• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Neurological Assessment
 

Neurological Assessment

on

  • 852 views

 

Statistics

Views

Total Views
852
Views on SlideShare
852
Embed Views
0

Actions

Likes
0
Downloads
13
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft Word

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Neurological Assessment Neurological Assessment Document Transcript

    • VIII-52 CITIZENS SCHOOL OF NURSING MAJOR ASSESSMENT Nursing 202 – Neurological Specifics Total points – 7.5 pts Blanks – deduct .5 pts. Student’s Name: __________________________ Date(s) of Assessment: __________________________ Institution where completed_______________________________ Patient’s Initials: ______ Age: ______ Sex: ______ Room Number: ______ Allergies: _____________________________________________________________________________________________ Primary/Admitting Diagnosis: Definition of Admitting Diagnosis: Reference(s) used for definition of admitting diagnosis: Secondary/Concurrent Medical/Surgical Diagnoses: Past Medical History: Source of information: (i.e. patient, family, current chart, old medical record) Signs & Symptoms on admission:
    • 2 VITAL SIGNS Temperature Current temperature: ______________ Route: _______________ Range: ___________________ Chilling: Yes □ No □ Diaphoresis: Yes □ No □ Comments: Include laboratory studies specific to infection, i.e. WBCs. Blood Pressure Blood Pressure: Right arm ______ Left arm ______ Range during hospitalization: ______ - ______ Orthostatic Blood Pressure: Lying_____________Sitting_____________Standing_____________ Pulse Apical: Rate ____________ Range ____________ Volume _____________ Rhythm: Regular □ Irregular □ Radial: Rate ____________ Range ____________ Volume _____________ Rhythm: Regular □ Irregular □ Respirations Respirations: Rate _________ Range _________ Depth _________ Rhythm _________ Ease _________ PAIN If your patient experienced pain on admission and pain is controlled at the time of your major assessment, please comment/ identify description of original pain below in the blanks provided. Write comment (in section provided) identifying the outcome of medical/surgical interventions to control pain and the patient’s current pain scale score. Pain:  No Pain  Location: ______________________ Radiation: _______________________________ Characteristics: Severity: _____________ (0-10) Effects on ADL _______________ Effects on sleep _________________________ Aggravating factors: ___________________________ Alleviating factors: ___________________________ Severity in past 24 hours: ____________ (0-10) Acceptable level _______________ (0-10) Nonverbal signs/symptoms: _________________________________________________________________________ Barriers to pain control: Cultural  Educational  Philosophy of Caregiver Physical  Emotional  Spiritual Financial Other  Comments:
    • 3 NEUROLOGICAL/SENSORY ( .5 pts) Level of consciousness: Alert  Lethargic (or Somulent)  Stupor (or semi-coma)  Coma (Completely unconscious)  Oriented: Person  Place  Time  Disoriented: Person  Place  Time  Affect: Appropriate  Anxious  Hostile  Suspicious Elated  Flat  Indifferent  Depressed  Communicates well Communication Barrier  Global aphasia  (Severely impaired language comprehension and expression) Expressive aphasia  (Speech typically totally incomprehensible and effortful) Receptive aphasia  (Speech is effortless and well articulated; often is characterized by word substitutions, made up words, and is incomprehensible. The patient has great difficulty understanding spoken words) Pupil size: ______mm Pupils Equally Round and Reactive to Light and Accommodation (PERRLA) Brisk Sluggish  Non-reactive  Unequal/React to Light  Glasgow Coma Scale  Patient’s score ____________ Frequency of exam ____________ Vision: Glasses Yes  No  Used for ______________________________ Contact Lens Right  Left  Last eye examination: ______________________________________ Hearing: Deficits Yes  No  Describe: _____________________________ Hearing aids Right  Left  Has patient had a hearing examination to determine cause of hearing loss? Yes  No  Date ____________________ Diversional activities: Home _____________________________ Hospital__________________________________ Sensory deprivation: Yes  No  Sensory overload: Yes  No  Signs/Symptoms: ________________________________________________________________________________ Comments: PULMONARY (.5pts) Respirations: Normal (rate 14-20 per minute, regular, non-labored) Rapid shallow breathing (tachypnea) Rapid deep breathing (hyperpnea, hyperventilation) Slow breathing (bradypnea)
    • 4 Cheyne-Stokes breathing (deep breathing alternating with apnea) Obstructive breathing (prolonged expiration, pursed lip breathing) Lung sounds: RUL:  Clear  Diminished  Rales  Rhonchi  Wheezes RML:  Clear  Diminished  Rales  Rhonchi  Wheezes RLL:  Clear  Diminished  Rales  Rhonchi  Wheezes LUL:  Clear  Diminished  Rales  Rhonchi  Wheezes LLL:  Clear  Diminished  Rales  Rhonchi  Wheezes Dyspnea: None  At rest  With exertion  Cough: Yes  No  Productive: Yes  No  Color of Sputum: ________________________ Consistency of Sputum: ________________________ Oxygenation: Oxygen delivery device: _____________ Flow/Percent: ______ L/min ______% Continuous  Prn  Tracheostomy  Type ______________________ Size ____________ Suctioning  Type: Naso-tracheal  Tracheal  Oral  Other Respiratory Therapy: Nebulizer/Spontaneous aerosol  Bipap  C-pap  Incentive spirometry  Flutter valve  Chest Physical Therapy (CPT)  Pulmonary Specialty Bed : Rotation  Vibration  Percussion  Frequency/Duration __________ Pulse Oximetry _________% Cyanosis: Nailbeds  Peri-oral Conjunctiva  Oral mucosa  Skin  Smoking: Never  Previous  Current  Packs per day ______ Number of years ______ Comments: Include laboratory & diagnostic studies specific to oxygenation. CARDIOVASCULAR (.5pts) Heart Sounds: S1>S2 @ Apex ________ S2>S1 @ Base ________ Intensity: ______________________ Presence of arterial pulses: Pulse strength left: Pulse strength right Carotid Doppler 1+ 2+ 3+ 4+ Doppler 1+ 2+ 3+ 4+ Radial Doppler 1+ 2+ 3+ 4+ Doppler 1+ 2+ 3+ 4+ Femoral Doppler 1+ 2+ 3+ 4+ Doppler 1+ 2+ 3+ 4+
    • 5 Dorsalis Pedis Doppler 1+ 2+ 3+ 4+ Doppler 1+ 2+ 3+ 4+ Posterior tibial Doppler 1+ 2+ 3+ 4+ Doppler 1+ 2+ 3+ 4+ Temperature of Skin: __________________ Temperature of Extremities: __________________ Capillary Refill:  Immediate return of color Delayed return of color Presence of edema: Left Right Pedal  0 1+ 2+ 3+ 4+  0 1+ 2+ 3+ 4+ Ankle  0 1+ 2+ 3+ 4+  0 1+ 2+ 3+ 4+ Calf  0 1+ 2+ 3+ 4+  0 1+ 2+ 3+ 4+ Sacral  0 1+ 2+ 3+ 4+  0 1+ 2+ 3+ 4+ Other_____________________  0 1+ 2+ 3+ 4+  0 1+ 2+ 3+ 4+ Comments: Include laboratory & diagnostic studies specific to the cardiovascular system. GASTROINTESTINAL Height: ____________ Weight: (present) ____________ (ideal) ____________ (usual) ____________ Amount of weight change over what period of time __________ (indicate gain or loss) Intentional? ________ Difficulty chewing? Yes  No  Difficulty swallowing? Yes  No  Taste perception: __________________________ Smell perception: ________________________________ Nausea Yes  No  Frequency __________ Duration __________ Vomiting Yes  No  Frequency __________ Duration __________ Diarrhea Yes  No  Frequency __________ Duration __________ Abdominal inspection:  Normal – Flat, non-distended, rounded, symmetric, no evidence of enlarged liver or spleen, no rash, no lesions.  Abnormal – Distended, tense glistening skin, purple striae, evidence of enlarged liver or spleen, asymmetric contour. (Circle all that apply) Auscultation of bowel sounds: Absent Present Hypoactive  Hyperactive Auscultation of vascular sounds: Absent Present Abdominal percussion:  Normal – tympany over the stomach and gas-filled bowels, dullness over the liver, spleen or full bladder.
    • 6  Abnormal – Large dull areas (associated with presence of fluid or a tumor) Abdominal palpation:  Normal – Relaxed abdomen, no tenderness no masses  Abnormal – Hypersensitivity, tenderness, masses (Circle all that apply) Nutrition Diet (at home) __________________ (in hospital) _________________ % eaten (B) ____ (L) _____ (D) _____ Alternative feedings  Parenteral – Intravenous hyperalimentation (IVH), total parenteral nutrition (TPN)  Enteral – via Nasogastric tube (NGT), Keofeed tube, Percutaneous esophageal gastrostomy (PEG) (Circle route of administration for tube feeding) Formula for enteral feeding: ________________________________________________________ Free water administration (bolus or flush) – Amount __________ Frequency __________ Feeding administration:  Bolus Amount __________ Frequency __________  Continuous via pump Amount __________ Frequency __________ Frequency of checking residual: _____________________________________________________ Intervention for residual greater than allowance: ________________________________________ Rational for specialized diet order: ___________________________________________________________ Food preferences: ________________________________________________________________________ Food allergies: _____________________________ Food intolerance: ________________________ Food restrictions: ________________________________________________________________________ Fluid restriction: If fluid restriction is prescribed, identify the fluid plan: Dietary amount: _________ Nursing amount: 7-3____________ 3-11____________ 11-7____________ Ability to purchase & prepare food: __________________________________________________________ Elimination Last BM: Date ______________ Amount _______________ Color ______________ Consistency ________________ Usual frequency ________________ Usual characteristics ________________________________________________ Use of aids in elimination __________________________________________________________________________ Evacuation mode: Bathroom  Bedside commode  Bedpan  Presence of stoma: Yes  No  Ostomy care: ___________________________________________________________________________________
    • 7 Comments: Include laboratory and diagnostic studies specific to GI disorders, nutrition, and bowel elimination. GENITOURINARY Urine: Color _______________ Clarity _______________ Constituents ____________ Odor ___________ Usual frequency ___________________ Amount _________________ Continent: Yes  No  If incontinent, identify type: ________________________________________________________________ Urinary catheter: Yes  No  Type/size ___________ Reason ___________________________________ Voiding mode: BR  BSC  Bedpan  CVA (costovertebral angle) tenderness Yes  No  Unilateral  Bilateral  Bladder distention: Yes  No  Bladder scanned amount ____________________________________ Presence of urinary stoma: Yes  No  Presence of dialysis access: Yes  No If yes, identify type and insertion site below. Type: Udall/Permacath  A/V Fistula  Insertion site: _____________________________ Comments: Include laboratory & diagnostic studies specific to urinary elimination i.e. urine R&M, C&S MUSCULOSKELETAL Activity Tolerance/Intolerance: _______________________ Muscle Strength: ____________________________________ ROM: Active Passive Posture: ______________________ Gait: Assisted Unassisted Steady Unsteady Assistive devices: Type _________________________________________ Current use  Chronic use  Ability to perform ADLs Feeding: Self  Partial  Complete  Hygiene: Self  Partial  Complete  Toileting: Self  Partial  Complete  Activity: Self  Partial  Complete  Comments:
    • 8 INTEGUMENTARY Condition of skin: Intact  Broken  Moisture: ____________________________________ Note presence of incisions, scars, lesions, sores, rashes, ulcers and any other identified wound on figures below. Number each area. Describe each alteration in detail noting stage of skin breakdown, size, color, drainage & odor (when applicable). Wound care: Condition of hair & scalp: mouth: teeth: Dentures: Upper  Lower  Partial 
    • 9 nails: Comments: Include laboratory studies specific to wounds i.e. cultures. FLUID AND ELECTROLYTES 8 Hour Intake __________ 8 Hour Output __________ 24 Hour Intake __________ 24 Hour Output __________ Drainage apparatus: Type ____________ Amount of Drainage ____________ Color____________ Urine: Color ____________________ Concentration ____________________ Weight: ______ Change (in past 24 hours) ______Loss  Gain  (past 1-2 days) ______ Loss  Gain  Skin turgor: ________________________________________ Excessive Thirst: Yes  No  Edema: Location ____________________________________________ Degree ______________________ Hydration of Mucous Membranes: ___________________________________________________________ Intravenous therapy: Yes  No If yes, identify type of IV access: IV cap for intermittent infusion or emergency  Peripheral IV for continuous infusion  PICC  Mid-line  Central line  Infusaport  Other __________________________________________________ IV solution and infusion rate:________________________________________________________________ Nursing care associated with IV device: _______________________________________________________ Comments: Include laboratory and diagnostic studies specific to fluid and electrolytes ENDOCRINE Physical findings related to Diabetes Mellitus and / or thyroid disorders? Comments: Laboratory results: i.e. blood glucose levels, TSH, T3, T4, etc. REPRODUCTIVE/SEXUALITY Male History of STD's: Yes o No f Describe: _______ Concerns about sexuality or sexual identity: Yes e No a ______
    • 10 Any pain, discoloration, tenderness or edema of external genitalia (penis, scrotum, testicles): Yes p No Does the patient perform self testicular exam? Yes / No Any surgery on reproductive organs: _______________ Comments: Female History of STD's: Yes o No f Describe: ______________ Concerns about sexuality or sexual identity: Yes e No a ______ Any pain, discoloration, tenderness or edema of external genitalia: Yes p No Does the patient perform self breast exam? Yes No ¤ If not, does the patient require teaching? Yes No Any surgery on reproductive organs: _______________ Hormone replacement therapy: Yes o No e __________________________________________________________ Last mammogram: ____________ Last pap smear: ____________ Last menstrual period: ____________ Comments: REST AND SLEEP Sleep: Current amount __________________________ Usual amount _______________________________________ Preferred position: _______________ Number of awakenings Reason Early morning awakening Difficulty in falling asleep  Sleep continuity disturbance  Sleep deprivation: signs Voiced symptoms Naps: Frequency ______________ Duration__________________________________________________________ Comments: Include sleep studies SAFETY AND SECURITY Safety Physical: Orientation Status _________________ History of injury: Yes  No  Describe:_____________________ Restraints: Yes  No  Describe: __________________________________________________________________ Uses Tobacco Yes  No  Type _________________________ Amount ________________________________ Uses Alcohol Yes  No  Type _________________________ Amount __________________________________ Uses Drugs Yes  No  Type _________________________ Amount __________________________________ Environmental Safety Hazards: Hospital: ___________________________________________________________
    • 11 Home: ____________________________________________________________ Is there anyone or anything in the patient’s home environment that makes him/her feel unsafe? Yes  No  Describe _______________________________________________________________________________________ Bacteriological: Isolation Yes  No  Type ____________________ For ________________________________ Presents risks: _________________________________________________________________________________ Comments: Security Financial: Occupation ______________________ Employment status: ___________________________________ Income concerns: ________________________________________________________________________________ Type(s) of medical insurance: ______________________________________________________________________ Is medical insurance adequate? Yes  No  Comments: SPIRITUAL Religion: ___________________ Role of religion_________________________ Clergy visits: Yes  No  Comments: EMOTIONAL/PSYCHOLOGICAL Fears/Concerns:_____________________________________________________________ Loses (recent/anticipated): ________________________________________________________________________ Current Growth & Development Stage (according to Erikson): ___________________________________________ Expected Growth & Development Stage (according to Erikson): __________________________________________ Describe: _______________________________________________________________________________________ Need for community resources: Yes  No  Describe____________________________________________________ Discharge plan: Comments:
    • 12 PSYCHOSOCIAL NEEDS Support Marital status: Single  Married  Divorced  Widowed  Support system: _________________________________________________________________________________ Visitors during the shift: __________________________________________________________________________ Observable Behavior: ____________________________________________________________________________ Comments: Esteem Previous level of independence (including living arrangements): __________________________________________ Current level of independence: _____________________________________________________________________ Locus of control: Nurse  Patient  Shared  Explain _______________________________________________ Cognitive Level of Education: _______________________________________________________________________________ Knowledge of healthful living behaviors: ______________________________________________________________ Demonstrates need for education: Yes  No  Describe _______________________________________________ Understanding of health teaching: Yes  No  Learns best by ___________________________________________ Affective Emotional status: _____________________ Support needs: ______________________________________ Comments: SELF ACTUALIZATION Ability to deal with problems: ___________________________________________________________________ Satisfaction with life achievements: ______________________________________________________________ Future goals: ________________________________________________________________________________ Comments: ***HIGHLIGHT ALL PROBLEM AREAS***
    • 13 (.5pts) List all relevant nursing diagnosis (in 3 part form) that addresses all problem areas that you identified. You may use the back of this form and attach an additional sheet if necessary. (1Pt) List all current medications including the route, dose, and frequency of administration. You may attach your medication sheets however you must also address medications that your patient is receiving even if not administered by you.
    • 14 1/17/01 Revised 1/9/03 Proposed 1/2/06 Edit 1/9/06 Edit 3/24/06 Edit 6/05/06 Edit 6/10/06 Edit 6/16/06 Edit 10/31/06 Neurological Addendum – Describe how you would test the area and the patients response to the testing. Mental and Emotional – 1 pt Memory and orientation Attention span and retention______________________________________ Recent Past____________________________________________________ Remote Past___________________________________________________ Intellectual performance Calculations Serial 7’s________________________________________________ Simple math problems_____________________________________ Thought process Proverbs Concrete__________________________________________ Abstract___________________________________________ Insight__________________________________________________ Judgment_______________________________________________ Mood and affect__________________________________________
    • 15 Language and communication Verbal ____________________________________________ Fluent_______________________________________ Nonfluent_____________________________________ Nonverbal__________________________________________ Cranial Nerve Exam (1.5pts) Olfactory Smell/dysfunction_________________________________________________ Optic Visual Acuity (with corrective lenses, using Snellen chart if possible) Right_______________________________________________________ Left________________________________________________________ Both_______________________________________________________ Visual Fields_______________________________________________________ Oculomotor Pupillary constriction Direct______________________________________________________ Indirect (consensual)___________________________________________ Convergence_______________________________________________________ Elevation of the eyelid_______________________________________________ EOM’s ___________________________________________________________ Nystagmus_______________________________________________________ Diplopia_________________________________________________________
    • 16 Dysconjugate gaze__________________________________________________ Trochlear EOM’s____________________________________________________________ Trigeminal Branches Ophthalmic___________________________________________________ Maxillary________________________________________________ Mandibular_______________________________________________ Corneal reflex___________________________________________________ Movement of the jaw________________________________________________ Abducens EOM’s_________________________________________________________ Facial Expressions____________________________________________________ Eyelid closure___________________________________________________ Taste___________________________________________________________ Acoustic Hearing________________________________________________________ Equilibrium_____________________________________________________ Glossopharyngeal Gag and swallow_________________________________________________ Vagus Gag and swallow_________________________________________________
    • 17 Uvula__________________________________________________________ Spinal Accessory Shoulder shrug_________________________________________________ Head rotation__________________________________________________ Hypoglossal Tongue________________________________________________________ Brain Stem testing (.5pts) Oculocephalic (Doll’s eyes)__________________________________________ Oculovestibular (Ice water calorics)____________________________________ Decorticate posturing________________________________________________ Decerebrate posturing________________________________________________ Motor assessment (.5pts) Handedness______________________________________________________ Symmetry_________________________________________________________ Handgrips________________________________________________________ Barre, Pronator’s or Drift sign________________________________________ Bicepts____________________________________________________________ Tricepts___________________________________________________________ Lower extremities___________________________________________________ Muscle tone Hypotonia___________________________________________________ Cogwheel rigidity_____________________________________________ Coordination (.5pts)
    • 18 Rapid alternating___________________________________________________ Ability to point smoothly and accurately_________________________________ Tremors Intentional__________________________________________________ Unintentional________________________________________________ Fasciculation’s_______________________________________________ Clonus____________________________________________________ Gait, Sensory and pathologic (.5 pts) Hemiplegic_______________________________________________________ Propulsive________________________________________________________ Pain Superficial_________________________________________________ Deep pain_________________________________________________ Temperature_____________________________________________________ Proprioception______________________________________________________ Pathologic signs Babinski____________________________________________________