NUR 211 Neurological Assessment Lab Practice
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NUR 211 Neurological Assessment Lab Practice Document Transcript

  • 1. GEORGIA BAPTIST COLLEGE OF NURSING OF MERCER UNIVERSITY NUR 211 Neurological Assessment Lab Practice SUBJECTIVE: Fainting, seizures, memory, orientation, hallucinations, phobias, coordination of movement, paralysis, tics, tremors, spasm, paresthesia, tingling sensation. If indicated, refer to symptom analysis form. OBJECTIVE: General Survey: MOTOR: Finger-nose Heel-shin Rapid alternating movements Proprioception: (Romberg) Gait: SENSORY: Vibration Light touch Pain
  • 2. REFLEXES: Right Left Biceps Triceps Brachioradialis Patellar Achilles Plantar MENTAL: Mini-Mental Status Examination Orientation: Person, Place, & Time Registration (name 3 objects, say each one second apart, then patient repeats) Attention/Calculation: Serial 7 Add (1+1, 21 +30) Recall (ask to recall 3 objects) Naming Repetition Comprehension Reading Writing Drawing Total Score: Maximum score: 30, Normal: 24-30 (no cognitive impairment).
  • 3. Neurological Exam 1. Mental Status • General appearance and behavior • Level of consciousness • Intellectual performance • Emotional status 2. Cerebellar function (balance and coordination) • Whole body coordination o Gait o Heel-toe (tandrum) o Rhomberg • Upper body o Rapid alternating movements o Finger-nose • Lower body o Heel-shin 3. Motor System • Muscle size • Muscle tone • Muscle strength • Involuntary movements 4. Sensory system • Light touch • Pain (temperature) • Vibration • Motion and position • Two-point discrimination • Point localization • Sterognostic function • Graphesthesia 5. Reflex Status • Range of findings o 0 = no response o 1+ = diminished o 2+ = average, normal o 3+ = brisker than normal o 4+ = extremely brisk, hyperactive o Clonus • Deep Tendon Reflexes o Biceps o Triceps o Brachiorradialis o Quadriceps (Patellar/Knee Jerk)
  • 4. o Achilles (ankle jerk) • Superficial Reflexes o Abdominal o Plantar reflex (Babinski) 6. Cranial nerves • Olfactory (I) • Optic (II) o Visual acuity o Visual fields o Fundascopic • Oculomotor (III), Trochlear (IV), Abducers (VI) o Cardinal fields of gaze (EOM’s) o Oculomotor’s other functions  Direct, consensual constriction  Accommodation  Lid strength (ptosis) • Trigeminal (V) o Sensory  Light touch  Pain  Corneal reflex • Motor o Masseter and temporal muscles • Facial (VII) o Sensory = anterior tongue o Motor = facial movements • Acoustic (VII) o Watch tick o Weber o Rinne’ • Glossopharyngeal (IX) & Vagus (X) o Swallowing o Rise of soft palate o Gag • Spinal accessory (XI) o Strength of shoulder and neck muscles • Hypoglossal (XII) o Protrude tongue o Strength of tongue
  • 5. MENTAL STATUS ASSESSMENT (Jarvis, Ch. 7) OBSERVATION: 1. Appearance: a. Posture b. Body movements c. Dress d. Grooming and Hygiene 2. Behavior a. Level of consciousness b. Facial expression c. Speech d. Mood and affect Questioning/Testing: 1. Cognitive functioning a. Orientation Person Place Time b. Attention span Ability to concentrate c. Recent memory 24-hour diet recall Time of arrival at agency d. Remote First job Birthday Historical event e. New learning The Four Unrelated Words Test
  • 6. f. Word comprehension g. Reading h. Writing 2. Thought Processes and Perceptions a. Thought processes b. Thought content c. Perceptions d. Screen for suicidal thoughts Revised CTH 4/02 Rev 05/05/MSS
  • 7. NEUROLIGIC SAMPLE CHARTING: Person’s posture is erect, with no involuntary body movements. Dress and grooming are appropriate for the season and setting. Alert and oriented X 3. Appropriate facial expression and fluent, understandable speech. Affect and verbal responses are appropriate. Recent and remote memory intact. Can recall four unrelated words at 5-, 10-, and 30-minute intervals. Perceptions and thought processes are logical and coherent. No suicide ideation. No atrophy, weakness, or tremors. Gait smooth and coordinated, able to tandem walk, negative Rhomberg. Rapid alternation movements (RAM)—finger to nose smoothly intact. Pinprick, light touch, vibration intact. Stereognosis—able to identify object. No babinski’s sign. DTRs 2+ and equal bilaterally. 05/05/MSS