial nerve II Optic (sensory) Visual acuity – snellen chart (omit) (verbal) Test for visual field Examine with opthalmoscope Cranial nerve III Oculomotor (motor) Six cardinal gazes Test for fixation and accomodation Papillary constriction- direct and consensus Observe for ptosis of upper eyelid Cranial nerve IV Trochlear (motor) Inferior lateral movement of eyes Cranial nerve VI Abducens (motor) Inferior lateral eye movement Cranial nerve V Trigeminal (sensory and motor) Corneal reflex (omit) Sensation of skin of the face (eyebrow, cheeks and chin), using a wisp of cotton Motor – chewing, biting, lateral jaws movement, against resistance Cranial nerve VII Facial (sensory and motor) Taste – anterior 2/3 of the tongue Sweet/ salt/ sour/ bitter ( omit) Motor – movement of forehead and mouth Raise eyebrows, show teeth, Smile and puff out cheeks, close eyes tight and against resistance Cranial nerve VIII Acoustic ( sensory) Hearing, balance Weber and Rinnie tests Whisper test Otoscope Cranial nerve IX Glossopharyngeal (sensory and motor) swallowing and phonation (saying ahh) taste – posterior 1/3 of tongue (omit) No Comments Basic Health Assessment and Clinical Skills 17. Cranial nerve X Vagus (sensory and motor) sensation of posterior 1/3 of tongue, throat (omit) motor – gag reflex swallowing and phonation 18. Cranial nerve X Spinal accessory (motor) shoulder movement, shoulder shrug, head rotation – push against examiner’s hand 19. Cranial nerve XII Hypoglossal (motor) tongue movement – protrude tongue, push tongue into the cheek saying sounds of letter l, t, d (e.g. letter, dinner) 24. 27. 28. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. Assess motor system Muscles (inspect and palpate) Size Strength Tone Involuntary movements Assess cerebellar function Balance tests Gait (including tandem walking) Romberg test Coordination and skilled movements Rapid alternating movements (RAM) or Rapid finger-to-thumb Finger-to-finger test Finger-to-nose test Heel-to-shin test Assess sensory system Pain—sharp and dull Light touch Vibration Position (kinesthesia) Tactile discrimination (fine touch) Stereognosis Graphesthesia Assess reflexes Stretch, or deep tendon reflexes (DTRs) Biceps Triceps Brachioradialis Quadriceps Achilles (ankle jerk) Plantar Hand hygiene Document findings (verbal)