University:
The Pennsylvania State University
Course:
NURS 100 | Nursing
Academic year:

2024
Views:

464

Pages:

4
Author:

Aaron B.

PHYSICAL EXAMINATION OF NERVOUSNESS PROCEDURE A. Pre-Interaction Stage 1. Verify data 2. Wash your hands 3. Move the device close to the patient B. Orientation Stage 1. Greeting as a therapeutic approach 2. Explain the objectives and procedures for the action to the family/client 3.Ascertain the client's readiness before the activity is carried out C. Work Phase 1. Read tasmiyah 2. Maintain client privacy Inspection 3. Observe for various neurological abnormalities:  Seizures  Tremors/shaking  Twitching(short-lived spasmodic effects such as muscle fatigue, local pain)  Korea(involuntary/unconscious, rude, aimless, fast, jerky, uncoordinated)  Parese (incomplete muscle paralysis/weakness)  Paralysis (complete paralysis)  diplegia (paralysis of two limbs) Paraplegia  (paralysis of lower limbs) Tetraplegia/paresis  (paralysis of all four limbs) Hemiparesis/plegia  (paralysis of one side of the body/limb) 4. Reflex examination - Superficial Reflexes -method: scratch the abdominal skin with four scratches forming a rectangle below the xiphoid (above the symphysis) - Tendon Reflex -knock usingHummeron the biceps, triceps, patella and Achilles tendonsresults :biceps (flexion occurs at the elbow joint), triceps (extension occurs at the elbow), patella (extension occurs at the knee joint) -hyperreflex - upper motor neuron -hyporeflex - lower motor neuron - Pathological Reflexes reflexbabinskyby scratching the plantar surface of the foot with a slightly pointed instrument -thumb extension reaction, then the result is positive The scale for ranking reflexes is: 0 = no response 1 = hypoactive / decreased response, weakness (+) 2 = normal (++) 3 = faster than average, not necessarily considered abnormal ( +++ ) 4 = hyperactive, with clonus (++++) 5. Check for meningeal signs - Stiff neck -ps lying down, neck bent -normal: chin stuck to chest and no resistance - Brudzinsky I -PS standing up, place one hand under the head, the other hand placed on the chest to help the body lift, then the head is flexed. - Brudzinsky II -PS on the back, passively flex the upper leg at the pelvis, following the flexion of the other leg. -If the other knee joint is in extension, there are miningeal signs. - Kerniq sign -If the patient is lying on his back, flex the upper leg slightly straight, then straighten the lower leg at the knee joint. -normal: can form an angle of 135 degrees to the lower leg D. Termination Stage 1. Tidying up clients 2. Evaluate actions 3. Reading tasmiyah and tidying up clients 4. Tidy up the tools 5. Wash your hands 6. Say goodbye 7. Record activities on the nursing record sheet