Neurological Assessment Learning Template

ACTIVE LEARNING TEMPLATE: Nursing Skill STUDENT NAME _____________________________________ assessment SKILL NAMENeurological ____________________________________________________________________________ REVIEW MODULE CHAPTER ___________ Description of Skill Neurological assessment is an evaluation of a person's nervous system, which includes the brain, spinal cord, and the nerves that connect these areas to other parts of the body. Indications The nervous system consists of the brain, the spinal cord, and the nerves from these areas. There are many aspects of this exam, including an assessment of motor and sensory skills, balance and coordination, mental status (the patient's level of awareness and interaction with the environment), reflexes, and functioning of the nerves. -The extent of the exam depends on many factors, including the initial problem that the patient is experiencing, the age of the patient, and the condition of the patient. Outcomes/Evaluation Identify patient Neurological Status. Potential Complications Risk for falls. -Increase patient distress. ACTIVE LEARNING TEMPLATES CONSIDERATIONS Nursing Interventions (pre, intra, post) 1.Mental status. Mental status (the patient's level of awareness and interaction with the environment) may be assessed by conversing with the patient and establishing his or her awareness of person, place, and time. The person will also be observed for clear speech and making sense while talking. This is usually done by the patient's healthcare provider just by observing the patient during normal interactions. 2. Motor function and balance. This may be tested by having the patient push and pull against the healthcare provider's hands with his or her arms and legs. Balance may be checked by assessing how the person stands and walks or having the patient stand with his or her eyes closed while being gently pushed to one side or the other. The patient's joints may also be checked simply by passive (performed by the healthcare provider) and active (performed by the patient) movement. 3. Sensory exam. The patient's healthcare provider may also do a sensory test that checks his or her ability to feel. This may be done by using different instruments: dull needles, tuning forks, alcohol swabs, or other objects. The healthcare provider may touch the patient's legs, arms, or other parts of the body and have him or her identify the sensation (for example, hot or cold, sharp or dull). 4. Reflexes in the older child and adult. These are usually examined with the use of a reflex hammer. The reflex hammer is used at different points on the body to test numerous reflexes, which are noted by the movement that the hammer causes. 5. Coordination exam: Using rapid alternating movement, Point-to-point movement, Romberg's test, and Proprioception. 6. Pupil Scale (2-9 mm) 7. Cranial Nerves Assessment: Cranial nerve I (olfactory nerve). This is the nerve of smell. The patient may be asked to identify different smells with his or her eyes closed. *Cranial nerve II (optic nerve). This nerve carries vision to the brain. A visual test may be given and the patient's eye may be examined with a special light. Cranial nerve III (oculomotor). This nerve is responsible for pupil size and certain movements of the eye. The patient's healthcare provider may examine the pupil (the black part of the eye) with a light and have the patient follow the light in various directions Client Education Teach patient to attempt tasks that they are comfortable to prevent falls Nursing Interventions Do not force patient to attempt tasks that beyond their limitations and be prepare to catch patient when assessing Gait, Balance, and Coordination.